Summarising notes will be vital under the new contract
Rob Barnett is secretary of Liverpool LMC, a GPC representative and a GP in Liverpool
In order to make the most of the new contract, having well-ordered notes suitably summarised and available on the practice computer will be essential.
The easiest way to demonstrate how a practice is working and delivering services, together with proving that the quality and outcome framework has been embraced, will be by using IT, and to make the most of the computer system it is important to ensure relevant, accurate medical details about patients are recorded in a retrievable fashion.
It is important that practices have a plan to determine what is to be recorded on the computer this should be agreed by all clinicians. Help may be available from the PCO's information department.
The first question is, are paper records in order, with letters and results as well as the written notes tagged and in date order? Do all letters and notes refer to the same patient? Getting this right is a time-consuming task, but if not undertaken will make any progress in note summarising very difficult.
The next stages involve personnel with some clinical skills or knowledge, as it is necessary to be able to identify significant clinical events. Doctors' and nurses' time is expensive, so one should also consider the possibility of using medical students, those working in professions allied to medicine or even suitably trained summarisers.
With a protocol agreed on what to look for, the process of summarising can begin.
Hospital letters can be easily reviewed, and more recent ones may have details of significant events or diagnoses with dates. Earlier letters may have diagnoses embedded within the text. Reviewing the hand-written notes is, alas, more difficult; nevertheless these should not be overlooked as significant events, important family history, immunisations, recent BP readings and lifestyle (height, weight, smoking status, alcohol consumption) may be found.
Once the information has been identified, it can be transferred onto the practice computer. Summarisers or data processors need clear guidelines on where to record information. It is essential that all data and diagnoses are entered in a Read coded fashion. This is to ensure that information can be retrieved to assist in making disease registers for the quality and outcome framework, help confirm that work has been undertaken to achieve quality points, and assist for audit purposes. Unfortunately, free text information cannot be retrieved, and will be of little use in working the contract.
It will be necessary to prioritise the work. The amount being made available under the time-limited Directed Enhanced Service is only £1,000 to £5,000 per average practice, with the sum most likely being determined by the current state of the practice's notes. Overall, this equates to only £1 per record, so it is vital to concentrate on important clinical areas.
One should consider prioritising patients in the 10 clinical domain areas of the framework. Patients can be identified easily from repeat prescribing information. A decision will need to be made as to how far back to go within records to retrieve data. Thick medical records for (often elderly) patients with much pathology will be more time-consuming than those of younger, healthier patients. A judgment will have to be made on how cost-effective it would be to summarise events from 50 years ago, which have no bearing on current health issues. However, omitting significant events could lead to gaps in the patient's computerised medical record.
Finally, having commenced the process with existing patients, it is important to see that there is an ongoing process for updating records as events arise, and ensuring new patient records are summarised.