In a recent Nuance blog post, Dr. Alastair Dickson discussed ways that physicians are able to see more patients in less time.
Editor's Note: This blog originally appeared on Nuance’s website
The pressure for physicians to improve the quality of their patients’ medical records is coming from many angles. This is difficult in today’s busy primary care environment where a General Practitioner (GP) will see more patients in less time than predecessors. However, a small change in a GPs daily routine can make a big difference in improving patient outcomes and a physician’s quality of life.
Medical, Legal and Health Policy Pressures
The UK’s General Medical Council’s current guidance for good medical practice states that physicians must keep clear, accurate, and legible records that report relevant clinical findings, the decisions made, the information given to patients, drugs or other treatment prescribed, and identify who is making the record and when. This goes on to say that notes may become important later if there is a complaint or claim, which can be made months or years after a consultation.
When you look at what is recorded in the patient note, the impact of not following this guidance is easy to see. Let’s take low back pain, something I am confronted with regularly when treating patients. This type of pain is complex and there is a great deal of information that should be recorded in a patient’s note. Pertinent information includes how long the patient has suffered with the pain, how and when it started, the specific symptoms, if there are any red flags, what treatment has been offered, whether they have tried physiotherapy, and other remedies they have tried themselves. However, in a busy practice, you will find that many GPs don’t have the time to record this level of detail so it never makes it into the patient health record. This is increasingly a problem as patients become more litigious.
To continue reading, click here.