Summary: An overview of how we receive medical records, physically and digitally, and how these records are processed.
Who’s it for: Medical Records Clerks & Summarisers
Glossary:
- GP2GP → how digital records are transferred between GPs
- Lloyd George (LG) → physical copy of medical records
Procedure
See the full process flowchart here, or follow the steps below.
Receiving Physical Records
Medical records clerk
- LG records arrive at the surgery from PCSE in a sack labelled with the site and date
- Acknowledge LG received on patient’s EMIS record
- If the patient is inactive ❌
Stick a yellow label on the box → ‘Inactive records to be returned’
Return the LG to PCSE → follow procedure for PCSE returns
If the patient is active ✅
Continue following the process under GP2GP 👇
GP2GP
Medical records clerk
- Check whether records were received via GP2GP
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- If yes to 1., check whether all digital data is on GP2GP (including notes summary)
- If yes, add Code 3 - ‘Notes summary’ to patient’s EMIS record
- Stick green label on the box → ‘Notes summary is ready for quality assurance’
- Complete quality assurance of the GP2GP summary and add Code 4 - ‘LG record destroyed’ to patient’s EMIS record
- Shred patient’s records and LG wallet
If no to 1. or 2., continue following the process under Digitisation & Summarising 👇
Digitisation & Summarising
If the LG wallet is large, records will be sent for third-party digitisation
- Add Code 1 - ‘LG record checked’ to patient’s EMIS record
- Stick blue label on box → ‘Records will be sent to Iron Mountain for digitisation’
When records return from Iron Mountain:
- Add Code 2 - ‘LG record received’ to patient’s EMIS record
- Stick orange label on box → ‘Records are ready for summarisation’
If the LG wallet is small, records will be digitised in-house
- Stick brown label on box → ‘Records will be digitised in surgery’
- Complete in-house digitisation
- Add Code 2 - ‘LG record received’ to patient’s EMIS record
- Stick orange label on box → ‘Records are ready for summarisation’
Summariser
For all records that required Digitisation & Summarising:
- Complete summarisation
- Add Code 3 - ‘Notes summary’ to patient’s EMIS record
- Stick green label on box → ‘Notes summary is ready for quality assurance’
Medical records clerk
- Complete quality assurance
- Add Code 4 - ‘LG record destroyed’ to patient’s EMIS record
- Shred patient’s records and LG wallet
Resources:
