Summarising Medical Records

The Summarising Medical Records course will allow delegates to gain hands-on experience of organising and summarising medical records.

Delegates will also learn associated abbreviations and appreciate confidentiality issues surrounding medical records.  In addition the course enables delegates to understand the relevance of summarising in relation to the achievement of QOF clinical targets.

The practical lessons will be discussed in the light of each delegate’s own practice protocol. Delegates will be provided with a course manual and a certificate upon completion of the course.

Course objectives

The course is designed to enable participants to:

  • understand the importance of having a logical approach to summarising medical records;
  • create protocols for summarising medical records in conjunction with the Practice Manager and GPs;
  • be able to summarise medical records in an efficient and effective manner;
  • gain an overview of QOF clinical targets and how summarising can help in the achievement of these targets;
  • understand how confidentiality can become compromised in the process of summarising;
  • have an overview of Data Protection in so far as it relates to their role;
  • identify issues that they need to follow up when returning to their place of work.

Please note that this course does not cover any issues in relation to practical issues of computer data entry or specific read code usage.