Thomas, Kay; (2005) Design, implementation and evaluation of a structured medical record in urology. Doctoral thesis , UCL (University College London).

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Abstract

Traditional narrative medical records (TNR) have become multidisciplinary tools, however, the quality of documentation in them remains poor and their lack of structure inhibits the retrieval of information. Previous attempts to restructure the TNR have achieved limited success because they have entailed duplication of the information in the existing TNR. The aims of this thesis were to; agree a minimum dataset, design a structured medical record (SMR) around the dataset, compare the completeness of documentation of key clinical information when using the SMR versus TNR, determine the time taken to use a SMR versus TNR, implement the SMR in routine clinical practice in a variety of settings (i.e. ward, outpatients, theatre) and assess its acceptability. A SMR designed around a dataset agreed by consensus was successfully implemented in routine practice throughout one specialty (urology). The SMR resulted in improved completeness of documentation without adding extra time to the consultation and was acceptable to the majority of users. Agreeing a structure for medical records is not only pertinent to the paper records but is a necessity before they can be converted electronically. This locally agreed datatset and structure could form the template for restructuring of the medical record irrespective of specialty or medium used.

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