Overview
One of the great strengths of UK general practice is its diversity and its adaptability.
The General Practice Forward View 5 Year Plan had already begun to introduce new / emerging technologies and the demands of COVID-19 has seen the acceptance and adoption of these new technologies at pace. There have been two significant changes to the delivery of care in general practice.
The first is the acceptance that virtual consultations will be the default method by which most of all clinical / patient contact will take place. The second is that contact with the practice team will be routed through digital methods rather than by attending or calling in person.
Accurately recording activity provided by our GP practice teams is complex and constantly changing, it is not always easily captured. Whilst we adapt and embed new methods of recording the care we provide, there is recognition that GP Practices will still need to have robust processes to manage 'previous' medical data.
Learning Objectives
Managing “degraded data” and extracting data from paper records is a recognised and acceptable inheritance, by the receiving practice, however it can be problematic and resource heavy. This training will focus on safely managing ‘degraded’ virtual information and reviewing and extracting significant and minor past medical and social histories from paper records.
Programme
Welcome & Introductions
Introduction to Summarising Medical Records
- Understand how new technologies have influenced the way GP’s and Clinicians behave in practice
- The importance of managing incoming retrospective data, known as “summarising”, to ensure safe clinical care
- Understand the importance of applying Protocols
Understanding Medical Terminology
- Brief overview of basic Medical Terminology
- Common words/ phrases / abbreviations used in General Practice
Identifying relevant data
- Understand the 4 Principles and the 5 Processes of Document Management
- The two-step process of Summarising
- ‘NHS Spine’ and facility to transfer NHS GP records virtually between practices within 24/48 hours of registration, when all necessary information is correct and accepted.
- Explore ‘GP2G data transfer’ process and how this data must be reviewed and managed upon receipt because:
- Actions to take on receipt of data that has been virtually transferred between practices, including:
- Confirming which method, the practice choses to accept, manage and 'declare degraded data'.
- Identify 'Degraded data' that has been entered into a patient's medical records under codes that are not compatible with the current SNOMED codes e.g:
- Practice created codeLocally agreed codes
- System generated codes
- Free text
- Degrades can be substantial in number as in the past GP practices were encouraged to create codes to reflect and capture the nature of the consultation.
- How to identify and prioritise these entries so that all significant and minor medical history is captured, this will include:
- presenting history, personal past medical history, relevant family history, examinations, discussion/reflection on past diagnostics, referral for current diagnostics, current treatments and possible treatments etc.
- Discuss why the virtual transfer of data via GP2GP and why it is not always possible
- Looking at previous medical (paper) records and reviewing and identifying all significant data and enter it into the current medical record.
- Review methods of managing paper records and howe to ensure the relevant data is not overlooked
Managing Risk and Audit
- Identify risks, obstacles and barriers to summarising safely
The Audit Process
- There must be a robust process to achieve this aim
- How familiar are staff following protocols and working on their own?
- What will need to happen back in your practices to support your role?
Review of Learning Objectives and Concerns
Q&As
Close
