13 MRS – Medical Records

Main Scale

The doctor’s records tend to be perfunctory , incomplete , and do not facilitate good care at follow-up consultations. The doctor does not always ensure that the records are always immediately available to the practice. The doctor’s records provide a complete and accurate account of the patient’s problems, management, and plans for future care. They are suitable for such purposes as audit, medico-legal reports, and research. They are backed up by other components of the medical record system and are always available to the practice.
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


The doctor’s clinical notes are:

Rarely Occas
Often Usually
(a) A complete record of the current situation including symptoms, findings, analysis and plan.
(b) An accurate record.
(c) Concise.
(d) Legible.
(e) Conform to current criteria of good practice (eg, are maintained in chronological order).
(f) Clear about long-term therapy.
(g) Written promptly, but without hindering the doctor-patient interaction.
(h) Read before the consultation.
(i) Used in clinical decision making.

Notes for raters

Scales (a)-(f) are best assessed during case discussions and subsequentrandom sampling. Scales (g)-(i) are best assessed by direct observation: sittingin or video. See Appendix E for scales (j )-(m) which areconcerned with the way the trainee conforms to practice policy.



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