Quality framework @ GPcontract.info
IHD
Cancer
Mental Health
Asthma
Records
Patient info
Education training
Practice management
Medicines.management
Additional services
Patient experience

Records & information about patients (a)

Summary of Indicators

Essential A. Records and information about patients
Records 1
1 point
Each patient contact with a clinician is recorded in the patient's record, including consultations, visits and telephone advice
Records 2
1 point
Entries in the records are legible
Records 3
1 point
The practice has a system for transferring and acting on information about patients seen by other doctors out of hours
Records 4
1 point
There is a reliable system to ensure that messages and requests for visits are recorded and that the appropriate doctor or team member receives and acts upon them
Records 5
1 point
The practice has a system for dealing with any hospital report or investigation result which identifies a responsible health professional, and ensures that any necessary action is taken
Records 6
1 point
There is a system for ensuring that the relevant team members are informed about patients who have died
Records 7
1 point
The medicines that a patient is receiving are clearly listed in his or her record
Records 8
1 point
There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded
Records 9
4 points
For repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004). Minimum Standard 80%
Records 10
6 points
The smoking status of patients aged from 15 to 75 is recorded for at least 55% of patients
Records 11
10 points
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 55% of patients
Records 12
2 points
When a member of the team prescribes a medicine, there is a mechanism for that prescription to be entered into the patient's general practice record
Records 13
2 points
There is a system to alert the out-of-hours service or duty doctor to patients dying at home
Records 14
3 points
The records, hospital letters and investigation reports are filed in date order or available electronically in date order
Records 15
25 points
The practice has up-to-date clinical summaries in at least 60% of patient records
Records 16
5 points
The smoking status of patients aged from 15 to 75 is recorded for at least 75% of patients
Records 17
5 points
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 75% of patients
Records 18
8 points
The practice has up-to-date clinical summaries in at least 80% of patient records
Records 19
7 points
80% of newly registered patients have had their notes summarised within 8 weeks of receipt by the practice

Records Indicator 1

Each patient contact with a clinician is recorded in the patient's record, including consultations, visits and telephone advice

Records 1.1 Practice guidance
Compliance with this indicator will help practices to meet the recommendations of "Good Medical Practice for General Practitioners". This is also recommended as good practice by the Medical Defence Organisations. GP-employed nurses should refer to the Nursing and Midwifery Council (NMC) guidelines on records and record-keeping (www.nmc-uk.org).

Most practices record consultations and visits in the patient records. It should be noted that telephone advice given by clinicians should also be recorded and the practice should have a system to ensure this happens. The receptionists may be questioned at a monitoring visit on whether this happens.

Records can be on paper or on computer.

Records 1.2 Written evidence
Each practice should have a policy on recording contacts with clinicians in the practice (Grade C).

Records 1.3 Assessment visit
Clinical staff could be questioned as to how contacts are recorded.

Records 1.4 Assessors' guidance
If a patient phones for advice, how is this recorded in the notes?
All patient contacts need to be recorded.

Records Indicator 2

Entries in the records are legible

Records 2.1 Practice guidance
Good Medical Practice for General Practitioners states that "paper records should be legible" and your actions can more easily be defended if your records are legible.

If the clinical records are held on computer the practice should have no problems with this indicator. If the practice considers it difficult to read any of the writing in the records steps should be taken to overcome this. An external assessor may have more difficulty than any member of the team, as team members become familiar over time with interpreting a colleague's writing. Examples of compliance might involve asking the poor writer to print the diagnosis, management or therapy, having typed entries for all or some clinical staff or moving to a computer-based record system.

Records 2.2 Written evidence
Each practice should be willing to allow a survey of patient records (minimum 50) recording their understandability (for definition see Records 2.3). (Grade A)

Records 2.3 Assessment visit
A random sample of 20 notes will be inspected to confirm the understandability of the clinical entry.

Records 2.4 Assessors' guidance
If one assessor can read the entries made in the past year the criterion is passed. The important elements are diagnosis, management and therapy. If the meaning of these elements is not clear in more than one entry in the past year where they should be present, then the criterion is not passed. Doctors who have subsequently left the practice, locums and registrars can be excluded.

Records Indicator 3

The practice has a system for transferring and acting on information about patients seen by other doctors out of hours

Records 3.1 Practice guidance
Good Medical Practice for General Practitioners states that the excellent GP "can demonstrate an effective system for transferring and acting on information from other doctors about patients". Out-of-hours reviews in England and Scotland have emphasised the importance of the effective transfer of information.

If the practice undertakes its own out-of-hours cover, there needs to be a system to ensure that out-of-hours contacts are entered in the patient's clinical record.

If out-of-hours cover is provided by another organisation, for example a co-operative, deputising service or shared rota there needs to be a system for

- transferring information to be transferred to the practice
- transferring that information into the clinical record
- identifying and actioning any required follow-up.

Records 3.2 Written evidence
There must be a written procedure for the transfer of information. (Grade B)

Records 3.3 Assessment visit
Inspection of the procedure for the transfer of information may be carried out on an assessment visit.

Records 3.4 Assessors' guidance
Receptionists and doctors will be questioned on the system for the transfer of information.

Records Indicator 4

There is a reliable system to ensure that messages and requests for visits are recorded and that the appropriate doctor or team member receives and acts upon them

Records 4.1 Practice guidance
One recognised area of risk in general practice is message-taking; hence it is important to ensure that there is a robust system.

The system should not rely on word of mouth or "post-it pads". All receptionists should have full knowledge of the system.

Records 4.2 Written evidence
A description of the system for message-taking and requests for visits is required. (Grade C)

Records 4.3 Assessment visit
Inspection of the system of message taking and requests for visits may be carried out.

Records 4.4 Assessors' guidance
The receptionists should be observed where possible when they receive a message on the telephone. The system whether it be paper-based or computer-held should be inspected. Interviews with reception and clinical staff may be carried out.

Records Indicator 5

The practice has a system for dealing with any hospital report or investigation result which identifies a responsible health professional, and ensures that any necessary action is taken

Records 5.1 Practice guidance
To decrease the risk of error it is important that a system for dealing with incoming reports and investigations is in place. Many practices which receive paper reports or results use a stamp on incoming mail to ensure action is taken. The health professional who takes the decision should also be identifiable eg by initialling the action to be taken. Those receiving electronic mail should ensure that an equivalent system is in place.

Records 5.2 Written evidence
There should be a description of the system for reviewing and actioning any investigation or letter. (Grade A)

Records 5.3 Assessment visit
The visit should allow inspection, when appropriate, of the system for reviewing and actioning any investigation or letter.

Records 5.4 Assessors' guidance
The system should ensure that all abnormal results are identified and acted on.

Records Indicator 6

There is a system for ensuring that the relevant team members are informed about patients who have died

Records 6.1 Practice guidance
It is most distressing to bereaved relatives if members of the team do not know of a patient's death.

Constructing a procedure for receptionists on what do to do when a death is notified to them is important. The key element of the system is notification of relevant members of the primary care team about the death.

Records 6.2 Written evidence
There should be a description of the system for informing team members of a patient's death. (Grade C)

Records 6.3 Assessment visit
The receptionists might be asked to demonstrate the system of what they do when notified of the death of a patient.

Records 6.4 Assessors' guidance
An example of how information was transferred following a recent death might be examined.

Records Indicator 7

The medicines that a patient is receiving are clearly listed in his or her record

Records 7.1 Practice guidance
Good Medical Practice for General Practitioners states: "The records of patients on long term medication should include a clear summary of medication".

This indicator applies to all prescriptions, acute and repeat, but only repeat prescriptions will be assessed.

If the computer is used for issuing and recording repeat prescriptions then this criterion is easily achieved.

If paper records only are kept, then a separate sheet may be kept as one method of listing the repeat medication.

Records 7.2 Written evidence
The practice should record all patients' medication. (Grade C)

Records 7.3 Assessment visit
A search of patient records might be conducted.

Records 7.4 Assessors' guidance
Drug therapy refers to repeat medication as far as the assessment is concerned.

Records Indicator 8

There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded

Records 8.1 Practice guidance
It is important that a clinician avoids prescribing a drug to which the patient is known to be allergic. Not all patients can recall this information and hence records of allergies are important.

All prescribing clinicians should know where such information is recorded. Ideally the place where this information is recorded should be limited to one place and not more than two places.

Records 8.2 Written evidence
There should be a statement as to where drug allergies are recorded. (Grade C)

Records 8.3 Assessment visit
The practice should be able to demonstrate where drug allergies are recorded.

Records 8.4 Assessors' guidance
The place where drug allergies are recorded can be on the computer or in the paper records. This information should be easily available to the prescribing clinician at the time of consultation.

Records Indicator 9

For repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004)

Records 9.1 Practice guidance
When reviewing medication, it is important to know why a drug was started. This information in the past has often been difficult to identify in GP records, particularly if a patient has been on a medication for a long time or has transferred between practices. It is proposed that this information needs to be recorded clearly in the clinical records.

It is recognised that most practices utilise computer systems for repeat prescriptions and it is intended that an IT solution will be available to assist practices in meeting this indicator. The start date for this indicator has therefore been delayed to 1 April 2004 as not all GP clinical IT systems can link diagnosis to repeat prescriptions. A system for doing this will need to be initiated in many practices when the software has been modified. This criterion will not be assessed until after 1 April 2004.

In practices where the computer is not utilised for repeat prescriptions, the clinician should write clearly in the patient record the diagnosis relating to the prescription. This need only be done once when the medication is initiated.

The survey to show compliance should be a minimum of 50 patients who have been commenced on a new repeat prescription from 1 April 2004.

Records 9.2 Written evidence
A survey of the drugs used should be carried out; previous surveys have shown that an indication can be identified for at least 80% of repeat medications. (Grade A)

Records 9.3 Assessment visit
The records should be inspected.

Records 9.4 Assessors' guidance
As part of the inspection of records those drugs which have been added to the repeat prescription from 1 April 2004 should be identified and an indication for starting them should be clear. The help of practice staff may be required to achieve this. The records of twenty patients for whom repeat medication has been started since that date should be surveyed. If the standard is not achieved then a further twenty clinical records should be surveyed and the cumulative total should be used. The minimum standard is that 80% of the indications for repeat medication drugs can be identified.

Records Indicator 10

The smoking status of patients aged from 15 to 75 is recorded for at least 55% of patients

Records 10.1 Practice guidance
There is evidence that when doctors and other health professionals advise patients to stop smoking, this is effective. This indicator examines whether smoking status is recorded in the clinical record.

Dependent on how practices record smoking status, the survey can be undertaken by computer search or a survey of the written records.

Although smoking status recorded ever is sufficient to fulfil this criterion, it is good practice to ask smokers their status on a regular basis.

A similar indicator is proposed as Records Indicator 16 but a higher standard must be achieved.

Records 10.2 Written evidence
A survey of written records or a computer search of patients aged from 15 to 75 years should be carried out (surveying a minimum of 50 records), to determine th percentage where smoking habit is recorded at least once. (Grade A)

Records 10.3 Assessment visit
A random sample of 20 notes or computerised records of patients aged from 15 to 75 should be inspected, to confirm that smoking status is recorded at least once.

Records 10.4 Assessors' guidance
The practice's own survey is verified by inspecting 20 patient records at the visit. If the result differs from the practice survey then a further 20 patient records should be checked.

Records Indicator 11

The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 55% of patients

Records 11.1 Practice guidance
Detecting elevated blood pressure and treating it is known to be an effective health intervention. The limit to patients aged 45 and over has been pragmatically chosen as the vast majority of patients develop hypertension after this age. It is anticipated that practices will opportunistically check blood pressures in all adult patients.

Depending on whether practices record blood pressure in the computer or manual record, the survey can be undertaken by computer search or a survey of the written records.

A similar indicator is proposed as Records Indicator 17 but a higher standard must be achieved.

Records 11.2 Written evidence
A survey of the records of patients aged 45 and over (a minimum of 50 records) or a report from a computer search should be carried out, showing that blood pressure has been recorded in last 5 years. (Grade A)

Records 11.3 Assessment visit
A random sample of 20 notes or computerised records of patients aged 45 and over should be inspected, to confirm that blood pressure has been recorded in last 5 years.

Records 11.4 Assessors' guidance
The practice's own survey may be verified by inspecting 20 clinical records of patients aged 45 and over at the visit. If the result differs from the practice survey, then a further 20 records need to be checked.

Records Indicator 12

When a member of the team prescribes a medicine, there is a mechanism for that prescription to be entered into the patient's general practice record

Records 12.1 Practice guidance
Nurse prescribing is increasing and expanding. It is important that all prescribed medicines are recorded in the clinical record. This should include all medications prescribed by any team member.

Useful references are 'Nurse Prescribing: a guide for implementation' 1998 [concerning district nurse/health visitor prescribing] and 'Extending Independent Nurse Prescribing within the NHS in England: a guide for implementation' March 2002 [concerning extended formulary nurse prescribing].

Records 12.2 Written evidence
There should be a statement as to how prescriptions are recorded, and in particular how nurse-initiated prescriptions are recorded. (Grade C).

Records 12.3 Assessment visit
A sample of records should be inspected.

Records 12.4 Assessors' guidance
Nurse prescribers should be questioned on the system for entering prescriptions in patients' records and the system should be checked with any other members of the team involved.

Records Indicator 13

There is a system to alert the out-of-hours service or duty doctor to patients dying at home

Records 13.1 Practice guidance
Good Medical Practice states that when off duty the doctor ensures there are arrangements which "include effective hand-over procedures and clear communication between doctors". It is especially important for patients who are terminally ill and likely to die in the near future at home or where clinical management is proving difficult or challenging.

The practice should have developed a system with their out-of-hours care provider to transfer information from the practice to that provider about patients that the attending doctor anticipates may die from a terminal illness in the next few days and hence may require medical services in the out-of-hours period. If a practice does its own on call duties then a system should ensure that all doctors in the practice are aware of these patients. A single-handed doctor who usually covers his or her own patients out of hours should have a similar system in place when he or she is absent from the practice eg on holiday.

Records 13.2 Written evidence
The system for alerting the out-of-hours service or duty doctor to patients dying at home should be described. (Grade C)

Records 13.3 Assessment visit
The doctors in the practice should be questioned on the system that is in place.

Records 13.4 Assessors' guidance
The team should be questioned on their system by asking for recent examples of patients who have been terminally ill, dying at home and what information was passed to the out-of-hours service or duty doctor.

Records Indicator 14

The records, hospital letters and investigation reports are filed in date order or available electronically in date order

Records 14.1 Practice guidance
Good Medical Practice for General Practitioners states that the excellent doctor "files GP notes, hospital letters, and investigation reports in date order".

Any combination of paper and computer records is allowable.

Records 14.2 Written evidence
A survey of patient records (minimum 50) should be carried out, recording the percentage of records, hospital letters and investigations are filed in date order. A minimum of 80% is to be achieved. (Grade A)

Records 14.3 Assessment visit
A random sample of 20 clinical records should be examined to confirm the percentage of records in which the hospital letters and investigations are filed in date order.

Records 14.4 Assessors' guidance
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.

Records Indicator 15

The practice has up-to-date clinical summaries in at least 60% of patient records

Records 15.1 Practice guidance
Good Medical Practice for General Practitioners 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 a 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.

A similar indicator is proposed as Records 18 but a higher standard must be achieved.

Records 15.2 Written evidence
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)

Records 15.3 Assessment visit
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.

Records 15.4 Assessors' guidance
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.

Records Indicator 16

The smoking status of patients aged from 15 to 75 is recorded for at least 75% of patients

Records 16.1 Practice guidance
See Records 10.1.

Records 16.2 Written evidence
See Records 10.2. (Grade A)

Records 16.3 Assessment visit
See Records 10.3.

Records 16.4 Assessors' guidance
See Records 10.4.

Records Indicator 17

The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 75% of patients

Records 17.1 Practice guidance
See Records 11.1.

Records 17.2 Written evidence
See Records 11.2. (Grade A)

Records 17.3 Assessment visit
See Records 11.3.

Records 17.4 Assessors' guidance
See Records 11.4.

Records Indicator 18

The practice has up-to-date clinical summaries in at least 80% of patient records

Records 18.1 Practice guidance
See Records 15.1.

Records 18.2 Written evidence
See Records 15.2. (Grade A)

Records 18.3 Assessment visit
See Records 15.3.

Records 18.4 Assessors' guidance
See Records 15.4.

Records Indicator 19

80% of newly registered patients have had their notes summarised within 8 weeks of receipt by the practice

Records 19.1 Practice guidance
The criterion refers to the time the notes have been received by the practice and not the time of registration. For some practices that take on many patients at a set time of year achievement of the indicator will require some forward planning.

Read codes may be utilised to record this information and can then be searched for on the practice computer system.

Records 19.2 Written evidence
A survey should be carried out of the records of newly registered patients whose notes have been received between 8 and 26 weeks previously (either a sample of 30 or all patients if there have been fewer than 30 such registrations), noting if the records have been received and summarised.

Alternatively a computer print-out should be examined, showing the patients registered where the records have been received between 8 and 26 weeks previously, to confirm whether the computer record contains a clinical summary. (Grade A)

Records 19.3 Assessment visit
A sample of 20 records of patients whose records were sent to the practice between by the PCO between 9 and 26 weeks ago should be examined, to ascertain if the records have arrived and have been summarised.

Records 19.4 Assessors' guidance
A list of patients registered in the past 12 months and whose records have been forwarded between 9 and 26 weeks ago to the practice will be obtained from the PCO. A sample of 20 records, or all if there have been fewer of these patients, will be checked. If the result differs from the practice survey a further 20 records will be checked if appropriate.
 

 

 

 

 

GPcontract.info™

Site design © 2004 - Amrit Takhar GP and Botox Stamford and Peterborough