Electronic patient records are the essential prerequisite for a modern, digital NHS.

Never has it been more important to learn the requirements for summarising medical records, following the recent announcement from the Health and Social Care Secretary who has set out his priorities for health care by harnessing the power of technology at the Health Service Journal Digital Transformation Summit.

He announced ambitions including for 90% of NHS trusts to have electronic patient records in place or be processing them by December 2023. This move underpins the Government’s drive that the NHS should be using technology to improve productivity, reduce costs and ultimately enhance patient care.

In announcing the launch of a new data in health strategy at London Tech Week’s HealthTech Summit, the NHS app is set to become a central point of access for GP appointments, prescriptions and hospital records. The app will also make it easier for patients to get hold of their GP records. Improvements to the mobile app to make it easier to request historic information including diagnoses, blood test results and vaccinations are set to be rolled out by the end of next year.

Good training in summarising medical records not only ensure that electric data is accurate but can help to achieve QOF targets. All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one. The information held in the Summary Care Record gives health and care professionals, access to information to provide safer care, reduce the risk of prescribing errors and improved patient experience. The Summary Care Record contains basic information about allergies and medications and any reactions patients may have had to medication in the past. Some patients, including many with long term health conditions, have previously agreed to have additional information shared as part of their Summary Care Record. This additional information includes information about significant medical history (past and present), reasons for medications, care plan information and immunisations.

Currently, the app has 28 million users, around half of England’s population. The rollout plan has a target of 75 per cent of the adult population to be registered to use the NHS App by March 2024, with the overall aim for the app to be a “one-stop shop for health needs”.

The Health Secretary also promised in February to speed up the digitisation of the NHS, with 90 per cent of patient records to be held electronically by next year.

Summarising medical records is not without its issues and good training provides an understanding of how confidentiality can become compromised during summarising

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Woman given erectile dysfunction cream for dry eye in prescription mix-up

basic understanding of medical terminology and medicines

The importance of a basic understanding of medical terminology and medicines is as important as it ever was, and has been highlighted recently by this example of two medications with similar spellings – but for completely different complaints

A patient, had to be treated in hospital after she was given the wrong medication due to a mix-up.On attending the emergency department of a Glasgow hospital, the patient was found to have conjunctivitis and a defect on her cornea. However, the erectile dysfunction cream that was dispensed to her had a similar name, Vitaros, to the eye lubricant she was actually prescribed – VitA-POS. The patient suffered with blurred vision, a swollen eyelid and redness and discomfort immediately after putting the erectile dysfunction cream into her eye.

Experts have said GPs must use block capitals when writing prescriptions after a woman was mistakenly given erectile dysfunction cream for a dry eye

Eye doctors from Glasgow’s Tennent Institute of Ophthalmology, who treated the woman, have now written an article on the case in BMJ Case Reports, the medical journal

“It is unusual in this case that no individual, including the patient, general practitioner or dispensing pharmacist, questioned erectile dysfunction cream being dispensed to a female patient with ocular application instructions.

“We would like to raise awareness that medications with similar spellings exist,” the report said.

Importantly, doctors noted that one in 20 prescriptions were estimated to be affected by a prescribing error.

The original report can be read here

Training non-clinical staff in Primary Care

non-clinical staff in primary careOver the last 16 years I have delivered face to face training to non-clinical staff in primary care. In light of easy access to technology and information on the internet, what are the training needs today for non-medically trained professionals working in close contact with the medical profession?

What’s required of the role?

The class of 2016 are involved extracting and imputing key medical data from medical notes. Often referred to as note summarising, they scan medical reports onto IT systems and link them to a problem title. Then once this has been done read codes are attached to each medical diagnosis, operation or problem. This process requires clarity and key medical knowledge; it is not enough to record a patient as having had a hysterectomy (uterus removed). There are at least 10 different codes or ways of having a hysterectomy, and it must be correctly coded.

The non-clinical team also update medical summaries as letters arrive from hospital departments. Staff are expected to work with other agencies and need background information to deal with patients, doctors and other multidisciplinary staff.

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Medical terminology transcription errors ‘putting patients’ lives at risk’

Transcription errorsMedical terminology transcription errors could be putting patients lives at risk, because of a growing number of cash-strapped hospitals sending medical notes abroad to save money, Unison warned today.

The union has compiled a dossier showing that 21 NHS trusts are piloting the outsourcing of confidential patient information to India and South Africa, which are then sent back to the UK and added to patients’ individual records.

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To Err is Human – the impact of poor medical terminology training

To Err is human

Breast cancer, vehicle crashes, AIDS and medical error. Which do you think causes the most deaths per year? It may surprise you to learn that it is medical error.

A report issued by the U.S. Institute of Medicine (To Err is Human: Building a Safer Health System) concluded that up to 98,000 people die each year in the US as a result of preventable medical errors, including lack of medical terminology training. For comparison, fewer than 50,000 people died of Alzheimer’s disease and 17,000 died of illicit drug use in the same year.

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