The Use of a Structured Form during Urology Out-patient Consultations A Randomised Controlled Trial

Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR). Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire.in a teaching and district general hospitals Results: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p