An instrument for collecting problem oriented, problem linked data in primary medical care

Aim: To describe a new form for collecting problem oriented, problem linked data from primary care. Method: A novel form is described which has been used to collect these data. These data were validated against secondary data collections. Results: The form has been used to record 10,937 encounters in a variety of primary care settings. The form was acceptable to general practitioners (GPs) and was completed on 87% of eligible patients in a one week data collection. Data captured provide descriptive data about the problems encountered and services provided during the consultation. These elements of the medical record are linked so that it is possible to address questions about patterns of service provision. Uncomplicated lower urinary tract infection is used as an example of how data from the form can be used to examine clinical practice and resource utilisation. Conclusion: A method has been demonstrated to collect problem oriented, problem linked data which may be used for clinical costing and to demonstrate compliance with clinical practice guidelines. (author abstract)