Patient's electronic medical records - Abigail's story

1. St Petersburg April 26th 2018
"Patient's electronic medical records - Abigail's
story“
Abigail Davies Pupil at Simmondley Primary
School
Edna Davies Mother of Abigail Davies
Dr Richard Fitton

2. Abigail

3. Abigail’s premature birth and
perinatal problems
• Abigail is 11 years old. She had twin delivery at
26 weeks of gestation.
• Abigail suffered intra-cerebral haemorrhages
leading to - cerebral palsy, spastic quadriplegia
– presenting high tone in all four limbs and
low tone in the torso”.

4. Abigail – has many professionals involved in
her care who could benefit from a shared
NHS Patient On Line record:
• Her GP,
• School special educational needs coordinator,
community paediatrician,
• physiotherapist,
• occupational therapist,
• orthotics,
• wheel chair service,

5. Abigail – has many professionals involved in her care
who could benefit from a shared NHS Patient On Line
record:
• upper limbs specialist,
• specialist hand occupational therapist,
……..lower limb specialist,
• specialist teacher for children with physical
needs,
• moving and handling advisor,
• inclusions officer
• and social worker.

6. Physiotherapists and Occupational
therapists
Physiotherapist (physio) – Looks after gross
motor skills, creates programs for and
monitors progression of moving and handling
Occupational Therapist (OT) – Looks after fine
motor skills, seating position, and advises on
aids to help dressing, eating, washing and
other day to day operations of life.

7. Checking and completing Abigail’s
medical record
Edna checked the contents of Abigail’s medical
record. Edna notified the GP of the inaccuracies
and a more accurate and complete record was
achieved.

8. 25% of patients in England use “Patient On
Line”.
“I am a working mum looking after a small child,
““I order my prescriptions, book my
appointments to see the doctor and checks my
test results on line. “
NHS Patient on line.
https://www.england.nhs.uk/patient-online/

9. Edna’s mobile phone screen
shots icon and welcome page

10. Edna checking Abigail’s summary
One entry stated that Abigail has learning
difficulties.
She does not.
This was corrected.

11. Mum checking the summary
Abigail’s twin birth was not in Abigail’s summary.
This was added.
Abigail’s notes entry “congenital cerebral palsy”
was incorrect.
This was corrected

12. Codes we found to complete the summary in
Abigail’s record
1. Severe mobility issues and is a wheel chair
user.
ZV462“Dependence on Wheelchair”
2. She crawls as a mode of mobility Around the
house,
N097 “difficulty in walking”

13. Codes we could not find to complete
the summary in Abigail’s record
4. She can self-transfer into seating – nothing
suitable found
5. She can now get up against a settee and turn
and sit - nothing suitable found

14. Conclusion
Patients may check and share the record with
whoever they wish.
Codes to represent all types of impaired function
are not yet available in the GP record.
We would like the conference to ask the UN to
include record access in the UN standard for
rehabilitation.

15. Thank You Abigail and Edna….