Summarising medical records

  • LEAD event

The course covers how to organise and summarise medical records in an efficient manner, including abbreviations and confidentiality requirements.

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Target audience:Any staff managing medical records systems, including those responsible for undertaking the organising, sorting and summarising of medical records and for whom this may become part of their role, and for those responsible for clinical data entry including QOF data.
Time:Start: 1:30pm     End: 4:30pm

Allow 10 minutes before the start of the session for registration and AV equipment check

Delivery mode:Virtual platform – Zoom
  • £95 per delegate (inclusive of VAT) for attendees from Londonwide practices.
  • £120 per delegate (inclusive of VAT) for attendees from practices from other areas.
Course overview:The course will allow delegates to learn how to organise and summarise medical records. and will also include ‘off-line’ hands-on practical exercises using hard copy material we supply to delegates before the session. The course will include some relevant medical abbreviations and terminology and explain confidentiality issues surrounding summarising medical records. In addition, the course enables delegates to understand the relevance of summarising in relation to the achievement of QOF clinical targets. The practical lessons will be discussed in the light of each delegate’s own practice protocol. The course covers the following areas:

  • overview of paper and electronic medical records;
  • organising and pruning medical records;
  • protocol formation;
  • summarising medical records and editing the electronic patient record (EPR);
  • data protection and confidentiality;
  • terms and abbreviations;
  • summarising practical exercises.
Course aims:The course will teach delegates how to organise and summarise medical records in an efficient manner. It will also give them the confidence to ask relevant questions when summarising back in the Practice and will empower them to be able to challenge the current processes where appropriate.
Learning outcomes:At the end of the course the delegates will be able to:

  • explain the importance of summarising medical records;
  • follow best practice regarding the summarising process and explain the importance of having a protocol for summarising medical records;
  • summarise medical records logically, efficiently and effectively;
  • explain the importance of confidentiality and data protection in the process of summarising;
  • identify issues to follow up when returning to their place of work.

(This course does not cover any issues in relation to particular software systems or coding).

  • Group activities
  • Group discussion;
  • PowerPoint presentation;
  • Informative resources for further learning and reference after the course.
Presenter(s):Mrs Alison Bingley

BSc. Hons degree in Physiology and Pharmacology and has almost 30 years’ experience as an associate trainer.