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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