problems

Problems, summaries and read codes

To ensure patient records are kept clean & accurate, Wiltshire CCG has the following guidance:

Problems and summaries

Only GPs can add Problems or Summaries to a patients record.

If a non-GP organisation (eg Community, OOH) thinks something should be added to a Problem or Summary, then they are to send a task to the patients GP to highlight this to them, but they should still not add it as a Problem or Summary.

All non-GP organisations templates must be checked before being published and must be signed off by a governance panel to ensure that no template fields are automatically linked to mark a template field as a Problem or Summary.

Wiltshire CCG recommends that problems are only used for long term conditions or significant other information. Problems should not be used for minor illnesses, symptoms or other items, as this can cause confusion. The easiest way to search for a “shoulder injury” issue, rather than using problems just type “shoulder” in the search box in the tabbed journal.

Read codes

Only GPs can add long term condition read codes to a patients record, for example asthma, diabetes, breast cancer.

If a non-GP organisation (eg Community, OOH) thinks a long term condition read code should be added, then they are to send a task to the patients GP to highlight this to them, but they should still not add the read code.

All non-GP organisations templates must be checked before being published and must be signed off by a governance panel to ensure that no template fields contain inappropriate read codes.

All non-GP organisations all are required to have the Wiltshire CCG Read Code Protocol running in the background too. This will mean that if a non-GP organisation accidently enters an inappropriate long term condition read code, an alert box will pop-up to remind them that they are not permitted to enter this code and it must be deleted from their record.