The quality of electronic patient records in Finnish primary healthcare needs to be improved.

摘要

OBJECTIVE: To analyse the technical quality of electronic patient records in relation to legislation and to evaluate their quality associated with the quality of consultations as rated by patients and GPs. DESIGN: Cross-sectional study of electronic patient records. SETTING: Four primary healthcare (PHC) centres in Finland using three different electronic patient record systems. SUBJECTS: Patient records of 175 PHC consultations by 50 GPs, rated as the best (n=86) and the worst (n=89) of a total of 2191 consultations. MAIN OUTCOME MEASURES: Documentation of records compared with legislation, the general informative value of records, and its relation to the experienced quality of consultations and to the electronic system employed. RESULTS: Reason for encounter was mentioned in 79% of cases and patient history in 32%. An acute problem was described moderately well or well in 84%, examination findings in 62%, medical problem or diagnosis in 90%, and treatment in 95% of cases. Medication was documented adequately in 38% of the cases where medication was documented. Concerning general informative value, 18% were assessed as poor, 62% as moderate, and 20% as good. No correspondence was found between experienced quality of consultation and general informative value in the patient records. The quality of patient records was found to change according to the electronic system employed. CONCLUSIONS: Finnish patient records are inadequate documents of consultations and below the standard of that country's legislation. Developing better models of recording would guarantee a higher quality of work.