Family Practice Advance Access originally published online on June 12, 2008
Family Practice 2008 25(4):215-220; doi:10.1093/fampra/cmn023
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Identifying patients with a cancer diagnosis using general practice medical records and Cancer Registry data
a Centre for Primary Health Care and Equity, University of New South Wales, Sydney 2052, Australia
b Department of Primary Care and Public Health, North Wales Clinical School, Cardiff University, Wrexham Technology Park, Wrexham LL13 7YP
c Academic Unit of Primary Care, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds LS2 9JL
d Hull York Medical School, University of York, Heslington YO105DD, UK
e RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
f Cancer Research UK Clinical Centre, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
Correspondence to Shane W Pascoe, Centre for Primary Health Care and Equity, University of New South Wales, Sydney 2052, Australia; E-mail: shanewpascoe{at}hotmail.com
Received 1 August 2007; Revised 4 February 2008; Accepted 21 April 2008.
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Abstract |
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Background. The medical records of patients with cancer need to accurately record diagnoses for professionals to provide quality care.
Aims. (i) To develop a methodology which identifies medical records of patients with a cancer diagnosis. (ii) To describe the effectiveness of search strategies to identify all patients in primary care with a cancer diagnosis compared with a diagnosis identified by a Cancer Registry.
Methods. The design of the study was a retrospective analysis of primary care medical records. Five general practices were recruited in the UK. The completeness and correctness of searches were measured and compared both within the practices and compared with a diagnosis identified by a Cancer Registry.
Results. One in five of all primary care patients with cancer was not identified when a search for all patients with cancer was conducted using electronic codes for malignancy. One in five patient records with an electronic code for a malignancy that was confirmed by registration with the Cancer Registry actually lacked the necessary documentation to verify the cancer type, date of diagnosis or any other aspect of the malignant condition. Overall, electronic codes for cancer in these medical records have a poor level of completeness (29.4%) and correctness (65.6%) when compared with the Cancer Registry.
Conclusions. The electronic codes in five general practices were not able to identify all patients on the practice lists with a cancer diagnosis. Practices will only be able to comply with guidelines and meet quality targets if they can identify all of their current patients with a cancer diagnosis and will require information from a Cancer Registry in order to do this.
Keywords. Primary care, cancer, medical records.
Pascoe SW, Neal RD, Heywood PL, Allgar VL, Miles JNV and Stefoski-Mikeljevic J. Identifying patients with a cancer diagnosis using general practice medical records and Cancer Registry data. Family Practice 2008; 25: 215–220.
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  A. Majeed, J. Car, and A. Sheikh Accuracy and completeness of electronic patient records in primary care Fam. Pract., August 1, 2008; 25(4): 213 - 214. [Full Text] [PDF]
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