reviewing a patient’s cas card or last dictated letter · introduction of lorenzo, cas cards and...

© Tameside NHS Foundation Trust

Reviewing a patient’s Cas Card or Last Dictated Letter

FC04

Version 3.0

Operational Areas Included

Fracture Clinic

Roles Responsible for Carrying out this Process

Nurse

Consultant

Operational Areas Excluded

All Other Areas

Associated Procedures

GEN01 Logging into Lorenzo

TAMESIDE HOSPITAL NHS FOUNDATION TRUST Reviewing a patient‟s Cas Card or Last

Dictated Letter

Version 3.0 13/03/2013 (Draft)

CHECK THE INTRANET FOR LATEST VERSION


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Contents Reviewing a patient‟s Cas Card or Last Dictated Letter ................................................................................ 1

Reviewing a patient‟s Cas Card or Last Dictated Letter Description.............................................................. 4

Opening the Clinic Pegboard .................................................................................................................... 5

Viewing a Patient‟s Cas Card ....................................................................................................................... 9

Viewing a Scanned Cas Card ................................................................................................................... 9

Viewing a Lorenzo CAS card .................................................................................................................. 13

Viewing a patient‟s last dictation letter ........................................................................................................ 15

Viewing a Medway dictation letter ........................................................................................................... 16

Viewing a Lorenzo last dictation letter ..................................................................................................... 20


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Process Flow

Patient arrives for Fracture Clinic appointment

Nurse checks Lorenzo clinc pegboard and identifies arrived

patient

Nurse collects patient tracking sheet from

reception

Nurse views the patient's cas card or

last dictated letter on Lorenzo

Nurse places tracking sheet in time order

ready for consultant's attention

Nurse sends patient for X-Ray

Nurse sends patient for treatment


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Reviewing a patient’s Cas Card or Last Dictated Letter Description.

This process covers the behaviour required to view the patient‟s last dictation letter or the Emergency department cas card. Historically cas cards and dictation letters used to be sent with the patient‟s notes, but with the introduction of Lorenzo, cas cards and the last dictation letters will be available to view electronically. The cas card is not meant to be printed or used to track a patient‟s movement through the department; the patient tracking sheet will meets those requirements. The loss of the notes has also been replaced by the patient tracking sheet.


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Opening the Clinic Pegboard The clinic pegboard provides a real time view of the patients attending the fracture clinic; the patients are highlighted in various colours as they move through the department. This activity needs to be done only once for the day, unless the user has to leave the PC and remove their smart card (in which case the steps below may need to be repeated).

Activity Additional Guidance

1. Log into Lorenzo using your smart card. See GEN01 Logging in to Lorenzo if you require further guidance. Once opened, Lorenzo defaults to the My work application tab.

2. Select Clinics from the My work menu on the left hand side.

3. In the Search Criteria pane which opens up, type the clinic or session name. e.g.

or

If you don‟t know the name of the clinic or session, the wildcard character „%‟ can be used, e.g. Bari%


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4. Change the To date to today‟s date. You can remove the date entirely and use the shortcut „TD‟ and press Enter to enter todays date.

If you do not enter a To date, the system will return every session for the next two weeks.

5. Click Find

6. Select the clinic session you would like to see by ticking the box to the left of the correct row. Multiple sessions can be opened by selected more than one session. Each session is an individual consultant‟s stream, e.g “Bari Fracture Tues PM” would be Dr Bari‟s fracture clinic on a Tuesday afternoon.

7. Click OK to open the clinic session


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8. Click the pin icon in the corner of the Search Criteria pane. This will remove the pane and provide a larger view of the clinic information.

9. The clinic pegboard is displayed. This pegboard displays real-time information about a patient‟s status. The colour legend and the bottom of the pegboard indicates the various stages a patient maybe in during their outpatient visit.

Patients who not been arrived electronically will remain in a yellow colour.

Patients who have arrived in the clinic will be highlighted in a blue colour


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10. It is important to note the Comments column to indicate if this is a patient referred via the Emergency Department or if they have been referred directly to fracture clinic. Comments may include:

ED Patient

X-Ray on arrival

Treatment on

arrival

ED Patients will have cas cards that will need to be viewed Non ED Patients will have the last dictation letter that will need to be reviewed electronically

Comments Column


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Viewing a Patient’s Cas Card During a short interim period a patient‟s cas card maybe stored in one of two places. The interim period is not expected to be beyond ten weeks of using Lorenzo. This process will cover the activities needed to look for the cas card in both places. Subsequently the cas card will be stored in a single place.

Viewing a Scanned Cas Card This process shows how to access cas cards created before the introduction of Lorenzo. During the first six weeks of using Lorenzo, patients may attend who have attended the ED department before Lorenzo was introduced and therefore their cas cards will not exist within Lorenzo.


1. Click the patient‟s name to open the patient‟s electronic record (EPR)

2. The patient‟s EPR is displayed to the user.


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3. Click the down arrow on the patients EPR Tabs and scroll to the Non-clinical documents

4. Click the Non Clinical Documents Tab


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5. A list of non-clinical Document are displayed. Select the first check box against the Cas card

Document Name = CAS Card dd.mm.yy Document type = Scanned Item

6. Click Preview

7. Scanned CAS card is displayed; Use the Scroll bar to review the entire cas card.

8. On return to the patient‟s EPR view, click the down arrow next to the Back icon in the top left hand corner.

The down arrow allows the user to go back to a specific section of a previously visited part of the Lorenzo system.


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9. Click Clinics pegboard from the list of recently accessed screens.

10. The clinic screen should now be displayed again, allowing you to select another patient or carry out another activity.


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Viewing a Lorenzo CAS card This process shows how to access the patient‟s electronic cas card. These cas cards are only available for patients who have been through the ED Department after Lorenzo has been introduced. Once Medical secretaries start using Lorenzo, the last dictation letters will also be stored in the same place, allowing clinicians to review all clinical letters for a patient from a central repository.



2. On the right hand side of the screen click on the tab named Clinical Documents

3. The patient‟s clinical document screen is displayed, showing all previous documents created on the patient‟s record. The list is organised in date order with the newest clinical letters at the top.

4. In the Column called Note name look for the cas card. The naming conventions are as follows: RMP CAS Card<author>YYYYMMDDHHMMSS


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5. Place a tick in the box to the left of the document Click Preview

6. The patient‟s cas card should be displayed. Review the document ensuring you scroll through all the pages.

7. Once the cas card has been reviewed, click the down arrow next to the Back icon at the top of the EPR.




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Viewing a patient’s last dictation letter This section looks at the requirement to access the patient‟s last dictation letter. This could indicate to the nurses potentially what the patient may need before seeing the consultant. Dictation letters will be available in two separate areas of the system and for a short period users will have to review both areas. Patients who have had any dictation letters written in Medway will not have those letters on Lorenzo but as Medway will not be available after the introduction of Lorenzo, the Trust has made them available in a document repository. Patients who have had dictation letters written in Lorenzo will not have those letters in the document repository but they will instead be stored within the patient‟s EPR. Both methods to access the documents will be demonstrated in the following sections.


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Viewing a Medway dictation letter Patients who have had any dictation letters written in Medway will not have those letters stored on Lorenzo. As Medway will not be available after the introduction of Lorenzo, the Trust has made them available in a document repository. This process discusses how to access those letters.



2. The patient‟s EPR is displayed to the user. In the bottom left corner click the link Click Here to Complete an e-Form

3. From the pop up box select Medway Letters


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4. Patient Dictation letters are displayed in the speciality and letter type order

5. Click the + symbol next to the letter type

6. The dictation letters are displayed in Date order. Click the View Hyperlink


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7. Dictation letter is displayed

8. Once the document has been reviewed click the X icon

9. Click the X icon to close the list of Medway Letters

10. User is returned to the patient‟s EPR view, Click the down arrow next to the Back icon in the top left hand corner.




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Viewing a Lorenzo last dictation letter Patients who have had dictation letters written in Lorenzo will not have those letters in the document repository but they will instead be stored within the patient‟s EPR. This process discusses how to access to letters.



2. On the right hand side of the screen click on the tab named Clinical Documents

3. Patient‟s clinical document screen is displayed. In the Column called note name look for the word The naming conventions is as follows Card>author>YYYYMMDDHHMMSS

The list is organised in date order with the newest clinical letters at the top.


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4. Place a tick in the box to the left of the document Click Preview

5. The patient‟s dictation letter should be displayed. Review the document ensuring you scroll through all the pages.

6. Once the cas card has been reviewed, click the down arrow next to the Back icon at the top of the EPR.





Document Control

Version Number

Date Document Status Author / Modifier / Reviewer Details Approved Signatory

0.1 12/07/2013 Draft Bilal Bham First draft

2.0 30/07/2013 Draft Monika Vorberg Minor wording changes

3.0 03/10/2013 Final Monika Vorberg Updated to Final