Information Management in General Practice Recording Accurate Clinical Information

Learning Objectives use the correct tools to record clinical measurements use coded diagnoses and reason for contact at all times accurately record history items avoid “free text” wherever possible understand that better clinical outcomes for patients is dependent on “clean” data (understand the concept of “rubbish in, rubbish out” understand that “data cleansing” is an ongoing process complete a health assessment or care plan To…

Why record information accurately Other health providers need to easily find the information you have entered and the clinical information must be legible and easy to follow Accurate clinical data leads to better patient outcomes You are able to create accurate disease and other registers The quality of data search results is dependent on the quality of the data entered (RIRO) You are meeting accreditation requirements …and it is just plain common sense

What type of course is this? leader led “hands-on” training course X number of participants per computer You can go through the training book by yourself And remember 20/80 rule Learn by doing “Hands in Pockets”

Part 1 Registering a nurse in MD –Full non-GP access Downloading templates –Follow instructions to the letter –Never open a template in Word

Part 2 Medication list History list Investigations and immunisations Check the accuracy of…

Part 3 Accurately record… BP and Ht/Wt Patient details –Allergies/warnings –Family and social history –Smoking and alcohol Perform a mini mental if comfortable and confident to do so

Part 4 Complete a health assessment or health check or care plan… Only open the template once all preparatory work has been completed (histories checked, measurements recorded…) Work your way through the template Save and print once complete