9. Record keepers

Elizabeth Mitchell and Graham Smith

While the technical aspects of record keeping have attracted much attention, the social and historical contexts have been neglected. (1)  Little has been written on the impact of record keeping innovations on everyday practice, or on the relationship between the information that is recorded and details that are remembered.

A definitive report on quality assessment in general practice, states that primary care records are “more than an aide-memoire to the doctor or nurse”, indeed good quality record keeping is regarded as an “essential aspect of care”.  In addition, during the last two decades practices have had to demonstrate high standards in record keeping as a condition of training practice accreditation. (2)  However, this has not always been the case, and the record serves a multiplicity of functions, which continue to vary between practices both in degree and use.

Doctors who began in practice before 1948 have claimed that they made little use of records and relied on their memories for patient care. (3)  It was only with the development of educational initiatives, mainly by the College, that the importance of record keeping in longitudinal care became more widely accepted by practitioners.  Even if GPs had been convinced of the need to keep more detailed records, and most were not, there was little in the way of infrastructure in practices for storing and maintaining large volumes of paper records. 

By the 1950s records were still infrequently referred to, but were more likely to be used to monitor the workload of individual partners, especially regarding house-calls.  A decade later, however, some practices were adopting new approaches to record keeping, linked to attempts to persuade senior partners to abandon strict adherence to individual patient lists.  Yet, the pace of change was uneven and as late as the 1980s some practices in Paisley continued to keep patient records in ways that would have been recognizable to practitioners in the 1930s.  One GP, for example, recalled an older partner making the joke that, ‘Someday we’ll get those files out and find out what’s wrong with the patients’.  The files were only taken out when a younger partner, with a general practice training, joined the partnership in 1982. (4)

Although use of the A4 record was trialed in the late 1960s and was suggested as a replacement for the Lloyd George envelope in both 1974 and 1977, plans to introduce it as the standard throughout the UK were never fulfilled.  In 1983, however, it was offered to practices in Scotland.  In the Paisley study, A4 records were identified by older working, and recently retired, GPs as a key change in the history of general practice.  These GPs were responsible, and often took part in, transferring patient records from Lloyd George envelopes to A4 folders.  This, they believed, added significantly to their understanding of individual patients.

The testimonies suggest that there are differences in the ways Paisley’s GPs have used A4 records.  Even with the possibility for greater completeness that the A4 record system affords, most of Paisley's working GPs are aware that they continue to rely a great deal upon their own memories and that of colleagues, particularly in recalling community and kin relationships. (5)

Electronic record keeping had emerged in parallel with manual systems, but its use in general practice only became more widespread in the 1980s.  The 1990 contract emphasized patient targeting and disease prevention, linked remuneration to practice activity and, as a result, encouraged further adoption of electronic records.  Not only did practices need to identify groups of patients by age and sex, they now also had to identify them by disease.  Categorizing and identifying patients in this way is quicker and easier with a computer and this, together with the Department of Health’s offer of 50% reimbursement on costs, led to an increase in the number of computerized practices from around 30% in 1989 to over 60% in 1991. (6)

Paper records, according to Paisley's younger practitioners remain useful for a number of reasons.  Some believe that paper-based recording has increased in the 1990s as a result of fears of patient litigation.  Others highlight the deficiencies of electronic recording and argue that paper records complement the doctor’s memory of patients (often and somewhat ironically referred to as a 'database').  Longitudinal care encourages memories of individual patients to be rearranged, or retranscribed, over time, while the paper record builds layer upon layer with each medical encounter.  In addition, hand written paper records can provide the practitioner with opportunities to recall consultations and patients with a detail and depth that electronic recording has yet to match.  Not only do paper records allow for uncertainty and speculation in ways that electronic coding systems do not, but rereading hand-written records also offers the possibility of recalling the context of particular consultations, including the state of mind of the practitioner.

More than 30 years ago the role of the GP was described as a ‘clerk' of a community's 'records’ who ‘represents them' and 'becomes their objective (as opposed to subjective) memory’ (7).  In the intervening period there have been fundamental changes in the doctor-patient relationship (8) and practitioners are now much less likely to take such a central part in the populations they serve.  However, whether aided by paper or electronic record keeping systems, doctors' memories of patients and their social contexts remain significant to patient care.

The oral evidence

Andrew K:  We had Lloyd George and we kept them in cabinets… now these were our receptionists …pride and joy and not taken out at any time.  They were stored, everything was stored there, but we never used the files.  The files were not brought out for us to use.  So I didn’t have [as a new doctor in the practice] any knowledge of the patients coming to see me.  The patients would come with all their bottles, with all the medication, and say. ‘Doctor, that is what I’m getting’, and I would just write out what the medication was.  But we never got the files out.  The partners’ attitude at the time was, ‘Well we know the patients, we don’t need files, we, I’ve known them all their life… why would I want to write anything down’.  …We kept the letters that came in from the hospitals in a pile, which just got bigger and bigger… (9)

Many doctors who entered practice before the 1950s did not take record keeping as seriously as subsequent generations would.

Donald W:  Records are a very useful tool … how you previously treated people, whether it worked… When I joined this practice [c. 1964] there were two other doctors… and they both had their records in their rooms.  It took me a couple of years, but I got them all amalgamated…  It was a very personal list system…”  If you’ve got records you actually know that these are your patients, because before people used to walk in the door and you didn’t have records for them, but you treated them.  [Before] they didn’t know that they weren’t your patients … (9)

By the end of the 1980s most Paisley practices either already used or were engaged in converting to A4 records.

Carol S:  We moved [premises] in March 87.  …We took hundreds [of records] home.  Months and months.  I did most of them. About that time about five or six thousand [short pause].  … It was hard work and it had to be done and it’s important to do it; good records make a huge difference. But it was very tiring doing it all yourself.  They were transferred immediately but then they had to be summarized.  You know they would have been in the Lloyd George envelope so they would have been, we put them into their new envelopes, filed them, but then we systematically had to go through every single one and summarize it (10).

Eleanor H: I mean we spent weekends [in 1982] transferring notes and the whole team was involved you know receptionists, practice manager, and partners.  We just all came down over several weekends and just transferred all the data …and of course it wasn't just a question of transferring the notes we had to get shelves built and reorganise the storage space (11).

Standards in record keeping were enforced through postgraduate education.

David D: I'm not sure to what extent other partners felt that they had their notes up to date but I don't think even they were feeling that they were 100%.  So I think we were given a year to get ourselves sorted out before we were knocked back completely, but we used that year to, to get everything up to scratch and did actually get reaccredited after a year but we went a year without a trainee… (12).

Some GPs are acutely aware of the limitations of records, whether paper or electronic.

Colin R: There’s also thousands of snippets of information that we know about patients that isn’t in the records – you know, who their auntie is. You know, we have one patient – I think he’s dead now – but I mean he was a bronze medallist in the 1924 Olympic steeplechase.  Right.  Now that’s of no relevance really to his medical history but it’s a nice wee thing to know about the person.  So that’s not in the summary but that might be in his records somewhere.  You know, one of us will have written it in.  I wrote in about one patient, “She traced her family back to the Spanish Armada”.  …That’s general practice as opposed to the bald facts – diabetic, thyrotoxic, hypertension.  So the computer doesn’t tell you the whole story... 

Well you see the other thing is you store [in memory] lots of information about patients which comes from extraneous source… You know you store it in your head and it’s not written down.  I mean I suppose if you were to write everything down the records would be enormous (13).

Margaret G: Oh well that doesn’t go into any envelope or A4 or anything else.  That only comes with growing up with the practice and is invaluable.  But you can’t hand that down to somebody. You see if a man of twenty has bad indigestion, well you have to look into it, but if you know that his grandfather died in their house with cancer of the stomach, well there is no way that can be written down on his [the young man’s] case sheet to tell a stranger [pause].

But if you know that you can think maybe he has indigestion from something, maybe he is worrying that he has cancer like his grandfather had.  Ehem, when very often that was the case and if it’s brought up then he is reassured [and] the indigestion got better.  ... A man dies of cancer of the stomach you’re not going to put [that] into a grandson’s sheet ... and that is where the family doctor comes in (14).

Other doctors point to the idiosyncratic aspects of record keeping.

Fiona T: In the time it takes from calling them [patients] to getting them through I have at least scanned quickly through their summary sheets, their last consultations, their drugs and their hospital correspondence.  … I make notes …they may have told me about employment or something like that; things that, that build up a picture of them as a person.  I also make notes about my plans for their management…  I have got a way of putting that down within the written notes that reminds me the next time …that was what I was going to do, but I may not have told them.  Or if it [the note] is in a different place I will have discussed it…  Other partners may not understand my systems.  It’s my system (laughs).

It’s one of the reasons that I am nervous about the concept of a paper less practice, although, not negative about it.  But anxious that, you loose that subtlety of where you wrote it, or how you wrote it.  What size you wrote (laughs).  I don’t know…  Something they have said, you know, that you maybe want to explore a bit more...  I haven’t got secret signs but definitely sort of occasionally put a wee underline or something beside it to say next time they’re in push that area a little bit further and see if they can find out what’s going on.  How do you do that on a computer screen? (15)

David D: I link patients to an address. If I see them at home on a regular basis I certainly link them to an address.  And, it wouldn't be the first time I'd have gone to someone's previous address ehh because I still link them to that …I don't know that I see, 'There's Mrs Stroke or there's… Mrs Neurotic'… I'll probably be able to name first and then follow on that with some aspects of their medical history. …All too often it's 'nutter', you know (laughs) (16).

References

(1)   Even promisingly titled papers are disappointing in this area.  See for example Gill GM.  Chaos in A4 records in general practice.  Health Bulletin 1981;39 (3):153-6 - a paper that has more to say about shelf sizes than the understanding and use of records.

(2)   Roland M, Holden J, Campbell S.  Quality assessment for general practice: supporting clinical governance in primary care groups.  Manchester: National Primary Care Research & Development Centre, 1999.

(3)   Such claims have been made by both GPs in the Paisley study, funded by the Wellcome Trust’s History of Medicine programme and in the earlier study, The Oral History of General Practice in Britain, c. 1935-52.  Also funded by Wellcome, the recordings are archived at the British Library’s National Sound Archive. 

(4)   GPP 25.

(5)   One practitioner claimed that he knew of 'practices who have kept family folders' (GPP 30).

(6)   Mitchell ED, Sullivan FM.  Chapter 8: Information technology in primary care.  In: Primary health care sciences: a reader.  Sims J (Ed.). London: Whurr, 1999.

(7)   Berger J. A fortunate man: the story of a country doctor. London: Allen Lane the Penguin Press, 1967, p. 109.

(8)   See Smith, G. An oral history of everyday general practice 8: Patients and populations, Br J Gen Pract, 2003; 53: 486; 76-77.

(9)   GPP 25.

(10)           GPP 08.

(11)           GPP 12, see GPP 07, GPP 09 and GPP 22 for very similar accounts

(12)           GPP 09.

(13)           GPP 22.

(14)           GPP 24.

(15)           GPP 28.

(16)           GPP 09.

Project Description | Participants | Recordings | BJGP Articles | Resources | Home Page|