PSIS 2008-A Clinical Storyboards

Amendment History:

Version	Date	Amendment History
1.0	28-Sep-2007	Revised presentation of Clinical Scenario Document (NPFIT-FNT-TO-DPM-0606)

Forecast Changes:

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This document inherits its approved status from NPFIT-FNT-TO-DPM-0606.

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Ref no	Doc Reference Number	Title	Version
1	NPFIT-FNT-TO-DPM-0597	PSIS 2008-A Process and Data Models

1. Introduction

The delivery of the NHS Care Records Service (NHS CRS) is a central part of the National Programme for IT (NPfIT) and is being delivered by NHS Connecting for Health, an agency of the Department of Health. The NHS CRS’s primary role is to deliver integrated IT systems and services to help modernise the NHS and provide systems that will support patient centred care.

The recent National Audit Office report on the NPfIT confirmed that the NHS CRS is much needed and can bring great benefits to both the NHS and patients through improved efficiency (fewer wasted consultations or repeat investigations) and better communication between healthcare professionals and organisations (missing records).

The NHS CRS will provide a patient record service 24 hours a day seven days a week; accessible by health professionals whether they work in hospital, primary care or community services. When implemented, the NHS CRS will function across care settings and organisations and will support planned, emergency and unscheduled care.

The NHS Summary Care Record (NHS SCR) is the national element of the NHS CRS which will create a summarized electronic care record for every registered NHS patient in England by 2010. It will be held on a national database known as the Personal Spine Information Service (PSIS), ensuring that demographic and clinical information such as major diagnoses, allergies, adverse reactions to drugs, other significant information, medications and details of treatment in secondary care are always accessible.

This document contains a number of clinical storyboards which provide clinical contexts for the example messages and information examples.

2. Storyboards – Emergency Department

2.1. Jake (Child with laceration of the tongue)

Jake, a boy of 6, is on holiday when he falls and lacerates his tongue. His father takes him to the nearest Emergency Department. They arrive and the receptionist logs this with the Local Service Provider (LSP) system, which queries the Personal Demographics Service (PDS) and verifies Jake’s demographic details. The nature and time of the injury is recorded on the Local Service Provider (LSP) system and legitimate relationships (LR) are created for the ED team.

The Triage Nurse using a smart card and PIN accesses the LSP - ED system and finds the entry for Jake. Selecting the entry for Jake opens a screen which allows clinical details to be entered into the LSP system and also displays Jake’s Summary Care Record held on PSIS, which shows a history of asthma, his current medication, a possible allergy to penicillin and his tetanus immunisation status.

Upon examining Jake’s tongue, the nurse finds that the bleeding has now stopped and the injury does not require any further treatment; she issues a patient advice leaflet from the Local Service Provider (LSP) system and recommends that Jake’s father gets some paracetamol syrup. Jake is discharged from the department.

An Emergency Department Report is prepared which includes details of the care episode relevant times, advice given and medication recommendations. The report is validated and sent by the Triage Nurse to the PSIS and to Jake’s GP.

Notes:

The Triage Nurse is an independent practitioner and therefore has Role Based Access Control (RBAC) permissions and an LR with the patient, so she can send messages to PSIS.

2.2 Sally (Adult visiting Emergency Department)

Sally, a 20 year old student, is brought to the Emergency Department with heavy PV blood loss. Reception staff accesses PDS via the Local Service Provider (LSP) system, which confirm her details and legitimate relationships (LR) are created for the ED team. This shows that she is registered with a GP in Harlow.

Sally is seen by the emergency department physician who accesses the LSP ED system using a smart card and PIN and selects the entry for Sally on the LSP – ED system, which opens a screen allowing clinical details to be entered and also displays Sally’s Summary Care Record held on PSIS. She confirms that the information retrieved from PSIS is correct. It showed that she has been taking the OCP and was prescribed a course of penicillin two months ago to treat tonsillitis. It is also noted that Sally’s LMP was 8 weeks previously.

When questioned she said that she had been sexually active during the last few months. On examination, Sally has supra pubic pain and low back pain in addition to the bleeding PV. Sally’s vital signs are recorded; none were compromised.

A urine pregnancy test was found to be positive and a differential diagnosis of ectopic pregnancy or miscarriage is made. Sally is admitted to the 24 hour observation ward and is given analgesia. She has some blood taken for testing, including a full blood count, blood group in case Rhesus negative and a Kleihauer test.

The next day, an U/S scan confirms a blighted ovum. Sally is keen to return to her student home. She is discharged by the Gynaecology Registrar, who gave her an advice leaflet and he instructed her to seek advice if the bleeding did not stop. An Emergency Department Report of Sally’s care is written and saved on the Local Service Provider (LSP) system

Sally is prescribed co-codamol, which is collected from the pharmacy by the nurse.

Later that day, Sally’s Kleihauer test result is returned as positive, she is confirmed as Rh-Ve. These results are reviewed by the gynaecologist, who completes the Emergency Department Report including a request for the GP to undertake anti D immunisation as per local policy. He verifies the report and sends it to PSIS and to the GP’s system. The Gynaecology Registrar phones the GP’s surgery to advise the GP to read and act upon the report he has sent.

2.3 Mavis (Adult with Subarachnoid Haemorrhage) Part I

Mavis who is known to have migraine, develops a severe headache and is worried by the associated photophobia and vomiting. She decides to attend the local Emergency Department. When she arrives she gives her details to the receptionist who logs into the Local Service Provider (LSP) system which checks her details on the Personal Demographic Service (PDS). The nature and time of the headache is recorded on the Local Service Provider (LSP) system and legitimate relationships (LR) are created for the ED team.

Dr Carter (ED) sees Mavis having already reviewed her Summary Care Record and decides that a CT scan is required, because she has developed neck stiffness in addition to her previous symptoms. The CT is performed and Dr Carter is able to view the scan via PACS. He sees a small Subarachnoid Haemorrhage and decides to refer her to the Neurosurgical department. Mr Head (consultant neurosurgeon) is based at the local teaching hospital, he records Mavis’ NHS number whilst speaking to Dr Carter and views the CT scan on PACS. Mr Head’s opinion is that the haemorrhage is more clinically significant than Dr Carter had initially anticipated.

Mr Head recommends that Mavis should be admitted to the Neurosurgical Unit. Later that day Mavis is transferred to the Neurosurgical Unit, Dr Carter composes an Emergency Department Report which is sent to PSIS and to the GP.

3. Storyboards - Discharge

3.1. Mavis Part II

Following deterioration in Mavis’s clinical state, a further CT scan leads to a decision to operate on a Berry Aneurysm in the Circle of Willis. She suffers a left sided stroke with right sided weakness; post-operatively she is transferred to the hospital’s rehabilitation unit from where she is discharged home.

Mr Head’s Specialist Registrar writes her Discharge Report which includes details of her admission, her treatments, her discharge medications (taken from EPS) and a plan for further rehabilitation and ongoing care with community support from the charity Headway. The Discharge Report is verified and a copy is sent to PSIS, her GP, the physiotherapist, the occupational therapist and the speech therapist involved in her care and Social Services (to arrange a social worker visit). An additional letter including abbreviated details of her care is sent to PSIS and the charity Headway.

Notes:

This scenario demonstrates the case in which documents are sent following Mavis’s discharge from both ED and Neurosurgery. However, clinicians might choose to send a single Discharge Report following Mavis’s discharge from the Neurosurgical Department that covers Mavis’s treatment within ED and Neurosurgical Department.

3.2. Colonel Mustard (Adult with Myocardial Infarction)

Colonel Mustard, an 85 year old man, is at home in the Library when he experiences crushing central chest pain and looses consciousness. On hearing him fall his housekeeper Miss Scarlet rushes into the room and dials 999. Ambulance control take details of the event and send a paramedic ambulance to the house. Ambulance Control Staff retrieve the Colonel’s NHS Summary Care record from PSIS via the Clinical Spine Application (CSA (web based viewer)). It shows that he consulted his GP two days previously when he was noted to have high blood pressure and had been asked to return to have his blood pressure checked in a few days time.

When the Ambulance arrives, Colonel Mustard has recovered consciousness and is able to tell them that he had chest pain. They transfer him to the ambulance, and perform an ECG which confirms a Myocardial Infarction.

On arrival at the hospital, he is admitted directly to CCU. The registrar on duty obtains the Colonel’s summary Care Record from PSIS specifically looking at the medication summary, allergy and adverse reactions and diagnoses. It is confirmed that he is suitable for Thrombolysis and Streptokinase is given, along with diamorphine for pain.

Colonel Mustard gradually recovers and is discharged from CCU to the General Medical Ward.

Four days after his admission he is considered fit for discharge home. Whilst in hospital the clinical staff realised that Miss Scarlet is also quite elderly and it is discovered that she is 84 and not as healthy as she once was; therefore a social service assessment was conducted for Colonel Mustard. The ward doctor prescribes his take home medication via the LSP system which is sent directly to the hospital pharmacy. After dispensing, a message is sent from pharmacy updating his medication record on the LSP system indicating that the one month’s supply had been dispensed.

The ward doctor then prepares a Discharge Report containing the information in the table below. The discharge summary is sent to PSIS, Colonel Mustard’s GP and local Social Services.

Note: As the initial investigation and diagnosis is made by the paramedic in the ambulance the clinically relevant time will be prior to the admission time.

3.3. Harriet (Child with Cerebral Palsy admitted as a day care patient for examination)

Harriet is a 3 year old child with cerebral palsy, who is admitted as a day care patient for Examination under Anaesthesia and injection of Botulinum Toxin to her hamstrings and adductors. She is accompanied by her Mother.

The Theatre Nurse using a smart card and PIN accesses the Harriet’s Detailed Care Record on the LSP system and finds her name on the theatre list. Selecting her entry opens a screen which allows clinical details to be entered into the LSP system and also displays her Summary Care Record held on PSIS, The details of the admission are recorded by the nurse.

The surgeon examines Harriet’s lower limbs on the ward and makes careful note of the range of movement. This data is recorded by the orthopaedic house officer in the pre operative assessment field of the detailed record.

Following Harriet’s procedure, a description of the procedure, findings and plan for follow up care are added in text form to the detailed record. Harriet is discharged later in the day and the date and time of discharge is recorded.

After the surgical procedure the Consultant Orthopaedic Surgeon records the operative details using a Dictaphone in theatre. This includes details of the treatment given, and a brief summary of the anaesthetic. The tape is given to his secretary at the end of the day. She types the operative details into the detailed care record three days later, and then produces a discharge summary using the PDS admin details, relevant details from the pre-operative assessment page and the operative details.

SNOMED encoded Data in fields, such as “Diagnosis” from the Detailed Care Record is used to populate Harriet’s Discharge Report which is then seen and verified by the Orthopaedic Specialist Registrar and then sent electronically to the PSIS and to the GP.

Note:

It is assumed that the parents and GP are aware of the follow on activities, such as physiotherapy and so this would not be recorded in discharge note.

3.4. Mary - Maternity Discharge Summary Example

Mary is a 27 year old female of Black Caribbean ethnicity. She becomes pregnant and her antenatal provider is her GP. Her pregnancy is complicated by hypertension and, since she is pregnant with twins, she is referred to the local hospital for shared care with the maternity unit. At 38 weeks gestation she attends St Elsewhere’s maternity unit for an elective caesarean section.

On 20/9/06 she is admitted to the unit, her details checked and the relevant investigations undertaken. On 22/9/06 she undergoes an elective caesarean section under spinal anaesthesia and is delivered of two healthy babies, Alex, and twin 2 who remained un-named. The procedure is relatively uncomplicated although Mary does suffer a moderate loss of blood. Mary’s subsequent recovery is uncomplicated and the twins are well, with no problems noted at their neonatal checks.

The receptionist at the Maternity unit logs into PDS enters appropriate demographic information for the babies and generates 2 new NHS numbers.

Mary and the babies are discharged on 27/9/06, back to the care of the community services. At this point one of the babies has still not been named but each has been allocated an NHS number. Mary is given a post-natal out-patient appointment for 10th November at St Elsewhere’s maternity unit.

Mary is given some advice on contraception use.

Three Discharge Reports are sent, one relating to Mary and one for each of the twins.

The letters are sent to PSIS, the GP and copied to the Health Visitor and the Practice Nurse.

3.5. John (Paediatric Intensive Care – Long Discharge Report)

John, a previously well 9 year old boy, was admitted to the Emergency Department of Macclesfield Royal Infirmary (A District General Hospital), on 10th March 2007, with a short history of fever, headache and lethargy. Shortly after reaching hospital he suffered a severe deterioration, including cardiovascular collapse and loss of consciousness. A diagnosis of septicaemia and meningitis was made and he was transferred to St Eleswhere’s Paediatric Intensive Care Unit on the same day.

Initially he was extremely unstable, requiring inotropic support, sedation, ventilation, and antibiotics. Pneumococcal sepsis was confirmed on blood culture and PCR. Following an initial CT scan and confirmatory MRI scan showing cerebellar tonsillar herniation, he underwent a foramen magnum decompression under the care of the neurosurgical team.

After a prolonged admission to PICU, John was eventually discharged to Macclesfield Royal Infirmary 6 months later on September 11th 2007.

At discharge he had a flaccid quadriplegia and remained ventilator dependent. He was fed using a gastrostomy and required intermittent catheterisation. He had problems with chronic pain and was being managed by both St Elsewhere’s chronic pain team and the Spinal Injuries Unit at Stoke Mandeville.

He required the fitting of a lumbar brace by the Spinal Surgeons at St Elsewhere’s and was confined to a wheelchair.

During his admission John was noted to have a severe reaction to the antibiotic Teicoplanin.

At discharge from PICU a Discharge Report was composed by the Paediatric Intensive Care Fellow. The local system automatically populated the document with the medications dispensed from the pharmacy. The document was then verified by the PIC Consultant and sent to PSIS, as well as the following recipients:

Dr A Davies (John’s GP)

Dr D Duncan, Consultant Paediatrician, Macclesfield Royal Infirmary

Dr F Moody, Consultant in Spinal Injury, National Spinal Injuries Centre

Dr I Lewis, Consultant Paediatric Neurologist, St. Elsewhere’s Hospital

Dr Dooley, Consultant Paediatric Endocrinologist, St. Elsewhere’s Hospital

Dr F Hurt, Consultant Anesthestist / Pain Management, St. Elsewhere’s Hospital

Mr L Head, Consultant Neurosurgeon, St. Elsewhere’s Hospital

Mr B Boswell, Consultant Spinal Surgeon, St. Elsewhere’s Hospital

4. Scenarios - Outpatient

4.1. Wilfred (Adult with Lipoma)

Wilfred consults his GP about a lump he has noticed on his thigh, the GP records this in the detailed record as significant data. This sends a GP update to PSIS The GP books an appointment using Choose and Book and sends a referral letter/message. When Wilfred arrives at the outpatient clinic, the receptionist checks his details on the Local Service Provider (LSP) system which confirms Wilfred’s demographic details with PDS and the appointment with Choose and Book.

The Surgeon reviews Wilfred’s referral letter and Summary Care Record, he takes a medical history and examines the patient. He agrees that it is probably a Lipoma and that it needs to be removed under general anaesthetic. The surgeon records his findings on the detailed care record using the Local Service Provider (LSP) system in the hospital and books him onto the operating list in 2 months time.

At the end of the clinic the surgeon reviews the patients he has seen and prepares an Outpatient Report which is sent to PSIS and Wilfred’s GP.

4.2. Ethel (Adult attending Cardiology Rapid Access Chest Pain Clinic)

Ethel has had Chest Pain for a number of weeks and has referred herself to the Rapid Access Chest Pain Clinic. On arrival at the clinic the receptionist registers her attendance with the LSP system which checks her demographic details on PDS and books her into the clinic that morning.

The clinic nurse using a smart card and PIN accesses the LSP system and finds the entry for Ethel. Selecting the entry for Ethel opens a screen which allows clinical details to be entered into the LSP system and also displays Ethel’s Summary Care Record held on PSIS. The nurse checks her current medication, takes a history which confirms that Ethel conforms to the clinic’s referral criteria and takes blood from Ethel. The specialist registrar examines Ethel and decides she is fit enough to have an exercise ECG and a chest X-ray; he records his finding on the detailed care record of the LSP system.

Ethel has her Chest X-ray, with the image stored on PACS. On her return to the clinic, Ethel has a resting ECG recorded. As the trace is essentially normal, Ethel has an exercise ECG.

The senior physician reviews Ethel’s clinical history including the summary care record, which has been seamlessly integrated into the screen displaying the detailed care record from the Local Service Provider (LSP) system, blood results, ECG and Chest X-Ray. He confirms the diagnosis of angina and records this within the Hospital’s detailed care record system. He then arranges for her to have fasting glucose and lipid tests and to come in for coronary angiography in 2 weeks.

He prescribes aspirin, and atenolol. At the end of the clinic an Outpatient Report of Ethel’s attendance is prepared using information stored in the detailed care record held on the Local Service Provider (LSP) system.

Term	Definition
ESP	Existing Service Provider
LSP	Local Service Provider
NASP	National Application Service Provider
NPfIT	National Programme for Information Technology
PCT	Primary Care Trust
PDS	Personal Demographics Service
PSIS	Personal Spine Information Services
SCR	Summary Care Record
TMS	Transaction & Messaging Service
CDA	Clinical Document Architecture
EPS	Electronic Prescribing Service
RBAC	Role Based Access Control
LR	Legitimate Relationships