CSAPHN - Medical Director Data Cleansing Guide

MEDICAL DIRECTOR DATA CLEANSING GUIDE Quality Improvement Program November 2019 (incorporating Health Care Homes principles, the 5th Edition Standards of Accreditation and the Code of Conduct for Nurses, 2018 edition)

MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

ACKNOWLEDGEMENTS Country SA PHN acknowledges and thanks the Sydney North Health Network for contributions to the content used in this Data Cleansing Guide. We would like to acknowledge that some material contained in this Guide has been extracted from external organisations including the Australian Government Department of Health & Medical Director. These organisations retain copyright over their original work, and we have abided by licence terms. Referencing of material is provided throughout.

While the Australian Government Department of Health has contributed to the funding of this material, the information contained in it does not necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed, by the Australian Government. The Australian Government is not responsible in negligence or otherwise for any injury, loss or damage however arising from the use of or reliance on the information provided herein.

FURTHER SUPPORT AND INFORMATION For further support and information please contact the Practice Support Team at Country SA PHN practice.support@countrysaphn.com.au Team members: Julie Di Rito Manager – Practice Support Telephone: 0439 707 996 Jane Williams Practice Support Officer Telephone: 0439 019 140 Nabil Rashid Practice Support Officer Telephone: 0427 156 168 Hannah Quigley Practice Support Officer Telephone: 0439 222 594

DISCLAIMER Whilst every effort has been made to ensure that the information included in this Manual is current and accurate, you should exercise your own independent skill and judgement before relying on it. Refer to AGPAL, RACGP, Department of Human Services and Nursing and Midwifery Board for current information.

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

Table of Contents DATA CLEANSING ACKNOWLEDGEMENTS ...................................................................................................................................1 FURTHER SUPPORT AND INFORMATION ........................................................................................................1 DISCLAIMER ....................................................................................................................................................1 HOW TO INACTIVATE PATIENTS .....................................................................................................................4 HOW TO MERGE DUPLICATE PATIENT FILES...................................................................................................9 HOW TO RECORD ALLERGIES ........................................................................................................................11 HOW TO RECORD HEIGHT, WEIGHT, WAIST & BLOOD PRESSURE ...............................................................13 HOW TO ENTER A CODED DIAGNOSIS ..........................................................................................................15

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HOW TO INACTIVTATE PATIENTS

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO INACTIVATE PATIENTS Inactivating Patients – Bulk Inactivation 1 Main screen (ensure no patient files open) Click Search and from drop down select Patient 2 Tick Not seen since and insert date. Click Search

3 Select Inactivate Patients (this will inactivate all patients).

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

4 To confirm, select Yes

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INACTIVTING PATIENTS - INDIVIDUALLY 1 Main screen, Open and search patient name (do not open file). Highlight name and click Delete

2 Select Mark as inactive (note: this list will not be permanently deleted)

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO VIEW INACTIVE PATIENTS 1 From main menu select patients, and select list 2 Click current patients by name and select inactive patients from dropdown

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO ACTIVATE INACTIVE PATIENT 1 From main screen, select open and tick include inactive patients Once the inactive patient file is opened, it automatically reactivates it

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO MERGE DUPLICATE PATIENT FILES 1 Main menu, select Open and search patient name 2 Highlight patient file you wish to keep and click Merge

3 Highlight patient record you wish to merge in the record you previously selected Click Next

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

4 Select Next to confirm the merge process

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO RECORD ALLERGIES 1 In patient file, double click Allergies & Adverse reactions white box (as outlined)

2 If the patient has No Known Allergies/Adverse Reactions click on this box and click Save.

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

3

If the patient has a known allergy, select Add to record the patient allergies. Select allergy from coded list and fill in Nature of Reaction, Reason Type and Severity.

Click OK & Save.

Repeat this step if the patient has multiple allergies.

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MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

HOW TO RECORD HEIGHT, WEIGHT, WAIST AND BLOOD PRESSURE 1 Open patient file and select the scales icon

2

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Fill in patient’s Height, Weight & Waist measurements

MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

3

Click on Blood Pressure tab to enter BP and click Save

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TO ADD IN A CODED DIAGNOSIS IN PAST HISTORY 1.

2.

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Open patient file and select Past History and + to add Search condition and select from the list. Click OKA private room/desk should be utilised

MEDICAL DIRECTOR DATA CLEANSING GUIDE.V1_ November 2019

TO ADD A CODED DIAGNOSIS WHEN ADDING A PRESCRIBED MEDICATION 1.

2.

3.

4.

5.

6.

7.

Open patient file Add a prescribed medication suing Current Rx tab - Fill in details The last step will request - Enter reason for medication Enter first few letters in Pick from list (coded) and select from the options.

Tick Save in past medical history-Unless condition is in existing past history (green box below) to avoid double up Tick Save as reason for contact-if applicable Click Ok

Note: In cases where the condition you’ve searched is not on the list, select the condition that is the closest match and use the comment section to fill in the details. As seen below.

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HOW TO AVOID DUPLICATE CONDITIONS IN PAST HISTORY WHEN PRESCRIBING MEDICATIONS 1 Main screen, Tools and select Options from dropdown 2 Select Prescribing tab 3 Untick Save in the past medical history and preselect Save as reason for contact.

Click Save.

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