Improving GP summaries SCIMP conference 1 St November ‘11
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Transcript of Improving GP summaries SCIMP conference 1 St November ‘11
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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE
Dr George Fernie – Senior Medico-legal AdviserDr Andrew Power - Medico-legal Adviser
Edinburgh
Improving GP summariesSCIMP conference1St November ‘11
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Purpose of summaries
To provide a GP summary dataset for use by other clinicians in unscheduled care settings. The GP summary will provide the clinician who is seeing the patient with an extract of events in the patient’s medical record that may have a bearing on the current consultation.
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Data Protection Act 1998
Principles and mechanisms for processing and protecting personal data
The right to seek factual corrections Data controllers are those who determine purposes
and manner in which any personal data are to be processed
Patient = ‘data subject’
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The First Data Protection Principle
The information to be contained in personal data shall be processed, fairly and lawfully and, in particular, shall not be processed unless certain conditions are met
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Second Data Protection Principle
Personal data shall be obtained for one or more specified lawful purposes and shall not be further processed in any manner incompatible with that purpose
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Third Data Protection Principle
Personal data…shall be adequate, relevant, and not excessive in relation to that purpose
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Fourth Data Protection Principle
Personal data shall be accurate and where necessary, kept up to date
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Fifth Data Protection Principle
Personal data held for any purpose or purposes shall not be kept for longer than is necessary for that purpose or purposes
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Sixth Data Protection Principle
Personal data shall be processed in accordance with the rights of data subjects under this Act
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Seventh Data Protection Principle
Appropriate security measures should be taken against unauthorised access to, or alteration, disclosure or destruction of, personal data and against accidental loss or destruction of personal data
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
The Eighth Data Protection Principle
Personal data shall not be transferred to a country or territory outside the EEA unless…an adequate level of protection…
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Essential factors
Accuracy Completeness Up to date Safety Relevance Consistency appropriateness
Any information (particularly relating to third parties or family members) should not contain any personal data that could breach Caldicott Guidelines.
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Content: basic
Drugs Allergies and adverse
reactions Additional information
agreed by patient and GP
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Local system
Major diagnoses Conditions that may have a relapse or chronic course Conditions for which the patient receives repeat
medication Conditions that are persistent and serious
contraindications for classes of medication Major operations Significant therapies and treatment plans Significant investigations Fractures immunisations
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
For example
Major diagnoses: MI, diabetes, terminal illness Conditions that may have a relapse or chronic course: gout Conditions for which the patient receives repeat
medication: diabetes Conditions that are persistent and serious contraindications
for classes of medication: dyspepsia, asthma Major operations: hysterectomy, cardiac surgery Significant therapies and treatment plans: radio-, chemo-
therapy Significant investigations: CT, Echocardiogram Fractures: significant Immunisations: including batch numbers
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Where GP summary may have helped
44 year old female Documented penicillin allergy on three occasions CLO positive endoscopy Consultant writes to GP suggesting ‘triple therapy of
your choice’ GP prescribes, clarithromycin, omeprazole and
amoxicillin Patient sustains severe allergic reaction Inevitable settlement of claim
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Where GP summary may have helped
28 year old female 4 months postnatal Attends with constipation GP plans to add bisacodyl to Movicol® In error chooses bisoprolol 5mg Patient calls OOH service complaining of fatigue Admitted for observation and develops bradycardia of
30bpm Inevitable settlement of claim
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
Where GP summary may have helped
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
GP summary
Is dynamic and needs to be actively reviewed Tension between salience and inclusiveness Clinical judgement is required to decide which parts
are relevant to include in discussion with patients
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MPS: PROFESSIONAL SUPPORT AND EXPERT ADVICE
GP summary
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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICE
Dr George Fernie – Senior Medico-legal AdviserDr Andrew Power - Medico-legal Adviser
Edinburgh
Improving GP summaries