DORIS PATIENT JOURNEY

“Doris is a 74 year old woman who has been married to Frank for 53 years. She is overweight, has diabetes and cataracts. Doris also has osteoarthritis and is
on a waiting list for a hip replacement”

This pathway concentrates on her diabetes and hip pathology.

TSUNAMI STORYBOARD R0 REFERENCE R1 REFERENCE

1 TIER 2 TIER

GP Doris’ hip symptoms are worsening OUT OF SCOPE

She rings her GP. OUT OF SCOPE OUT OF SCOPE
GP receptionist locates Doris’ record and books Doris in
over the phone
Doris attends her appt & sees her GP: OUT OF SCOPE OUT OF SCOPE

GP elicits symptoms of left hip:

- Progressively worsening symptoms over the past 10
years
- Worsening pain: worse at end of day, background
pain when resting. Often wakes her from sleep.
- Joint is very stiff and getting worse (esp. after a
period of rest)
- Some swelling
- She can’t walk down the road to the shops and can’t
do her stairs

The local measures used by the GP have not been

working:
- Pain relief
- Load reduction, e.g. walking stick, weight loss etc.
GP makes a written referral to the Trust to Mr Yardley, a OUT OF SCOPE OUT OF SCOPE
Consultant Orthopaedic Surgeon
TRUST Orthopaedic Dept Letter comes into the Orthopaedic Dept – opened and Cerner R0 CD > The Patient R1 > Spine.
 received by Orthopaedic Admissions Clerk (OAC here) Journey >
“GP Referral Letter Arrives Show SingleSignOn and
Clerk searches Millenium and sees that Doris has not at the Hospital” how RBAC codes don’t
been seen before. allow clerk access to clinical
notes
Clerk registers Doris on M as a new patient
NHS number & NHS
The GP letter has some clinical details on: number allocation

Past medical history

Type 2 diabetes
Mild angina

Drug History
Metformin 500mg BD
Ramipril 10mg OD
GTN PRN
Atorvastatin 40mg OD

Allergies
Penicillin

The clerk creates a record and enters these into PC

(ask me when doing this)

How enter medications?

Does clerk do this?
If not, who – not consultant!
Letter scanned EDM – by clerk Say this is an “Additional
into M Bundle”
Orthopaedic The Consultant electronically reviews his referrals list, “Reviewing & Accepting the
Consultant views the patient's electronic patient record, and places Referral”
requests for the appointment (and an x-ray), thus
accepting and prioritising the referral. Also:
 1. Sees the referral on PC R0 Theatres Workflow
2. Sees there are no previous encounters screenshots
Consultants 1. Makes a request for Doris to attend OPD “Reviewing & Accepting the
makes requests (priority = routine) – ie. schedules her to come Referral”
onto the W/L
2. Orders 2x Hip Xrays to be done on admission Also:
(AP and Lateral views – ring me when doing this)
R0 Theatres Workflow
(Note – other details for scheduling are: screenshots

- Schedule with lead clinician

- Reason for encounter:
“Worsening left hip pain with stiffness and swelling.
Awakes patient from sleep. ? Osteoarthritis”
Appointment Clerk: “Scheduling of Outpatient
scheduled - Looks at her worklist Appointment”
- Sees Doris has been requested an OPA from Mr
Yardley Also:
- Schedules her in
R0 Theatres Workflow
screenshots
Letter sent out Letter printed and sent out to Doris from Orthopaedic ?? Not sure how to do this??
Dept for Outpatient Department To Come In dates
ALTERNATIVE Mr Yardley sees letter as it comes into OPD directly and
SCENARIO writes on it:
PRIORITY: Routine
Lateral view Hip XRay on Arrival

The OAC then enters data into M

OUTPATIENT Doris arrives in Doris arrives at clinic and hands referral letter to clinic R0 CD > Patient journey >
DEPT clinic nurse Outpatient Appointment
Check-In
Nurse searches for OPA – show how can see everyone
else booked in for that day
 Right clicks on OPA and “checks” Doris in
Mr Yardley sees Looks through notes and sees no previous encounters Powerchart tabs R1 spine >
Doris  Problems & Show SingleSignOn and
Sees allergies, medications and past medical history Diagnoses how RBAC codes allow Mr
entered from GP note  Allergies Yardely access to clinical
notes
Takes a full history and examination
Results to Mr Yarley sees that the hip Xray has been done
endorse
There is no formal report yet, but he sees the Xray.

He notes osteoarthritis of the left hip and decides a left

THR is needed – he writes in the electronic notes his
assessment of the hip Xray as there is no formal report
(check this bit)
Records findings 1. Of history & examination in PC > Documentation
2. That he has seen XR and what he saw

Schedules for Puts on W/L for left THR R0 CD > Patient journey > R1 Theatres enhanced
theatre - Schedule: soon Outpatient Appointment patient scheduling:
- Primary surgeon = him Attendance & Requests for
- Preassessment: yes (2w before surgery) Surgery 1. Historical averages
based on actual system
usage
2. Automatic scheduling of
pre-anaesthesia
activities
Doris signs Written form and Doris signs (None) EDM only in R1
consent form Scanned into M (see Mr Oakes video)
Checks out of (do all on this video, except for bit where Doris says she R0 CD > Patient Journey >
clinic will go home to discuss with her family. ) Surgery Waiting List Entry &
Outpatient Check-Out
IMPT: Bit at end of video about CDS returns
WAITING LIST The Orthopaedic admissions manager (or the “waiting Waiting List Management &
list manager”) regularly reviews the waiting list to ensure Surgery Scheduling
 no breaches are made. They also validate the list (eg-
phone patients who are on the list for a while to ensure
they still need the operative procedure).

Do all on the R0 CD
??? How schedule for PAC ???
the surgery scheduler is notified to proceed with
completing the surgery request.

The surgery request is completed (case is scheduled),

and the surgeon, room, patient, and schedulable
resources (equipment and/or instrument sets) are
conflict checked.

The theatre list is generated and distributed.

Where does the information filter from Mr Yardley to here

that Doris must be first on the list because of her
diabetes?

A To Come In letter is printed and then sent to Doris.

PRE- Clinic worklist Doctor in training looks at his worklist for the day
ASSESSMENT He sees he is due to see Doris
Doris attends The Doctor in training sees Doris Where does doc record his R1 > PC > Assessments
clinic PAC findings – no template
He examines her and asks questions. in R0 There are “daycase”
He notes her diabetes in her medical history. assessments – would we be
allowed to use these for
records history and examination on paper inpatients – ask Lax
Doris fails pre-assessment due to high BP and a mild On W/L:
chest infection. Put on "deferred" list - ie.
clock stops on W/L
She is referred back to her GP and rescheduled in PAC When OK, off deferred list to
for 2 weeks time W/L
(Not PowerChart -
 Scheduler)

NOTE FROM LAXMAN:

1. Once a surgical order has
been placed, and the patient
scheduled to theatres, any
changes to the Order
(including modifiers) should be
made via the “RESCHEDULE”
option ONLY;
2. Modify should NOT be used
once the surgical procedure for
the patient has been ordered
and the patient scheduled into
the theatre;
3. Use of modify at this stage is
NOT appropriate;
4. Auto generation (and cost) of a
letter needs to be balanced
with the primary objective of
the highest standard of patient
safety.  The letter, if not
required, should be discarded.
5. For avoidance of doubt, the
standard practice of ensuring
correct patient, surgical
procedure, laterality, etc is the
medico-legal and professional
accountability of the operating
surgeon and should prevail
irrespective.

Reattends PAC in 2 weeks time – and passes

SURGERY Bed availability Doris rings central admissions unit as requested on her R0 CD> “Inpatient
check TCI letter admission”
(only up to 1st 58 seconds of
Clerk checks bed availability video)
Doris cancelled There is a massive bed crisis on and no free beds. R0 David Oakes videos:
Operational Managers >
Doris’s procedure is postponed for today Cancel of day of surgery
Bed management Central admissions clerk: R0 David Oakes videos >
Bed Management
1. Filters bed by overdue and dirty
2. Rings the ward Also:
3. Manages to get a long stay ENT patient
discharged R0 CD > PAS > Admissions,
4. Books Doris into this bed tomorrow Discharge, Transfers (20
mins in, location search)

Doris Doris is told to come in tomorrow. R0 CD> “Inpatient

rescheduled admission”
Clerk tells Doris it is OK for her to come in tomorrow. (only up to 1st 58 seconds of
video)

How reschedule theatre slot

& beds on ward
Doris checked Ward clerk sees her on her TCI worklist R0 CD> “Inpatient
into ward (worklist > TCI by date (IP waitlist) admission”
(1min 10 secs of video
Right click – complete IP admission forms onwards)
Seen by nurse Nurse shows Doris to her bed R0 CD > “Nurse DVT assessment in
Does initial observations observations” powerchart also

Do exactly as on this – good

R0 – charting of vital signs

show
Nurse summons Nurse sends a message to the doctors inbox, asking him R0 CD > Clinicals > Logon
doctor to review Doris before surgery and Inbox

Doctor responds – saying he will be there in an hour

Doctor logs in Show how a doctor: These are all the same as
your R0 videos you did
- Creates his lists (Clinicians tab)
- Customises his inbox
 - Can see a list of problems & diagnoses How does a doctor know
how to assign Doris to his
patient list?
Doctor reviews Doctor in training sees Doris after the nurse Some of R0 > Doctor Pre-Op
findings Review of Patient
1. Reviews blood tests that were taken in pre-
assessment
2. Graphs vital signs taken by nurses
3. makes a note in PC > “OK for surgery”
4. checks consent form (paper)
5. marks site (not cerner)

How does the doctor review the bloods and CXR done
from Pre-assessment clinic?
Requests The anaesthetist has not seen Doris, so SHO creates an Inbox > Right click > Inbox
anaesthetist “Inbox message” to ask him to come to ward message

“Doris is on ward for left

THR and needs pre-op
review”
Prescribes Started on an insulin sliding scale pre-op
medications
Prophylactic antibiotic cover is given about half an hour
prior to surgery - and continued for 24-48 hours
afterwards until the drains are removed.

Prophylactic anticoagulation (subcut heparin) pre-op –

40mgs BD of Clexane

All charts updated in Millennium

Theatres Records logging The procedure is done

The various data items are logged:

(see R0 and R1 as different)
 The procedure is coded in SNOMED, and is written in Yes Yes
full text. (PAS)
>> How code an operation note
(ie. problem = OA
Procedure = THR)

PowerChart > Problems & Diagnoses Tab

> Add Diagnosis (bottom of screen)
> Add Code
> (this is where clinicians enter their activity codes in >
ECG, >CXR)

>> Also show how to set-up a coding “favorites list” in

coding workscreen
Management & scheduling of staff, theatres and Yes yes
equiptment
R1 Theatres Peri-operative
Nursing.

Show intra-operative case

logging on the following
forms:
- Case Times;
- Case Personnel;
- General Case Data
details;
- Surgical Procedures;
- Delays;
- Final Count Status;
Core Document R1 Clinicals:
Management
(not the Surgeon draws an operation
Additional) note, scans it in as a JPG
and attaches it to the clinical
notes
Post-op Recovery Doris is transferred into recovery for monitoring R0 CD > PAS > Admissions,
immediately after the procedure Discharge, Transfers (10
mins in – 18mins)

This is under “Pending

Transfers”:

1. Pending from theatres

into ITU
ITU receive
Assessment Glasgow Coma Scale assessment form in Powerchart R0 CD > PAS > Admissions,
Discharge, Transfers
(we can go through what to write on this)
Ward Immediately Doris is transferred back to the ward from ITU R1 > Powerchart > Pain
assessments
Various powerform assessments are completed in
Powerchart by the nurse: R1 > Powerchart > Wound
assessments
BP, HR, Temp charts, written notes
Day 2 2x Xrays are requested: R0 > Requests > CareSets R1 > Powerchart > Referral
(Anteroposterior & Lateral of hip) to physiotherapist to help
with mobility and start
Blood test requested: walking
- Full Blood Count
- Urea and Electrolytes (U&E)

*** CREATE THESE AS A “CareSet”

Update clinical notes from ward round:

“Doing well. Gradually introduce weight bearing”
PATHNET Two scenarios here: There is no R1 bundle for There is no R1 bundle for
PathNet, only R0 and R2. PathNet, only R0 and R2.
1. If no PathNet (or using a 3rd party system), can’t
request bloods in PC
2. If PathNet, follow steps & screenshots as
 documented in “PathNet R0.doc”

WARD Day 3 SHO checks his Inbox later that day– there are some R0 – charting of U&E results
results to endorse
- Blood tests from previous
- Chest XR if alternative scenario above done

2x hip Xrays are also returned to SHO. R0 PC > Flowsheet >

However, he is junior, so forwards them to the Highlight results > Forward
consultant, Mr Yardley, to sign.

(the joint and prosthesis stem are holding, so fine)

Day 4 It was picked up on a ward round that Doris (Nothing to show) Clinicals > Powerchart >
Dietician asked to see Doris because of her diabetes. Requests

- Dietary:
The dietary requests will
be a documentation of
the dietary status of the
acute care patients;

DISCHARGE Request OPA Now fit for discharge. R0 CD > Request for Follow-
Up Outpatient Appointment
Book OPA OPA scheduled for Mr Yardleys clinic in 2 months R0 CD > Scheduling of
Follow-Up Outpatient
No slots free in 2 months, so search for 3 months time Appointment

Slots found – book Doris in there and then

Book two Xrays again on arrival in clinic – an AP and

Lateral view of the left hip
 ? Does an OPD letter get printed out then or later
offline?
Doris leaves R0 CD > Discharge
ward
Discharge Do as on this video R0 CD > Discharge
Summary Summary & Conclusion
Template Discharge note:
Also:
“Operation date:
Indication – Severe OA R0 CD > Clinicals >
Procedure – Left THR Discharge summary
Follow-up:
Clips out 10-14 days
3 month F/U
Xrays on arrival”

Also show:
Right click on discharge summary > Import/export as .rtf
templates

Pharmacist to sign drugs – then import back in

Transport home R1:

Powerchart > Requests
Book transport home
(R1 > BookTransport.ppt)

CODING Clinical Coders Coders get a worklist to code R0 CD > PAS > Coding

Doris has been discharged. Couldn’t find this coding

application in Conversations
 Show:

1. Coders worklist
2. How translate Doris’
SNOMED procedure into
ICD10 and OPCS4 in
PAS
HRGs sent off The OPCS4 codes are used monthly for HRG returns to Once month, PAS "CDS"
the Department of Health. extract -> ClearNet or SUSS
for sending to PCT

CDS reports??

The following table shows a list of reports that have been designed for R1:
We just have to show one or two.

Design Area Report Name Business Function of report

Theatres Personnel Log Report All operations for specific consultants by date
range.
Theatres Daily Theatre Show a summary of numbers of procedure
Summary List performed by Theatre
Theatres Operation Surgeon Management report to show number of
Usage Report operations by a surgeon across a date range
Theatres Booking Cancellation Show summary of why operations have been
Summary cancelled. Detailed report shows patient level
information
Theatres Session Theatre Summary of the theatre utilisation report
Design Area Report Name Business Function of report
Utilisation
Theatres Theatre Utilisation Utilisation per session, start, finish and actual
start time with reason for delay to include :
Operating Theatre Usage by Speciality
Theatres Average Surgery Utilisation linked to average Surgery time per
Time procedure
Theatres QMCO This is a statutory report for showing cancelled
operations for non clinical reasons
Theatres NCEPOD Theatre Report to show the theatre utilisation for selected
Use procedures and/or surgeon by NCEPOD
classification
Theatres Peri-operative Deaths Need to list those patients who died in theatre
R&RR Summary of running The main use of requesting information captured
totals of each in the Millennium database for Catering is
diet from each ward through reporting. For instance a simple report
that can be run by Catering staff as required that
lists the following:
i. Patient Name
ii. Patient MRN or NHS Number
iii. Patient Sex
iv. Patient Location (Ward & Bed)
v. Diet requested
vi. Summary Running totals of each diet
ordered for each location.
Would allow the catering dept. to assess the
number of patients that were currently Nil by
Mouth and so reduce wastage due to
unnecessary food preparation.
R&RR Patients Requiring A detailed report showing the transport
Design Area Report Name Business Function of report
Transport requirements of patients which can be printed for
mobile workers. A summary report of totals of
types of transport pending requests is also
required for management.
PAS & Bed Utilisation Report all transfers for a ward by:
Scheduling Specialty
Consultant
PAS & Clinic Utilisation There are two parts to this report:
Scheduling - Future
Utilisation report between Time Available and
Time Actual Divided into New and F/U slots
which are booked or unbooked Grouped by
Treatment Function and divided by Resource
List to show Consultant and Non Consultant
- Past
Utilisation report of patients Seen or DNA
(Group by Attend or Did Not Attend) by
Resource List
PAS & Psychiatric CDS Admitted Patient Care CDS
Scheduling
PAS & Admitted Patient Care Annual Refresh
Scheduling CDS type - detained
and - or long term
psychiatric census
PAS & KP90 - Admissions, Statutory report
Scheduling Changes in Status
and Detentions under
the Mental Health Act
PAS & Mental Health Statutory report
Design Area Report Name Business Function of report
Scheduling Minimum Data Set
PAS & QMOP - Outpatient Statutory report
Scheduling clinic waiting times
PAS & FastTrack – GP to Retrospective Report - Collection designed to
Scheduling Consultant waiting collect the monthly monitoring return on a
times plus provider basis
PAS & PTL (Primary Forward looking GP to Consultant referral waiting
Scheduling Targeted Listed) times. List of service users who may breach 13
week target if not acted upon
PAS & Group Session This is a report on the number of patients
Scheduling Utilisation scheduled for each session in a group or day
hospital vs. the capacity of the group session or
day hospital session
This will enable managers to see how close to
capacity resources are running
PAS & Patients on MHA Enables ward, RMO, CMHT to see the status of
Scheduling Section their patients under Section of the MHA Data
items to include; including Age, Gender, Ethnic
Group, Date/Time of Section and Response
Times
PAS & Children Admitted to Admissions of children aged under 18 at time of
Scheduling an Adult Ward admission to adult wards
PAS & Deaths of Patients List of all patients who died whilst under a section
Scheduling Under a MH Section of the Mental Health Act
PAS & Count Me In A census to be submitted once a year on 31st
Scheduling March which reviews all ethnic minority inpatients
under Mental Health care
PAS & Team/HCP Caseload Allows a team or HCP to review their caseload.
Design Area Report Name Business Function of report
Scheduling By allowing closed referrals, it also allows things
such as clinical audits to be undertaken
Clinicals CPA Review List The Service will include facilities to ensure that
CPA review dates are set in all cases where they
are required, to prompt for due/overdue reviews,
and to monitor the planning of reviews against
the policy of the service in line with mandatory
Department of Health reports.

There are two parts to this report:

- Part A:
List of those patients who require a CPA
review
- Part B:
Those patients who did not attend the CPA
review appointment
Clinicals Care Co-ordinator's Gives Care Co-ordinators (CC) list of their current
Active Caseload caseload. Could be used by manager if CC is ill
or otherwise absent. Need to be able to select
more than one care co-ordinator for the report
Clinicals Outstanding work for Enables team manager to identify those patients:
CPA - Who have not had a care plan recorded and
who is responsible; and
- Who have not had an assessment recorded
and who is responsible
Clinicals Enhanced CPA There is a requirement for all Enhanced CPA
Patients who have patients to be followed up within 7 days of
been Followed Up in discharge. This is a Performance Monitoring
7 days Report for Commissioners
Design Area Report Name Business Function of report
Clinicals HoNOS Scores A real time report whereby Services/Localities
Report can see the number of patients with a set range
of HoNOS scores by:
- Member of staff;
- Diagnosis;
- Frequency of contact;
- Last date contacted.