Continuity of care through medical records - An explorative study on GPs' management considerations

Abstract

Background. The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. Aim. To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records. Design of study. Cross-sectional study of 5741 consultations. Setting. Thirty GPs from 17 practices in a region in the eastern part of The Netherlands. Methods. The GPs responded to an electronic questionnaire, directly after 200 successive consultations. The questionnaire included items on management considerations, consultation characteristics and personal continuity. We compared the data from the questionnaire to the actual recording of management considerations in the patient records. Results. The GPs had management considerations in 66.4% of the consultations, involving mainly considerations about additional testing (15.5%), adjustment of medication (22.5%), alternative treatment plans (18.6%), possible referral (11.8%) and coping behaviour (18.0%). These considerations were seldom recorded in the electronic patient record; additional testing (3.0%) adjustment of medication (2.9%) and alternative treatment plans (4.1%). Surprisingly however, GPs rarely found that management considerations from earlier consultations were lacking in the medical record. Conclusion. GPs often have thoughts on how to deal with this patient, but hardly ever record such considerations. We recommend the development of tools that facilitate the recording of management considerations in electronic patient records. © The Author (2006). Published by Oxford University Press. All rights reserved.