|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.
|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.
The doctor’s clinical notes are:
||A complete record of the current situation including symptoms, findings, analysis and plan.
||Conform to current criteria of good practice (eg, are maintained in chronological order).
||Clear about long-term therapy.
||Written promptly, but without hindering the doctor-patient interaction.
||Read before the consultation.
||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.