Note Summarising in Primary Care

By the end of the course delegates will understand:

• The process of summarising paper and pre-existing computerised records
• How to analyse the medical record and detail significant past medical history including the progress of chronic disease
• How to scrutinise the medical record for errors of fact, misfiled data, omissions and irrelevant or out-of-date information
• Coding hierarchy and disease registers
• How to code information onto computer to build a meaningful list of significant problems for each patient
• The importance of including appropriate numerical data and QoF-relevant data to aid clinicians and add value to practice