The completeness and accuracy of patient record transfer between practices.

OBJECTIVES: In addition to the paper record, most general practitioners now use a parallel electronic record system on their practice computer. When a patient changes practice at present, the written records are transferred from the patient's previous practice to the next. An up to date computer generated summary or print out should also be sent. Our aim was determine the completeness and accuracy of this process of patient record transfer. DESIGN: A survey of an opportunistic sample of one hundred patient records in transit between general practices during a single week. Accuracy of information transferred was assessed by examining the records. Further analysis of discrepancies was conducted by one of the authors (FS) to assess their clinical significance. SETTING: September 1995, primary care department of Lanarkshire Health Board. RESULTS: Only 46% of practices transfer the complete record compared to the 85% of practices with computers which would have been expected to do so. Even in those which transferred a paper copy of the electronic record, a total of 51% showed discrepancies between the computer and manual format in recording of some or all of the following: diagnoses, prescribing data and the results of investigations. CONCLUSION: Practices should ensure all relevant data is transferred when a patient moves from one practice to another. The current arrangements do not ensure that this occurs.