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.’