TY - JOUR T1 - A simple approach to improve recording of concerns about childmaltreatment in primary care records: developing a quality improvement intervention JF - British Journal of General Practice JO - Br J Gen Pract SP - e478 LP - e486 DO - 10.3399/bjgp12X652346 VL - 62 IS - 600 AU - Jenny Woodman AU - Janice Allister AU - Imran Rafi AU - Simon de Lusignan AU - Jonathan Belsey AU - Irene Petersen AU - Ruth Gilbert Y1 - 2012/07/01 UR - http://bjgp.org/content/62/600/e478.abstract N2 - Background Information is lacking on how concerns about child maltreatment are recorded in primary care records.Aim To determine how the recording of child maltreatment concerns can be improved.Design and setting Development of a quality improvement intervention involving: clinical audit, a descriptive survey, telephone interviews, a workshop, database analyses, and consensus development in UK general practice.Method Descriptive analyses and incidence estimates were carried out based on 11 study practices and 442 practices in The Health Improvement Network (THIN). Telephone interviews, a workshop, and a consensus development meeting were conducted with lead GPs from 11 study practices.Results The rate of children with at least one maltreatment-related code was 8.4/1000 child years (11 study practices, 2009–2010), and 8.0/1000 child years (THIN, 2009–2010). Of 25 patients with known maltreatment, six had no maltreatment-related codes recorded, but all had relevant free text, scanned documents, or codes. When stating their reasons for undercoding maltreatment concerns, GPs cited damage to the patient relationship, uncertainty about which codes to use, and having concerns about recording information on other family members in the child’s records. Consensus recommendations are to record the code ‘child is cause for concern’ as a red flag whenever maltreatment is considered, and to use a list of codes arranged around four clinical concepts, with an option for a templated short data entry form.Conclusion GPs under-record maltreatment-related concerns in children’s electronic medical records. As failure to use codes makes it impossible to search or audit these cases, an approach designed to be simple and feasible to implement in UK general practice was recommended. ER -