Summarising Medical Records & QOF

Medical Terminology Course NHSSummarising is the process of taking a set of patient’s notes and extracting an accurate medical history in chronological order. The process applies to paper as well as electronic records when received for new patients via GP 2 GP transfer.  It includes, significant past medical history, continuing problems, key diagnoses, allergies, operations, procedures, investigations, child protection and mental health register indicators. These notes require checking, tidying and editing. This Summarising Medical Records & QOF course is designed for anyone invlived in this process.

Summarising medical records is important because it allows clinicians to deliver medical care safely and efficiently without having to look at any other past background information or to refer again to the paper record. This is made possible because the most significant clinical information for the patient can be readily identified on screen.  Not only does improved data quality and accessibility of data improve patient care, but it makes it easier to keep disease registers up to date. Furthermore, one of the additional benefits is the time savings when it comes to the production of computerised insurance reports and referral letters

When done properly, good summarising means that data will then be available for upload to the spine in a compatible format for use in the Summary Care Record

Under current NHS guidelines, practices must work towards paper light ways of working so the Summarising Medical Records & QOF course will allow delegates to gain hands-on experience of organising and summarising medical records.

Delegates will also learn associated abbreviations and appreciate confidentiality issues surrounding medical records.  In addition the course enables delegates to understand the relevance of summarising in relation to the achievement of QOF clinical targets.

The practical lessons will be discussed in the light of each delegate’s own practice protocol.

Course objectives

The course is designed to enable participants to:

  • Understand the importance of having a logical approach to summarising medical records
  • Create protocols for summarising medical records in conjunction with the Practice Manager and GPs
  • Summarise medical records in an efficient and effective manner
  • Gain an overview of QOF clinical targets and how summarising can help in the achievement of these targets
  • Understand how confidentiality can become compromised in the process of summarising
  • Have an overview of Data Protection in so far as it relates to their role
  • Identify issues that they need to follow up when returning to their place of work.

Please note that this course does not cover any issues in relation to practical issues of computer data entry or specific read code usage.

This course is delivered through our partners Medical Services Training