Abstract:
Following a patient’s visit to the GP for their patient 6-8 week baby check, I witnessed the GP use a pre-created format on SystmOne for this consultation. I recognise the importance of record keeping both in the GP clinical IT system and also the baby’s red book, and how this template ensures this expectation is met.
Completion of each section within the template ensures that all components of the NIPE infant 6-8 week baby check are done thoroughly. Due to its accessibility, I believe all doctors should be using this pre-created template to guarantee that all parts of the screening are completed accurately.
I decided to explore the GP clinical records for all 6-8 week baby checks completed in an 8 week period. Of the 20 baby checks completed, 9 records had this format completed following their appointment. A further 5 of those 20 baby checks have been recorded with an alternative but still sufficient template. However, I would like for this template to be the gold standard within the practice.
Ideally the standard of the template’s use should be 100%. I presented the data I found with the doctors at the surgery undertaking the 6-8 week baby checks, and have recommended the use of this template, including details of how to access it. I plan to review this data in 6 months.
After 6 months, I have gone through the SystmOne records, again looking at all baby checks completed in the prior 8 weeks. Of the 14 completed, 13 used the template sufficiently.
Overall, there has been a clear improved performance from a percentage achievement of 45% increased to 93%.
