Summarising Medical Records

This workshop is suitable for: Non-clinical staff

Information

Data quality is essential for continuity of care, and it improves the usability of themedical record.It also facilitates the Quality & Outcomes Framework with comprehensive diseaseregisters.Summarising requires intense concentration and attention to detail.It is imperative that summarisers recognize the importance of the facts they are derivingfrom medical records and understand the choice of codes

Aims and Objectives.

By the end of this course Candidates will have gained the necessary knowledge, skillsand, having completed practical assessment and competencies at their workplace(working from their Practice Protocol), will be able to carry out their role safely andeffectively.

Learning Outcomes.

Candidates will have gained an understanding of:

• the purpose and significance of summarising medical records.

• systematic summarising of medical records.

• the impact of the Quality and Outcomes Framework.

Agenda

• What is a records summary?

• Systematic summarising of medical records [with sample medical notes]

• Quality & Outcomes Framework – clinical targets/ coding

• Classification of problems

• GP2GP – overview

• SNOMED CT – overview

• Relevant terminology and linked medication – some examples

• Data Protection and Confidentiality

• Summarising Medical Records Policy – what it should include.

• Systems to support staff.e.g. Training Schedule/Mentor/QA/Action plan