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  Home > Management Search Step Action Notes HRT commenced Add current problem .66U Hormone replacement therapy (synonym Menopause monitoring) If this current problem is not present it should be added. Use wcs hrt.gdl Sophie Initial assessment .66U1 menopause initial assessment .66U7 HRT started Follow-up assessment .66U2 menopause follow-up assessment .66U9 HRT changed .66UA HRT […]

  Home > Management Search IT responsibility BNC Stephen The IT security document is kept by Stephen. This details hardwarespecifications, licences, software, etc. Password access Maximum password age: expires in 30 days Minimum password age: allows changes immediately Minimum password length: at least 6 characters including at least one numeric character Password uniqueness: password can

  Home > Management Search Step Action Notes Pregnancy test .645 Urine pregnancy test Positive added as free text on receipt. Patient sees doctor or nurse. Enter new current problem .62 Pregnancy care. Patient should sign maternity form and read code added (use sophie). Remember folic acid. Patient to reception. Antenatal examinations 26 weeks: 36

  Home > Management Search Step Action Notes Patient sees doctor at surgery with problem requiring minor surgery. Enter the appropriate current problem for the diagnosis. This may be a vague [D] code. When performing minor surgery use WCS minor surgery Sophie. Minor surgery performed in Casualty. Take top copy of casualty card and pass

  Home > Management Search Step Action Notes Child registers Enter new current problem .64 Child health care. Enter note .9192 Child health surveillance registered when form signed. If not CHS registered add @!H Administration form due with CHS as free text. The child’s usual health visitor should be recorded as .6656 Shared care GP/HV

  Home > Management Search Step Action Notes Child registers Enter new current problem .**** Immunisations Patient sees nurse or health visitor in immunisation clinic. Dr or HV completes immunisation information on appointment list and passes to Anne. Note DNA’s on appointment list: any read codes, clinical notes and prescriptions should be recorded also. Computer

  Home > Management Search Read codes – structure and use Asthma Breast screening mammography Cervical smears Child health Child health and developmental assessment Child immunisations A child’s usual health visitor Domestic violence ECG recording Housebound patients HRT Hypertension Immunisations Ischaemic heart disease Learning disabilities Maternity and pregnancy Minor surgery Referral letters Screening Smoking Stroke

  Home > Management Search Step Action Notes Patient sees doctor or nurse. Enter new current problem .61 Contraception if not already existing. All notes relating to contraception should be added here eg: appropriate BP, weight, urine tests. General contraception (not IUCD’s) No reminders necessary  Patients should be reviewed annually, prescriptions are usually given for

  Home > Management Search Step Action Notes Patient sees doctor at surgery with problem requiring ECG Enter @!J2. ECG due code under appropriate current problem (IHD and hypertension Sophies will do this automatically). Tell patient to make ECG appointment at the desk. Routine ECG appointments are available Thursdays 11.30-2.30 ECG performed Perform ECG Add

  Home > Management Search All housebound patients who are living in their own homeshould have a current problem Housebound. This read code need not be entered for patients in nursing homes or part III accommodation, but be entered for patients in warden-controlled accommodation if appropriate. The read code should not be applied to patients