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09 June 2014
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Q. At the ICGP AGM there was a discussion about a recent medico-legal case involving chickenpox in pregnancy. How can a GP hope to document in their practice software system the advice given during a consultation?

A. It is difficult to type in everything you do and say during a consultation, including the advice provided to the patient or parent. For childhood chickenpox, this might include advice on symptomatic treatment, when to seek medical review, how long to keep the child isolated and a specific enquiry about pregnant women, newborn babies or anyone with impaired immunity in the household or family. There
are different approaches to this problem.

The easiest is to provide a patient information leaflet for the specific condition, to document this in the consultation note and to keep copies of the information leaflet on file. Another approach is to create a template for the condition as a reminder to yourself of the questions to ask and the advice to give. Using the built-in feature on your GP practice software system or an-add on text expander software, you can trigger this template for the condition in question. So, for example, you could set up a text expander so that typing 'cpox' would input all the required text for a chickenpox in childhood consultation. Examples of text expander software for Windows include Phase Express and Breevy. Talk to your GP software vendor to check what is possible from within your software system and try the text expander free before you purchase it.