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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. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic situation was achieved. Results: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainly and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patients. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of populations data or as quality target indicators rather than as an enabler of the next consultation. Conclusion: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carriers assumptions about certainly, and is perceived by clinicians to potentially jeopardise their relationships with their patients. Further research to elicit patients' views may help clarify the magnitude of this barrier.

Type

Journal article

Journal

Methods of Information in Medicine

Publication Date

30/10/2003

Volume

42

Pages

416 - 422