FGMC Computer Training Session 2 – Finding Information

There is key information that you should be able to access from a medical record:

  • Summary of patient’s current and past disease & illnesses
  • Previous consultations
  • Correspondence and letters
  • Investigation results
  • Medication

Read Coding

Information can be stored in a patient’s MR is several different forms - the main forms are prescribed medication, lines of text (free test) and designated codes (Read codes – named after a GP, Dr Read). Read codes are the medical coding system used in all GP computer systems. In theory, you could hunt out a code for every last scrap of information that you enter onto the computer, but finding the correct code takes time. For example, to record that the patient has not had a fever, it is quicker to type “No fever” than hunt out code “1651” which means “No temperature symptom”

Why bother to use any Read codes? Important information needs to be entered as a Read code as only coded information can be retrieved easily. If you want a list of patients with diabetes whose BP is over 140/90, the only practical way is to search on the Read codes for diabetes and blood pressure. If this information, for a particular patient, is not coded, they will be missed. In addition, a series of consultations for the same problem can be linked easily if they all share the same Read code title. Less important information should be entered as “free text” as this is much quicker. A large slice of GP Pay is now for “payment by results” (Quality & Outcomes Framework – QoF points) and all of this is audited automatically using Read Codes. Failing to use Read Codes correctly costs us money!! Although we are very nice people, we do like you to learn quickly!

Learning what counts as important codes and how to enter codes efficiently will take a few weeks. We have a list of important diagnosis codes for quick reference and you should spend some time browsing through the coding system on the computer.

Diseases and Illnesses
This section on the <MR> summary page lists all previous recorded Read Codes. Obviously this can start to run into hundreds to the “Problem List” is a way of organising and prioritising previous clinical Read Codes. More on problems and coding later! It is hard to keep these lists up-to-date, they will never be 100% accurate

Problem summary on MRActive problems (ie problems that are currently being investigated or treated)

Significant past problems (ie major previous illnesses and events)

Display full problem listPress <P>

Previous Consultations

Before 1996This surgery – most consultations after 1996 are on the computer record

Previous GP – records not yet transferred electronically, so ALL are in the written record

After 1996From the MR page, press <C> to display consultations

<Page up> to find the information that you need

Correspondence & Letters

Before 1996(And letters from previous doctors) if available, will be in the written record

1996 – 2000Scanned in as “letter text” look for *RL<number> in previous consultations

2000 – dateScanned in as “image attachments”look for *RA<number> in previous consultations

From the MR page, press <C> to display consultations

<Page up> to find the letter you need - either *RA(newer) or *RL (older)

The name of the letter should indicate Hospital, department and date letter was written.

To access the letter referenced:*RL3, press <*>, followed by <L> <3>

*RA6, press <*>, followed by <A> <6>

Investigation Results

Lab ResultsBefore 1996(And results from previous doctors) if available, will be in the written record

After 1996From the MR page, press <V> - displays the most recent result

To look at previous results - use   to select the line, followed by <L>

X-raysBefore 1996(And results from previous doctors) if available, will be in the written record

After 1996Ask patient for approximate date so you know where to look.

Report may be typed in or scanned in

TypedFrom the MR page, press <X> - short reports are typed in

ScannedFrom MR page, press <C>, and display same as for a letter

Medication

From MR page, press <M> to display medication page. The information pages “Using the computer” describe how to enter medication on the system and generate a script

AcuteMedicines usually issued as a one-off, eg course of antibiotic, nsaid’s

RepeatMedication that the patient is allowed to re-order without seeing doctor

<B> prints off a re-order form for the repeat prescriptions

Dispensing

We issue medicines mainly for Deepcut patients. Please look for “Dispensing Patient” - shown variously at bottom left and right of medication screen

When issuing medication for dispensing patients, at the final step, select <D> to dispense, not <P> to print. Instruct the patient to go to dispensary to collect the medication (nothing comes out on your printer). Most common items are stocked. If in doubt, please ask dispenser (Extension 224)

Session 2 – Finding Information Exercises

Read Codes

Exploring the Read code hierarchy

  1. Bring up a test patient and display their MR / summary page
  2. Press <A> to add information and then <return> to select today’s date
  3. Select option <G> “Full Classification” and spend 5-10 minutes flicking through the Read code lists

Common Read Codes:

What Read codes could be used for –

HypertensionDiabetes

Back painUpper Respiratory Tract Infection

What does the following Read code denote –

G308H4F

H33T534

(Note the pattern with the first letter – H= chest disease, G=CV diseases, T=bizarre etc)

Diseases & Illnesses

  1. Display “Virginia Test”What are her “Minor Past” illnesses?
  1. Find patient 345 (Now deceased) What were her “Active problems?”

Previous Consultations

  1. When was “Virginia Test” first seen here?
  1. How many times did I see patient 345 in 2004?

Correspondence & Letters

  1. In September 1998 we had a letter from patient 345’s optician – what did they request?
  1. Patient 345 thought she had cataract surgery at Frimley Park in 1982 or 1983 – which consultant?
  1. When, according to our letters, did the Chiropodists last treat patient 345?

Investigation Results

  1. What is patient 345’s lowest HbA1c recorded on the computer and when was that?
  1. What is the highest BP recorded on patient 345’s computer record and when was that?
  1. Has patient 345 ever had thyroid function checked?
  1. Patient 37738 had a shoulder XR in April or May 2004 – what did the report say?
  1. She had two CXR’s in 1999 – what did the reports say?

Medication

  1. Patient 49538 thinks she is on a cholesterol tablet – which one?
  1. Which other lipid lowering drugs did she try during 2006?
  1. Virginia Test had a bad throat. She had an antibiotic a couple of years ago that was great

Generate a script again for this antibiotic

  1. Patient 11152 – when was he first prescribed an ACE inhibitor?

What was his creatinine before he started the ACE inhibitor?