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Thursday 24 May 2012
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GPs to be assessed on record keeping as part of revalidation

07 Feb 2012

GPs and hospital doctors are set to be assessed on their record keeping as part of revalidation, in a move aimed at improving exchange of information between primary and secondary care.

The move is being proposed by a Government-backed working group which is also looking to hand doctors responsibility for shaping how hospital discharge summaries are structured and the information they contain.

 

The plans have been described as a ‘massively significant' step in improving the quality of medical records across the NHS, and particularly in boosting the quality of hospital discharge records.

A joint working group, established by the Department of Health, tabled a business plan earlier this month for an independent professional record standards development body led by doctors and set up initially under the Academy of Medical Royal Colleges, including the RCGP.

A report by the joint working group, chaired by Dr Charles Gutteridge, national clinical director for informatics, claims proper use of professional care standards will be ‘incorporated in mainstream education, and in appraisal and revalidation processes, ensuring widespread adoption and resulting in improved record quality'.

Dr Mark Davies, medical director of the NHS Information Centre and a GP in Hebden Bridge, West Yorkshire, said: ‘This is massively significant for GPs. At the moment a lot of letters we get are unstructured. We will be able to influence standards.'

The GMC said record keeping was a key part of doctors' appraisals, which would feed into revalidation: ‘Good record keeping helps to ensure patients receive the best possible care.'

READERS' COMMENTS

Anonymous, Other healthcare professional,
10 Feb 2012
That would be brilliant! I spend half my life looking at discharge letters and can't tell why meds have been stopped or initiated (esp PPIs, why does everyone come out on them??!!!), having more detail would be so helpful (Practice Based Meds Man Pharm Tech)
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Anonymous, GP Partner,
21 Mar 2012
Yes it is brilliant. I would love the best record and readcoding. But have you ever thought of the time given to see a patient and how much time you can give for the patient to come inside your room, how much time for the patient to explain his problem and to take appropriate furhter history, examination, discussion, conclusion and then recording appropriately when you have to use one finger for your typing on the keyboard looking for the alphabets! Days have changed. In 10 min consultation it is not easy. one has to sit and experience before commenting.
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Anonymous, GP,
22 Mar 2012
i agree there should be detailed record keeping.but where is the time in a 10 min consultation.20 mins would be ok,but then general practice would come to a standstill.in america a family practitioner has at least 30 mins per patient.the same in mainland europe.this nation should be v gratefull for what gp's do.i am glad i am going to retire soon.
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