Summarising Medical Records
The ‘summary’ is the process of summarising a patient’s electronic and paper notes in an accurate, comprehensive and chronological order. It includes, significant past medical history, continuing problems, key diagnoses, allergies, operations, procedures, investigations, child protection and mental health register indicators.
Whilst ideally clinicians are best placed to summarise a patient’s record, this can be impracticable and therefore, Scan House trained staff can carry out the summarising of notes under guidance and a protocol.
Scan House will collect the notes requiring summarisation, perform the service and, if required, digitise the notes. Once complete, the paper notes can be either returned to the practice or stored with an on-demand service put into place.
Benefits/Aim of an accurate summary by Scan House
- Allows current and future clinicians to deliver medical care safely and efficiently without having to look at any other past background information or to refer again to the paper record.
- The on-going management and most significant clinical information for the patient can be readily identified on screen.
- Ease of access for all current, new and temporary practice staff, particularly locums, to patient details.
- Enables production of computerised insurance reports/referral letters etc. thus saving clinician time
- Facilitates generation and upkeep of disease registers.
- Improved data quality and accessibility of data improves patient care.
- Data will then be available for upload to the spine in a compatible format for use in the Summary Care Record
- Improves efficiency and reduces duplication of work.
The Scan House summarisation service frees up valuable practice resources. You'll realise the benefit straight away too, so you won't have to wait to see a return on your investment.
contact us for more information or if you would like a quotation.