Foundations of General Practice : A workbook for nurses
Primary Care Data Quality Foundations
The Primary Care Data Quality Education is a CSIRO training program, funded by the Australian Department of Health, is designed to support healthcare providers to:
- improve use of clinical information systems
- enhance the usefulness of patient records
- improve interoperability and sharing, and
- support better healthcare outcomes for patients.
A series of resources have been developed Train IT Medical in collaboration with RACGP, ACCRM, AAPM, APNA and Aboriginal Community Controlled Health Organisations across Australia.
Data Quality Education for Primary Health Care Nurses
APNA is developing a series of online learning modules for primary health care nurses about data quality in MedicalDirector, BP Premier and Communicare.
These resources provide you with structured learning of coding clinical information, rather than ‘ad hoc’ on the go skill development. They have been designed to increase your confidence to code clinical information correctly and to support other clinical team members on best practice coding and help you implement change management strategies to improve coding within your workplace.
For more information go to the APNA online learning store
Why is this important?
High quality primary care data that conforms to national data standards will support better clinical outcomes, enhance the usefulness of the information in the practice record and improve the interoperability of health information shared with other health care providers and organisations.
Primary health care nurses frequently have a leadership or coordinating function in an organisation, which among other things includes the handling of health-related information. This may include performing data extraction and analyses for data quality improvement and population health (prevention) activities. In addition data searches are utilised to formulate structured Chronic Disease Management and Healthy Ageing support and care planning for patients.
Data quality and cleansing is very important.
Some of the key ways you can ensure your data is clean and up to date are by:
- Updating Allergies and adverse reactions
- Checking and confirming diagnosis listed
- Documenting reason for visit
- Updating medications and reasons for use
- Ensure consistent clinical terminology by utilizing drop down menus where possible – minimizing free text entries
- Archiving inactive patients
- Removing multiple sample patients
- Merging duplicate patient records
- Maintaining recall lists
- Completing and clearing outstanding ‘actions’ or ‘requests’ etc
Improving data quality is a core foundation to ensure interoperability and meaningful use of information whether it is for individual or population management, point to point or point to share communication, decision support or analytics.