Summarising medical records

• any staff managing medical records systems.
• staff responsible for undertaking the organising, sorting and summarising of medical records and for those for whom this may become part of their role.
• staff responsible for clinical data entry including QOF data

• £95 per delegate (inclusive of VAT) for attendees from Londonwide practices.
• £120 per delegate (inclusive of VAT) for attendees from practices from other areas.

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.

In particular 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);
• summarising and the effect on QOF and disease areas;
• data protection and confidentiality;
• terms and abbreviations;
• summarising practical exercises.

• 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 QOF targets and how summarising can help in achievement of these targets;
• 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.

• Group activities
• Group discussion;
• PowerPoint presentation;
• Informative resources for further learning and reference after the course.