Introduction Much discussion has recently taken place about the design and use of medical records; and there is increasing evidence from general practice and the hospital service that the present records are inadequate, both for service purposes and as a source of information for planning medical care. This is disturbing because a patient's medical record provides the foundation for his medical care and the effectiveness of management depends to a large extent on its quality. When considering patterns of morbidity within a community and how these might be influenced by medical intervention, the problems of introducing a satisfactory form of medical audit, and the establishment and appropriate allocation of resources within the health care system, the fundamental importance of having a satisfactory record system becomes immediately apparent. Traditionally, information on the provision of medical care in the National Health Service was collected independently by the three main branches of the Service, the general practitioner, the hospital, and the local authority services. The record systems used were different and often incompatible and could not be integrated to provide information about the total health care of individuals or specific groups. The reorganisation of the National Health Service in 1974, with its emphasis on integration, and the establishment of district management teams with responsibility for medical planning, has provided an opportunity and incentive to develop a more relevant and comprehensive system of medical recording. Some information is already available from Hospital Activity Analysis (HAA) and Hospital In Patient Enquiry (HIPE) about the provision of care in hospitals, and information about some health events, such as home nursing or health visiting has traditionally been provided by local health authorities. But there is no information on a local or national scale about care in general practice, where the vast majority of health consultations take place-about 250 million annually, compared with 25 million elsewhere in the National Health Service. The only information on this sector so far has been obtained from a few sample surveys carried out nationally by the Royal College of General Practitioners and the General Registry Office, or from surveys conducted by individual practitioners. The general-practitioner service is the point at which the majority of patients enter the medical care system, and it forms the pivot around which health care revolves. Therefore, if a satisfactory information system is to be achieved, it will necessarily be dependent on the quality of the recording system and information gathering at the level of primary care. Much research on medical records is now being carried out throughout the country. In 1970 the Department of Health and Social Security set up a joint working party on the redesign of medical records in general practice
and an interim report recommended an A4 format.' This was based on the work previously undertaken on the 'Wantage Project' of the Oxford Regional Hospital Board2 and by Harvard Davis in Cardiff.3 The studies in the St. Thomas's General Practice Unit have been based on the work in both these centres. All three projects used a computer to store collected information and to allow for linkage with other computer systems. They differ, however, from the studies of Livingston4 and Southampton5 which have attempted to computerise much of the day-to-day information of the practice records. There is a temptation, particularly when working in an academic unit, with extra resources available, to develop a highly sophisticated record, tailor-made to special requirements, but likely to be of only limited relevance to general practice as a whole. Throughout this study emphasis has been laid on the development of a basic record which can be used by any group practice within the National Health Service, supported by average resources of ancillary staff. The constraints imposed by everyday general practice are fully appreciated and have been borne very much in mind. At the same time we have tried to develop a system that would allow for modifications and additions to be made when particular needs are to be met and additional facilities available. This report describes the first stage of the record project carried out in the Lambeth Road Group General Practice of the Teaching and Research Unit at St. Thomas's Hospital Medical School. This practice provides care for 8,500 patients. Details are given of the way in which the design of a new record format was evolved and of the criteria that were used during this process. The way in which the introduction of the new record into the practice has been implemented has been described in considerable detail in the belief that this practical information might be of value to other practices contemplating a similar conversion. The report contains the details of several separate studies about different aspects of the project. These include the development and evaluation of a selfadministered questionnaire for patients for obtaining information about patients, the identification of problems suitable for the Summary Problem List, and an assessment of the knowledge that the doctor had of some basic information about his patients when using the old record. This document, therefore, serves three different purposes. It provides a descriptive account of the means by which the new record format was arrived at, it acts in part as a handbook with practical details for those interested in undertaking a similar changeover of their records, and finally it gives details of studies relating to some aspects of record keeping in general practice. We hope that as a result of attempting to satisfy these three different aims, our report is not too disjointed.