We all know the importance of keeping good records, and now GPConsult.co.uk makes it easier than ever for doctors to make clear, timely patient notes. GP Dr Rima Aboud talks about her experience with record keeping and how this new resource can help.
Good medical records are essential for the continuity of care of patients and play a vital role in responding to a complaint or defending a clinical negligence claim. If a complete and accurate medical record is documented, it can make all the difference. Most medicolegal cases focus at some level on the availability of medical records and their contents, so they can make the difference between whether a case is defendable or not.
I’ve always been very aware of how important it is for me to take the time to document every discussion I’ve had with a patient, every examination I’ve carried out and any action plan that’s been put in place. It creates a lot of work and takes time but ultimately it is best practice. Prior to becoming a GP I worked as an engineer, so I am always interested in utilising technology in medical practice.
GPConsult.co.uk was created by me and a GP/pharmacist colleague, Dr Paul Ryan, in order to make our working lives easier while still practising safe medicine. It started as short summaries of UK relevant guidelines but has now grown to templates that incorporate history, examination and management plans, including relevant red flags to look out for. The templates are based on everyday conditions seen in general practice.
Once logged in to GPConsult.co.uk, GPs can search through a range of categories, such as Respiratory, ENT and Cardiology. Each category contains templates including relevant questions to ask the patient as well as treatment plans for a number of symptoms and conditions. The GP can quickly browse the relevant template, depending on what the patient presents with, and can copy the template into their patient management software system to help keep an accurate and concise record of the consultation.
GPs can also add their own tips and advice for any of the templates published. We have a team of GP moderators who ensure that any advice submitted is evidence-based and relevant before we add it to the existing template.
Feedback from GPs who use the site has been overwhelmingly positive, as the templates and treatment plans can save them up to three minutes per consultation. There is also a great sense of camaraderie and a willingness from GP users to share information between one another. GPs and GP trainees who register will be joining a community of GPs who want to make the working lives of their peers easier and safer. They do this by sharing knowledge that they have accumulated from their own experience in practice. GPConsult’s aim is to guide GPs, to save them time and to enable them to learn from their peers. I hope to see it grow and become a resource that can not only help GPs but also improve patient care throughout the UK.
GPConsult.co.uk is a free resource available to all members of Medical Protection. Simply visit gpconsult.co.uk to sign up.