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
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.
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
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.
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
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)
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)
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.
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
The oral evidence
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
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.
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).
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.
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…
Some GPs are acutely aware of the
limitations of records, whether paper or electronic.
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).
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
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.
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)
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).
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.
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.
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
One practitioner claimed that he knew of 'practices who have kept family
folders' (GPP 30).
Mitchell ED, Sullivan FM. Chapter
8: Information technology in primary care.
In: Primary health care sciences: a reader.
Sims J (Ed.). London: Whurr, 1999.
Berger J. A fortunate man: the story of a country doctor. London: Allen
Lane the Penguin Press, 1967, p. 109.
See Smith, G. An oral history of everyday general practice 8: Patients
and populations, Br J Gen Pract, 2003; 53: 486; 76-77.
GPP 12, see GPP 07, GPP 09 and GPP 22 for very similar accounts
Project Description | Participants
| Recordings | BJGP
Articles | Resources | Home