This is an online session and will take place over Microsoft Teams
Data quality is essential for continuity of care and summarising 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, ongoing problems, key diagnoses, allergies, operations, procedures, investigations, child protection and mental health register indicators.
This Summarising Medical Records course is designed for non clinical staff involved in this process.
Good summarising reduces the need to access the patient’s paper records, reducing time whilst enabling the patient to receive the most appropriate level of care in a timely manner.
Objectives
- Understand the need for a structured logical approach to summarising and the need for accuracy in coding data
- Gain an understanding of how confidentiality can become compromised during summarising
- Have an overview of data protection and the importance of good record keeping
- Apply the criteria for selecting information to summarise
- Record information accurately in a medical record, as part of the summarising process
- Understand how summarising can help to achieve QOF targets
This course does not include read coding or IT input
Please note feedback is mandatory and a certificate will not be issued until feedback is complete.
An outlook calendar invite will be sent out after booking and a link will be sent out closer to the time of the session so make sure the email address you have provided is accessed before the session.
If you are booking more than one person on the session you need to ensure an email address is provided for each person
For anymore information or questions regarding the session please contact
wyicb-wak.conexusresilienceacademy@nhs.net
