Therapists will have varying levels of competence and access to resources needed to handle emergencies. An anaesthetist witha trained team and sophisticated equipment will have completely different preconditions for handling a patient in shock thana single foundation doctor located two hours away from the nearest hospital.
In different care settings, doctors must have varying approaches to the amountof medical risk they should take, based on their level of competence and the resources available. Alert information should therefore be described in neutral and precise terms in light of the situation at the time, without any recommendations to colleagues regarding how they should address later situations. A foundation doctor in a rural district should show extreme care in prescribing drugs to which the patient is allergic, while an anaesthetist in a hospital has all the necessary resources to handlea possible anaphylaxis.
In the Summary Care Record, alert information should be registered with the highest level of precision possible. For allergic reactions against medications,the product should preferably be entered, alternatively at the ATC level (Anatomical Therapeutic Chemical Classification System). A first-time reaction should be documented, ideally with the date, alternatively with the patient’s age at the timeof the reaction. It is also possible to note whether the information has been provided by the patient, his or her next of kin, patient records or test results, as well as the registering doctor’s opinion as to whether this isa suspected, likely or confirmed reaction. Thus, the information will be recorded with the prevailing degree of certainty, and the next doctor can use the information in light of the patient’s situation, availability of resources and medical risk. Alert information provides a better basis for this assessment than the classic «Cave Penicillin».
To alert new healthcare providers to a potential risk for the patient, it is essential that all doctors document alert information as soon as possible after becoming aware of this information. A new feature in the introduction of the Summary Care Record is that this information becomes available nationwide, and alert information will no longer restricted to separate electronic medical records in local institutions. It is thus essential for doctors to be consistent and use a standardised method for documenting the information, like the one we are now testing for the Summary Care Record. A revised standard for alert information will be submitted for a national hearing round in the autumn of 2014. In the longer term, the vision is for alerts to be automatically included in the ordinary documentationin the electronic medical record, thus eliminating the need for manually documenting alert information separately, as we are doing today.
For those who wish to try the new model, a demonstration version of the Summary Care Record is available on the web andvia Norsk Helsenett, the Norwegian Secure Health Network (7).