Recording Consultations - GP

Description

Outcomes

For a Patient:

There is a detailed and standardised history of consultations including those between Health or Care Professional that supports more efficient and timely diagnosis and treatment.

For General Practice:

Standardised recording and maintenance of accurate Consultation data. Enable timely and efficient access to Consultation data to support Patient care and safety.

For the wider NHS and social care system: 

Enabling Healthcare Professionals from a variety of services and settings to access accurate and detailed Consultation data in support of decision making and provision of Patient services.

MUST Epics - Describes the minimum functionality required to deliver a Capability. Solutions MUST be successfully evaluated against each Epic and Acceptance Criteria via Capability Assessment in order to be associated with this Capability

MUST Epics - Describes the minimum functionality required to deliver a Capability. Solutions MUST be successfully evaluated against each Epic and Acceptance Criteria via Capability Assessment in order to be associated with this Capability

E00135 - record information for Consultations

As a Health or Care Professional

I want to record information for Consultations for Patients

So that a full history of Consultations can be maintained for each Patient

Acceptance criterion 1: record basic data for Consultation 

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to record basic data information for a Patient Consultation

Then start date and time for the Consultation are recorded

And the organisation for which the Consultation is being performed can be recorded

And the location of where the Consultation is being performed can be recorded

Acceptance criterion 2: record Patient characteristics and interventions

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to record Patient characteristics and interventions for a Patient Consultation

Then coded clinical terms can be recorded

And Episode Type can be recorded for coded clinical terms

And free text can be recorded

And numeric values can be recorded

And the Consultation is recorded

Acceptance criterion 3: view a Consultation for a Patient

Given the Health or Care Professional is permitted to view Consultations

When the Health or Care Professional selects to view a Consultation for a Patient

Then the Consultation is displayed

E00135 - Additional Implementation Details

Solutions MUST comply with the following when implementing this Epic:

E00135 - Supporting Information

  • The following information MAY be recorded as part of a Consultation:

    • Medical, family and social history

    • Symptoms, signs, observations and investigation results

    • Diagnoses, allergies, sensitivities and problems

    • Surgical, diagnostic and preventative procedures

    • Direct access services

    • Counselling and health education

    • Prescribing medicines and medical devices

  • Consultations are recorded for:

    • Planned Consultations - those that are planned in advance within a date range, for example, but not limited to:

      • Consultation booked as a result of an Appointment

    • Unplanned Consultations - those which have not been planned in advance, for example, but not limited to:

      • Out of Hours

      • Accident and Emergency

      • NHS 111

      • Walk-in Centre Consultations

  • Examples of locations for Consultations include, but are not limited to:

    • Practice

    • Patient’s home

    • Hospital clinic

  • The Mode of a Consultation MAY be recorded, for example, but not limited to:

    • Face to Face

    • Telephone

    • Video Consultations

    • Online Consultations

  • For coded clinical terms, see Data Standards for requirements


E00136 - extract Female Genital Mutilation (FGM) data

As a Health or Care Professional

I want Female Genital Mutilation (FGM) data to be submitted to NHS Digital on behalf of my Healthcare Organisation

So that aggregated counts of FGM information can be submitted to NHS Digital to enable monitoring

Acceptance criterion 1: extract Female Genital Mutilation (FGM) data

Given there is Female Genital Mutilation (FGM) data to be submitted by the Solution

When the creation of the Female Genital Mutilation (FGM) data file is triggered

Then the Female Genital Mutilation (FGM) data file is created

E00136 - Additional Implementation Details

Solutions MUST comply with the following when implementing this Epic:


E00137 - Electronic Yellow Card Reporting

As a Health or Care Professional

I want reports of suspected Adverse Drug Reactions (ADRs) to be sent to the Medicines and Healthcare products Regulatory Agency (MHRA) on behalf of my Healthcare Organisation

So that information on ADRs for each Patient can be submitted to MHRA to enable monitoring and to meet safety standards by providing information on potential drug safety issues as part of the Yellow Card scheme

Acceptance criterion 1: submit suspected Adverse Drug Reactions (ADRs) data to the MHRA

Given a Health or Care Professional is permitted to submit suspected Adverse Drug Reactions (ADRs) data to the MHRA

When the Health or Care Professional selects to submit suspected Adverse Drug Reactions (ADRs) data for a Patient

Then the suspected Adverse Drug Reactions (ADRs) data is submitted to the MHRA for the Patient

E00137 - Additional Implementation Details

Solutions MUST comply with the following when implementing this Epic:


E00138 - eMED3 (Fit Notes)

As a Health or Care Professional

I want to record eMED3 (fit notes) data

So that eMED3 (fit notes) forms can be produced for Patients and data can be submitted to NHS Digital to support research analysis

Acceptance criterion 1: create eMED3 data for a Patient

Given the Health or Care Professional is permitted to create eMED3 data for Patients

When the Health or Care Professional selects to create the eMED3 data for a Patient

Then the eMED3 data is created

Acceptance criterion 2: print eMED3 form for a Patient

Given the Health or Care Professional is permitted to print eMED3 form for Patients

When the Health or Care Professional selects to print an eMED3 form for a Patient

Then the eMED3 form is printed

Acceptance criterion 3: create eMED3 data for submission

Given there is eMED3 data to be submitted by the Solution

When the creation of the eMED3 data file is triggered

Then the eMED3 data file is created

E00138 - Additional Implementation Details

Solutions MUST comply with the following when implementing this Epic:

MAY Epics - Describes additional functionality associated with the Capability. Suppliers should consider all MAY Epics as part of their User Research. Suppliers can choose to map their Solutions to these Epics and they will be evaluated via Capability Assessment. Framework Authorities or purchasing organisations may require these Epics as product qualification or requirements criteria

MAY Epics - Describes additional functionality associated with the Capability. Suppliers should consider all MAY Epics as part of their User Research. Suppliers can choose to map their Solutions to these Epics and they will be evaluated via Capability Assessment. Framework Authorities or purchasing organisations may require these Epics as product qualification or requirements criteria

E00139 - manage Consultation form templates

As a Health or Care Professional

I want to manage Consultation form templates

So that Health or Care Professionals can create Consultation information for Patients using pre-configured Consultation form templates

Acceptance criterion 1: create Consultation form template

Given the Health or Care Professional is permitted to manage Consultation form templates

When the Health or Care Professional selects to create a Consultation form template

Then the Consultation form template is created

Acceptance criterion 2: view Consultation form template

Given the Health or Care Professional is permitted to manage Consultation form templates

When the Health or Care Professional selects to view a Consultation form template

Then the Consultation form template is displayed

Acceptance criterion 3: amend Consultation form template

Given the Health or Care Professional is permitted to manage Consultation form templates

When the Health or Care Professional selects to amend a Consultation form template

Then the Consultation form template is amended

Acceptance criterion 4: delete Consultation form template

Given the Health or Care Professional is permitted to manage Consultation form templates

When the Health or Care Professional selects to delete a Consultation form template

Then the Consultation form template is deleted

Acceptance criterion 5: view Consultation form template version history

Given the Health or Care Professional is permitted to manage Consultation form templates

When the Health or Care Professional selects to view the version history of a Consultation form template

Then the Consultation form template version history is displayed

E00139 - Supporting Information

  • Creating a Consultation form template MAY include:

    • A unique identifier or name, and version

    • Template status (whether draft, published / available for viewing and use across the Solution, or obsolete)

    • Basic business logic/rules, such as the ability to:

      • auto-populate data items from within the Patient Record e.g. use of merge fields

      • auto-populate data items based on other data within the form

      • set mandatory data items


E00140 - record Consultation using published form template

As a Health or Care Professional

I want to record a Consultation for a Patient using a published Consultation form template

So that consistency is maintained when recording Consultations

Acceptance criterion 1: record Consultation using published Consultation form template

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to record a Consultation using a published Consultation form template

Then the Consultation is recorded

Acceptance criterion 2: save a partially completed Consultation form

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to save a partially completed Consultation form

Then the partially completed Consultation form can be saved

Acceptance criterion 3: return to a partially completed Consultation form to continue data entry

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to update a partially completed Consultation form

Then the partially completed Consultation form is updated


E00141 - Consultation form template version roll back

As a Health or Care Professional

I want to roll back a Consultation form template to a previous version

So that I can go back to the previous version and continue with the Consultation form that is suitable

Acceptance criterion 1: Consultation form template version roll back

Given the Health or Care Professional is permitted to manage Consultation form templates

And there is a Consultation form template that has a previous version

When the Health or Care Professional selects to roll back the Consultation form template to a previous version

Then the Consultation form template is updated to that version


E00142 - upload attachments for Consultations

As a Health or Care Professional

I want to upload attachments when recording a Consultation for a Patient

So that attachments can be added to support the Consultation

Acceptance criterion 1: upload attachments for Consultations

Given the Health or Care Professional is permitted to record Consultations

When the Heath or Care Professional is recording a Consultation for a Patient

Then the Health or Care Professional can upload attachments for that Consultation

Acceptance criterion 2: view attachments for Consultations

Given the Health or Care Professional is viewing a recorded Consultation for a Patient

And that Consultation includes an attachment

When the Health or Care Professional selects to view the attachment

Then the attachment is displayed


E00143 - share Consultation form templates between organisations using the same Solution

As a Health or Care Professional

I want to share Consultation form templates with other organisations using the same Solution

So that Consultation forms are available to other organisations for them to use when recording Consultations

Acceptance criterion 1: share Consultation form templates

Given the Health or Care Professional is permitted to share Consultation form templates

When the Health or Care Professional selects to share the Consultation form template

Then the Consultation form template is shared

Acceptance criterion 2: use shared Consultation form templates when recording a Consultation for a Patient

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to record a Consultation using a shared published Consultation form template

Then the Consultation is recorded


E00144 - use Supplier implemented national Consultation form templates

As a Health or Care Professional

I want to record a Consultation for a Patient using a Consultation form template based on national forms that are created by the Supplier 

So that Health or Care Professionals don't have to create these Consultation form templates and data for nationally contracted services can be recorded

Acceptance criterion 1: use Supplier implemented form templates

Given the Health or Care Professional is permitted to record Consultations

When the Health or Care Professional selects to record a Consultation using a published Consultation form template

Then they can choose to use a Consultation form template based on a national form provided by the Supplier

And the Consultation is recorded

E00144 - Supporting Information

  • These are Consultation forms created and configured by the Supplier. These forms should ensure the appropriate data is captured to support nationally contracted services including, but not limited to:


E00145 - data recording for Call and Recall processes

As a Health or Care Professional

I want to record Calls and Recalls for Patients

So that care for Patients who are subject to certain surveillance can be managed

Acceptance criterion 1: recording Calls

Given the Health or Care Professional is permitted to record Calls for Patients

When the Health or Care Professional selects to record a Call for a Patient

Then the type of surveillance is recorded

And a Call date is recorded

And the Call is recorded

Acceptance criterion 2: recording Recalls

Given the Health or Care Professional is permitted to record Recalls for Patients

When the Health or Care Professional selects to record a Recall for a Patient

Then the type of surveillance is recorded

And a Recall date is recorded

And the Recall is recorded

E00145 - Supporting Information

  • Call and recall is a process of inviting eligible people for activities such as screening or reviews on a regular basis. For example, Cervical Screening


E00146 - view Calls and Recalls report

As a Health or Care Professional

I want to view reports for Patient Calls and Recalls

So that I can view Patients whose Call or Recalls are due or overdue

Acceptance criterion 1: view report on Calls and Recalls

Given the Health or Care Professional is permitted to view reports of Patient Calls and Recalls

When the Health or Care Professional selects to view Patient Calls and Recalls report

Then the report results are displayed


E00147 - view report of Consultations

As a Health or Care Professional

I want to view a report of Consultations that have been recorded for Patients

So that I can view a report of Consultations

Acceptance criterion 1: view a report of Consultations

Given the Health or Care Professional is permitted to view reports of Consultations

When the Health or Care Professional selects to view a report of Consultations

Then the report is displayed

E00147 - Supporting Information

  • Consultations are recorded for:

    • Planned Consultations - those that are planned in advance within a date range, for example, but not limited to:

      • Consultations booked as a result of an Appointment

    • Unplanned Consultations - those which have not been planned in advance, for example, but not limited to:

      • Out of Hours

      • Accident and Emergency

      • NHS 111

      • Walk-in Centre Consultations

Other Applicable Standards

Other Applicable Standards

Suppliers will also have to attain compliance with these additional Standards during the compliance stage before they can be live on a framework with this Capability:

Items on the Roadmap which impact or relate to this Capability

Items on the Roadmap which impact or relate to this Capability