Block 11 Flashcards
Define quality in terms of healthcare
the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Main functions of the clinical record
Support patient care
Improve future patient care
Social purposes at the request of patients
Medico-legal document
Medical functions of the clinical record
- Ensure clarity of diagnosis
- Record treatment plans
- Enable comprehensive monitoring
- Help maintain a consistent explanation for the patient
- Ensure continuity of care
How do clinical records assist in the clinical care of the practice population?
- assesses health needs of the population
- identifies target groups enabling call + recall programmes
- monitor progress of health promotion initiatives
- supports medical audit
- provide pts. w an opportunity to contribute to their record
List some non-clinical purposes of the clinical record
- used to support claims for benefits + other additional social support
- providing reports + info for 3rd parties
- providing legal evidence for a patient that makes a claim against a 3rd party
Advantages of handwritten notes for clinical record
- continuous - reads like a book
- writer identified
- usually written at time you see the pt → contemporaneous
Disadvantages of handwritten notes for clinical record
- structural problems - if page goes missing/falls out can mess up structure of all notes
- legibility issues
- functional problems with maintaining it
- must remember to date and sign it or it is not valid
Benefits of computerised clinical records
- problem orientated → driven by coding
- gives audit trail
- searchable
- helps w provision of disease registers as problems can be easily traced back to code
Disadvantages of computerised records
- dependent on doing correct coding → if incorrect can impact patient safety
- Wannacry - ransom attack, data breach
How might electronic recording impact communication skills
- patient may feel like you’re ignoring them
- can be distracting
Key differences between hospital and primary care clinical records
GP
- paper light
- increasingly computerised
- patient orientated
- correspondence rich - long entries
- multiple records for different professionals (due to referrals etc.)
Hospital
- largely paper-based
- disease orientated
- shared by all in hospital
- slow + poor quality computerisation
What should be included in the clinical record? (TIP: think of a typical consultation structure!)
- presenting symptoms + reasons for seeking healthcare
- relevant clinical findings
- diagnosis + important differentials
- options for care + treatment (safety netting - who pts. can contact etc.
- discussions about risks + benefits of care + treatment
- decisions abt care + treatment
- action taken + outcomes
Why type of clinical record do all patients in England have?
Summary Care Record contains: - Name, address, date of birth and NHS number - Medication - Allergies
Differences between paper + electronic records
Paper - Continuous, portable, writer identified, legibility issues, must be dated and signed
Electronic - Problem orientated, searchable, structured, safer prescribing, clinical decision support software
What is the use of records in audit, research and management?
Support clinical audit
Facilitates clinical governance - audit trail, support seasonal initiatives e.g. flu vaccines
Facilitates risk management - prescription alerts, reminders
Support clinical research - identify pts. eligible for a study by searching the database
What is Clinical governance? (this is to help understand role of clinical records in management)
system through which NHS organisations are accountable for continuously improving the quality of their service
What is the purpose of antenatal screening tests?
to identify major abnormalities
Types of antenatal screening tests: (3main elements)
- Screen for infectious diseases:
Hep B
HIV
Syphillis
- Screen for Sickle cell and Thalassemia
- Screen for foetal anomalies (FASP)
- Down’s syndrome
- Edwards’ syndrome
- Patau’s syndrome
incl. 20wk scan for 11 physical conditions:- abdominal wall defects
- renal agenesis
- cleft lip
- congenital diaphragmatic hernia
- congenital heart disease
- triosmy 13
- triosmy 18
- NTDs
List the 11 physical conditions scanned for at the 20wk scan:
- abdominal wall defects
- renal agenesis
- cleft lip
- congenital diaphragmatic hernia
- congenital heart disease
- triosmy 13
- triosmy 18
- NTDs
What are the types of newborn screening? (3main elements)
- Physical examination => within 72hrs
- overall check of eyes, heart -> congenital defects, hips -> DDH + testicles(male) - Hearing -=> 4-5 wks ideally but up to 3months
- Blood spot => ~5days pld
- screen for 9 rare conditions:
SCD
CF
Congenital hypothyroidism
6 inherited metabolic diseases:- [phenylketonuria (PKU)]
- [medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- [maple syrup urine disease (MSUD)
- [isovaleric acidaemia (IVA)
- [glutaric aciduria type 1 (GA1)
- [homocystinuria (pyridoxine unresponsive) (HCU)]
What was the main outcome of the Peel Committee Report (1970)?
Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital
What is the medical model of birth?
- Birth seen as a dangerous journey
- only normal in retrospect, therefore assume the worst
- Low threshold for intervention (to fix defective bodies)
Why are childhood poisonings declining?
Due to more child resistant containers + safer medicines
How do most adolescents die?
> 50% due to RTCs - boys more likely to die than girls