Introduction

Rosmellyn Surgery in Penzance has been benefitting from Microtest’s Major Headings’ functionality for Read coding in order to carry out efficient QOF coding and Enhanced Services claiming, as well as to provide other administrative information. The Major Headings module was designed by the team at Microtest to streamline and standardise claiming and recording within practises, by restricting the picking list and helping clinicians to easily pick the correct Read code. A number of surgeries in Penzance now use Major Headings and, as some staff work across numerous sites, the same set up can be copied across the group. The standardised system for logging work and claiming payments enables greater efficiency and collaboration across sites.

Easier for staff

Trina Williams, the Clinical System Manager at Rosmellyn Surgery, says: “We find the Major Headings functionality really useful. It means that our Read coding is consistent for everyone in the practice. We have set it up so that a keyword is used and this means we do not need to try to remember Read codes, which is of course a lot easier for everyone.”

Saving time for clinicians and administrative staff

Trina explains “When a clinician is typing within a patient record, by hitting the # key it takes them into the coding box in the history module, so they can start typing the first few letters of a word into the major heading box, which will be linked to the Read code. When you return to the consultation note, the Read code is incorporated. It is a much more efficient way of working as it saves typing time, and clinicians are Read coding at the same time. It has also standardised and streamlined the process, as clinicians using the correct code” This new improved “setting up” process of Major Headings is moving to Evolution and will appear very shortly as part of the Open Evolution.

Multiple codes

Trina adds: “You can also set Major Headings up for multiple codes which is really handy. For example, we have the heading of “smoke” to which the relevant QOF smoking Read codes are attached. You choose the code from the list – which includes current smoking habit and cessation advice if needed – and it is incorporated into your consultation note as well. Another extremely useful feature is that we can code multiple records in one go from a search result. For example, with our chronic disease register invites – we add the codes of 1st, 2nd and 3rd invites with one click of the mouse.”

Quick to set up

“A Major Heading is quick to set-up,” says Trina. “I get frequent requests from doctors, nurses and receptionists to set one up. We discuss which word should be used; for example, we have set up a heading called “decline” which has multiple vaccination decline codes attached, including the correct “declines flu” code.”

More efficient claiming – no more trawling through clinics to find claims

At the end of each month, Trina carries out pre-scheduled searches using the codes linked to the Major Headings to assist with Enhanced Services claims. Trina explains: “This is particularly useful for the numerous claims for the pre/ post op work we carry out for secondary care. One word is linked to multiple different codes and so you simply choose the code you need from the drop down list. It also really comes into its own with coils, implanons, minor ops, joint injections and so on, as the clinician simply codes as they do the work. This means there is no need for administration staff to trawl through clinics trying to find claims, because the clinician is doing this as they go along, rather than the administration staff having to do it for them. This saves back office time and is simple but really effective, so you are claiming for all the work carried out and nothing is getting missed. Even our doctors who are most ‘allergic’ to computers really appreciate this solution!”