Information to Be Taken from Correspondence

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Bradley Sieve

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Administrative guidelines

Re: information to be taken from correspondence

Blood pressure

·  246 O/E Blood Pressure Reading

·  8I3Y Blood pressure procedure refused (Exception)

Smoking status

·  1371 Never Smoked

·  137S Ex Smoker

·  137P Cigarette Smoker

·  137J Cigar Smoker

·  137H Pipe Smoker

·  137M Rolls own cigarettes

Smoking Advice

·  8CAL Smoking cessation advice

·  9N2k Seen by smoking cessation advisor

·  9N4M DNA - Did not attend smoking cessation advice

·  9OO% Anti-smoking monitoring admin. Etc

·  8B2B Nicotine replacement therapy

Alcohol intake

·  136 Alcohol consumption

·  1361 Teetotaller

·  1367 Stopped drinking alcohol

Height - 229 O/E Height

Weight - 22A O/E Weight

Urine

·  467 Urinalysis – Protein

·  R110. [D]Proteinuria (DM13/15)

·  R1100 [ D]Albuminuria (DM13/15)

·  1A45 Blood in urine – Haematuria

·  46S..12 Sugar in urine (Urine Biochemistry)

·  466 Urinalysis – Glucose

·  46W. Urine microalbumin (DM13)

·  46TC. Urine albumin:creatinine ratio (DM13)

Test Results

·  44P.. Serum Cholesterol (DM16/17)

·  44PJ Serum total cholesterol level (DM16/17)

·  44OE. Plasma total cholesterol level (DM16/17)

·  44J3. Serum creatinine (DM14)

·  44JF. Plasma creatinine level (DM14)

·  R1103. [D] Microalbuminuria (DM15)

·  42W% Hb. A1C - diabetic control (DM5/6/7)

·  442A Thyroid Stimulating Hormone (MH4)

·  42W Serum TSH (MH4)

·  42X Plasma TSH (MH4)

·  44W8. Serum lithium level (MH3/5)

·  44J3. Serum creatinine (MH4)

·  44JF. Plasma creatinine level (MH4)

·  442% Thyroid function tests (Thyroid 2)

Investigations

·  5882 Spirometry (COPD 2/3)

·  339O. Forced expired volume in 1 second (COPD 6)

·  339R. FEV1/FVC percent (COPD 6)

·  3395.12 Peak flow rate (Asthma 2)

·  567..11 CAT scan (Stroke2)

·  569..11 NMR Scan (Stroke2)

·  569..12 Magnetic resonance imaging (Stroke2)

·  5853.11 Echocardiography (LVD2)

·  3213% Exercise ECG etc (CHD2)

Imms and Vaccs

·  All children’s immunisations

·  65E Influenza vaccination

·  68NE. No consent - influenza imm (Exception)

·  9OX5. Influenza vaccination declined (Exception)

·  6572 Pneumococcal vaccine

Miscarriages – L04..11 Miscarriage

Reviews

·  662d Hypertension annual review

·  662e Stroke/CVA annual review

·  662W Heart failure annual review

·  66AS Diabetic annual review

·  66YJ. Asthma annual review (Asthma 6)

·  66YM COPD annual Review

·  6A4 Coronary heart disease review

·  6A6. Mental health review (MH2)

·  8BAV. Cancer care review (Cancer2)

Follow up dates i.e. date seen in clinic if CHD, diabetic clinic with review date.

·  6629 Hypertension follow-up

·  66AM Diabetic follow-up

·  66YK. Asthma follow-up (Asthma 6)

·  66YL.11 COPD follow-up

·  8HB6 Radiotherapy follow-up

·  8HB7 Chemotherapy follow-up

·  8HB8 Mental therapy follow-up

·  8HBD Retinopathy follow-up

·  8HBE Heart failure follow-up

·  8HBF Chiropody follow-up

·  ZV67400 Fracture follow-up

Seen in

·  9N01.00 Seen in general surgery clinic

·  9N02.00 Seen in geriatric clinic

·  9N03.00 Seen in hypertension clinic

·  9N06.00 Seen in thoracic surgery clinic

·  9N08.00 Seen in chiropody clinic

·  9N07.00 Seen in fertility clinic

·  9N09.00 Seen in oncology clinic

·  9N0A.00 Seen in breast clinic

·  9N0a.00 Seen in paediatric surgery clinic

·  9N0b.00 Seen in hearing aid clinic

·  9N0B.00 Seen in psychogeriatric clinic

·  9N0D.00 Seen in radiotherapy clinic

·  9N0E.00 Seen in rehabilitation clinic

·  9N0F.00 Seen in physiotherapy dept

·  9N0f.00 Seen in rapid access chest pain clinic

·  9N0h.00 Seen in osteoporosis clinic

·  9N0I.00 Seen in lipid clinic

·  9N0i.00 Seen in minor injuries department

·  9N0j.00 Seen in immunology clinic

·  9N0J.00 Seen in cholesterol clinic

·  9N0L.00 Seen in GU medicine clinic

·  9N0K.00 Seen in orthodontic clinic

·  9N0X.00 Seen in fracture clinic

·  9N0U.00 Seen in family planning clinic

·  9N19.00 Seen in hospital casualty

·  9N1A.00 Seen in hospital out-pat.

·  9N1b.00 Seen in chest clinic

·  9N1C.00 Seen in own home

·  9N1e.00 Seen in colposcopy clinic

·  9N1d.00 Seen in asthma clinic

·  9N1g.00 Seen in gastroenterology clinic

·  9N1f.00 Seen in colorectal clinic

·  9N1i.00 Seen in diabetic foot clinic

·  9N1I.00 Seen in urology clinic

·  9N1J.00 Seen in gynaecology clinic

·  9N1j.00 Seen in neurosurgery clinic

·  9N1K.00 Seen in ophthalmology clinic

·  9N1k.00 Seen in pain clinic

·  9N1L.00 Seen in ENT clinic

·  9N1l.00 Seen in prostate clinic

·  9N1m.00 Seen in nephrology clinic

·  9N1M.00 Seen in psychology clinic

·  9N1m.11 Seen in renal clinic

·  9N1N.00 Seen in antenatal clinic

·  9N1n.00 Seen in EMG clinic

·  9N1O.00 Seen in rheumatology clinic

·  9N1P.00 Seen in cardiac clinic

·  9N1p.00 Seen in orthopaedic clinic

·  9N1Q.00 Seen in diabetic clinic

·  9N1q.00 Seen in oral surgery clinic

·  9N1R.00 Seen in neurology clinic

·  9N1S.00 Seen in dermatology clinic

·  9N1T.00 Seen in psychiatry clinic

·  9N1v.00 Seen in diabetic eye clinic

·  9N1U.00 Seen in elderly assessment clinic

·  9N1V.00 Seen in paediatric clinic

·  9N1Y.00 Seen in gastroscopy clinic

Diabetes

·  9N2f Seen by retinal screener (DM8)

·  9N2U Seen by optician (DM8)

·  9N2V Seen by optometrist (DM8)

·  R110. [D]Proteinuria (DM13/15)

·  R1100 [D]Albuminuria (DM13/15)

·  8H7r Refer to diabetic foot screener (DM9/10)

·  9NND. Under care of diab foot screen (DM9/10)

·  66Ac. Diabetic peripheral neuropathy screening (DM10)

·  311A. Monofilament foot sensation test (DM10)

·  46W. Urine microalbumin (DM13)

·  46TC. Urine albumin:creatinine ratio (DM13)

·  R1103. [D] Microalbuminuria (DM15)

·  42W% Hb. A1C - diabetic control (DM5/6/7)

·  44J3. Serum creatinine (DM14)

·  44JF. Plasma creatinine level (DM14)

·  44P.. Serum Cholesterol (DM16/17)

·  44PJ Serum total cholesterol level (DM16/17)

·  44OE. Plasma total cholesterol level (DM16/17)

Diabetes Exceptions

·  8I3C. Statin declined (Exception DM16/17)

·  8I27. Statins contraindicated (Exception DM16/17)

·  TJC24 Adverse reaction to simvastatin (Exception DM16/17)

·  TJC25 Adverse reacton to pravastatin (Exception DM16/17)

·  8I3W Diabetic foot examination declined (Exception DM9/10)

·  8I6G Diab Foot Exam not indicated (Exception DM9/10)

·  8I3X Diabetic retinopathy screening refused (Exception DM8)

·  8I6F. Diab ret screen not indicated (Exception DM8)

·  14LM. H/O: angiotensin converting enzyme inhibitor allergy (Exception DM15)

·  8I28. Angiotensin converting enzyme inhibitors contraindicated (Exception DM15)

·  8I3D. Angiotensin converting enzyme inhibitor declined (Exception DM15)

·  14LN. H/O: angiotensin II receptor antagonist allergy (Exception DM15)

·  8I2H. Angiotensin II receptor antagonists contraindicated (Exception DM15)

·  8I3P. Angiotensin II receptor antagonist declined (Exception DM15)

Mental Health

·  442A Thyroid Stimulating Hormone (MH4)

·  42W Serum TSH (MH4)

·  42X Plasma TSH (MH4)

·  6A6. Mental health review (MH2)

·  44W8. Serum lithium level (MH3/5)

·  44J3. Serum creatinine (MH4)

·  44JF. Plasma creatinine level (MH4)

Mental Health Exceptions

·  665B Lithium stopped (Exception MH3/4/5)

Hypothyroidism

·  442% Thyroid function tests (Thyroid 2)

COPD

·  5882 Spirometry (COPD 2/3)

·  68M Spirometry Screening (COPD 2/3)

·  6637 Inhaler technique observed (COPD 7)

·  339O. Forced expired volume in 1 second (COPD 6)

·  339R. FEV1/FVC percent (COPD 6)

Asthma

·  3395.12 Peak flow rate (Asthma 2)

·  5882 Spirometry (Asthma 2)

·  68M Spirometry Screening (Asthma 2)

·  66YJ. Asthma annual review (Asthma 6)

·  66YK. Asthma follow-up (Asthma 6)

·  9OJA. Asthma monitoring check done (Asthma 6)

Asthma Exceptions

·  9OJ2 Refuses asthma monitoring (High Level Exception)

Cytology

·  685H. No smear- benign hysterectomy (CS1)

·  7E05.12 Vaginal hysterectomy (CS1)

·  6859. Ca cervix - screen done (CS1)

Cytology Exceptions

·  6853. Ca cervix screen - not wanted (Exception CS1)

·  685L. Cervical smear refused (Exception CS1)

CHD

·  9N0f Seen in rapid access chest pain clinic (CHD2)

·  3213% Exercise ECG etc (CHD2)

·  44P.. Serum Cholesterol (CHD7/8)

·  44PJ Serum total cholesterol level (CHD7/8)

·  44OE. Plasma total cholesterol level (CHD7/8)

CHD Exceptions

·  8I3C. Statin declined (Exception CHD7/8)

·  8I27. Statins contraindicated (Exception CHD7/8)

·  TJC24 Adverse reaction to simvastatin (Exception CHD7/8)

·  TJC25 Adverse reacton to pravastatin (Exception CHD7/8)

·  8I3S. Exercise tol test refused (Exception CHD2)

·  8I26. Beta blocker contraindicated (Exception CHD10)

·  8I36. Beta blocker therapy refused (Exception CHD10)

·  14LL. H/O: betablocker allergy (Exception CHD10)

·  TJC6. Adverse reaction to betablockers (Exception CHD10)

·  14LK. H/O: aspirin allergy (Exception CHD9)

·  TJ53. Adverse reaction to salicylates (Exception CHD9)

·  8I24. Aspirin prophylaxis contra-indicated (Exception CHD9)

·  8I38. Aspirin prophylaxis refused (Exception CHD9)

·  14LP. H/O: warfarin allergy (Exception CHD9)

·  TJ42 Adverse reaction to anticoagulants (Exception CHD9)

·  8I25. Warfarin contraindicated (Exception CHD9)

·  8I3E. Warfarin declined (Exception CHD9)

·  14LQ. H/O: clopidogrel allergy (Exception CHD9)

·  812K. Clopidogrel contraindicated (Exception CHD9)

·  8I3R. Clopidogrel declined (Exception CHD9)

·  14LM. H/O: angiotensin converting enzyme inhibitor allergy (Exception CHD11)

·  8I28. Angiotensin converting enzyme inhibitors contraindicated (Exception CHD11)

·  8I3D. Angiotensin converting enzyme inhibitor declined (Exception CHD11)

·  14LN. H/O: angiotensin II receptor antagonist allergy (Exception CHD11)

·  8I2H. Angiotensin II receptor antagonists contraindicated (Exception CHD11)

·  8I3P. Angiotensin II receptor antagonist declined (Exception CHD11)

Epilepsy

·  667F. Seizure free > 12 months (Epilepsy2/4)

·  6675. Fit Frequency (Epilepsy2)

·  6678. Epilepsy treatment changed (Epilepsy3)

Epilepsy Exceptions

·  8BL3. Patient on maximal tolerated anticonvulsant therapy (Exception Epilepsy4)

LVD

·  5853.11 Echocardiography (LVD2)

·  33BD. Echocardiogram requested (LVD2)

LVD Exceptions

·  5534 Angiocardiography declined (Exception LVD2)

·  56F1 Echocardiogram declined (Exception LVD2)

·  14LM. H/O: angiotensin converting enzyme inhibitor allergy (Exception LVD3)

·  8I28. Angiotensin converting enzyme inhibitors contraindicated (Exception LVD3)

·  8I3D. Angiotensin converting enzyme inhibitor declined (Exception LVD3)

·  14LN. H/O: angiotensin II receptor antagonist allergy (Exception LVD3)

·  8I2H. Angiotensin II receptor antagonists contraindicated (Exception LVD3)

·  8I3P. Angiotensin II receptor antagonist declined (Exception LVD3)

Stroke

·  567..11 CAT scan (Stroke2)

·  569..11 NMR Scan (Stroke2)

·  569..12 Magnetic resonance imaging (Stroke2)

·  44P.. Serum Cholesterol (Stroke7/8)

·  44PJ Serum total cholesterol level (Stroke7/8)

·  44OE. Plasma total cholesterol level (Stroke7/8)

Stroke Exceptions

·  5695. MRI scan declined (Exception Stroke2)

·  56F0. CT scan brain declined (Exception Stroke2)

·  8I3C. Statin declined (Exception Stroke7/8)

·  8I27. Statins contraindicated (Exception Stroke7/8)

·  TJC24 Adverse reaction to simvastatin (Exception Stroke7/8)

·  TJC25 Adverse reacton to pravastatin (Exception Stroke7/8)

·  14LK. H/O: aspirin allergy (Exception Stroke9)

·  TJ53. Adverse reaction to salicylates (Exception Stroke9)

·  8I24. Aspirin prophylaxis contra-indicated (Exception Stroke9)

·  8I38. Aspirin prophylaxis refused (Exception Stroke9)

·  14LP. H/O: warfarin allergy (Exception Stroke9)

·  TJ42 Adverse reaction to anticoagulants (Exception Stroke9)

·  8I25. Warfarin contraindicated (Exception Stroke9)

·  8I3E. Warfarin declined (Exception Stroke9)

·  14LQ. H/O: clopidogrel allergy (Exception Stroke9)

·  812K. Clopidogrel contraindicated (Exception Stroke9)

·  8I3R. Clopidogrel declined (Exception Stroke9)

Cancer

·  8BAV. Cancer care review (Cancer2)

·  8BAP Specialist palliative care

·  Z172 Palliative care

·  ZL9AR00 Seen by palliative care physician

Aspirin OTC

·  8B63. Salicylate prophylaxis

·  8B3T. Over the counter aspirin therapy

·  8B6P Clopidogrel prophylaxis

·  67I8. Advice about taking aspirin

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