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Computerised patient records
.
There is an agreed manner in which to record our patient contacts and use the computer system. We have a protocol for summarisation of clinical records.

Clinical summary. As a practice which has adopted the paper light approach we endeavour to enter a summary of medical details for new patients records on to our computer system shortly after they arrive in the practice.

Incoming mail. We have a policy to outline the appropriate procedure for the distribution of all mail coming into the practice.

Home visits. It is important that home visits are undertaken at the most appropriate time. Each request is recorded and the receptionist makes an assessment about the urgency of the visit. Our written policy makes it clear that if the receptionist is in any doubt about the level of urgency then a doctor is informed forthwith. Information from visits is kept in the computer records.

Blood pressure/ smoking data recording is an essential element of our primary and secondary health prevention process.

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