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Where is the relevant history and examination recorded? A review of documents in general practice

Moyez Jiwa , Michael Gordon , Paul Skinner , Bridgitte Colwell

This study aimed to compare specific clinical parameters as recorded in a matched set of general practice medical records and referral letters relating to patients with lower bowel symptoms referred to a colorectal surgeon in the UK. Data from 48 matcheddocuments suggest that there is more relevant information recorded in referral letters than in the general practice records. There was an absence of important details recorded in either document.