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9348. Computer summary updated
9344. Notes summary on computer
9311. Lloyd-George+problem summary (v9)
9313. Lloyd-George culled+summarised (v9)
Good medical practice for general practitioners (2002) states: “Important information in records should be easily accessible, for example, as part of a summary.”
If a system for producing summaries is not in place then this will involve a great deal of work. The practice will need to decide which conditions it will include in the summary. The practice would be expected to have a policy on what is included in the summary. All significant past and continuing problems should be included.
If a computer is used the practice will need to decide which Read codes to use for common conditions. It is best to use a set of codes that has been agreed within a PCO or nationally to allow comparison and exchange of data.
Similar indicators are proposed as Records 18 and Records 20 but higher standards must be achieved.
A survey of patient records (minimum 50) should be carried out, recording the percentage that have clinical summaries and the percentage which are up to date. (Grade A)
A random sample of 20 patient records should be examined to confirm the percentage that have clinical summaries and the percentage which are up to date.
The practice’s own survey is verified by inspecting 20 clinical records. If the result differs from the practice survey then a further 20 records need to be checked. Assessors may need to clarify with the practice what information they would normally include in a clinical summary ensuring that they do not assess this indicator based on their own experience and beliefs.
Note: A logical query and dataset (business rule) is available to support this indicator.
Prepared By Jean Keenan