Also see: Residential Institute RI Codes
There are several ways to locate the Care Home Residents template:
1. Auto-Consultation> ardens GENERAL> Care Home Residents
2. If the appropriate read code has been added to the patients record, the following icon will show in the demographics box click the icon to open the template.
the blue stars indicate there is income related to a National Enhanced Service for this field. The yellow stars indicate the income relate to a Local Enhanced Service.
Care Home Status
From this main tab there are links to PCSP Assessment/PCSP Plan/MDT review and different types of visit.
Residence - A NCD PCN DES contract requirement (blue star). From the drop down select the most appropriate read code as to where the patient resides. Once added to the record, this will enable you to access the template selecting the icon in the patients demographics box. There is also an Ardens report to find patients on this register, detailed below.
The 'view' or window at the bottom of the template shows information that is currently missing which you may want to consider adding. Below this is any relevant coding previously recorded in the patients record including Safeguarding, DNACPR status, Special Notes & Key Messages, Treatment Escalation Plan, Sharing, Care Plans etc.
PCSP Assessment tab - (Personalised Care & Support Plan)
Ensure you add the appropriate PCSP read code indicated with the blue star, as part of the PCN DES contract. This will also enable you audit patients records to find where this work has been completed or is outstanding.
The Care Plan itself can be printed from the button directly beside the code along with an Assessment Form. The Care Plan will auto populate with all information captured in this template. If the information has been newly added, before printing the Care Plan, you will need to click OK on the template and re-open to ensure any new data will populate the plan. Click to launch the Care Plan. Make sure you complete the Assessment below first
Assessment section allows you to record any Delirium, Falls Risk and a Psychosocial assessment again highlighted with a blue star. To the right of these codes are the relevant scored assessments or templates or documents needed.
Use other coding & links as appropriate for Frailty Status, Memory, Mobility, Nutrition etc.
There are also some numeric fields for you to capture any vitals taken at the time - including BP, Pulse, Weight, Height etc. You can also click in to these boxes to view historical data in the yellow pane at the right side of the template.
PCSP - Plan
Both the Treatment Escalation & Special Note fields allow free text entries or use the 'Preset' notes alongside to select from a list of preset text. Hold down the 'Ctrl' button on your keyboard to select multiple lines of text.
Advanced Care Plan
Input information around the patient's future care such as Advanced directive, Capacity to give consent, add preferences for death and any EoL QOF codes to add the patient to the register. Code the Resus status and print a DNACPR form using the link next to the coded status, the patients details will auto-populate the form. Add any ReSPECT codes if applicable in your area and access the ReSPECT Plan using the link to the right.
In this section you can add any Communication Needs the patient may have such as hearing difficulties, problems with vision or interpreter requirements. Allocate Named GP and record Next of Kin details.
Both SystmOne Sharing and Summary Care Record codes can be added here.
The Structured Medication Review (SMR) code can be added can be added here. There is a link along side this to the Drug Review template.
Record any vaccination advice given or open the Flu or Pneumococcal immunisation templates to record a vaccine given or declined.
Another opportunity to add the PCSP code and generate Care Plan (this is also located at the top of previous tab 'PCSP Assessment').
MDT Review Tab
This tab will enable you to record details of any MDT reviews (ensure you tick the MDT review box with Blue Star). Clicking in to any section will display previously recorded information in the yellow panel on the right-hand side of the template. This allows you to review and add at each MDT review.
There are separate tabs for Remote Encounter, Initial Visit, Review Visit & Acute Visit dependant on the type of visit/review with the patient. All of the tabs have similar codes and links as above.
Clinical Reports for Care Home activity can be found under:
Clinical Reporting > Ardens > Conditions | Frailty and End of Life
Clinical Reporting > Ardens > Contracts | 21021 22 | NCD PCN DES