CV or Hypertension Management Plan

 

Access the CV & BP Management Plan by one of the following methods by right clicking on the CV & Hypertension line from the navigation pane (MRO column on Patient Record), and selecting Management Plan. This displays the CV & Hypertension entries necessary for recording and managing the hypertensive patient.

See also Cardio-vascular related Read Terms which lists the Read codes for C-V symptoms and diagnoses.

Click in the far right cell on the column marked + in the row you want to add data. The relevant Add screen displays and you can complete each screen in turn, or skip to subsequent screens, or eventually press Cancel if you do not want to make an entry at a screen.

  • Coronary Heart Disease register - The Chronic Disease Registers in Vision 3 have been superseded by Vision+, please see the Vision+ Help Centre for help with managing your patients with chronic diseases.

  • Hypertension Register - The Chronic Disease Registers in Vision 3 have been superseded by Vision+, please see the Vision+ Help Centre for help with managing your patients with chronic diseases.

  • Cardiovascular Disease Risk - Add - The Read term default is 68B3.00 Risk factors present at heart disease screen. In Cardiovascular risk status, select from General Advice only, Opportunistic intervention, or Priority and enter a figure in Risk score.

  • Family History - The default Read code is 12... 00 Family History, for example, 12C5. 00 FH:Myocardial infarction. Also enter a Read Term for Condition, for example, G30.. 00 Acute myocardial. See Family History for details.

Pre-Treatment BP - (CVS/BP). Record the systolic and diastolic as in "Blood Pressure". In Reading, choose from: None, First Reading, Second Reading, Third Reading, > Third Reading.

Angina- From DLM 186 update, angina entries will go to a Medical History screen with the Read term G33..00 Angina pectoris. Prior to DLM 186, there was an Angina Add screen with an Angina present box. This has now become redundant and moved to Superseded Records at the bottom of the navigation pane.

After DLM 186, existing G33 Angina pectoris entries will be converted to Medical History entries if the Angina box was ticked on the old Angina Add form. If the Angina box was cleared of its tick (i.e. the patient did not have angina), then the record will be converted to Absence of Condition. Historically, unticking this box still recorded G33 on a patient's record.

Note that should you want a list of angina patients for a virtual register, then you are advised to use Populate Problems with G33 as the Read code.

Angina Present box is ticked by default. Leave ticked if the patient has angina. If the box is unticked because the patient has no angina, there is no entry made to the patient record (i.e. no recording of No anginapresent). If the patient has no angina, you are best to skip this screen altogether by pressing <ESC>. Otherwise just unticking the box still adds a Read code of G33..00 Angina to the patient record. Clinical Audit groups of G33 patients Angina do exclude patients with no angina.

You need to be aware of this when searching in order to exclude these negative entities.

Alcohol - see Alcohol

Smoking - see Smoking.

Exercise - The default Read term is 138.. 00 Exercise Grading, In Type of Exercise, in place of <None>, you may also choose Inactive, Moderate, Vigorous, Gentle.

CV/BP Consultation - The default Read term is 66f..00Cardiovascular disease monitoring. Enter any record of CV/BP Consultation, and any free text notes.

Heart Examination - The default Read term is 24... 00 Exam of cardio-vascularsystem. In Rhythm, Size/Failure, and Sounds, the default is <None>, but you may also choose Normal or Abnormal.

Peripheral oedema - Select a Read term, if required, other than the default R0234 00 [D]Peripheral oedema. In Peripheral oedema, the default is <None> and the choice also Absent or Present. In Laterality, choose from None, Left, Right, Midline, Intermediate, Bilater. In Site of oedema, select fromToe, Foot, Ankle, Lower Leg, Whole Leg.

Weight, Height - See Weight and Height

Blood pressure - The default Read term is 246 O/E - blood pressure reading. Other options are 2461-2467 O/E - BP reading, 2469 - 246J O/E - systolic BPreading, 246N-246Z Standing systolic blood pressure, 662L 24 hr bloodpressure monitoring. Qualify the systolic/diastolic with options from Laterality, Position and Cuff. Other ways to enter a blood pressure are listed in Blood Pressure.

Postural drop in blood pressure - The default Read term is 2468 O/E - BP reading postural drop. The Result qualifier has None, Normal, Abnormal, Potentially abnormal.

Fundoscopy - the Read code default is 3128 Fundoscopy. Other options are 2BAO/E - optic disc inspection or 2BB O/E - retinal inspection Select a Read term, and either <None>, Normal or Abnormal in Result. In Laterality, select from: Left, Right, Midline, Intermediate, Bilateral.

Foot Pulses (R leg and L leg) - The foot pulses are headed with R dorsalis pedis, R post tibialis, L dorsalis pedis and L post tibialis:

  • 246EA O/E - absent right foot pulses
  • 24EB O/E - right foot pulses present
  • 24EC O/E - Right dorsalis pedis abnormal
  • 24ED O/E - Right posterior tibial pulse abnormal
  • 24EZ O/E - R.leg pulses NOS
  • 24E1 O/E - R.leg pulses all present (default for R dorsalis pedis, or Foot Pulse Right Leg)
  • 24FA O/E - Absent left foot pulses
  • 24FB O/E - Left foot pulses present
  • 24FC O/E - left dorsalis pedis abnormal
  • 24FD O/E - Left posterior tibial pulse abnormal
  • 24FZ O/E - L.leg pulses NOS
  • 24F1 O/E - L.leg pulses all present (default for Foot Pulses Left Leg)

Urinalysis - Glucose - default 466 Urine test for glucose and hierarchical codes.

Urinalysis - Protein - default 467 Urine proteintest, and hierarchical codes, andincluding 44JG Overnight albumin excretion rate.

Urea/Electrolytes - The default is 44JB Urea and electrolytes, but there are other options.

Serum Cholesterol - default 44P Serum cholesterol, including 44OE Plasma totalcholesterol level.

Chest X-ray - The default is 535 Standard chest X-ray. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal.

Electrocardiogram - The default is 32 Electrocardiography. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal. Enter any free text notes.

ECG Exercise - The default is 3213 Exercise ECG. Options are further hierarchical codes. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal.

ECG Ambulatory - The default is 3214 Ambulatory ECG with two normal or abnormal options. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal.

Ambulatory Blood Pressure - The default is 315B Ambulatory blood pressurereading. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal.

Doppler Ultrasound Peripheral Pulse - The default is as well as 5858 Doppler studies plus hierarchical codes, and also 5C10 Carotid artery doppler abnormal. In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal. Note that the record is stored under Test Results - Diagnostic Tests - Cardiovascular Investigations.

Echocardiogram - The default is 5853.11 Echocardiogram but options include other hierarchical codes, and 33BD Echocardiogram requested, and 5C20 Echocardiogram equivocal. There is a numeric percentage entry for LV Ejection Fraction (33BB Left ventricular ejection fraction). In Result Qualifier, choose from None, Normal, Abnormal, Potentially Abnormal.