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Issues for clinical records

Standards for computer records

  • Clinical entries should be made in a problem-orientated fashion on the current screen
  • clinical entries should always be made on computer under the appropriate current problem
  • prescriptions should always be produced on computer under the appropriate current problem
  • all important Read codes are automatically summarised by the computer
  • Clinical entries should never be made in the unlinked section
  • Referrals codes are always entered by the referrer under an appropriate current problem heading.
  • All referrals should have a referral code
  • All referral letters are generated by System 6000 and attached to this code
  • All referral codes are audited monthly for attachments to pick up missed referrals
  • Incoming correspondence
  • Filing test results performed electronically
  • Scanning
  • Summarising records
  • Home visit reports are printed out if required, and always for a visit not performed by the patients usual doctor (eg holidays, GP registrar)
  • Entries will be made for face to face consultations, telephone consultations, out of hours advice and all home visits. Home visit records should be entered on return to the surgery.
  • Adverse reactions and sensitivities to drugs are entered into the record.
  • Sophie templates should be used where available.
  • All significant events should be entered on computer including investigations, operations Clinical summaries are produced automatically
  • Clinical notes
  • Should be contemporaneous
  • Clinical entry should contain:
  • date (automatic)
  • type of encounter eg surgery, home visit, telephone call
  • diagnosis or definition of problem - the current problem
  • management plan
  • treatment prescribed: all prescribing should be computer based
  • information given to patient
  • follow up plan
  • Patients' access to records

    Records and confidentiality