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 |
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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