Interactive workshop environment for discussion and peer review focused on quality medical records and their role in clinical handover, continuity of care and risk management.
Relevance to General Practice
General practitioners are said to spend approx. one hour per day recording information about patient consultations (1). Consultation notes are an important source of information (2) and should contain sufficient information for another GP or other medical practitioner to safely and effectively carry on management of the patient (3). Continuity of care is an essential principal of primary care (4). Continuity is achieved when services are delivered in a complimentary and timely manner (5) and is said to improve patient outcomes (6). General practitioners working with Home Doctor Service (referred to as Deputising Doctors) treat patients in their home after hours on behalf of their principal GP. It is vital that the therapeutic relationship between the patient and their principal GP is preserved and that deputising doctors provide the principal GP with consultation notes that contain sufficient information to allow the GP to carry on safe and effective care of that patient (7).
- Develop practical medical record keeping procedures to ensure patient safety and continuity of care.
- Analyse medical records to identify potential issues relating to continuity of care, patient safety and medico-legal matters.
- Outline the RACGP requirements for good record keeping.
Domains of General Practice
D1. Communication skills and the patient-doctor relationship
D2. Applied professional knowledge and skills
D3. Population health and the context of general practice
D4. Professional and ethical role
D5. Organisational and legal dimensions
Curriculum Contextual Units
- Adult health
- Care of older people
- Children and young people health