New Patient Check City and Hackney

Transcription

1 Template Control Page New Patient Check City and HackneyTemplate Guide Title New Patient Check City and Hackney Author CEG Status Active Date September 2016 DOCUMENT MANAGEMENT REVISION HISTORY Version Date Summary of Changes 1.0 July 2013 The version number starts at 1.0 to reflect the rationalisation process. August 2013 In City and Hackney Version only: Additions: Text information about INSTI tests. Added RIVA library item. 2.0 Nov 2013 Addition of TB screening page 1 September 2016 NEW TO THE EMIS LIBRARY Added Protected Characteristics Library. Added Accessible Information Library. Replaced TB with TB library. Replaced Mammography page with Mammography library. Deleted old codes for shared electronic record Added pulse irregularly irregular Updated information re bowel screening programme Updated contraception Removed rubella screen Added Accessible Information library. AUTHORISATION Reviewed by Approved by Date Katherine Nishikant Dr Sally Hull / Dr Kambiz Boomla July 2013 Luis Rivas Dr Sally Hull August 2013 Luis Rivas Dr Jose Figueroa Nov 2013 EMIS Web Library Items Lifestyle Intervention CEG 1.0 Protected Characteristics Accessible Information Mammography Physical activity Cervical Smear CEG 1.0

2 Ethnicity CEG 1.0 Contraception status and advice CEG NHS Screening and health programmes info 2

3 New Patient Check City and Hackney Template Guide New Patient Check New patient screen done Did not attend new patient screening Shared electronic record Consent SMS text messaging 68R2 9OWA Picking List: Consent given for electronic record sharing (9Nd7) No consent for electronic record sharing (9Nd1) Consent given for communication by SMS text messaging (9NdP) Declined consent for short message service text messaging (9NdQ) 9344 Notes summary on computer Is a carer 918G Up to date with immunisations? Examination Yes/No Prompt. Choose from: Yes (68N1) No (68N2) Text line O/E height 229 Enter the value for height Examination O/E weight 22A Enter the value for weight Examination Waist Circumference 22N0 Enter value for waist circumference (cms) Examination Body Mass Index 22K Calculated by EMIS if requested Examination Diet Advice: brief 8CA4 intervention Systolic BP 2469 Systolic blood pressure value Examination Diastolic BP 246A Diastolic blood pressure value Examination Peak exp. flow rate: 3395 Enter value Examination PEFR/PFR Predicted peak flow 339H Enter value Examination For Those Aged 65Y and Over [Visibility Rule on the next 3 prompts: will only show for patients aged 65Y and over.] O/E - pulse rhythm O/E - pulse rhythm regular (2431) Examination O/E - irregular pulse (2435) O/E - pulse irregularly irreg (2432) O/E pulse rate 242 Enter the value Examination Refer for ECG 8HR1 Refer for ECG recording (8HR1) FAMILY HISTORY PAGE 3

4 Family FH: IHD<60 First Degree Relative? FH: Diabetes First Degree Relative? 12C2 Yes/No Prompt. Choose from: FH:IHD<60 (first degree relative) (12C2) No FH: IHD (1226) Text line: Family Member 1253 Yes/No Prompt. Choose from: FH: Diabetes (first degree relative) (1253) No FH: Diabetes (1228) Family Family Text line: Family Member FH of Ischaemic Stroke/TIA FH: CVA/stroke 12C4 Text line: Family Member Family No FH: Stroke/TIA 1225 Family LIFESTYLE INTERVENTIONS PAGE (add here) SCREENING INFO AND RISK SCORES PAGE Risk Scores [Visibility Rule on this : will only show for patients aged 40Y 80Y inclusive.] QRisk 10 y CVD Risk 38DP Calculates the risk of developing CVD in the next 10yrs Assessment QDScore 10 y risk EMISNQQ D1 Calculates the risk of developing diabetes in the next 10 years NHS Screening/Health Programmes Info Text Info National Cancer Screening Programme Please reinforce the NHS screening programmes to eligible patients. Remind patients about cancer screening: - Ask when last attended screening/completed a test kit. - Report possible cancer symptoms without delay. Cervical Screening Every 3 years for women aged Every 5 years for women aged At age 65 years: routine cervical screening ceases. Women over 65 should be screened if: - they have not had a smear since the age of 50 - a recent cervical screening test has been abnormal Cervical screening does not stop until a woman with a previously abnormal result has had 3 negative results. Assessment Breast Screening Every 3 years for women aged 50 and over. Tel.No: CELBSS Bowel Screening Every 2 years for those aged (Those aged are sent a self-test kit.) People over 74 can request a self-test kit. Tel.No: (Demonstrate the kit and check that the correct address/phone number are recorded to ensure delivery of invitations.) Abdominal Aortic Aneurysm Screening Once for men aged 65. 4

5 Antenatal & Newborn Screening For pregnant women. NHS Health Checks Every 5 years for those aged Shingles Immunisation A single injection for those aged 70 and over. Pneumonia Immunisation Once every 10 years for those ages 65 and over. Seasonal Influenza Immunisation Every year for those aged 65 and over and all those in an at risk category. Hepatitis B Green Book Hep B Imm Guidance Text Info Hyperlink Hepatitis B immunisation For those at increased risk of contracting Hepatitis B. (Occupational, travel, lifestyle considerations.) s-b-the-green-book-chapter-18 MAMMOGRAPHY PAGE [Visibility Rule on this page: will only show for female patients aged 50Y and over.] Mammography Mammogram done 537 Tooltip: Enter the date of the mammogram if one has been done (i.e. not today s date). Mammography normal (5372) Mammography abnormal (any abnormality) (5373) Mammography declined 9OHD Mammography not attended (5375) Tooltip: Indicates that the patient has decided to opt out of the programme Examination Assessment Bilateral mastectomy Assessment FH of breast cancer 1243 Family Health Ed- breast 6795 examination Next screen due 537 Tooltip: Enter the due date of next mammogram. Three years if previous mammogram was normal. SEXUAL HEALTH Screening Chlamydia/Gonorrhoea Chlamydia test offered (9Oq0) screening Chlamydia screening declined (8I3T) Info When offering an INSTI test, please fill in the screening offered prompt below and then add the INSTI test results HIV screening HIV screening offered (9Op0) HIV screening declined (8I3p) Hepatitis B screening Hepatitis B screening offered (9Op2) Hepatitis B screening declined (8I3u) Contraception status and advice Visibility rule: Female aged CEG 5

6 Contraception counselling 6777 Contraception method Intra-uterine contr. Device 61K.. Subcutaneous contraceptive Oral contraceptive 61N.. Transdermal contraceptive 61B.. Depot contraceptive 61c.. Barrier contraception method 61G.. Contraception: vasectomy Contraception: 61H.. Contraception: female sterilis No contraceptive precautions Contraception not needed Text line General contraceptive 611 advice LARC advice 8CAw Pre-pregnancy 676 counselling Info Check Rubella titre as part of preconception advice Testicular Information [Visibility Rule on this : will only show for males aged 15Y 50Y inclusive.] Testicular Information Hyperlink Leaflet INSTI (RHIVA) Non-reactive rapid HIV antibody test EMISNQN 026 Reactive rapid HIV antibody test Invalid rapid HIV antibody test Indeterminate rapid HIV antibody test Info HIV Screening Test Declined EMISNQR E117 EMISNQI N62 EMISNQI N61 43C1 For all Reactive or Indeterminate RHIVA test results, please refer to GP and send a blood test for serology INVESTIGATION REQUESTS/RESULTS PAGE Text Info Please request the following investigations as clinically appropriate. Text Info For Diabetes: Cholesterol HBA1C egfr Urine ACR/PCR For Hypertension &/or CKD: Cholesterol egfr Urine ACR/PCR For Thyroid disorders: TFT For those who may be anaemic: Hb Ferritin 6

7 Serum cholesterol 44P Enter the value. Serum 44lF Enter the value. cholesterol/hdl ratio HbA1c (IFCC) 42W5 Enter the value. egfr 451E Enter the value. Urine 46TC Enter the value. albumin:creatinine ratio Urine protein/creatinine ratio 44lD Enter the value. Serum free T4 442V Enter the value. Serum TSH 442W Enter the value. Haemoglobin 423 Enter the value. estimation Serum ferritin 42R4 Enter the value. Rubella Titre Picking list: Rubella antibody absent (4392.) Rubella antib. present immune (4393.) DEMENTIA SCREENING PAGE HIGH RISK TB PAGE ES Info Target population a) Entered UK within last 5 yrs from a high risk country (Sub- Saharan African or countries with an annual incidence >150/100,000 OR b) Other high risk groups (homeless/drug users/those released from prison). AND Aged years No history of TB either treated or untreated Never screened for TB in UK Link to gov.uk website Hyperlink 7

8 Text info Country of birth 65Y9 A picking list Ethnicity A picking list Date of entry to UK 1L5 Date prompt Tuberculosis contact 65P2 **Consent to share Consent to share pt data with national latent TB screening patient data with national latent TB screening programme prog. (EMISNQCO246) Declined consent to share pt data with national latent TB screen (EMISNQDE65) Positive LTBI Referral Info Positive LTBIs to be referred for treatment Referral for treatment IGRA Test **Interferon Gamma test (T-spot) Interferon Gamma Positive Interferon Gamma Negative Interferon Gamma Indeterminate Mantoux Test Picking List: Referral to respiratory nurse specialist (8HHJ) Referred to chest physician (8HC4) 42YL Tick Box and Date Prompt Test 43bL Tick Box and Date Prompt 43bK Tick Box and Date Prompt 43bJ Tick Box and Date Prompt **Mantoux test done 3321 and Date Prompt Test Mantoux Test Mantoux: negative (3323) Mantoux: positive (3325) PROTECTED CHARACTERISTICS PAGE 8

9 Info One of the additions to the clinical commissioning and engagement contract is a requirement for practices to request that newly registered patients complete a form to collect and record protected characteristics (including disability, gender reassignment, ethnicity, etc.) Disability Info Under the Equality Act 2010, you re considered disabled if you have a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities. long-term means 12 months or more substantial is more than minor or trivial, e.g. it takes much longer than it usually would to complete a daily task like getting dressed Disabled 13VC. Disability status not 13VC6 given - patient refused Ethnicity Info Make sure the Ethnicity page has been used to record patient s ethnicity Ethnic group not given 9SD.. - patient refused Religion/Beliefs Religion 135% Selective browser Religion not given - patient refused Gender Gender reassignment patient Sexual Orientation Sexual orientation Sexual orientation not given 135Q. Info Gender male/female is already recorded via the Registration module. You can use this to record that a patient has changed gender. 1K4.. Bisexual (1b0) Heterosexual (1b1) 1b20. Lesbian 1b21. Male homosexual 1b4 ACCESSIBLE INFORMATION PAGE 9