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A simple approach to improve recording of concerns about child maltreatment in primary care records: developing a quality improvement intervention.

Woodman, J; Allister, J; Rafi, I; de Lusignan, S; Belsey, J; Petersen, I; Gilbert, R; RCGP Multisite Safeguarding Audit (2012) A simple approach to improve recording of concerns about child maltreatment in primary care records: developing a quality improvement intervention. Br J Gen Pract, 62 (600). e478 - e486. ISSN 0960-1643 https://doi.org/10.3399/bjgp12X652346
SGUL Authors: De Lusignan, Simon

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Abstract

Background: Information is lacking on how concerns about child maltreatment are recorded in primary care records. Aim: To determine how the recording of child maltreatment concerns can be improved. Design and setting: Development of a quality improvement intervention involving: clinical audit, a descriptive survey, telephone interviews, a workshop, database analyses, and consensus development in UK general practice. Method: Descriptive analyses and incidence estimates were carried out based on 11 study practices and 442 practices in The Health Improvement Network (THIN). Telephone interviews, a workshop, and a consensus development meeting were conducted with lead GPs from 11 study practices. Results: The rate of children with at least one maltreatment-related code was 8.4/1000 child years (11 study practices, 2009–2010), and 8.0/1000 child years (THIN, 2009–2010). Of 25 patients with known maltreatment, six had no maltreatment-related codes recorded, but all had relevant free text, scanned documents, or codes. When stating their reasons for undercoding maltreatment concerns, GPs cited damage to the patient relationship, uncertainty about which codes to use, and having concerns about recording information on other family members in the child’s records. Consensus recommendations are to record the code ‘child is cause for concern’ as a red flag whenever maltreatment is considered, and to use a list of codes arranged around four clinical concepts, with an option for a templated short data entry form. Conclusion: GPs under-record maltreatment-related concerns in children’s electronic medical records. As failure to use codes makes it impossible to search or audit these cases, an approach designed to be simple and feasible to implement in UK general practice was recommended.

Item Type: Article
Additional Information: PMCID: PMC3381274
Keywords: Age Distribution, Child, Child Abuse, Clinical Coding, England, General Practice, Humans, Medical Audit, Medical Records, Physician's Practice Patterns, Quality Improvement
Journal or Publication Title: Br J Gen Pract
ISSN: 0960-1643
Dates:
DateEvent
1 July 2012Published
PubMed ID: 22781996
Web of Science ID: 22781996
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URI: https://openaccess.sgul.ac.uk/id/eprint/102264
Publisher's version: https://doi.org/10.3399/bjgp12X652346

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