The General Consultation template is accessed by clicking on the ‘Doctor’s Bag’ icon below the patient demographics box.
The template is designed for minor illness consultations, rather than that of a specific chronic disease. The template is divided into specific tabs across the top, that all cover the most relevant minor illnesses a patient might come in for:
The General tab can be used for recording general information about the consultation, but if the minor illness is more specific, you can navigate to the relevant tab across the top. Every tab follows the same format, but will be tailored for that specific minor illness.
E.g. If the patient came in complaining of a sore throat, then you can navigate directly to the 'ENT + Oral' tab.
ENT + Oral Consultation
Each tab is laid out in the same way, and they are divided into three sections: An Assessment section, Diagnosis section and a Management section.
In the History and Examination boxes you can free text any observations from the patient. To make things easier, there is a preset button to the right of each box that will display some of the most common History and Examination text you are likely to write. For example, on the presets for the History box you will get the following options:
Select the option you wish and press OK. (You can select more than one option by holding down the CTRL key and selecting the relevant options)
There is then an area to record the most relevant numerics for this type of consultation. Simply enter the numeric in the box you wish. When you click in the box, the past numerics for that reading that are recorded in this patient record are visible in the yellow right hand column of the template.
There are also links to the Vitals & Lifestyle template to record any other numerics such as weight, height and smoking status, and there is a link to the Sepsis Risk Stratification template.
The Diary section will display the most relevant diary for the tab that you are on. In this case of ENT & Oral, a Symptom Diary can be printed off and given to the patient. In some of the other tabs e.g. Respiratory, you can print more specific diaries, such as a Peak Flow Diary.
The Scores section will link you to any relevant scores for that condition that you can then perform. E.g. If that patient is asking for antibiotics for their sore throat, by clicking on Fever Pain you can go through the questions with the patient:
There is also a link to print out the RCGP Leaflet for the patient if Antibiotics are not indicated.
Once you have done your assessment of the patient, the last option will allow you to launch the Phlebotomy template which will display any past blood results in the patient record, and allow you to launch your external electronic pathology requesting, such as ICE or TQuest.
The drop down list here will give you an A-Z list of the most common diagnosis codes for the tab that you are on. Simply select the most appropriate code. If for some reason the code is not listed, then click on the New Coded Entry button to search the code browser for any code you wish. There is also a box to enter any appropriate free text.
The Plan box allows you to free text the plan for the patient. As with the History and Examination boxes above, there is a Preset button with common safeguarding text that you would most commonly write for this specific condition. There is also a tick box to code 'Advice, no better or concerns' and a link to a Referral Safety Net Letter that can be printed that advises the patient of the local hospital numbers to call if they are being referred and have not heard back.
The Leaflets button will link through to a list of links to relevant leaflets for the minor illness tab that you are on. You can click through and print these off, or copy the link with Ctrl + C, and send it via SMS or Email using the buttons on the side.
The MED3 & Letters button will launch a template with links to various patient specific letters, including a MED3 and Travel Summary letter.
The Medication section will link through to the various formularies that are most applicable for the minor illness tab that you are currently on. In the ENT & Oral tab, this means we have access to such formularies as the Sore Throat Formulary.
Here will be listed the 1st and 2nd line drugs to prescribe, as well as links to any scores etc if you haven't already performed these. The box at the bottom will display any other medication alerts applicable for that patient, as well as a list of Allergies & Sensitivities, and any other medication this patient is currently taking.
Clicking on one of the lines will display the specific drugs that are recommended for prescribing:
In the example above, a 5, 7 or 10 day course is offered. All you need to do is click on the relevant button and the drug will be prescribed. The normal SystmOne allergies and interactions that are set at your organisation will kick in, as well as any other programmes such as ScriptSwitch or OptimiseRx. Once prescribed, the scripts can then be printed or sent electronically as normal.
At the bottom of the template is a button to launch the Referral Criteria protocol that will allow you to view and record the relevant criteria for the chosen condition.
This video gives a good starting point on how to use the General Consultation template: