Elderly Management Plan or Summary Form

You can make entries for elderly patients on either the Elderly Assessment Summary Form or the Elderly Management Plan. Both include entries needed to manage a patient who is elderly.

Either from the Summary menu – Routine Health Checks – Elderly (or Alt-S, U, E) for the Elderly Summary Form

Or from the Patient Record – right click on the Elderly line on the navigation pane and select either Summary Form or Management Plan. Note that if this Elderly line is coloured red, this implies existing entries. Left mouse click to see the "elderly" entries filtered chronologically under the Filtered tab.

You can also reach the Summary Form by:

Select Add - Select Data Entry Form, or click on ; double click on AllTabbed Forms - double click on Elderly Assessment; or click on ElderlyAssessment, then click on . Selecting Clinical Entities, then Elderlylists the separate Add screens for all entries.

From the Options on MRO column (Consultation View) - Management - Routine Checks - Elderly.

If you want to make entries outside of the Elderly Form or Plan. In this case, use History-Add, and the specific READ term – many are listed as examples in Community Nurses’ READ Codes.

Entries on Elderly Assessment Form or Plan

The Elderly Assessment Summary Formhas four sections: Background, Prevention, Assessment, and Examination. Start with the Background screen, but you can click on the tab of one of the others to display the relevant screen, eg click on Assessment.

To make an entry, point the cursor at an entry, for example, point to Next of Kin, click on the right mouse button, then click on Add.

Note - You can also enter the patient's next of kin in Contacts for Carers and Next of kin

This displays an -Add screen for the entry. As you complete and click OK for each screen, the next screen is automatically displayed. Skip a screen by clicking on Next. A green tick means there is already an entry at this prompt; a red cross means no entry yet.

The Elderly Management Plan shows the data in grid format, each column representing a different consultation date, and each row the data. Click on the far right cell of a row (or right mouse click, then Add) to enter new data.

Elderly data entries

Elderly Assessment - Background - The fields include:

Residence - 13F Housing dependency scale, 13F1-13F7, 13F9-13Fz; ie excludes 13F8 Hospital In patient but includes 13F81.00 Long stay hospital in patient. Residence records are stored under Lifestyle but can be entered from the Summary - Elderly Assessment form.

Next of kin.

Carers for Elderly people should be entered in Patient Details for the elderly patient, on the Contacts tab (see Contacts for Carers and Next of kin). Carer entries made on the Elderly Summary Form are placed in Superseded Records at the bottom of the navigation pane.

Risk Factors – Elderly - note there is an extra box – Risk factorspresent. Leave this ticked if there are risk factors present, but uncheck it if the elderly person has no discernible risks.

Other entries include:

Allowances received,

Optician Last Seen,

Previous occupation,

Exercise,

Diet.

This completes the Background Tab on the Summary Form.

Elderly Assessment - Prevention – On theSummary Form, click on the Prevention Tab and complete the following:

Allergies and Intolerances

Recalls

Smoking and Alcohol - remember to re-select a READ description as well as choosing the smoker/non-smoker and drinker/teetotaller options.

On theSummary Form, click on the Assessment tab.

Elderly Assessment - Assessment - The fields include:

Vision, Hearing (Over 75 years), Mobility Level, Mental cognitive, Mental emotional, Sleep, Physical Health, OTC drug use (Over the counter drug use), Drug compliance, Hygiene, Continence (Urinary, Bowels).

Elderly Assessment - Examination - The fields include:

Over 75 consultation, Weight and Height, Pulse, Visual acuity (Left eye and Right eye), Peripheral oedema, Foot care, Urinalysis (glucose, protein).

In Advice given, the default READ term is 679..11 Advice to patient - subject. In Type ofadvice given, the default is Advice, but you may also choose <None>, Leaflet and Advice, Internal counselling, External counselling. In Advice, choose from <None>, Alcohol, Smoking, Diet, Family History, Breast self-examination, Testes self-examination, Menopause counselling.

In Referred to, select either Hospital, Community Care, SocialServices, GP, Other Agency, or <None>.