Ct Scan Template - Excel by sbl12066


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									Chronic Disease entry for New patient summaries:                                                        (RAG draft 4/2005)
When patients notes are first summarised they may be found to have several of the GMS chronic diseases.
The entry of data regarding these is crucial, and is best picked up by the summariser and then checked by a GP.
Key points are:
1) The coding and dating of the diagnosis. Important to record the onset date of the condition (month+yr).
2) If it is after 1/4/2003 then there are several extra details that are important to seek in the record.
3) It is important that diary entries are made so the patients get appropriate follow up. The GP may bring these forward/fix an appt.
All Diary Entries can be found on the relevant template (marked with a #) AND on the list in A for add and D for recall (if marked@)
Always check that immunisations e.g. flu etc. are on the computer.
BP and smoking/ smoking advice should always be picked up by the nurse who has done the new patient registration. She may have added the diary entries.

Condition                              1-Coding 2- Details to check (if       Enter by:          3- Diary entry
On problem list as active, significant          diagnosis after 1/4/03)    ** template as on     (put in todays date unless
with date of diagnosis                          details from 3m before to 1y EMIS system at      already an entry)
                                                after diagnosis **
                                                Otherwise latest of each

COPD/COAD,                 Chronic    Ask Kath Spirometry done **                COPD Proven COPD monitoring due @
obstructive airways disease,                   FEV1 **                           Template (P)
emphysema/chronic bronchitis                   FVC ** tecnique good/poor
                                               (Kath to do enter these but
                                               please find the information for
                                               her- e.g. letter with details)
Asthma                                H33      Asthma review done (66YK)         Asthma T.(D)    Asthma monitoring due @
Angina                                G33      Exercise ECG **                   Angina          f/u cardiac assessment@
                                               Last cholesterol                  template (H)
Myocardial Infarction (mark each      G31      Takes OTC aspirin' (if entered                    BP monitoring@
MI)                                            in last 15months)                                 Serum cholesterol
Heart Failure                                  Echocardiogram **                 Heart failure   F/U Heart failure @
Left Ventricular Failure              G581     (U/s of heart)
Congestive Heart Failure              G580
Left Ventricular Systolic Dysfuncti   G5yy9
Left Ventricular Diastolic Dysfunct   G5yyA
Stroke/TIA                                                                                     BP monitoring@
Cerebrial Arterial Occlusion                    CT scan or MRI scan              Cerebrovascul F/u CVA/TIA =neuro
(cerebral infarct)                                                               ar Template   assessment@
Intracerebral haemorhage              G61..                                      (F)           Serum Cholesterol
Stroke / CVA Unspecified (if
unknown/ no CT scan. Always use
one of 2 codes above where known)     G66..
Transient Cerebral Ischaemia (TIA)    G65

Hypertension                         G2        Last BP recorded unless           BP Template    BP monitoring@
                                               already one on notes              (J)
Essential hypertension               G20
Secondary Hypertension               G4
                                               Scan last annual review and       Diabetes       BP monitoring@
Diabetes Mellitus   *                          code annual rev done (where)      template (G)
Type 1 Diabetes(juvenile onset)      C10E      Last cholesterol                                 Digital retinal screen
Type 2 Diabetes (mature onset)       C10F      Last HBA1C
(ask if uncertain)                             Last creatinine                                  Diabetes annual review@
                                               last microalbumin
                                               Last Diabetes retinal screen
                                               Last fit frequency (x times per   Epilepsy
Epilepsy                               F25     month)                            template (K)   Follow up Epilepsy@
   or lower level F25 code for more            Use fit free for >12months if
detailed diagnosis of epilepsy.                notes say that
Acquired Hypothyroidism
(free text if after radio-iodine or                                              Thyroid
surgery)                               C04     Last TSH                          template (Y/Z) f/u TSH
Congenital Hypothyroidism           if
present from birth                     C03     Last Free T4
Cancer   *
Generally use cancer or malignant              Within 6months after the
neoplasm of the stomach or                     diagnosis there should be a    Cancer
wherever, not a code with {M} before           code for cancer care reviewed. template-
it.(see Notebuster list)             B0-B6     Check to see, and enter.       diagnosis (I/A)
Mental Health For codes use J** on
the coding screen (schizophrenia
                                               Only go on register in our
and bipolar depression (manic                  practice when we put them on
depression) are here or as on the    Eu20 and so old data doesn't need
Notebuster list)                     Eu31 etc. entering.
* Circle on printout for the doctor when passed on.
** Is or practices place on the
access screen where we can select
psychiatric diagnoses. They are
basically the same as those on the
Notebuster list


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