Clinical Scenarios
Programme	NPFIT	DOCUMENT NUMBER
Sub-Prog/Project	Comms & Messaging	National Prog	Org	Prog/Proj	Doc Type	Seq
Prog. Director	Max Jones	NPFIT	FNT	TO	DPM	0285.01
Sub-Prog/Proj Mgr	Steve Bentley
Author	Steve Bentley	Version No.		0.6
NPO/PSO Contact	Sarah King	Status		Issued

Contents

Change History

In Version	Author	Date	Amendment Details

1 Purpose

The purpose of this document is to record some clinical storyboards to support the development of Message Examples for P1R2 Provision of Care (POC), namely the Care Event Report and Discharge Summary messages.

The storyboards (or scenarios) demonstrate the Primary & Secondary healthcare settings applicable to these POC messages.

2 Dramatis Persona - Who is who/Cast of Characters

2.1 Care Professionals

GP Practice Staff

Senior partner – Dr Cantankerous
Junior partners – Dr Fixit
GP registrar – Dr Wobble
Locum Doctor – Dr Justin Case
Practice Nurse – Nurse Screens
Receptionist

Community Staff

Health Visitor - Mrs Jabem

2.2 Organisations

GP practices

PCT

Acute Hospital

Clinic Nurse 1 - Nurse Testem

Consultant Surgeon - Mr Cutit

Clinic Nurse 2 – Nurse Sortit

Consultant Cardiologist – Dr Ticker

Cardiology Specialist Nurse – Nurse Clear

ECG Technician – Mrs Cardio Gram

SHO in General Medicine – Dr Ian Training

Pathology lab

Maternity Hospital

Midwife – Keep Pushing

2.3 Patients

The Smith Family

Father – Paul Simon Smith DoB 17/8/72

Mother – Shirley May Smith DoB 15/4/74

Child 1 – James Robert Smith DoB 2/3/1998

Child 2 – Mary Heidi Smith DoB 4/3/2004

Grand Father – Wilfred Arthur Smith DoB 5/6/43

Grandmother – Ethel Doris Smith DoB 8/3/45

Brother in Law – Daniel Nathan Adams DoB 5/6/80

Brother of Wilfred - Frank Smith DoB 24/12/41

3 Primary Care

3.1 Simple - Single Problem

3.1.1 Aims

This scenario aims to give an example of a simple (and common GP scenario). This consultation stands on its own, in that the problem described by the patient is new, it is dealt with in it entirety by the single visit.

3.1.2 Summary

Our patient, Paul Simon Smith, attends his GP, Dr Fixit, complaining of a sore throat. He is examined and prescribed antibiotics.

3.1.3 Detail

Paul has been suffering with a sore throat for 4 days. His symptoms are getting worse so he decides he needs to see his GP. He therefore telephones his local surgery and makes an appointment to see Dr Fixit the next day.
The following day Paul arrives at the surgery for his appointment. He books in with the surgery receptionist. And takes a seat in the waiting room.
Dr Fixit finishes documenting the consultation of his last patient. He looks at his surgery list; he sees that Paul is next to be seen. Dr Fixit looks at Paul’s medical history on his computer. He sees that Paul is fit and well and that the last time he attended the surgery was 2 years ago with an Upper Respiratory Tract Infection. He calls him in.
Paul enters the surgery and sits down.
Dr Fixit asks Paul what the Problem is.
Paul tells Dr Fixit that he has had a Sore throat for 5 days. He has pain on swallowing. Over the last 2 days he has become feverish. He does not have a cough. He has taken paracetamol and throat sweets.
Dr Fixit examines Paul. He examines Paul’s cervical lymph nodes and looks in his throat. He finds bilateral enlarged cervical lymph nodes, enlarged inflamed tonsils with exudates.
Dr Fixit diagnoses tonsillitis.
Dr Fixit asks Paul if he is allergic to any medication. He responds that he had a rash after taking penicillin about 10 years ago. Dr Fixit prescribes erythromycin tablets.
Dr Fixit advices Paul to take paracetamol 500mg 2 tabs qds for his fever and to drink plenty of fluids. He requests that Paul comes back to see him if he is no better in 3 days.
Paul leaves the surgery and heads for the local chemist to get his antibiotics and some more paracetamol.
Dr. Fixit completes his consultation notes. And moves on to the next patient.

3.1.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issue	Sore Throat – 5 days	This will need to have a start date as the date of consultation with an end date as for 10 days in the future.
Diagnosis	Acute Tonsillitis
Allergies and Adverse Events	Allergy to Penicillin – reported by patient, rash when given penicillin 10years ago.
Clinical Observations and Findings	Fever – 2 days Pain on swallowing Bilateral enlarged tender cervical lymph glands. Bilateral enlarged/inflamed tonsils.
Medication Record	Erythromycin 500mg qds for 7days. Paracetamol 500mg 2 tabs qds (advised)
Procedures - Provision of Advice and Information to Patients and Carers	Plenty of fluids. See in 3 days if no better

3.1.5 Example Message

3.2 Multiple Care Professionals

3.2.1 Aims

This scenario involves more than one Care Professional from the Primary Care Team. There are 3 Care Events which occur in this one visit to the surgery with 2 care professionals. Medication is administered.

3.2.2 Summary

James Smith has over the last 2 days been suffering with his asthma. His mum decides that he needs to see the doctor. Whilst he is at the doctors he is given a nebuliser and his medication dose is changed.

3.2.3 Detail

Shirley Smith notices that James is unwell. He has been coughing a lot over the last few days and this morning he is wheezy. She rings the surgery to make an appointment. She is given an appointment for later that day.
Shirley and James arrive at the surgery and book in with the receptionist.
Dr Justin Case a locum doctor is covering the surgery today. He looks at his surgery list and he sees that James is next to be seen. He has a look at James’s record and sees that James has Asthma which is usually well controlled on beclomethasone and salbutamol diskhalers. He calls James in.
Shirley and James enter the surgery and sit down.
Dr Case asks them what the problem is. Shirley tells the Doctor what has been happening over the last few days.
Dr Case examines James. He gets James to do a Peak flow test the result is low (best ever PEFR is 240 today it is 160)
Dr Case decides that James needs a nebuliser. He rings the practice nurse to request that she set this up.
James and Shirley leave Dr Case’s room and sit outside the Nurses Room. (end of Care Event 1)
Nurse Screens calls them into her room and administers the nebuliser. (Salbutamol 2.5mg)
Part way through the administration of the nebuliser James starts to feel unwell he complains he is felling dizzy. Nurse Screens stops the nebuliser which has nearly finished. She examines James and notices that he is flushed, she takes his pulse which is raised at 130 (regular rhythm). She is aware that this is a side effect of the nebuliser. She calms James and rechecks his pulse after 5 minutes it has reduced to 90. James is now feeling much better. Nurse Screens asks James to repeat his peak flow again. This has come back to nearly his normal level (230). Nurse Screens phones Dr Case (who has meanwhile been seeing other patients) and asks him to review James.
James and Shirley sit back down in the waiting room (end of Care Event 2)
Dr Case finishes seeing his current patient. He calls James back in to see him.
James and Shirley enter the consultation room and sit down.
James tells Dr Case he feels much better. Dr Case examines his chest again and gets James to repeat his peak flow test (235). Dr Case is happy with this.
Dr Case consults his asthma guidance and sees that he needs to give James a 3 day course of steroids and to add a Salmeterol inhaler to his regular regime.
He advises Shirley that if James gets any worse again then he should call the surgery immediately. If he continues to get better then he should be review in 5 days (end of Care Event 3)

3.2.4 Information to be recorded

Care Event 1

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Cough – 3 days Wheezy – From this Morning	These problems should relate to a higher level problem – Asthma.
Clinical Observations and Findings	Mildly distressed Chest examination –high pitched wheeze through out chest. PEFR 160 (best 240)
Procedures - Treatments	To have nebuliser – Salbutamol 2.5mg

Care Event 2

Care Record Element	Information to be Recorded	Notes
Problems and Issue	As above	These should not be restated but referenced
Medication Record	Nebulised Salbutamol 2.5mg
Allergies and Adverse Reactions	Tachycardia and flushing with Salbutamol nebuliser
Clinical Observations and Findings	Feeling a lot better – no longer distressed PEFR 230
Administrative Procedure	Dr Case to review

Care Event 3

Care Record Element	Information to be Recorded	Notes
Problems and Issue	As above	These should not be restated but referenced
Clinical Observations and Findings	Feeling a lot better PEFR – 235
Medication Record	Prednisolone soluble tablets 5mg, six daily for 3 days. Salmeterol diskhaler 50micrograms bd (60 blisters)
Procedures - Provision of Advice and Information to Patients and Carers	If James’ wheeze returns she is to contact the surgery immediately. James is to avoid contact with anybody who has Chickenpox over the next 3 months. If he does have contact he should be seen ASAP.
Administrative Procedure	A review appointment made for 5 days

3.2.5 Example Message

3.3 Vaccination

3.3.1 Aim

To show a care event in which a vaccination is recorded

3.3.2 Summary

Shirley Smith brings along Mary for her 2^nd set of baby vaccinations.

3.3.3 Detail

At Mary’s first set of baby vaccinations Mrs Jabem the Health Visitor gives Shirley an appointment for Mary’s second set of Vaccinations a month later.
Shirley and Mary arrive at the Surgery and book in with the receptionist.
Mrs Jabem is running today’s Imms and Vacs clinic with Nurse Screens.
Mrs Jabem looks at her patient list and sees that Mary Smith is next. She looks at Mary’s record and sees that she is to have her second lot of baby vaccinations, she notes that there has been no contact with Mary since the last vaccinations. Mrs Jabem calls Mary into the consulting room.
Shirley and Mary arrive in the room and sit down.
Mrs Jabem asks how Mary has been. Shirley responds that she has been fine.
Nurse Screens administers the vaccinations.
Shirley and Mary leave the room and take a seat in the waiting room.
They wait 15 minutes and the leave.

3.3.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Medication Record	Administration of the following ; Adsorbed Diphtheria Tetanus and Pertussis vaccine. Haemophilus Influenza type b vaccine Meningococcal group C Conjugate Vaccine Administered intramuscular route, right thigh (if more than one injection need to state which into which leg) Poliomyelitis Vaccine (live, oral)	Need to record the DM&D codes for the actual preparations given? 4 in one etc…
Care Event type	?Routine Immunisation
Clinical Observations and Findings	Well. No temperature no problems with the last injection.
Provision of Advice and Information to Patients and Carers	Wait 15mins in waiting room then can leave

3.3.5 Example Message

3.4 Patient Not Present

3.4.1 Aim

To show how a consultation with the patient not present should be represented.

3.4.2 Summary

3 days after her vaccinations Mary is not her usual self. Shirley rings the surgery for advice.

3.4.3 Detail

Shirley notices that Mary is not her self she is irritable, not feeding as much as usual and appears flushed. She rings the surgery for advice.
Dr Cantankerous is in surgery this morning and he phones Shirley after he has finished seeing his last patient.
Shirley explains her concerns.
Dr Cantankerous reassures Shirley that the symptoms are a common consequence of the Vaccinations and advises her to give Mary some paracetamol suspension.
He prescribes the prescription and advises Shirley to collect the prescription.

Note – on this situation one Care Event Report is sent after Dr Cantankerous has spoken to Shirley on the phone.

3.4.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Irritable post vaccination	Needs to have a start and end date (2 days later)
Provision of Advice and Information to Patients and Carers	Reassured that these are a common consequence of the vaccination. Advised to give paracetamol as required.
Medication Record	Paracetamol Oral Suspension 120 mg/5 mL, 2.5ml qds PRN.

3.4.5 Example Message

3.5 Home Visit

3.5.1 Aim

The representation of a home visit and recording of risks and warnings.

3.5.2 Summary

Dr Fixit is called to visit Frank Smith. Frank was registered with another practice in the local area but his family have decided they were not happy with the care he was receiving. Dr Fixit has agreed to take him as a patient. He goes to see him on a home visit.

3.5.3 Detail

Prior to going on the home visit Dr Fixit calls up Frank’s record. He has no record of his own as he is a new patient. There has been no GP2GP transfer as Frank’s old GP did not keep computerised records. The paper record has yet to arrive.
Dr Fixit arrives at Frank’s home he notices that the house is in a state of disrepair, he hears a dog barking.
Dr Fixit rings the door bell, the dog continues to bark and there is no answer.
Dr Fixit decides to try the door, he opens it slightly and the dog sticks his nose out. Dr Fixit is confident around dogs so he calms the dog and walks in.
Inside he finds Frank in a back room sitting in front of the TV which is turned up high.
He manages to attract Frank’s attention and the TV is turned off.
Dr Fixit spends time talking to Frank. Frank appears to be mildly confused. He is surprised that his dog has not gone for the doctor. He says that last week he bit the post man.
Dr Fixit asks if Frank is taking any medication or is seeing any other Health professional. Frank says that he was in the Local Mental Health hospital about 10 years ago.
Dr Fixit is worried about Frank and he feels that he needs to find out more.
Dr Fixit leaves Frank’s house and returns to his surgery, where he enters information about the Care Event

3.5.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Confused – unknown cause
Risks to Care Professional or Third Party	Patient has a dangerous dog
Risks to Patient	Confused – may not be looking after himself
Clinical Observations and Findings	Confused – mini mental score
Administrative Procedures	To contact social services and mental health to see if they are aware of Frank.

3.5.5 Example Message

4 Outpatient

4.1 Single Care Professional

4.1.1 Aim

Simple outpatient attendance with one Care Professional.

4.1.2 Summary

Wilfred attends for his outpatient clinic appointment. He is seen and given a date to come in for his procedure.

Note – Wilfred’s blood tests performed in the “Ordering and Referring” Scenario were all normal.

4.1.3 Detail

Wilfred arrives at the hospital outpatient clinic. He books in with the receptionist. And takes a seat in the waiting room.
One of the clinic nurses, Nurse Testem, sees that Wilfred has arrived. She calls him in to a consulting room. She performs the routine clinic pre-tests - Height, weight, Blood pressure. Wilfred takes a seat in the waiting room.
Mr Cutit the Consultant Surgeon is ready for his next patient. He sees that this is Wilfred. He reviews the Wilfred’s notes. He then asks his clinic nurse to call him in to the consulting room.
Wilfred enters the consultation room he is asked to undress, put on the gown and lie on the couch. He does so.
Mr Cutit enters the consultation room. He asks Wilfred about the lump. He agrees with Dr Wobble that it is probably a Lipoma. This need removal under General anaesthetic. Mr Cutit leaves the consultation room to document the events.
Wilfred dresses. Nurse Sortit asks Wilfred about his general health and finds that he is well enough to have the procedure as a day case. She gives Wilfred some information leaflets about his upcoming procedure.
Wilfred leaves the hospital.

4.1.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Lump Right thigh	Ideally this should be a reference to the original problem. Need a simpler way for P1R2
Clinical Observations and Findings (by Nurse Testem)	Height – 172cm Weight – 82Kg Blood pressure – 150/90
Clinical Observations and Findings (by Mr Cutit)	Lump Right superior medial thigh 9cm across. Soft lobulated fluctuant.
Diagnosis (by Mr Cutit)	Subcutaneous Lipoma - Clinical
Procedure – Treatment (by Mr Cutit)	Planned – Surgical Excision of Lipoma
Social and Personal Circumstances (by Nurse Sortit)	Lives with his wife – who can collect him after surgery and look after him for the first week post op.
Administrative Procedures (by Nurse Sortit)	Appointment booked for 2 months time. (State date). Daycase unit.
Provision of Advice and Information to Patients and Carers (by Nurse Sortit)	Given information about procedure and the daycase unit. Advised about fasting prior to attend the unit etc….

4.1.5 Example Message

4.2 One Stop Clinic

4.2.1 Aim

Visit to an acute trust for a series of tests and consultations in one encounter.

4.2.2 Summary

Ethel Smith has been suffering from chest pain for a number of weeks. Her GP Dr Fixit decides to refer her to Dr Ticker’s Rapid Access Chest Pain clinic. She attends and is assessed.

4.2.3 Detail

Ethel has been suffering with Chest Pain for a number of weeks she has seen Dr Fixit (her GP) who has referred her to Dr Ticker’s Rapid Access Chest Pain Clinic (RACP).
Ethel arrives at the RACP clinic. She books in and takes a seat in the waiting room.
Nurse Clear is notified that Ethel has arrived. She calls Ethel into a consulting room.
Nurse Clear takes a history from Ethel and examines her. She confirms that Ethel conforms to the clinic’s referral criteria and that Ethel is fit enough to have an exercise ECG.
Nurse Clear takes blood from Ethel. (FBC, U&Es)
Ethel is then asked to go to the X-ray department for and Chest X-ray. She goes to the X-ray department and returns with he films (unreported).
Mrs Cardio Gram is informed that Ethel has returned from x-ray. She calls her into her consulting room. She performs a resting ECG. She confirms that he trace is essentially normal. Ethel then undergoes an exercise ECG. She then returns to the waiting area.
Dr Ticker is now available to see the next patient. He is informed that Ethel is next to be seen. He asks that Ethel be brought into his a joining consulting room. Meanwhile he reviews Ethel’s history and tests.
Dr Ticker goes into his consulting room. He confirms Ethel’s full history; he examines her cardiovascular and respiratory system.
From the history, examination and tests he confirms the diagnosis of angina. He arranges for Ethel to come in for angiography in 2 weeks. He prescribes aspirin, and atenolol. He arranges for Ethel to have fasting glucose and lipid tests the next day.
Nurse Clear gives Ethel some information about angina and the angiogram she is to have. And gives her smoking cessation advice.
Ethel leaves the hospital.

4.2.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Chest Pain – central crushing chest pain on exertion. Lasts for 5 minutes relived immediately by GTN. 6 occurrences in the last 2 weeks
Diagnosis	Angina - confirmed
Family History	Father died of heart attack at age 52
Clinical Observations and Findings	Blood Pressure 140/85
Investigation Results	Urine dipstix - negative Chest x-ray - normal lung fields, CTR(Cardiothoracic ratio within normal range) Resting ECG – no Ischaemic changes. Exercise ECG – significant ischaemic changes in antero-lateral leads. FBC – Normal U&E - Normal
Lifestyle	Smokes 15/day
Investigations	Angiography – appointment for 2 weeks. Fasting glucose and Lipids tomorrow.
Medication Record	Dispensed Aspirin 75mg daily 7days Atenolol 50mg daily 7days
Provision of Advice and Information to Patients and Carers	Chest pain advice leaflet given and explained (leaflet id code) Smoking advice given

4.2.5 Example Message

5 Inpatient

Note: Due to limited functionality of Acute systems, with specific respect to inpatient clinical noting, the scope of the inpatient discharge messages is therefore reduced. These messages will contain the equivalent information currently recorded in an immediate/interim discharge message. That is discharge medication, Major procedures performed, diagnoses made and follow up plan.

5.1 Surgical

5.1.1 Aim

Simple inpatient stay – either day case or short inpatient stay.

5.1.2 Summary

Wilfred (see Primary Care Scenario – Ordering and Referral and Outpatient – Single Care Professional) has arrived in the Day case clinic for his operation. He has his operation with no complications and he is discharged home.

5.1.3 Detail

Wilfred arrive at the day case unit he is allocated. He is shown to his bed.
His is clerked by the nursing staff and medical staff. Consent for the operation is obtained.
He is taken to theatre and under goes his operation
He has the lump removed under general anaesthetic. Closure of the wound is with 15clips.
He returns to the ward
He is seen by the nursing staff and is declared fit to go home
A copy of his discharge note is given to him
He is taken home by his wife

5.1.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Lump Right Upper Thigh	Should be referenced (not restated)
Diagnosis	Subcutaneous Lipoma Right Thigh	Should be referenced (not restated)
Procedures - Treatments	Surgical Excision of Lipoma Closure with 15 clips
Medication Record	Paracetamol 500mg/Codeine 30mg tablets one or two tablets QDS PRN (30)
Provision of Advice and Information to Patients and Carers	Advised to make an appointment with GP practice nurse for clips to be removed in 7 days

5.1.5 Example Message

5.2 Medical

5.2.1 Aim

Medical inpatient discharge report

5.2.2 Summary

Ethel Doris Smith (see one stop clinic scenario) is admitted to hospital with Chest Pain, she is diagnoses as having a Myocardial Infarction. She is treated and recovers and is discharged home.

5.2.3 Detail

Ethel Smith is doing her shopping on the high street when she gets another pain in her chest. This time it is worse than before, she collapses. A passer by see her and calls an Ambulance
The Ambulance arrives, the Paramedics attend to Ethel who is able to tell them that she has chest pain. They transfer her to the ambulance, and perform an ECG. The ECG confirms a Myocardial Infarction. ASA given.
The Ambulance crew phones ahead to the Coronary Care Unit (CCU) who confirms they have a bed. Ethel is rushed there.
On arrival on CCU Ethel is taken to a bed an initial clerking is performed. It is confirmed that she is suitable for Thrombolysis. Streptokinase is given. Along with diamorphine for pain.
Ethel gradually recovers whilst on CCU
She is then discharged from CCU to the General Medical Ward
3 days later she is recovering well
Dr Ticker and Dr Ian Training are performing their morning ward round. They come to Ethel, Ethel confirms that she is feeling a lot better.
They agree she can go home. Dr Ian Training fills out Ethel Discharge note/message.
Ethel is taken home by Wilfred Smith (her husband).

5.2.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	Chest Pain
Diagnosis	Acute Anterolateral MI
Investigations	To come for her angiogram as planned next week
Risks to Patient	Streptokinase - 1500000 units administered
Medication Record	Aspirin 75mg daily 7days Atenolol 50mg daily 7days Enalapril 5mg od 7 days Simvastatin 20mg nocte 7 days Increase Enalapril dose to 10mg if tolerated

5.2.5 Example Message

5.3 Maternity

5.3.1 Aim

To show how discharge messages from a maternity setting should be handled in P1R2

5.3.2 Summary

Shirley Smith is admitted to the Central Delivery Unit of the Maternity Hospital in labour. After a short labour she delivers baby Mary. Mary and Shirley are both well and are discharged after 6 hours

5.3.3 Detail

Shirley Smith is pregnant this is her second pregnancy it has been uneventful so far her expected date of delivery is 18/3/2004.38 weeks pregnant.
Overnight Shirley has noticed that she has started to get some abdominal pains after a few hours she thinks these are contractions. She phones the Central Delivery Unit (CDU) of the Maternity Hospital. She speaks to Midwife Keep Pushing who advises her to come down to the CDU to be assessed.
Shirley arrives on the CDU
Midwife Keep Pushing confirms Shirley’s history and examines her. She confirms she is in labour and admits her.
Shirley’s normal labour continues and is relatively.
At 2230 4/3/2003 Shirley delivers a baby girl.
Mum and baby are examined and are found to be fit and well.
Baby is allocated an NHS Number
Mum and babe recover and are reassessed 6 hour post delivery
They are both still well and are discharged home

5.3.4 Information to be recorded

Care Record Element	Information to be Recorded	Notes
Problems and Issues	In labour – Spontaneous onset	This is a sub problem of the high level P&I “pregnancy”. It needs to have a start date and time to match the patients estimate of the start time. The onset of labour is 0330. Time of admission is 0645. Time of delivery is 1305. Time of Discharge 19.30 All on the same day.
Medication Record	Pethidine 75mg IM administered at 0730. Entonox administered as required (self administered). Ferrous Sulphate 200mg tds (21 tablets dispensed)
Procedure - Treatments	Vaginal Delivery – Single live infant	Time of delivery 1305.
Clinical Observations and Findings	Vagina and labia intact (No sutures) Complete delivery of placenta Blood loss 300ml Breast Feeding