Quality data = Quality practice = Quality Outcomes
The RACGP standards (4th ed) place increased emphasis on minimum data in the patient’s electronic record. The Patient Summaries criterion states that GPs must maintain a GP Health Summary for more than 75% of their active patients. Greater emphasis is also placed on data quality ie. using coding from the appropriate “pick list”.

For example, when recording condition is Diabetes this should be entered in the appropriate field and not just free texted into the progress notes. 

Condition, eg. Diabetes can be entered into appropriate fields by one of the following methods:

• Reason for prescription when prescribing medication
• Reason for contact / visit in progress notes
• New history item in medical history section

Correctly entered and coded conditions will be displayed in the medical summary or any referral letter and the patient can be identified on the Diabetes register or by a database search.

You should identify whether the condition is active and if it should appear in the summary. If you do not select the Summary tick box then the condition will not appear on the summary. This is a common mistake, you do need to tick the summary field of the condition prior to generating a GP summary or referral letter.

Similarly, information like height and weight, blood pressure should always be entered into the appropriate fields and not free texted into the progress notes. Such information can then be extracted either by the database search or by the use of extraction tool such as PEN Clinical Audit Tool.

Medical Director has icons on the tool bar which take you to the Toolbox, a section where you can record height and weight, blood pressure and other relevant measures. Best Practice has an Observations section which also allows you to record these values.  Recording relevant measures into these sections at the beginning of the consultation then allows their extractions into appropriate templates or assessments - ie. health assessments.

Quality data is not only required for accreditation but can make your practice more efficient in delivering quality outcomes.