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Safe Patient Care: the Importance of Clinical Notes Summarising

Safe patient care and treatment is central to the current CQC operating model. How well a practice is able to deliver and demonstrate this can depend, in large part on, the quality of how it summarises its patients’ medical notes.

Whilst medical notes summarising isn’t the most high profile of primary care activities, doing it well means a practice can deliver the most patient-centred, safe and effective care possible.

This is recognised by the CQC’s Key Lines of Enquiry (KLOE) S3.2, which asks:

“Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way?”

The fact that there are presently over 50 vacancies for summarisers being advertised on the NHS jobs website demonstrates how valuable and in-demand such summarising skills are.

Thornfields have been delivering notes summarising training for nearly ten years. 

In that time our trainers have had a wide spectrum of delegates—those who have never summarised any notes, those that have done a few sets, and those who have been summarising notes for years and want to ensure they are still aware of (and complying with) best practice.

The summarising activity has evolved over time; at its inception it was more about computerising previously uncoded paper records. This sometimes highlighted that there were large gaps in patient records, where significant things may have been missing.

Now with GP2GP and the old Lloyd George notes being referenced much less, the process of summarising has become a lot more about quality assurance and data housekeeping—especially tidying and editing the electronic record.

Any previous assumption that GP2GP might reduce the need for summarising has been proved to be ill-founded. Inter- or intra-clinical system transfers of records still require accuracy checks.

Whilst this may appear purely an administrative process, it delivers important clinical benefits.

The time pressure that GPs and other health professional work under means that an accurate history on screen is imperative for diagnosis, care, treatment and referral. Where appropriate, this information also adds to a patient’s Summary Care Record which again reinforces the importance of its accuracy.

So notes summarising is undoubtedly a vital activity, with training for non-clinical staff being key.

Such staff—sometimes with limited healthcare experience—have to decipher what is significant and relevant enough in a patient’s medical history to be included in the summary. For some, this may appear a daunting and off-putting prospect.

Appropriate awareness of best practice principles and a practical, safe confidence should be instilled in those new to summarising. More experienced practitioners should also have their understanding of best practice refreshed, and renewing confidence in their abilities should be a vital part of any practice team’s annual training plan.

Follow this link to learn more about Thornfield’s Clinical Notes Summarising workshop.


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