Summarising patients' notes pays handsomely
Under the new GP contract it is worth expending time, effort and even money to achieve up-to-date clinical summaries in at least 60 per cent of patients' records, says Dr Jim Sherifi
Achieving up-to-date clinical summaries for more than 60 per cent of the patients on a practice's list will be worth a massive 25 points under the new quality and outcomes framework. And the true worth to the practice in terms of other dependent areas, such as maintenance of disease registers, is far greater.
So it is worth making a real effort to achieve this goal, although ultimately a target nearer to 100 per cent should be the aim.
Historically GP training practices have had to achieve clinical summaries rates of more than 80 per cent, demonstrating good clinical and organisational governance, to achieve and retain training practice status.
Similarly fundholding and, subsequently, PMS practices have also recognised the need for accurate summaries on which to base their budget applications. So the usefulness of such summaries has been tried and tested and should no longer be in doubt. But before embarking on the task, one first has to define what a summary is and what it should contain.
A summary provides the main points of an individual's medical history in an easily-accessible format. It must be accurate, brief and concise. It should provide a doctor with the information they need to know to manage the presenting complaint in a safe and effective manner. It should contain significant disorders and disease, repeat medication, allergies, vaccinations and other elements of preventive and public health such as cervical cytology and breast screening.
The ideal person to achieve the above is the doctor under whom the patient is registered, but this is unlikely to take place since GPs have so many other even more important calls on their time. But delegation of this task to nursing or administrative staff can be equally effective if a standard operating procedure (SOP) is put together by the person most proficient for the task – the GP.
Keep the SOP short and simple. Only include what is likely to be needed. Remember that the purpose of summaries is to improve clinical efficiency and that they are not a self-sustaining bureaucratic exercise.
Ensure staff are competent
Make sure whichever member of staff is doing the summarising is not only clinically competent but understands the need for good summaries from both a financial and clinical point of view. Sample auditing by a competent person needs to take place regularly in order to ensure quality is maintained. Summaries, when done well, save immeasurable amounts of time in any consultation. In our practice, we have set out a number of key areas for inclusion in a summary.
lMedical history The information is gleaned from the front cover of Lloyd George records, previous computerised summaries and diagnostic headings in hospital letters. The information is recorded against its year of origin and under appropriate Read codes. An attempt is made to match repeat prescription items to a medical condition.
lAllergies These are recorded under drugs the patient is allergic to and then the other substances.
lRepeat medication The information is taken from an existing repeat prescription sheet and is input by a pharmacist and checked by a GP. Sometimes it is input by the GP alone. An attempt is made to match repeat prescription items to a medical condition; for example, is propranolol being prescribed for hypertension, IHD, tachycardia, headache or anxiety?
lVaccinations A complete record is made for the under-fives, otherwise only the last recorded vaccine in any group is entered, by year.
lPublic health Cervical cytology under month and year is entered, and mammography ditto.
It takes around 10-15 minutes to properly complete a summary for each new patient joining our practice so the length of time required to summarise notes and enter data should not be underestimated.
Disease specific details such as BP, PFR, HBA1c are taken by the nurse for new patient registrations or input by a doctor when the patient is seen.
It is a paradox of modern-day primary care that, as it moves towards IT-led paperless practice – the IT being provided by fewer than a handful of software providers – records still cannot be transferred electronically from one practice to another.
So it is up to each doctor to rigorously maintain and update the summary. It is well worth it.
Jim Sherifi is a GP in Sudbury, Suffolk