Guidelines for Note Summarising in General Practice

Introduction

The purpose of this document is to explain the importance and overall benefit to Practices of adopting a well structured note summarising protocol. The document also serves as a practical guide for healthcare professionals within general practice to get the most out of note summarising.

In todays increasingly IT dominated general practice setting it has become of paramount importance to transfer the wealth of medical history that is held so ineffectively in our old Lloyd George paper notes. Instead of seeing this process as a chore it should instead be seen as an opportunity to improve the standard of care we offer and to also improve the efficiency of our practices to bring about a financial reward as well.

What is Note Summarising?

Note summarising is the transferring of medical information from a patient’s paper records to an electronic medical record. The only medical information which should be summarised is that which is required for the continuing care of the patient. Note summarising is undertaken most efficiently and safely by someone with a medical background, however as long as note summarisers are trained to a competent level and have a structured protocol by which to work it can be undertaken by persons without a medical background.

Why Note Summarise?

There are many good reasons to note summarise but for the purpose of being concise I will only discuss two. Firstly, when a patient comes to see a doctor or nurse on many occasions there will be some information in that patient’s past that will have a bearing on the decision making process of the GP or nurse. As an example a relatively new patient comes to see a GP for a continuing problem such as abdominal pain but the GP does not know which investigations if any have been carried out so then tries to elicit the history from the patient who does not recall exactly what was done and when, so the GP then scrolls through a bundle of pages which are practically falling apart to try and gather their past history. If these notes had been summarised we could for instance find that the patient had both a CT scan of the Abdomen and a Colonoscopy by looking up their past investigations in their electronic medical records at a click of a button.

Secondly, another direct benefit of note summarising is by fulfilling QOF indicators, as you know a variety of reviews and tests for patients are required for patients on the disease registers, so on many occasions we find newly registered patients requiring a barrage of tests at the end of the three month grace period, many a time you will find the missing data in its entirety within the patients paper records, therefore by making summarising a normal course of action you inevitably improve your QOF scores. It is also important to add that the best way of keeping your disease register prevalence accurate is by summarising notes as they arrive into the Practice. You must also not forget that Practices are awarded a total of 52 points (that’s over 5% of the total QOF allocation) just for note summarising targets.

Which notes should you summarise?

It is important to summarise both the newly arrived notes as well as existing patient notes. I would recommend that you start with the newly arrived notes to ensure that you capture all the relevant information of new patients joining the surgery as this will almost always be more fruitful. However, you should also allocate some protected time to summarise existing patient notes otherwise you will not make any progress on this front. For instance if you have 50 new notes arriving every month, it may be worth allocating time for a 100 notes so that you can keep up with all the new notes and at the same time make headway with the existing notes.

Who should be in charge?

It is crucial that someone is assigned the responsibility of the overseeing the notes summarising process at the Practice. You may find a suitable admin person to oversee this role, I would expect them to monitor the number of notes being summarised, they should beware of those summarising too many or too little over a specified time period, as an example someone summarising ten averaged sized notes an hour is probably going too quick while someone only summarising 2 an hour is probably going too slow. However each case should be looked at before deciding if this is inappropriate. I would also suggest spot checks are undertaken to monitor the quality of the summarisers; I would consider this to be essential for new summarisers so that problems are nipped in the bud early on. This named person should also provide the summarisers with a list of notes to summarise based on the need of the Practice.

If the person overseeing the note summary process is not a competent note summariser themselves I would expect that a clinician is assigned the role of carrying out the spot checks, in any eventuality a named clinician must be available for note summarisers to check clinical based question even if this named clinician is not responsible for overall note summarising process.

Step-by-step guide for note summarisers

In my experience the best way to note summarise is to start by looking at the electronic medical record and tiding this up. My step-by-step guide is as follows:

1) Go through the ‘problem list’ (in EMIS LV this is MR > P), sort this out so that everything here is appropriate, so only significant problems should be under this section, as an example Diabetes should be here as an active problem however if the problem is a past problem it should be filed as such, as an example a miscarriage
2) Go through the all codes section (in EMIS LV this is MR > X), this area covers all the non-value read codes added for this patient. At this stage all you should seek to do is upgrade anything that should be on main problem list on the MR page.
3) Go through the consultation pages, (in EMIS LV this is MR > C), this area covers all the consultations noted in the electronic medical record. Unlike in stage (2) this area could include free text that has been added by a clinician but that has not been coded which gives more importance to it as it is not retrievable via a search and will also have ramifications for QOF as this data will not be picked up.

Hint: The importance of stages (1) to (3) will vary in their importance depending on the Practice’s data standard level, i.e. if the Practice is very IT literate all round and has been recording data at a high level consistently for a long period of time it may be worth skipping these first three stages, however if the Practice has been under performing in terms of its data recording I would strongly adhere to this policy as you may find a substantial amount of information that has been inappropriately recorded, the most important is stage (3) where you may find significant amounts of free text data that is not read coded. These three stages are also of less importance for newly registered patienst as they will have only minimal data entry on their medical record.

4) Go through the paper records and add the following information (the different components have been clarified below):

a) Significant diagnoses (active or past)

1) This should be added to the main MR screen (in EMIS LV this would be done by going to MR > A), you should add this diagnosis with the actual date of diagnosis and not with today’s date

Hint: be careful not to add problems on the day you are note summarising as this could throw your QOF indicators all over the place, the reason for this is due to many of the QOF indicators being time specific, as an example AF2 necessitates that if a patient is diagnosed with AF after 01.04.2006 they require an ECG to confirm diagnosis, therefore if this patient had actually been diagnosed in 2004 but added in 2007 they would then require an ECG even though they do not require it from a QOF perspective purely due to the date discrepancy.

2) When adding the diagnosis bear in mind the need to use the correct code if dealing with a QOF disease, many diagnoses have more than one code that can be used however to ensure that the code you are using is accepted for QOF purposes you need to check which codes will include the patient on the register, as an example using the code C10 (Diabetes Mellitus) to add someone to the Diabetes register is not accepted, rather it should be either C10E or C10F (i.e. Type 1 or 2), you can find many other diseases with multiple codes some of which are not qualifying codes by the QOF criteria, there is a vast number of Cancer and Hypothyroidism codes of this nature that will not include patients on the relevant QOF register (In EMIS you can check the qualifying codes by going to population manager and checking the criteria of the specific indicator, ST > Z).

Hint: use specific codes and avoid in particular H/O (History Of) codes as they are almost all not qualifying codes for QOF. Similarly try avoid using NOS, not otherwise specified or NEC not elsewhere classified where possible and instead use the most appropriate and specific code, however when this not possible be careful not to specify a problem when all you have is a generic entry.

3) When adding the diagnosis make sure you add the code as a problem and to place it as either an active or past problem as this will make the summary page in the medical record clearer and more relevant, i.e. if a problem is significant but not active such as a past miscarriage it is imperative that clinicians have this information easily available and within the main summary as it may well have a bearing in their clinical care now or at a later stage but it should be placed appropriately as a significant past otherwise all problems will end up as active.

(See appendix 1)

b) Recording of drug and non-drug allergies

Make sure to add allergies in the appropriate section as this will ensure that they appear on the summary page of the medical record and will also appear as a warning when trying to prescribe a medication that is listed as an allergy. You can add both drug and non-drug allergies in this way (in EMIS LV from the MR you can do this by pressing A > choosing the relevant date > press F4 > choose A for Allergies and follow the onscreen instructions).

c) Significant operations/procedures/investigations

The above should be added in exactly the same way as diagnoses, again be aware similarly to diagnoses many procedures/investigations have a time specific requirement in relation to QOF and also have many different codes so you need to ensure that you use the qualifying codes with the right date. Unlike the diagnoses all investigations should be added as a significant past or in some cases not even as a problem altogether, for instance a normal smear should just be added via the template or entered as a code without grading it as a problem, i.e. it should be coded but should not appear under the problem list.

(See appendix 1)

d) Family history

Make sure to add family history with the appropriate code as this will ensure that they appear on the summary page of the medical record. The required code may be different from software to software, so check which codes will appear on the summary page and make sure all the summarisers stick to this code as some family history codes do not appear on the summary page.

e) Recent immunisations/vaccinations

When adding child immunisation this can be of great importance to the Practice targets so be careful to record this accurately. As for holiday and booster vaccinations this will not have the same bearing on targets but can be very useful when administering vaccines at the Practice as they will have vaccine history available on the screen (in EMIS this should be added from MR > I, this is the designated place to add all immunisations and vaccinations).

Hint: There is no need to record vaccinations that are past their protection period, as an example if you are summarising records of a patient who had the flu vaccine two years ago it has no bearing on the clinical care and hence does not need to be recorded.

f) QOF related data and recent lifestyle data

This section refers more specifically to the individual QOF indicators and not to the actual disease registers as this has been covered in the section on diagnoses. For best results I would recommend that all note summarisers are at least aware of all the QOF registers and their specific indicators as this will give them a better insight into what is useful data and that which is obsolete and of no real benefit. As a general rule the most relevant data will be that which falls under the past year, however this is not always the case as some indictors cover periods of up to 5 year such as Records 11 which covers BP readings for patients over 45 years old. Therefore my advice is to accustom your read coders to understand the workings of QOF in terms of both the qualifying codes and also time frames so that they capture what is useful whilst not over coding and hence making the process inefficient. This section also covers areas which are not part of QOF such as alcohol intake which is still useful to record so just make sure to look for the most recent entries and avoid adding data that is outdated.

Hint: QOF registers and rule sets are prone to change so maybe assigning one person to identify these changes and informing the read coders will keep the process more productive. For instance a recent change made in 2007 was the removing of Mental Health Review (6A6) as a qualifying code for DEM2 (Dementia reviews) which would have had an overnight negative affect on the QOF score for this indictor, however with a simple change of the code it could be rectified.

Hint: you may find it easier to enter some of the information via templates as this can speed up the process and will also prompt the summariser to which information is relevant to add. Additionally you can easily change the date of the entry and also show where it came from by adding a comment in the consultation entry to say this was retrieved from the paper notes.

Examples of useful data

· Alcohol consumption
· Blood pressure checks
· Cervical Smears
· BMI (Height and Weight)
· Smoking data
· Blood tests, e.g. Cholesterol, Creatinine/eGFR, HbA1c & TSH depending on the register
· Reviews for Asthma, Mental Health, Dementia, Diabetes etc
· Specialist tests which might also be covered under investigations, e.g. ECG, ETT, Spirometry etc

5) Concluding a note summary

These are the final steps needed to conclude a patient note summary:

a) Enter the code 9R8 (records help from), make sure to change the date to the earliest date that you have records for the patient and file as a problem so that it is visible on the summary page of the medical record, this also serves as a useful entry for General Practitioners Reports (GPRs).
b) Record the code 9344 (note summary on computer), this should be added with the date on which the summary took place and should also be filed as problem so that it is visible on the summary page of the medical record. I would also suggest that the read coders initial this entry so that is apparent who has summarised it and I would even suggest they initial every single entry as it can make a clinicians life a lot easier if they can account for why a code is in a patients record. An audit can be run to find out who summarised which notes but this does not serve as an easy reference when dealing with a patient in a consulting room.
c) Record at the back of the paper notes that the notes have been summarised along with the date and name or initials of the summariser.

Appendix 1 – A guide to some of the common problems, surgical procedures/operations and investigations

The following list is by no means a complete list but gives some guidelines as to the medical conditions that note summarisers should be recording. The golden rule that should always be observed is that whatever is deemed to still have a bearing on the patients continuing care is worth recording and if in doubt this should be checked with a clinician with overall responsibility for note summarising at the Practice. When summarising you should be seeking to add a confirmed diagnosis and not a symptom (e.g. add Spondylosis but not back pain or add Migraine but not headache).

1) Medical Conditions

Blood Disorders

Anaemia
Blood poisoning
Haemophilia
Hughes syndrome
Jaundice
Leukaemia
Multiple myeloma
Pernicious Anaemia
Septic shock
Sickle cell anaemia
Thalassaemia
Toxic shock syndrome

Cancers - All

Cardiolovascular – Heart and Blood Vessel diseases

Angina
Aortic stenosis
Arteriosclerosis
Atrial Fibrillation
Cardiomyopathy
Coronary Heart Disease
Deep Venous Thrombosis (DVT)
Ischaemic Heart Disease
Heart Failure
Hypertension
Left Ventricular Failure (LVF)
Myocardial Infarction
Pulmonary thromboembolism
Systemic lupus erythematosus

Dermatology

Dermatitis
Eczema
Impetigo
Psoriasis

Endocrine Disorders

Diabetes (Type 1 or 2)
Hyperthyroidism
Hypothyroidism
Hyperlipidaemia

ENT

Chronic Otitis Media
Deafness
Meniere's disease
Recurrent Tonsillitis
Sinusitis

Gastroenterology

Appendicitis
Cirrhosis of the liver
Coeliac disease
Hepatitis A, B or C
Irritable Bowl Syndrome (IBS)
Pancreatitis
Peptic ulcers
Ulcerative Colitis

Infectious Diseases

Chlamydia
HIV/AIDS
Kawasaki disease
Malaria
Poliomyelitis (Polio)
Syphilis
Tetanus
Whooping cough (Pertussis)

Mental Health

ADHD (attention deficit hyperactivity disorder)
Alzheimer's disease
Anxiety disorder
Attempted Suicide
Autism (Asperger Syndrome)
Bipolar disorder
Dementia
Depression
Eating disorders
Obsessive-compulsive disorder (OCD)
Personality disorder
Schizophrenia
Sectioned under Mental Health Act

Nephrology

Chronic Kidney Disease stages 1 to 5 (CKD)
Acute Renal Failure
Chronic Renal Failure
End Stage Renal Disease
Kidney Stones

Neurology

Achondroplasia
Amnesia
Brain Tumour
Creutzfeldt - Jakob disease (CJD)
Epilepsy
Huntington's disease
Meningitis
Migraine
Motor neurone disease (MND)
Multiple Sclerosis (MS)
Muscular dystrophy
Parkinson's disease
Peripheral neuropathy
Sjogren's syndrome
Stroke (TIA or CVA)
Sub-arachnoid haemorrhage
Tourette's syndrome

Obstetrics and Gynaecology

Eclampsia
Miscarriage
TOP (Abortion)

Ophthalmology

Age-related or Juvenile macular degeneration
Blindness
Cataract
Glaucoma

Respiratory

Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Legionnaires' disease
Pneumothorax
Silicosis
Tuberculosis (TB)

Rheumatology

Arthritis
Osteoporosis

2) Surgical Operations/Procedures

Appendectomy
Carotid Endarterectomy
Caesarean Section
Cataract Surgery
Cholecystectomy
Coronary Artery Bypass Graft (CABG)
Haemorrhoidectomy
Hysterectomy
Hysteroscopy
Inguinal Hernia Repair
Mastectomy
Prostatectomy
Releasing of Peritoneal Adhesions
Tonsillectomy

3) Investigations

Blood tests (if relevant and recent)
Cervical Smear
Colonoscopy
Colposcopy
CT Scans
ECG
Endoscopy
ETT (Exercise Tolerance Test)
MRI Scans
Spirometry
X-rays (if relevant)

Omer Hussein
GP Management Consultant