Summary on Read Coding Pitfalls and Summary Care Record.
Think about ethics, advantages and disadvantages of Summary Care Record.
Some Links.
NHS site
http://www.nhscarerecords.nhs.uk/
BMA
http://www.bma.org.uk/ap.nsf/Content/ncrs2
Pulse
http://www.pulsetoday.co.uk/story.asp?storyCode=4118449§ioncode=20
E health insider report on Greenhalgh evaluation
http://www.e-health-insider.com/News/3720/urgent_review_of_scr_consent_model_recommended
http://www.e-health-insider.com/News/3915/access_to_nhs_care_records_may_be_widened
whole report
http://www.ucl.ac.uk/openlearning/documents/scrie2008.pdf
The big opt out org.
http://www.nhsconfidentiality.org/?page_id=3
Guardian
http://www.guardian.co.uk/society/2007/nov/20/nhs.health
http://www.guardian.co.uk/society/2008/sep/18/health.nhs
Get the date right.
Difference between mode of birth as opposed to mode of delivery.
Cancers, don’t use morphology codes for clinical condition.
Difference between physiotherapy treatment and being a physiotherapist.
Know which codes count, and don’t count in QoF.
Be careful with use of h/o codes, useful before old records arrive or to remove a diagnosis from QoF searches.
Do not try and change the meaning of a code with free text.
Keep summaries up to date by adding correct code as diagnosis emerges, removing no longer appropriate summary items.
If altering an item make sure the audit trail contains your reasons for the alteration.
Be accurate with your psychological diagnoses.