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Records and information about patients

Dr John Couch on the money available and what is required to earn points from records and information about patients

Points achieved with complete ease

Records 1 Each patient contact with a

clinician is recorded in the patient's record, including consultations, visits and

telephone advice

Value one point

Any practice not already using its computer for all patient contacts must do so immediately. Record telephone consultations on the consultation screen. Enter visit details as soon as possible. Ensure all clinicians, including locums, comply.

Records 2 Entries in the records are legible

Value one point

Computer entry meets this requirement automatically. Written records are past history.

Records 4 There is a reliable system to ensure messages and requests for visits are recorded and that the appropriate doctor or team member receives and acts upon them

Value one point

Draw up a protocol to cover the chain from request received to contact completed. It should include fail-safe measures, whether computer- or paper-based. The system should also be retrievable for medicolegal and audit purposes.

Records 6 There is a system for ensuring the relevant team members are informed about patients who have died

Value one point

The simplest method is a 'deaths' book which all relevant staff should check daily. There should also be a recordable paper-based or computer system for reception staff to inform the responsible clinician of a patient's death as soon as any notification is received. Once again draw up a short protocol (also useful for verification).

Records 7 The medicines a patient is receiving are clearly listed in their record

Value one point

This is basic stuff which the vast majority of practices should already achieve via their computer systems.

Paper-based practices should convert to computers as a priority. Remember to keep records updated, and ensure locums are well briefed on your requirements.

Records 8 There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are

clearly recorded

Value one point

The whole practice should agree, via a protocol, how, where and by whom this data will be recorded. This information must flag up to any clinician prescribing for the patient. Generally it is wise to use the designated entry for your computer software. This should also ensure automatic appearance on all summary information.

Records 12 When a member of the team prescribes a medicine other than a non-medicated dressing, topical treatment or OTC medicine, there is a mechanism for that prescription to be entered into the patient's general practice record

Value two points

This is particularly important in the expanding areas of nurse and health visitor prescribing. Once again computer prescribing is the best way forward but not all software systems allow this. If they do not, develop a system for free text entry for now. Use new software as soon as available. Regular audit is important to ensure compliance.

Records 14 The records, hospital letters and investigation reports are filed in date order or are available electronically in date order

Value three points

If your written notes do not already comply make this part of your summary (see records 15) and continuing records strategy. Full computerisation, including scanning letters and results, and/or use of pathlinks, should automatically achieve this.

Points achieved with good planning

Records 3 The practice has a system for transferring and acting on information about patients seen by other doctors out-of-hours

Value one point

Transferring information can be done by direct computer entry or scanning with a link and relevant text on the consultation screen. There should be a clear protocol for acting on any relevant information with a fast-track system for urgent cases. The chain must be as short as possible, recordable and must end with the responsible clinician ­ who must also be defined.

Records 5 The practice has a system for dealing with any hospital report or investigation result which identifies a responsible health professional and ensures any necessary action is taken

Value one point

See records 3. Once again a clear protocol, known by all relevant staff, is essential. It should also take into account electronic results, with a mechanism for identifying alternative clinicians in the absence of the responsible one. Fail-safe mechanisms are vital. Some practices keep a separate record of abnormal results, checked regularly and ticked off only once actioned.

Records 9 For repeat medicines, an indication for the drug can be identified in the records (for drugs added to repeat prescription with effect from April 1, 2004)

Minimum standard 80 per cent ­ value four points

The delayed start date gives time for software systems to be updated to allow a diagnosis and source to be linked

to a new prescription entry. Watch for software information and set up your protocol now. Those continuing to use written records must make a clear diagnosis entry.

Records 10 The smoking status of patients

aged 15-75 is recorded for at least 55 per cent

of patients

Value six points

Virtually impossible to check unless you record this electronically. Practices that do not already gather and update this information must start now with every patient contact. All staff can take part, including receptionists. Although not currently a requirement, why not also hand out a stop-smoking leaflet and enter 8CAL Read code too? It may well become a requirement in future.

Records 11 The blood pressure of patients age 45 and over is recorded in the preceding five years for at least 55 per cent of patients

Value 10 points

Many practices will not currently achieve this level. Once again opportunistic checking is the only answer and the whole team must take part. Some practices are training receptionists to check blood pressures on relevant

patients at the same time as they get smoking data.

There will inevitably be extra workload, especially for raised or borderline readings, which you should

consider in advance.

Records 13 There is a system to alert the

out-of-hours service or duty doctor to patients dying at home

Value two points

This is standard good practice which many practices already achieve. With increasing out-of-hours opt-outs more practices will need to set up this system. Ensure all clinicians know how this works. A fax with telephone confirmation is the commonest method.

Points achieved with real striving

Records 15 The practice has up-to-date

clinical summaries in at least 60 per cent of patients' records

Value 25 points

This is the 'crunch' indicator, not only worth high points but also with knock-on effects to other organisational and clinical points ­ especially disease registers. Make it a priority. Do not underestimate how long it takes. A list of 2,000 patients with unsummarised notes will take the equivalent of one person eight to 10 weeks to summarise and data enter, if done well. Notes should be sorted into date order at the same time if necessary. Large practices starting from scratch will struggle to get above 60 per cent by 31/3/05.

Make sure you have received your quality

information payment and consider investing some of your 2004/5 aspiration payment if needed. Ensure you use Q&OF-approved Read codes for relevant disease categories. Have a written policy for important items to be included on summary ­ and those that need not. Once summarised, ensure records are kept up to date. If all practices summarise over the next two years, for new patients this task will be made considerably easier for all.

Records 16 The smoking status of patients age 15-75 is recorded for at least 75 per cent of patients

Value five points

See records 10. A 75 per cent or higher hit rate by 31/3/05 will also take considerable efforts by many practices but should be achievable by most by 31/3/06.

Records 17 The blood pressure of patients age 45 and over is recorded in the preceding five years for at least 75 per cent of patients

Value five points

See records 11 and 16.

Records 18 The practice has up-to-date

clinical summaries in at least 80 per cent of patient records

Value eight points

See records 15. With hard work most practices can achieve >80 per cent by 31/3/06.

Records 19 80 per cent of newly registered patients have had their notes summarised within eight weeks of receipt by the practice

Value seven points

This applies from when notes are received, not from registration. Record these dates as Read codes, as well as the date of summary, to allow easy audit and validation searching. Do not let this work build up. Make summarising new patient notes a priority

John Couch is a GP in Ashford, Middlesex

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