➡️Information
Data quality is essential for continuity of care and improves the usability of the medical record. It also facilitates the Quality & Outcomes
Framework with comprehensive disease registers.

Summarising requires intense concentration and attention to detail. It is imperative that summarisers recognize the importance of the facts they are deriving from medical records and understand the choice of codes.

Aims and Objectives
By the end of this course candidates will have gained the necessary knowledge, skills and, having completed practical assessment and
competencies at their workplace (working from their Practice Protocol), will be able to carry out their role safely and effectively.

Learning Outcomes
Candidates will have gained an understanding of:
• The purpose and significance of summarising medical records
• Systematic summarising of medical records
• The impact of the Quality and Outcomes Framework

Agenda
• What is a records summary?
• Systematic summarising of medical records [with sample medical notes]
• Quality & Outcomes Framework – clinical targets/ coding
• Classification of problems
• GP2GP – overview
• SNOMED CT – overview
• Relevant terminology and linked medication – some examples
• Data Protection and Confidentiality
• Summarising Medical Records Policy – what it should include
• Systems to support staff .e.g. Training Schedule/Mentor/QA/Action plan