Table 2 Criteria for quality assessment of medical records

Assessing the appropriateness of the referral against the criteria set

The problem is well within the competency of a typical GP and should not have been referred to the service

1

0 (0%)

The problem should be within the competency of a typical GP but confidence is variable and some referrals are to be expected

2

1 (3%)

The problem should be within the competency of a GP but access to cardiology investigations is required

3

6 (17%)

The problem is beyond the competency of a typical GP and falls within the remit of the service

4

28 (80%)

Assessing the quality of the record keeping by the ECR GP

There is no record of the consultation with the patient and no discharge record

1

1 (3%)

There is an incomplete record of the consultation with the patient

2

4 (11%)

There is a record including history, examination, investigations but the recommendations and/or management plan are inadequate

3

11 (31%)

There is a full record including history, examination, investigations and a management plan

4

19 (54%)

Assessing the quality of the assessment by the ECR GP

There is no record of the consultation with the patient and no discharge record

1

1 (3%)

The assessment of the patient is inconsistent with best practice

2

3 (9%)

The assessment of the patient is consistent with what might be expected of an ECR GP

3

20 (57%)

The assessment of the patient is entirely consistent with best practice for this type of case

4

11 (31%)

Assessing the quality of the management by the ECR GP

There is no record of the consultation with the patient and no discharge record

1

0 (0%)

The management of the patient is clearly inconsistent with best practice

2

1 (3%)

The management of the patient is consistent with what might be expected of an ECR GP

3

25 (71%)

The management of the patient is entirely consistent with best practice for this type of case

4

9 (26%)

Assessing the risk of harm under the care of the ECR GP

There is no record of the consultation with the patient and no discharge record

1

0 (0%)

There are acts of omission or commission that could put patient safety at risk

2

1 (3%)

There are some acts of omission or commission but safeguards are in place to mitigate any risk to the patient

3

6 (17%)

There are no acts of omission or commission and safeguards are in place to mitigate any risk to the patient

4

28 (80%)