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Viewpoint - We need to improve patient note summaries

Dr Pablo Millares Martin's electronic records audit shows protocols for data input are badly needed.

Dr Millares Martin: Electronic summaries should not contain minor ailments or admin tasks
Dr Millares Martin: Electronic summaries should not contain minor ailments or admin tasks

Nowadays, electronic medical records are stored centrally, accessible not only to the practice team but to other organisations, like out-of-hours services, district nurses and others.

The idea is make the information in the notes easier to retrieve and understand by the various healthcare professionals the patient comes into contact with.

While all well and good in theory this does not work well in reality, as there are no common rules or protocols for how data is entered. This is obvious when receiving the electronic records of patients transferring from other practices.

To focus just on summaries: these are supposed to record the most important items in the patient's medical history, so that the doctor/healthcare professional can quickly inform themselves about the patient. But this concept seems to have been forgotten.

If receptionists, healthcare assistants, nurses, practice managers and doctors all add items to the summary that should be stored elsewhere, a rapid overview is not possible.

Doubtful items
Looking at the records of patients registered at my practice for some time, I found many items I doubted should appear on the summary as well as items that should have been there but were missing (click here to see a chart of electronic records summary audit).

Turning to the records from patients joining us, I found much worse examples and decided to audit their current status.

People nowadays are very mobile, changing doctors more often. Over the past two years, more than 2,000 patients have joined our practice in Leeds and a similar number have left.

Some records have been electronically transferred many times, making it possible to take a snapshot of patients who have moved to us, to assess their summaries including how my practice has modified them, and to determine how fit for purpose the summaries are.

I decided to do an audit of notes summaries to check if in an emergency situation, or simply when assessing a patient not previously seen, the summaries are worth reading or are better bypassed. Would I glean information more quickly by taking a look at the patient's repeat prescriptions instead?

Summaries should not contain minor ailments. Symptoms should not appear and neither should administrative tasks, such as BP checks. The information should be updated as new conditions present and major and chronic conditions need to be in the summary for future reference. If a condition is considered no longer present - for example, asthma that has resolved - it is best to list it as 'asthma resolved' rather than omitting it or simply stating 'asthma' as the clinician can assume it is an ongoing problem.

A computer search produced 642 patients with electronic records initiated elsewhere - from 129 different practices. Two thirds came from just 21 Leeds practices. On average there were 15.4 items per summary, a number of entries that is readable in a short time.

However the range varied from no items at all to 174 items, impossible to scan quickly.

It was difficult to come to conclusions about how summaries were used by the practices supplying only very few records. But it was clear from the records from the five practices transferring two thirds of the records that summaries are used in very different ways. In this subset the average number of items varied from 9.3 to 41.3.

Fixing the summaries
The purpose of the audit was to fix these summaries, so they can be used quickly to assess the patient's needs and problems.

I removed irrelevant medical information from the 642 records together with the non-medical information that was plaguing these summaries.

At the end of this exercise about a sixth of the summaries were empty, no summary had more than 20 items and the average number of items per summary was 4.43.

But how up to date were the summaries? For 94 patients items did need to be added, totalling 182 new items altogether. The three most common omissions were hypertension (13 cases), hypothyroidism (eight) and gastroesophageal reflux disease (six).

As the NHS summary care record (SCR) programme is being rolled out with patients' data shared between primary and secondary care, the question that springs to mind is how useful are SCRs going to be in few years' time if there is no agreed protocol for the type of data they should hold?

Looking at the summaries on my sample, the amount of irrelevant information exceeded the amount of relevant data, indicating that SCRs are not getting off to a good start.

Some GPs may think there are more important things to worry about, but we are missing a big opportunity to put the records house in order before the guests arrive.

  • Dr Millares Martin is a GP in Leeds

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