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Case notes as indicators of the prevailing medical model: implications.
The New Zealand Medical Journal
|November 28, 1979
Summary
Recording of psychosocial factors in patient case notes remains low, with only slight increases in alcohol and occupation data over a decade. This highlights a gap in integrating psychosocial dimensions into hospital care models.
Area of Science:
- Medical Sociology
- Health Services Research
- Psychiatry
Background:
- Psychosocial parameters are crucial for comprehensive patient care.
- Previous studies highlighted the importance of recording psychosocial data.
Purpose of the Study:
- To assess the current recording frequency of psychosocial parameters in medical and surgical case notes.
- To compare current recording levels with data from 10 years prior.
- To explore reasons for observed recording trends.
Main Methods:
- Random selection of 50 medical and surgical case notes from a general teaching hospital.
- Quantitative analysis of recorded psychosocial data (alcohol intake, occupation, etc.).
- Comparative analysis of data collected over a 10-year interval.
Main Results:
- Overall low frequency of recording relevant psychosocial parameters was observed.
- Modest increases were noted only in the recording of alcohol intake and occupation.
- No significant changes in the recording of other key psychosocial factors were identified.
Conclusions:
- The current hospital illness model inadequately incorporates psychosocial dimensions.
- There is a discrepancy between acknowledged importance and actual clinical practice regarding psychosocial data.
- Findings have implications for medical education, practice, and resource allocation.
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