Main Scale
| 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. |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| 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. |
Perfect |
Subscales
The doctor’s clinical notes are:
|
|
Rarely |
Occas
ionally |
Fairly
frequently |
Often |
Usually |
| (a) |
A complete record of the current situation including symptoms, findings, analysis and plan. |
|
| (e) |
Conform to current criteria of good practice (eg, are maintained in chronological order). |
|
| (f) |
Clear about long-term therapy. |
|
| (g) |
Written promptly, but without hindering the doctor-patient interaction. |
|
| (h) |
Read before the consultation. |
|
| (i) |
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.
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