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Record content confusion for GPs and patients


9 April 2013

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Nearly 85% of doctors polled said the move to online records will mean more time explaining their contents to patients

Nearly 85% of doctors polled said the move to online records will mean more time explaining their contents to patients

The survey, carried out by the Medical Protection Society (MPS), showed that doctors (68%) and the public (63%) were overwhelmingly in support of online medical records. 
However there appear to be “differing expectations” of how the records should be written. 
Dr Nick Clements, MPS head of medical services said: “If this issue isn’t reconciled before online records are introduced, this could lead to tension and confusion between doctors and patients.”
According to the survey, only 21% of doctors believe that medical records should be written so that patients can understand them without assistance. 
But when polled 75% of the public said medical records should be written simply.
“This suggests that doctors strongly believe medical records are principally for health professionals and should be administered by themselves,” said Dr Clements. 
He added: “This could be problematic as it is at odds with what it appears patients expect – that medical records are about them and should be written with them in mind.” 
However the MPS warned that if GPs have to avoid using clinical jargon when writing medical records it could “compromise the usefulness of the record for other healthcare professionals.” 
Dr Clements called for more education for both doctors and patients to curb possible confusion on both sides. 

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