Faxed electronic summaries are valued by general practitioners

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7007.476 (Published 16 September 1995) Cite this as: BMJ 1995;311:476
  1. Allan Spigelman
  1. Lead clinician Information Management and Technology Department, St Mary's Hospital, London W2 1NY

    EDITOR,--Jane Smith's synopsis of the Audit Commission's report Setting the Records Straight: A Study of Hospital Medical Records highlights several timely issues.1 2 For example, clinical contracts are settled on the basis of information derived from coded data generated without appreciable input from clinicians. This may lead to incorrect estimates of activity, with resulting contracts providing a poor reflection of clinical need. One approach to solving this problem is that adopted at Central Middlesex Hospital, where clinicians do the coding themselves.3 Another is to use the data collected by most hospital information systems (data on the general practitioner and demographic data on the patient together with diagnostic and procedural codes), validate the clinical activity codes at regular meetings with the coding staff, and download these data to a standard word processing package that contains a free text module. The resulting discharge summary is then sent to the family doctor.

    At St Mary's Hospital we adopted the latter approach last January. Audit of 228 summaries over two separate one month periods was performed. Summaries were sent by post, with most arriving at their destination within 12 days of the patient's discharge. Use of the postal system resulted in a median delay between dispatch and receipt of five days; fax machines are therefore now used. Comments by general practitioners were favourable (“clear and concise,” “timely and comprehensive”), with support being expressed by both hospital clinicians and general practitioners for the adoption of Read coding instead of the sometimes tortuous ICD-10 (international classification of diseases, 10th revision) codes currently in use. We have already seen a considerable improvement in the accuracy of clinical coding; some clinicians were unaware of the potential for damage that incorrect coding carries. The system is also being piloted as a basis for clinical audit. Finally, the presence of a summary on the hospital information system allows access to recent clinical information in those cases in which timely retrieval of notes is difficult.

    This method of producing summaries addresses many of the issues raised in the Audit Commission's report, and the summaries represent a nascent electronic patient record.


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