Appendix E – Medical records

Medical records

Main Scale

Does not conform to practice policy. Conforms to practice policy.
1 2 3 4 5 6 7 8 9 10
Has little understanding of this. Attempts to do this but is not yet skilful and sometimes runs into difficulty. Attempts to do this and is usually successful but recognises his/her limitations. Perfect

Subscales

The doctor’s acceptance of the importance of good record keeping in general practice is shown by:

Rarely Occas
ionally
Fairly
frequently
Often Usually
(a) His/her readiness to initiate improvements.
(b) His/her willingness to conform to high practice standards.
(c) His/her ability to use properly other components of the record system such as age/ sex index or disease register.
(d) His/her care in seeing that the patient’s records are always available to the practice.

Notes for raters

This area of behaviour is best assessed in case discussion (eg ‘what did you tell the patient about. ..?” , ‘what did you warn him about…?”)

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