Filenews 5 December 2020 - by Marilena Panagi
Detailed data recording, justification of the decision of the personal doctor to issue a complaint to a specialist doctor or for laboratory or other diagnostic tests and description of the clinical image of the patient, now requires the computer system of the General Health System since the OAC, implementing its decisions, proceeded to change the relevant settings in the system software in an effort to put an end to the bad habits of beneficiaries and doctors of the GHS.
The need for the new arrangements arose from the OAC's findings, which were the result of an evaluation of the daily entries in the GHS software and the complaints of the system's own doctors about the mentality of a large number of their patients, who require the issuance of referers without this being decided or deemed necessary by them.
It is also indicative of the fact that, at international level and where the institution of a personal doctor is applied, the proportion of patients referred to the various medical specialties does not exceed 20%-25% while in the GHS it is recorded from the day of the implementation of the System, which is 70%.
Typical and the findings of the OSB for a huge number of referals bearing exactly the same justification, since in too many cases, the same general code concerning "health support/preventive medicine" is used.
As the director of the OAC Konstantinos Panagidis told "F", "with the new arrangements we are trying to stop the habits of several beneficiaries who are using the services of their personal doctors in the wrong way and are probably abusing the services offered to them by the GHS but also to somehow "force" doctors not to issue complaints if their extradition is not judged by them".
At the same time, "we also aim to improve the quality of services because through the detailed data recording, our doctors, personal and specialists, acquire better communication with each other, are better informed about the condition of their patients and in the end may be discharged from the GHS and by unnecessary retests for the same health problem concerning a patient".
At the same time, said Mr Panagidis, "a process is under way for additional changes, such as reducing the number of visits to be entitled in the first place to specialist doctors".
Currently the referents include three visits to a specialist doctor of this specialty. From the entries in the software, however, it is found that in several cases the same patients visit with the same referral, three different doctors of the same specialty who refer him to the same or different laboratory or diagnostic tests.
New instructions to doctors
• Doctors are invited to encode/record diagnoses and clinical notes so that they are complete, complete and clear and reflect the clinical picture of the patient as it is formed following the taking of the history, clinical examination and control carried out.
• Completion of the field of clinical notes on visits is mandatory. Clinical notes should be clear and sufficient to justify any further actions, such as referrals, prescription versions and any activities. They must also be complete, integrated and facilitate effective and two-way communication between providers.
Among other things, the reason for the visit should be indicated.
• Record the symptomatology and its characteristics.
• Provide information from the recording of the examination and from the findings during the investigation. Since the clinical picture is not always static but changes its evolution and recording in clinical notes it is necessary to have a measure of comparison in the course of the disease since the failure to record information from each examination reduces the level of health care.
Where communication between providers is applied, it must be two-way, so that there is full consultation within the framework of review and regular medical monitoring.
• Referral to a specialist is complete only when there is a clear answer to the reason for referral, as well as the recorded planning for review and regular medical monitoring.
The findings of the specialist doctors should be recorded in precision and detail in order to provide appropriate information to the cat who issued the relevant complaint and also to be used by other providers who may be monitoring the beneficiary.
For each referral, the necessary medical information, justification based on medical indications and diagnostic thinking (i.e. the reason for the referral) must be recorded.
