Detailed Coded Record (DCR) Review

Detailed Coded Record GP level consent is enabled from the DCR Review app .

This app enables you to select the following levels of patient access:

  • Allow patient access - Tick to allow the selected patient access to their DCR online, you can then select from either:
    • All - The selected patient has access to all their available coded records, or
    • Specific types of data - The selected patient only has access to the types of data selected from the list.
Note - It is not currently possible to select individual items within a category, you can either allow access to the full category or none of it.

To enable DCR at the patient level:

  1. From Apps Controller , select the DCR Review app .
  2. Select the patient required and their DCR Review screen displays:

  1. Tick Allow patient access, this is the equivalent of patient level consent.
Note - For Online Service User (OSU) registered patients the Allow patient access tick box is unavailable as OSU users do not have access to any service apart from booking appointments.
  1. Now define the level of access you wish to allow, tick either:
    • All, to allow this patient full access to all their coded records, or
    • Select from the available list to allow this patient restricted access to their record:

Important - Priority zero items are excluded from the DCR and if you have selected All or Investigations, the patient can see all autofiled test results regardless of whether they have been seen by a clinician yet.
  1. Select Save and the Save screen displays, listing the categories you have added and/or removed for the patient to access:

  1. Enter free text comments regarding the changes made during this review if required and then select OK.
  2. Now, either select the Back Arrow to return to Apps Controller, or Find Patient to select another patient to review.
Training Tip - Remember, you can process from a patient group you have already created within Apps Controller.

The following table displays the information included within each of the DCR selections:

  Data Included/ Displayed for your patient Comments
Current Active Problem Headers with Read codes starting A%, B%, C%, D%, E%, F%, G%, H%, J%, K%, L%, M%, N%, P%, Q%, R%, S%, T%, U%, ZV%, , 141% , 142%, 143%, 144%, 145%, 146%, 147%, 148%, 149%, 14A%, 14B%, 14C%, 14D%, 14E..%, 14E1%, 14E3%, 14E4%, 14E5%, 14EZ%, 14F%, 14G%, 14H%, 14I%, 14J%, 14K%, 14R%, 14S%, 14T%, 14U%, 14W%, 14Y%, 14Z%, 14c..%, 14d..%, 14g..% and no End Date. Inactive Problems are not included/displayed.
Past Read codes starting A%, B%, C%, D%, E%, F%, G%, H%, J%, K%, L%, M%, N%, P%, Q%, R%, S%, T%, U%, ZV%, , 141% , 142%, 143%, 144%, 145%, 146%, 147%, 148%, 149%, 14A%, 14B%, 14C%, 14D%, 14E..%, 14E1%, 14E3%, 14E4%, 14E5%, 14EZ%, 14F%, 14G%, 14H%, 14I%, 14J%, 14K%, 14R%, 14S%, 14T%, 14U%, 14W%, 14Y%, 14Z%, 14c..%, 14d..%, 14g..% and a completed End Date. Inactive Problems are not included/displayed.
  Data Included/Displayed for your patient Comments
Current Any entries with Read codes starting A%, B%, C%, D%, E%, F%, G%, H%, J%, K%, L%, M%, N%, P%, Q%, R%, S....%, S0%, S1%, S2%, S3%, S4%, S5%, S6%, S7%, S8%, S9%, SA%, SB%, SC%, SD%, SE%, SF%, SG%, SH%, SJ%, SK%, SL%, SM%, SN...%, SN0%, SN1%, SN2%, SN3%, SN4%, Sn55%, SN56%, SN57%, SN5A%, SN5z.%, SNz..%, SP%, SQ%, SR%, Sy%, Sz...%, T....%, T0%, T1%, T2%, T3%, T4%, T5%, T6%, T7%, T8%, T9%, TA%, TB%, TC%, TD%, TE%, TF%, TG%, TH%, TK%, TL%, TM%, TN%, TP%, Tz...%, U....%, U0%, U1%, U2%, U3%, U4%, U5%, U6...%, U61%, U62%, U63%, U64%, U7%, U8%, ZV...%, ZV0..%, ZV01%, ZV02%, ZV07%, ZV0y%, ZV0z%, ZV1..%, ZV10%, ZV11%, ZV12%, ZV13%, ZV15%, ZV1B%, ZV1C%, ZV1y.%, ZV1z.%, ZV2%, ZV3%, ZV4%, ZV5%, ZV6..%, ZV60%, ZV61%, ZV62%, ZV63%, ZV64.%, ZV642%, ZV643%, ZV644%, ZV645%, ZV646%, ZV647%, ZV648%, ZV649%, ZV64A%, ZV64y%, ZV64z%, ZV65%, ZV66%, ZV67%, ZV68%, ZV69%, ZV6A%, ZV6B%, ZV6C%, ZV6D%, ZV6E%, ZV6F%, ZV6G%, ZV6H%, ZV6y%, ZV6z.%, ZV7%, ZVu%, ZVy..% and ZVz..% and no End Date.  

Past

Any entries with Read codes starting A%, B%, C%, D%, E%, F%, G%, H%, J%, K%, L%, M%, N%, P%, Q%, R%, S....%, S0%, S1%, S2%, S3%, S4%, S5%, S6%, S7%, S8%, S9%, SA%, SB%, SC%, SD%, SE%, SF%, SG%, SH%, SJ%, SK%, SL%, SM%, SN...%, SN0%, SN1%, SN2%, SN3%, SN4%, Sn55%, SN56%, SN57%, SN5A%, SN5z.%, SNz..%, SP%, SQ%, SR%, Sy%, Sz...%, T....%, T0%, T1%, T2%, T3%, T4%, T5%, T6%, T7%, T8%, T9%, TA%, TB%, TC%, TD%, TE%, TF%, TG%, TH%, TK%, TL%, TM%, TN%, TP%, Tz...%, U....%, U0%, U1%, U2%, U3%, U4%, U5%, U6...%, U61%, U62%, U63%, U64%, U7%, U8%, ZV...%, ZV0..%, ZV01%, ZV02%, ZV07%, ZV0y%, ZV0z%, ZV1..%, ZV10%, ZV11%, ZV12%, ZV13%, ZV15%, ZV1B%, ZV1C%, ZV1y.%, ZV1z.%, ZV2%, ZV3%, ZV4%, ZV5%, ZV6..%, ZV60%, ZV61%, ZV62%, ZV63%, ZV64.%, ZV642%, ZV643%, ZV644%, ZV645%, ZV646%, ZV647%, ZV648%, ZV649%, ZV64A%, ZV64y%, ZV64z%, ZV65%, ZV66%, ZV67%, ZV68%, ZV69%, ZV6A%, ZV6B%, ZV6C%, ZV6D%, ZV6E%, ZV6F%, ZV6G%, ZV6H%, ZV6y%, ZV6z.%, ZV7%, ZVu%, ZVy..%, ZVz..%, , 141% , 142%, 143%, 144%, 145%, 146%, 147%, 148%, 149%, 14A%, 14B%, 14C%, 14D%, 14E..%, 14E1%, 14E3%, 14E4%, 14E5%, 14EZ%, 14F%, 14G%, 14H%, 14I%, 14J%, 14K%, 14R%, 14S%, 14T%, 14U%, 14W%, 14Y%, 14Z%, 14c..%, 14d..% and 14g..% and a completed End Date.

 

 
  Data included/Displayed for your patient Comments
Acute Issued in the last 2 years  
Acute History Issued over 2 years ago  
Repeat Repeat Masters that meet one of the following criteria: - The repeat master is inactive but the last issue date is within the last 6 months -The repeat master is active and the repeat until date is within the last 6 months - The repeat master is active and the last issue date is within the last 18 months - The repeat master is active with no repeat until date and it was added within the last 18 months  
Past Repeat Medication that meets one of the following criteria: - The repeat master is inactive and the last issue is over 6 months ago - The repeat master is active and the repeat until date is over 18 months ago - The repeat master is active and the last issue date is over 18 months ago - The repeat master is active and the repeat until date not completed and the event date is over 18 months ago  

 

  Data included/Displayed for your patient Comments
Encounters The following consultation types Clinic, Night visit, Deputising service, Follow-up/routine visit, Night visit, Local rota, Mail from patient, Night visit, practice, Out of hours, Practice, Out of hours, Non Practice, Surgery consultation, Telephone call from a patient, Acute visit, Mail to patient, Emergency Consultation, Telephone call to a patient, Children's Home Visit, Home Visit, Hotel Visit, Nursing Home Visit, Residential Home Visit, Twilight Visit, Triage, Walk-in Centre, Co-op Telephone advice, Co-op Surgery Consultation, Co-op Home Visit, Minor Injury Service, Community Clinic, Community Nursing Note, Community Nursing Report, Health Visitor Note, Health Visitor Report, Night Visit and Telephone Consultation  
Referrals A list of Referrals recorded  
Admissions All clinical entries with a Read code starting 8H%  
Recalls All recalls recorded  
  Data included/Displayed for your patient Comments
Blood Pressure Any blood pressure recorded  
Fundoscopy Any fundoscopy recorded  
Heart Exam Any heart exam recorded  
Pulse (CVS/BP) Any pulse class recorded  
Pulse Oximetry Any pulse oximetry recorded  
Visual Acuity Left Eye Any visual acuity left eye recorded  
Visual Acuity Right Eye Any visual acuity right eye recorded  
Weight Any weight recorded  
PF Current Any pf current recorded  
Respiratory Rate Any respiratory recorded  
Spirometry Any spirometry recorded  
Temperature Any temperature recorded  
  Data included/Displayed for your patient Comments
Operations All Medical History entries with Read codes starting 7% excluding 7F%, 7E2A2 and 7E2A3  
Immunuisations All Immunisation entries with a status of Given  

 

Remember - This includes filed test results that have not yet been seen by a clinician.
  Data included/Displayed for your patient Comments
Recent Tests All Tests entries recorded in the last 3 months  
Biochemistry All Test entries with Read codes starting 44%  
ECG All Test entries with Read codes starting 32%  
Haematology All Test entries with Read codes starting 42%  
Imaging All Test entries with Read codes starting 5%  
Microbiology All Test entries with Read codes starting 4J% and 4I1%  
Cytology All Test entries with Read codes starting 4K% excluding 4K2%, 4K3%, 4K4%, 4KA% and 4KZ%  
Physiology All Test entries with Read codes starting 337%, 338%, 339%, 33G%. 33H%, 33I%, 33J% and 33K%  
Urinalysis All Test entries with Read codes starting 46%  
Other All Test entries with Read codes starting 4% excluding 41%, 42%, 44%, 4J%, 46%, 4I1% and 4K%  
  Data included/Displayed for your patient Comments
Allergies Allergy entries with Read codes starting 14L%, 14M%, TJ%, 816%, 817%, U60%, ZV14%, SN5..%, SN50%, SN51%, SN52%, SN53%, SN54%, SN58%, SN59%, SN5y%, 360% and 1151. Read code 1151. only displays if there are no positive allergy codes recorded after the date Read code 1151. is added
Contraindications Contraindications with Read codes starting 8I2%, 8I6%, 8I7%, ZV640% and ZV641%  
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