The Primary Care Trigger Tool

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1 The Primary Care Trigger Tool Example of a General Practice Medical Record Mr. Joe Bloggs, D.O.B. 01/01/1935 This fictional medical record is intended to be used as part of the practical training in the use of the trigger tool method. It purposefully imitates an authentic printed summary sheet that the vast majority of practices generate on a daily basis. The correspondence and investigation results that are included have been designed to represent printed copies of documents as they would commonly be used in Scotland s general medical practices. The following should be taken into consideration when attempting a review: Review only the three full calendar months February-April 2010 The maximum time limit of this exercise should be twenty minutes Record extracted data on a trigger tool proforma. Incidental findings and descriptions can be entered into the space provided. The trigger tool process is described in a separate guide. Some of the key points were: The focus is harm, not error. You do not necessarily have to find every trigger. Most harm incidents will have more than one trigger helping to detect it. The trigger tool review process may be facilitated by remembering five questions: Can a trigger(s) be detected? Did harm occur? What was the severity of the harm? Was the harm incident preventable? Where did the harm incident originate? A full discussion of the practical findings of this case, including the number and type of triggers and harm events are available. Disclaimer This complete medical record is fictional. It was created by NHS Education Scotland to support training in the use of the Trigger Tool method. The patients, healthcare professionals, providers and all other persons referred to are entirely fictional. Any resemblance to any person (living or dead) is entirely unintentional. This training material is the property of NHS Education Scotland and may be used free of charge on request from 2010 NHS Education Scotland The Primary Care Trigger Tool: Clinical case study

2 Registration Mr. Joe Bloggs Service Code: Permanent Resident 23 Main Street D0B: 01/01/1935 FORTH, LANARK Age: 75 Telephone: Contact: Mr. Bloggs ContactRelship: Son ? CHI Number: NHS Number:? Dispensing: No Patient ID: Road: 0 Water: 0 FootPath: 0 Occupation: Pensioner Marital Status: Single Registered GP: Dr Carl De Wet Seen By GP: Dr Carl De Wet Repeat Consultation:? Acute Consultation: 02/06/2010 Registered: 21/01/2008 Confirmed: 29/01/2009 Records Received:15/02/2009 BMI: 15.2 Height: 1.83 m Weight: 51kg BP: 155/95 Parity: 0 Gravida: 0 SCI-DC Consent Given: Yes Priority Clinical I User Marker Date Recorded Start Date Priority Description Modifier 23/06/2009 None High Atrial Fibrillation 04/03/2008 None High Chronic obstructive pulmonary disease 23/07/2005 None High Glaucoma 28/03/2003 None High Upper Gastrointestinal endoscopy Freetext: gastritis, hiatus hernia 05/03/2002 None High Freeman total replacement of hip joint using cement Freetext: left Repeat Medication Intervals Drug/Preparation Quantity/Dose/Freq Start Last Pres. Review CMS Int. Verapamil Hydrochloride Mr CAPS 28 dly 23/06/ /06/ d 26w w. Ventolin Evohaler 200 Dose Cfc 1 as required -2 puffs 04/03/ /05/ d 52w w. Seretide 100 Accuhaler6o Dose 1 2 puffs 2x day 04/03/ /05/ d 52w w. Warfarin Sodium TABS 5MG 112 As directed 08/08/ /06/ d 52w w. Warfarin Sodium TABS 3MG 112 As directed 08/08/ /02/ d 52w w. Warfarin Sodium TABS 1MG 112 As directed 08/08/ /02/ d 52w w. Tiotropium Combopack 18 ug Caps 30 1 puff dly 28/01/ /04/ d 52w w. Xalacom Eye DROPS 2 1 drop both eyes night 14/09/ /06/ d 52w w. Aspirin disp. 75 mg 56 1 tab mornings 23/06/ /06/ d 52w w. Paracetamol TABS 500MG tabs 4x day 24/08/ /06/ d 52w w. Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 2

3 Adverse Reactions Read Code Description Clinical I User Marker Date Recorded Start Date Priority Description Modifier 28/05/2010 None Low Alcohol intake above recommended sensible limits 28/05/2010 None Low Assessing cardiovascular risk using SIGN score 28/05/2010 None Low Avoids even trivial exercise 28/05/2010 None Low Chronic obstructive pulmonary disease annual review 28/05/2010 None Low Current smoker 28/05/2010 None Low FH: Diabetes mellitus in first degree relative 28/05/2010 None Low Influenza vaccination 28/05/2010 None Low Smoking cessation advice 20/08/2009 None Low Lifestyle counselling 20/08/2009 None Low FH: lschaemic heart disease 20/08/2009 None Low Pneumococcal vaccination declined 20/08/2009 None Low Chronic obstructive pulmonary disease annual review 20/08/2009 None Low Smoking cessation advice 20/08/2009 None Low Alcohol intake above recommended sensible limits 20/08/2009 None Low Atrial fibrillation 20/08/2009 None Low Avoids even trivial exercise 20/08/2009 None Low Chronic obstructive pulmonary disease 20/08/2009 None Low Diabetes mellitus in first degree relative 20/08/2009 None Low lschaemic heart dis. >60 20/08/2009 None Low Influenza vaccination declined 20/08/2009 None Low Low MRC Breathlessness Scale: grade 3 20/08/2009 None Low Negative reversibility test to salbutamol 20/08/2009 None Low Pneumococcal vaccination declined 20/08/2009 None Low Low Refer to physiotherapist 20/08/2009 None Low Low Expected FEV1 20/08/2009 None Low Inhaler technique - good 20/08/2009 None Low Assessment of needs 20/08/2009 None Low Medication review done 20/08/2009 None Low Low Forced expired volume in 1 second Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 3

4 20/08/2009 None Low COPD self-management plan given 03/04/2008 None Low Chronic obstructive pulmonary disease annual review 03/04/2008 None Low Current smoker 03/04/2008 None Low Health education - chronic obstructive pulmonary disease 03/04/2008 None Low Smoking cessation advice 02/05/2007 None Low Sigmoidoscopy haemorrhoids Acute Prescriptions Drug/Preparation Quantity/Dose/Frequency Date Terbinafine Hydrochloride CREAM 30 apply twice dly 28/05/2010 Ciprofloxacin TABS 500MG 14 1 Tab Twice daily 28/01/2010 Ciprofloxacin TABS 500MG 14 1 Tab Twice daily 06/03/2008 Amoxicillin TABS 500MG 21 1 Tab Three times daily 04/03/2008 Inactive Repeat Drugs Drug/Preparation QuantitylDoselFrequency Start Last Pres Review CMS Int. Timolol eye DROPS 2 1 drop left right nocte 23/07/ /08/ d 26 w. Last Encounter Dr. Carl de Wet Date: 28/05/2010 New rash in groin - itchy. Generally well. ex - erythematous rash Imp - tinea corporosis Plan - top treatment Screening None Referrals Date Rec Priority Ref. appt Provider Specialty Reason for referral Ref. by Attendance 24/06/2009 Routine WGH Cardiology New AF GP Clinc Active Care Management Type Name Last Review Recall Next review Num Session Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 4

5 Acute/Inactive Care Management Type Name Last Review Recall Next review Num Session Acute 1 st SPICE Index 28/05/2010 N/A N/A 4 Chronic SPICE smoking 28/05/2010 Active 3 Chronic SPICE basic health values 28/05/2010 Inactive 3 Chronic SPICE COPD 20/08/2009 Inactive 3 Palliative Care Associates Title Forename Surname Relationship Relationship Type Associate Of Title Forename Surname Relationship Relationship Type Clinical Values Date Value Type Value 28/05/2010 Diastolic 95 09/09/2008 Height /05/2010 Systolic /03/2010 Weight 51 04/03/2008 ASSIGN CVR 6 F3 Clinical Notes Date Con Prov F3 Clinical Notes 28/05/2010 GP New rash in groin - itchy. Generally well. ex - erythematous rash with central clearing Imp - tinea corporis Plan - top treatment 15/05/2010 PN INR check General review - SPICE 17/04/2010 PN INR check 04/04/2010 PN INR BP 155/95 Inhaler check 22/03/2010 PN INR check Dressing changed 15/03/2010 PN Dressing on knee changed. No sign of infection and swelling much better. Patient is able to walk with a stick. INR checked Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 5

6 05/03/2010 PN Fell two days ago and injured left knee. Been to A+E and got x/r (told normal ). Knee is swollen, with a few lacerations. Plan - dressing and compression bandage. INR checked 28/02/2010 PN sister brought patient. Seems more unsteady. INR checked. 22/02/2010 PN INR check Just out of hospital - still coughing but generally better BP 155/98 04/02/2010 GP Worsening SOB, green sputum Ex - RR 36/min, coarse bilat creps Plan - continue oab, smoking cessation advice, advised to increase inhaler use 02/02/2010 GP Lab phoned - INR 6.5 Plan - phoned patient and advised to STOP Warfarin, PN review 3/7 for INR 02/02/2010 PN INR check Pt taking antibiotic for chest infection 28/01/2010 GP Increasing cough, dirty sputum (no blood), tiredness and wheeze for few days. Ex - Sa02 98%, RR26/min with bilat coarse creps and wheeze Imp - infective exac of COPD Plan - oab and review as needed 15/12/2009 PN INR checked Considering holiday with relatives down south - request extra inhaler 10/11/2009 PN INR check 15/09/2009 PN INR check 02/09/2009 PN INR check 20/08/2009 PN INR COPD review - inhaler technique checked. Smoking cessation - pt not keen at present INR bloods. BP 155/ /08/2009 GP Cardiology review - pt for Warfarin - to be commenced in clinic with GP f/u after. 23/06/2009 GP ECG confirms AF. Bloods normal. Plan: b-blocker relative ci - start Aspirin and ca-blocker, cardiology review?warfarin 20/06/2009 PN ECG and bloods done 18/06/2009 GP Increasing SOB but no change in sputum. 0cc palpitations. Examination - pulse> 100, irregular, BP 155/95 IMp - AF Plan - PN for bloods, ECG and review 06/03/2008 GP New rash and worsening SOB. Ex - maculo-papular rash, RR 32/mm Imp -?allergic reaction to penicillin Plan - stop Amoxicillin - start Ciprofloxacin 04/03/2008 GP Increasing SOB, sputum and generally unwell. Recent spirometry indicates likely COPD. Smoker for many years. Ex-miner. Ex - p80 Resp coarse creps bilateral Imp - Infective exacerbation of COPD Plan - smoking cessation advice, oral antitiobic Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 6

7 Dear dr. de Wet 19/11/ M 01/01/1935 BLOGGS JOE 23 MAIN STREET FORTH LANARK CHI ML11 Jane Smith Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 7

8 02/03/ :25 Joe Bloggs ID o5o5555 Sex: Male Age: 73 Factor: 100(Caucasian) Height: 1.83 Weight 57kg Smoking: Current smoker Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 8

9 SS/CC/ CHI No: Dictated: 15/07/2009 Typed: 29/07/2009 Dr. C. de Wet, Wellcome Practice, FORTH Dear dr. de Wet Re. JOE BLOGGS, 23 Main Street, FORTH. Date of Birth 01/01/1935. Hospital Number:, CHI no Atrial fibrillation Thank you for your referral of this 74 year old patient with a new diagnosis of atrial fibrillation. You have commenced him on Verapamil which seems to control his heart rate satisfactorily and he has had not had any complications. We have today discussed his options with him and with his sister. He is not suitable for cardioversion but would benefit from Warfarinization. We aim to commence this in the local clinic but would appreciate it if you would consider prescribing it and monitoring his INR as per the shared care protocol. I have discharged him from my cinic at present, but would be happy to see him should there be any new problems. Dr. A. Davies Consultant Cardiology Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 9

10 55555 Dr. A. Davis M 01/01/1935 BLOGGS JOE 23 MAIN STREET FORTH LANARK CHI ML11 Dear dr. de Wet Warfarin 1, 3 and 5 mg po Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 10

11 Dr. De Wet 11 November :00 Calll# :15 Patients name: JOE BLOGGS Age: (Age: 74) 23 Main Street, Forth, Lanark Main Street, Forth, Lanark Mr. J. Bloggs GP: Dr. De Wet Welcome Surgery, Forth Coughing, wheeze Nov-09 22:40 10-Nov-09 22:57 Attend PCEC :15 Coughing, wheeze and increased sputum for a few days. Occasional blood streak. Has COPD. Using inhalers with some benefit. Son is visiting tonight Joe Bloggs Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 11

12 Dr. C. de Wet, Wellcome Practice, FORTH 7 th February, 2010 Dear dr. de Wet Re. JOE BLOGGS, 23 Main Street, FORTH. Date of Birth 01/01/1935. Hospital Number:, CHI no INCREASING SHORTNESS OF BREATH CHEST X-RAY 7 FEB :45 INFECTIVE EXACERBATION OF COPD ADMITTED. Departure Ready Date/Time: 7 Feb :30, actual Departure Date/Time: 8 Feb :45 Dr. Jones Consultant Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 12

13 Dr. DuVe X Dr. A. Davis 07/02/ /02/ M 01/01/1935 BLOGGS JOE 23 MAIN STREET FORTH LANARK CHI ML11 Severe exacerbation of COPD DELETED DELETED MKA MKA GH/Bj 18/02 Please recheck INR within a week of discharge. Dr. F. Yi Dr. F. Yi /02 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 13

14 Dr. A. Davis s secretary: /02/ /02/2010 M 01/01/1935 BLOGGS JOE 23 MAIN STREET FORTH LANARK CHI ML11 X 01/01/ Dr. C. de Wet, Wellcome Practice, FORTH Lobar pneumonia Glaucoma Dear dr. de Wet This gentleman was admitted after worsening dyspnoea in spite of Ciprofloxacin. He was started on IVI Amoxicillin and Clarithromycin and oral Prednisolone. He developed a marked, generalized rash which was attributed to the penicillin. A chest x-ray showed consolidation of his left lower lobe in keeping with pneumonia. It would be worthwhile to repeat this in about six weeks to ensure that the infection has completely resolved. He is also known to have AF and needed Digoxin to stabilize his rate but this could be discontinued. He continued to make a steady recovery and have been discharged with home support from the community team. I would be grateful if you could monitor his INR which has been a bit erratic while in hospital. Dr. A. Davis s outpatient clinic Dr. J.r. First FTSA2 in Medicine Dr. A. Davis Consultant in DOME Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 14

15 Dr. C. de Wet, Wellcome Practice, FORTH 3 rd March, 2010 Dear dr. de Wet Re. JOE BLOGGS, 23 Main Street, FORTH. Date of Birth 01/01/1935. Hospital Number:, CHI no MARCH :20 ACCIDENTAL FALL INJURY LEFT KNEE X-RAY KNEE, FBC LARGE EFFUSION?HAEMATOMA DISCHARGED. Departure Ready Date/Time: 3 March :20, actual Departure Date/Time: 3 March :20 ORTHOPAEDIC OUT PATIENT Dr. Jones Consultant Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 15

16 Dr. C. de Wet, Welcome Practice, FORTH Dear dr. de Wet Re. JAMES BLOGGS, 24 Main Street, FORTH. Date of Birth 01/11/1935. Ms. I. Am Customer care manager Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 16

17 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK Dr. C. de Wet 20/08/ :15 20/08/ : /08/ :45 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 17

18 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 20/08/2009, 10:45 On Warfarin for AF 20/08/ : Lab Technician 21/08/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 18

19 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 02/09/2009, 10:45 On Warfarin for AF 02/09/ : Lab Technician 03/09/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 19

20 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 15/09/2009, 10:45 On Warfarin for AF 15/09/ : Lab Technician 16/09/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 20

21 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 10/11/2009, 10:45 On Warfarin for AF 10/11/ : Lab Technician 11/11/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 21

22 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK Dr. C. de Wet 1512/ : / : /12/ :45 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 22

23 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 15/12/2009, 10:45 On Warfarin for AF 15/12/ : Lab Technician 15/12/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 23

24 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 02/02/2010, 10:45 On Warfarin for AF 02/02/ : Lab Technician 02/02/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 24

25 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 02/02/2010, 10:45 On Warfarin for AF 02/02/ : Lab Technician 02/02/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 25

26 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 28/02/2010, 10:45 On Warfarin for AF 28/02/ : Lab Technician 28/02/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 26

27 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 05/03/2010, 10:45 On Warfarin for AF 05/03/ : Lab Technician 05/03/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 27

28 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK Dr. C. de Wet 05/03/ :15 05/03/ : /03/ :45 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 28

29 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 15/03/2010, 10:45 On Warfarin for AF 15/03/ : Lab Technician 15/03/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 29

30 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 22/03/2010, 10:45 On Warfarin for AF 22/03/ : Lab Technician 22/03/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 30

31 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 04/04/2010, 10:45 On Warfarin for AF 04/04/ : Lab Technician 04/04/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 31

32 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 17/04/2010, 10:45 On Warfarin for AF 17/04/ : Lab Technician 17/04/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 32

33 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK Dr. C. de Wet 15/05/ :15 15/05/ : /05/ :45 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 33

34 BLOGGS, Joe M 01/01/ The Wellcome Practice Forth Lanark Dr. C. de Wet 15/05/2010, 10:45 On Warfarin for AF 15/05/ : Lab Technician 15/05/ :55 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 34

35 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK 20/06/ :50 20/06/ :50 Dr. C. de Wet General review L.A.B. Technician 20/06/ :15 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 35

36 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK 20/06/ :50 20/06/ :50 Dr. C. de Wet General review 21/06/ :15 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 36

37 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK 02/02/ :50 02/02/ :50 Dr. C. de Wet General review L.A.B. Technician 02/02/ :15 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 37

38 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK 15/05/ :50 15/05/ :50 Dr. C. de Wet General review 15/05/ :15 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 38

39 Joe Bloggs M 01/01/1935 THE WELCOME SURGERY FORTH LANARK 15/05/ :50 15/05/ :50 Dr. C. de Wet General review L.A.B. Technician 15/05/ :15 Summary sheet: All Sections Printed at 14/06/2010, 17: NHS Education Scotland Page 39