Notes Summaries

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Notes Summaries

• Quality Data
• Quality points

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Doctor

• The out of hours doctor was quite right to ask
  you to come back and see me when about the
  discomfort youve been having.
• Especially when he read about you cholesterol.
  And family history on you Internet summary
• ICRS spine record is coming soon

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Date of
entry 26.10.2003


Entry Notes summary on computer
(Read code 9344)



Text AG








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Why Summarise?

• Assists care of individual
• Context for present symptom e.g.
• Referral information for secondary care
• Morbidity Register
• For chronic disease management and flu jabs
• For teaching
• For Vocational training accreditation

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Why Summarise?

• For Practice Audit and improving care
• For external audit (GMS2 and NSFs)
• To populate the ICRS spine
• Out of hours contacts
• Hospital/ AE and others in shared care
• GP2GP transfer

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BUT

• There is a danger with coded data that people
  will believe it is reliable because it is on the
  computer!
• They/ you can retrieve the data so you cant hide
  your errors and sloppiness.
• Invisible codes can still show up in searches
  and affect quality markers

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Coding issues

• Coding limitations
• Hip replacements
• Learning disabilities and types of abuse
• Negative codes
• Finding the right code. Use of formulary?
• Free text additions
• Associated features
• Standard searching Miquest/ GMS quality
• Problem structures? Active or Priority 1

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???

• How many of you have a good paper summary?
• Is it up to date?
• What about computer summaries?

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Hypertens

• Hypertensive Disease
  
• Essential Hypertension
• Hypertensive Heart Disease
• Borderline Hypertension-yearly obs
• Hypertensive renal Disease
• Benign Intracranial Hypertension
• D Raised BP reading
  
• Renal hypertension
  
• Secondary renovascular Hypertension
• Seen in Hypertension clinic

• G2
• G20
• G21
• 6624
• G22
• F282
• R1y2
• G22z-1
• G24z-0
• 9N03

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Squamous cell (cancer of bladder)

• M Squamous cell papilloma
• M papillary Squamous carcinoma
• M Squamous cell ca in situ
• Malignant neoplasm of bladder
• Squamous metaplasia of bladder
• M Squamous cell Ca metastatic
• Secondary malignant neoplasm of lung

• BB25
• BB26
• BB29
• B49
• K16y7
• BB2B
• B570

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Chest pain

• Atypical chest pain
• Central chest pain
• DMusculoskeletal chest pain
• Chest pain
• Ischaemic chest pain
• Chest pain not present
• Angina
• DNon cardiac chest pain

• 1828
• 1822
• R065A
• 182
• G33z4
• 1821
• G33
• R065B

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Depression

• Depressed
• XMixed anxiety and depressive disorder
• XDepressive episode
• Depressed mood
• XRecurrent depressive disorder
• XPostnatal depression NOS
  
• XDepression NOS
• Neurotic depression reactive type
• O/E depressed
• Bipolar affective disorder, currently depressed
• X Bipolar Affective disorder
  

• 1B17
• Eu412
• Eu32
• 1BT
• Eu33
• Eu530-1
• Eu32z-1
• E204
• 2257
• E115z
• Eu31

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Access screen for Mental H.

• XDepressive episode
• XBipolar affective disorder
• XGeneralized anxiety disorder
• XPanic episodic paroxysm anx
• XAcute stress reaction
• XAdjustment disorders
• XSchizophrenia
• XMulti-infarct dementia
• XMental retardation
• Drug dependence
• XIntentional self-harm

• XRecurrent depressive disorder
• XPostnatal depression NOS
• XPhobic anxiety disorders
• XMixed anxiety/depressve dis
• XPost - traumatic stress dis
• XObsessive - compulsive Dis
• XAnorexia nervosa
• XDementia in Alzheimer's Dis
• Alcohol dependence syndrome
• XOverdose - deliberate

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Read code Abbreviations

• M Morphology
• X ICD10 derived
• D Diagnostic symptom
• V health status
• SO Site of
• Code-1 Synonym for the preferred name
• h/o History of
• NOS Not otherwise specified
• OS Otherwise specified

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Spot the errorrs
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Active Problems 13 2 1999 Influenza Past
Significant 1 2 1996 Left salpingectomy
1 2 1996
Ectopic pregnancy 1996 Lower abdominal
pain following
salpingectomy 1996
Low back pain following salpingectomy
5 1994 SOFemale genital tract
problem bleeding following miscarriage
4 1994 Miscarriage

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• Active problems
• 5 11 03 Patient Pregnant
• 1 10 03 Gallstones Excluded on U/S
• 4 9 03 Abdominal pain ?cause
• 7 8 03 Contraception pill
• 8 2001 Insulin Dependant Diabetes Mellitus
• Past significant
• Bipolar depression on Lithium
• 11/98 Urinary Tract Infection
• Hypertension NOS
• 1993 NIDDM

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• Mrs P 55y old
• Active Problems
• 1996 Vaginal Hysterectomy
• 1995 Menorrhagia
• 11/94 Single Live Birth female..Bobby
• 10/93 Recurrent dislocation of joint Left, MUA
• 1992Patient pregnant

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How did we do it?
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Sunderland Notebusters

• Running from January 2002
• Local code formulary (pros and cons)
• Lead by local Primis trained facilitator
• Practice sign agreement
• Keep summary up to date
• Scan letters
• Move towards paperless records

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www.sunderland.nhs.uk/templates
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Timescale/ Training

• Currently 24 summarisers in teams 2-3
• Average time per set notes 2 per hour
• Training 1-2weeks dedicated time from PRIMIS
  facilitator going through notes
• Relatively good understanding 4w
• Totally confident 3m
• Beginning to spot ambiguous and incorrect info.
• After 22 months approaching 50 patients in
  Sunderland (of 256,000)

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Recorded details

• Average patient 10 items
• Problem patients 30-40
• ?2 a week per summariser
• Take 2-3hours
• Importance Responsibility/ results of incorrect/
  incomplete data
• Danger of incorrect dates from letters
• XR/ ECGs/ endoscopies (pros and cons)

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Test results

• Enter free text, line label, or move cursor , lt\gt
  to back up
• 
  
• A Plain X-ray spine B
  Barium meal - general
• C Standard chest X-ray D Barium
  swallow
• E Plain X-ray skull F
  Barium follow through
• G Plain X-ray thoracic cage H Barium
  enema - general
• I Plain X-ray pelvis J
  Ultrasound in obstetric diagn.
• K Plain X-ray shoulder/arm L Other
  diagnostic ultrasound
• M Plain X-ray hand N U-S
  heart scan
• O Plain X-ray hip/leg P
  Standard ECG
• Q Plain X-ray foot R
  Exercise ECG
• S Plain X-ray abdomen T Coronary
  arteriogr.-general
• U Computerised bone densimetry V Carotid artery
  angiogr-general
• W Nuclear magnetic resonance X Diagn fibr
  endoscopy upper GIT
• Y Diagnostic procedure NOS Z Diagnostic
  endoscopy of colon

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Outcome/ Benefits

• Of 75 GPs
• 18 Previously no use now use for everything
• 41 improved from occasional use to full use
• 16 Moved from No use to partial use
• 15 practices finished
• 9 consider themselves paperlight
• 6 feel restrained from that by personal training
  of 1-2 of partners, or waiting an event.
• many practices consider the arrival of
  Notebusters as their D-Day and without this push
  feel unable to change

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Doing In-House

• Space to work less of a problem
• Often starting with some medical knowledge
• Major problem with interruption
• Really need protected time and continuity
• Training-who? Danger poor quality checks
• For 1 GP with 1800 patients
• 100-120 staff days of work
• 1 staff per GP full time 6months

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Summary Updating

• For a practice list of 1800 per GP
• To keep all summaries within 12 months
• 4-5 summary update per surgery session
• To keep within 2 years
• 2-3 per surgery but each takes twice as long
• Also more work needs to be done pre referral or
  report.

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So How to keep up to date summary?

• Consultation problem/ diagnostic headings (?)
• Letters GP or staff first (pros and cons)
• XRs, other tests, child protection, AE protocol
• Opportunistically. ?temporary codes until GP
• Someone still has to check
• move date on and accept responsibility
• The clinician is the best person when they have
  seen/ are seeing the patient
• Quicker
• Can check details with the patient

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Typed Letters
Hospital Letters ?500/week

• Types of Scanning
• Cut, OCR and paste
• Attach image files

Date-Stamped Scanned
Doctor Reading, Coding Action (themselves or
highlight for secretary)
SHREDDED
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Have we managed?

• Hard work
• Easier as paper light since 1997
• League tables of partners quarterly
• Backlogs easy to run off, share and work through.
  (usually patients who rarely attend)
• Problem coding consultations

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How do I compare?
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Principles

• All data needs a date (some systems not
  automatic)
• Code needs to be accurate
• Text must never modify meaning
• The more major the diagnosis the more important
  to code and be accurate
• Use symptom or vague code until diagnosed (often
  start with a number or D)
• Chest pain gtgtgt angina after exercise tolerance
  test e.g.
• Sciatica gt prolapsed disc or lumbar spondylosis
• Wheezy or cough gtgtgtasthma
• Use preferred term codes rather than synonym
• Synonym may be marked as e.g. H33-1

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Principles -2

• HIP for CHD Data Items and Recording-principle 1
• The data collected must form part of normal
  clinical activity
• (any data required for the NSF must fall
  out of that activity)
• Keep summary compact
• What to merge/ inactivate/ remove from summary
• Modifying associated text/ merging
• Different systems merge/ inactivate/prioritise
• If there is a current script for it it should be
  on the summary.
• Complete/ Accurate/ Relevant/ Accessible/ Up to
  date
• Confidential
• ?use of personal history (13) with free text for
  lifestyle/TOP/ father
• Mark when summary updated and by whom (9344)

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Other Information

• Tests what codes are extracted for reports?
• 7 are procedures e.g. endoscopy/ surgery
• 3 are results e.g. colonoscopy normal
• 5 are radiology
• 9 are only really for admin of above
• Allergies
• Immunisations
• Child protection

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Other Information

• Allergies
• Immunisations
• Child protection
• Serious mental illness register
• Chronic Disease Management templates
• Base on NSF and good practice, not just GMS2

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Smoking cessation Advice

• Health Education Smoking
• Nicotine replacement Rx
• Smoking cessation advice
• Refer Smoking cessation clinic
• Smoking cessation milestones
• Anti smoking monitoring admin
• DNA Smoking cessation clinic
• Seen smoking cessation advisor
• Refer smoking cessation advisor

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GMS Quality Markers
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GMS audit screens

• Rogue Codes
• Hypertension G2 or not G2
• COPD
• Chronic Bronchitis H31
• Acute exacerbation COPD H314(?)
• Emphysema H32 Dont use unless correct
• Mild/ mod/ severe COPD H36-8
• COPD OS and NOS H3y,z
• Remember New codes C10E and F for Diabetes
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  Type I/ II (not C108/9)

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GMS2

• Lab result issues
• HBA1C (dcct aligned) 42W4
• not 42W HBA1C
• Serum creatinine 44J3
• not plasma creat 44JF
• Serum Cholesterol 44P
• not 44OE Plasma total cholesterol

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Passing the information on

• Referrals
• Insurance

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Insurance Report

• Timesaving
• Legible
• Very acceptable to Insurance companies
• Set up to National eGPR standards
• Pilots electronically before end 2003
• But
• Relies on data being entered onto system
• Summaries being updated
• GP removing inappropriate data before sending

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Passing the information on

• Referrals
• Insurance
• For next GP

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Consultation and Summary Printout
Farewell Summary on Clipboard
Farewell Template printed
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Consultation and Summary Printout
Farewell Summary on Clipboard
Paste to WORD file
Farewell Template printed
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Possible next stage
Image Files Recent scanned letters
Text letters (EMIS WP and old scanned-OCRd)

• Text File
• Practice details
• Confidentiality statement
• File types and how to use

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Who do our systems serve?

• Dont forget the Patient