OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers...
Keywords: Structured data, classification systems, computerised medical record, primary care, General Practice, Medical Informatics
01/2003 | Methods of Information in Medicine, SchattauerOBJECTIVES: This paper describes differences in the way general practitioners in Denmark, The Netherlands and Great Britain make codes fit into the local conditions under which they work. METHODS: An ethnographic study method has been used to collect data in Dutch, British and Danish general practices. RESULTS AND CONCLUSIONS: The paper argues that what counts as accurate data is locally constructed...
Keywords: Diagnostic codes, classification systems, General Practice, Electronic Patient Record, localization, accuracy, ethnography.
01/2003 | Methods of Information in Medicine, Schattauer