GP computerised summaries may not be accurate or complete

doi:10.1136/bmj.a477

BMJ 2008;336:1453 (28 June), doi:10.1136/bmj.a477

Letters

Aspects of summary care records

GP computerised summaries may not be accurate or complete

The first 150 words of the full text of this article appear below.

The focus group in the study by Greenhalgh et al was concernedabout the quality of data in the summary care record.¹ Computerisedmedical summaries in primary care may not be accurate or completemainly because of errors in transferring information from writtenmedical records. When checking the computerised medical summariesof new patients against the written notes and letters, I havefound a diagnosis coded and entered into the summary when theconsultant’s letter stated that the patient did not havethis condition; a provisional diagnosis entered as a definitediagnosis, even when it was later excluded; the wrong Read codebeing used; an important diagnosis omitted from the summary;and misunderstanding of clinical information.

Medical records summarisers need to be well trained, ideallywith a clinical background, and have enough time to do a thoroughjob. Quickly scanning through letters for diagnoses withoutreading the sentences leads to . . . [Full text of this article]

Pamela J F Smith, medical records summariser and former general practitioner

¹ Stockport

pjfsmith1@aol.com

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