Scanning & Letters Protocol

Practice Leads

  • Doctors: Ramesh Mehay & Pardip Sandhu
  • Admin: Sallie Parker & Vicky O'Shea

Date Reviewed

Sept 2017

Date of Next Review

Sept 2018

Note for the doctors: all scanned letters should be actioned within 5 working days

Who to allocate letters to

  • If a staff member is not working for 5 or more consecutive working days, please do not allocate any letters until they are back at work.
  • All partners, salaried GPs and registrars can be allocated letters.
  • All other GPs (including locum GPs), should not be allocated letters unless confirmed by the practice manager.

Notes for admin team

  • All letters should be scanned onto the system and allocated to a doctor within 5 working days of their arrival
  • If there are any problems adhering to this time-frame, this should be raised with the practice manager

THE PROCESS

Letter arrives (usually through NHS mail) >> Letters team will SRAR....

  1. Scan (and match to patient)
  2. Read
  3. Action
  4. Read Code

THE PRINCIPLES

The volume of posts is so high that in amongst the masses of posts there will be a few letters that have important things requiring action. Therefore, we need a system to sieve out and decide what sorts of letters will go to the doctors.      If the doctors are flooded with all the letters, those few letters that need something doing will get missed at some point and this sort of process which just relies on the doctors alone is too risky.   We have decided that only those letters that require an action need to go to the doctor.       In this way, if we can sieve the 'wheat' from the 'chaff' then we can focus on the stuff that matters - the 'wheat'!

OUR SYSTEM

We said we would trial the following system (Vicky to lead)

  1. letters are opened and scanned in straight away at the same time by the person opening the post (hence no need to stamp and date etc, which people found a pain in the xxx).
  2. Another member of scanning team then just simply works on all the electronic scanned letters and process them in the same way as they do NHS mail.  This should speed up the system.
  3. No need for urgent and non-urgent piles as all letters will be scanned on same day

We will try this by bringing all post to be opened upstairs to the scanning room.   If this doesn't work, we may need to move the scanner downstairs.  We may also need to purchase another scanner - but we shall see how things go first..

WHEN READING LETTERS

  • Remember what I said.  The most important bits of a letter is the beginning and the end.   The middle is often just some blurb about what went on.  But the beginning tells you what the things was all about, and the end will provide a summary of conclusions and things to do (if any).  Therefore, when reading a letter, read at your normal pace, but slow down your reading speed a little for the beginning and end bits.
  • There are some letters you can speed up for - DNA letters, clinic review letters where nothing needs doing.
  • But other letters, be a bit more cautious and slow down - cancer letters, medication discharges, letters from opticians, discharge summaries.

When reading medical letters, there are really on 2 questions to ask yourself...

  1. Does this letter have an action?   By action, I mean a task – like doing a referral, or a new medication adding, or some bloods or x-ray being requested.  (Actually, that’s about it).
  2. Does this letter have items that need Read Coding?
  • If answer to both is NO >>> File Letter
  • If action but no Read Coding >>> See if you can do the action (otherwise refer it on to doctor, nurse, pharmacist etc).
  • If no action but needs Read Coding --> Read Code and then File.
  • If yes to both - do both!   But do the action first so that you don't miss doing the important bit.

READ-CODING

  • Read coders will now highlight in yellow (using the S1 highlight tool) what they have Read-coded – so that GPs can see at a glance a letter has been done and do not send letters back to the team because of uncertainty around Read-coding (reducing duplication of work).
  • If you are unsure about what to Read code, ask our lead - Manjit.

ACTIONING

Don't be scared about reading letters.  Most of the actions (if there are any) are usually written in plain English!  Read on...   Also see the section below on specific things that require a specific action.  It's all quite easy really.

  • Most letters will require no action.  They are for providing information only.
  • Medication actions - some will say 'can you change the dose', or 'switch the patient to a new drug' or 'start/continue a new drug' >>> send to our in-house pharmacist.
  • Referral actions - if a letter says 'please can you refer this patient to...' >>> send letter to doctor.
  • Blood tests - if a letter says 'please can you arrange for a Full Blood Count (for example)' - ring patient and make appt with the nurse.
  • X-rays and Scans - if letter says 'can you arrange for a CXR/Scan' >>> send letter to doctor.

And that's mostly it.

IF A LETTER NEEDS ACTIONING BY TWO OR MORE PEOPLE

  • Let's say you get a letter than needs a referral to a specialist and the medication has been changed.
  • It's simple - send a copy of the letter to the doctor (to do the specialist referral) and another copy to the pharmacist (to do the medication thing).   Don't forget to do any Read-coding though yourself.

DON'T BE SCARED

Some admin people get scared about reading and actioning what is considered to be 'clinical' letters.  This is understandable because they feel they have little clinical training.   But don't worry.   Most letters that are written in plain english and spell out exactly what needs to be done if anything.   For example, if a letter says 'the patient did not attend the outpatient clinic' - you don't need to be a doctor to understand that.   Likewise, if a letter says 'this patient needs a regular full blood count blood test every three months,  I would be grateful if you would arrange this.', again, this is quite easy to understand and do.

WE HAVE A SAFETY NET

If there is a letter that you don't understand or are simply not sure about or even feel out of your depth, then simply scan and send it to a doctor.  We don't mind because what you are otherwise doing for us is brilliant anyway.

Some Specifics

Read-coding

  • Read coding gets its name from James Read - the bloke who developed the system.  He was a GP in Loughborough and developed the system in the 80s  (1980s, not 1880s!).
  • Please Read code all new diagnoses that have been confirmed.     And check to make sure any old diagnoses are not missed off.
  • Do not code tentative diagnoses.  By tentative, I mean suspected diagnoses that are not yet confirmed (also called working diagnoses'.   For example, if a letter says 'this patient might have Multiple Sclerosis', then please do not code this UNTIL a subsequent letter says 'This patient has Multiple Sclerosis'.
  • Read code investigations too.   So, for instance, if a letter says a 'This patient has had a Stroke.   A CT confirmed a frontal stroke.'.  Then code both 'Stroke' (G66) and 'CAT scan (brain)' 5675 (PS CAT scan and CT scan are the same thing).
  • The date you should be adding for the code should be the date the patient was seen or admitted.   For example, when you add a Read code like Asthma for a newly diagnosed asthmatic, do NOT use the date that the letter was written/typed -  use the date the patient was seen (either in the clinic or date of admission if hospitalised).  This date is always on the letter somewhere.
  • Pam Brown - because she keeps a register of new cancer patients, which the doctors also discuss at a team meeting.  Your task note might go something like: “Dear Pam, according to letter *RA12 this patient looks like they have a new cancer diagnosis: Pancreatic Carcinoma “

FOR NEW DIAGNOSES

  • For new diagnoses - always send a task to the Practice Nurse lead if there is one.    This applied for diabetes, asthma, COPD, epilepsy, learning disabilities, stroke, hypertension, heart attacks (also called myocardial infarction), and heart failure.
  • New Cancer diagnoses - please code and then send a task to 'PRACTICE NURSES'.

Lead Nurses

  • Heart -
  • Respiratory (Asthma/COPD) -
  • Diabetes
  • Dementia
  • Rheumatoid Drugs
  • Fractures
  • Osteoporosis
  • Child Protection Cases
  • Adult Protection Cases
  • Falls Assessment - refer to the District Nursing Team.

Nursing team will add patient to register and set recall for 12m.

Actions

READ CODE & FILE

  • Most of the letters you read will require no action.   Most of these letters will simply be giving information.   Information giving letters that require no action can be 'Read-coded and Filed'.
  • A letter which says 'the patient has been discharged back to your care' and there is no GP action >>> again 'Read Code and File'.
  • DNA (Did Not Attend) letters - file - unless the letter asks you to chase it up OR the DNA is for a child <18.  For children DNAs - highlight in a task to GP too.
  • National Screening letters - file.
  • Outpatient letter with 'no changes' - file.
  • Physio & Occ Health report - file if no action.
  • SALT (Speech and Language Therapy) letters - file.
  • OOH (Out of Hours letters) - most can be filed if no action (some type of action is rare).

PHARMACIST

  • All discharge letters & TTOs go to the pharmacist.
  • Letters which say 'can you prescribe', or 'can you change the dose' or 'can you switch xxx to yyy'.
  • Any letters from the Rheumatology department that either mentions methotrexate or denosumab >> send to pharmacist because the pharmacist will ned to make double sure the patient understand these drugs and the importance of blood monitoring.

NURSES & DOCTORS

  • If a letter says 'please do the following blood tests' - call patient to book appt for the blood test with the nurse.   If these are to be done regularly, hopefully the nurse will put onto a scheduled task system.
  • If the letter says 'please can you refer this patient to xxx', send letter to doctor to do.

CANCERS

  • If the letter is about a cancer, look in the medical record and see if it has been coded.
  • If it has NOT - then Readcode and send a copy of letter to Pam Brown who will make an appt for them to be reviewed with a doctor (within 2 weeks) and add them to our cancer register.

FRACTURES
A letter which detail a fracture of any kind - what you do depends on the age of the patient.

  • Under age 50 >>> Read code and File
  • 50 and over >>> send letter to our in-house pharmacist >>> who will then work out whether this is a fragility fracture, do a FRAX score and any other work up as part of the Osteoporosis protocol.
  • Notes for the pharmacist: give patient PIL, and order Bone Densitometry (DEXA) scan.  When report back, start Ca/vitD/Bisphosphonates if report says so.  Education Patient.  Lifestyle advice.  Refer to falls risk assessment if patient unstable on feet (i.e. refer to District Nurses).

DEXA SCANS (BONE DENSITOMETRY)

  • DEXA scans are basically scans which measure how strong your bones are.
  • In older life, people often become osteoporotic (in other words, they have weak bones).
  • But younger people can get this too, especially if they are on things like steroids or suffer from conditions like anorexia.
  • So, if you get a DEXA scan - there is no need to read all of it.   Just send all DEXA scans to the pharmacist, who will decide what needs doing or not.

DEMENTIA

  • Dementia goes to Lynne.
  • She puts on a recall.   Arranges bloods if none done.
  • Does monthly audits of who needs recalls and letters sent.
  • Does not get involved in Care Plan arrangements.

OPTICIAN'S LETTERS (GOS FORMS)

  • If the letter asks for a referral to an Ophthalmology service, first of all see if it says whether they want it urgently.  If it doesn't say 'urgent', 'as soon as possible' or 'for an early appointment', then it is pretty safe to assume it is routine.
  • If it is routine and the patient is 16 and over, then there is a template letter in S1 (called 'opticians letter').  Print off this covering letter and send with the GOS/Opticians letter to SOAP (Shipley Ophthalmic Assessment Project at Windhill Green Medical Centre).  No need for GP to sign.  But remember, the patient must be 16 or over.
  • If patient <16, and again, it is for nothing urgent (i.e. routine), send covering letter with the optician's letter to the Hospital Eye Service (HES) and BRI.
  • Remember, if the letter indicates anything towards an urgent ophthalmic assessment >>> send it to the doctor.
  • Minor Eye Surgery problems such as blocked tear ducts, cyst removal, and skin anomalies >>> send to Windhill Green's Eye Surgery Service.

IVF TREATMENT

  • Many of these letters will often say... ' As part of the HFEA regulations I have to ask you whether or not you know of any reason why this couple should not be considered for fertility investigations or treatment.'.
  • We have a template letter to send back in reply to the specialist (which basically says, they can come and look for this information themselves if they have sought the patient's consent - rather than us doing it - the obligation is on them, not us).

 

Some Specifics Things to Code for Certain Conditions

WHERE POSSIBLE, USE THE EXISTING DISEASE TEMPLATES TO CODE THE FOLLOWING INFORMATION - it's much easier!

Cardiology (The Heart) - G3

Coronary Heart disease (CHD) is anything to do with the heart. For example, a heart attach, which is medically referred to as a Myocardial Infarct or MI for short.  Other examples include angina, or acute coronary syndrome (ACS). Interestingly myocardial infarcts are sometimes referred to as an STEMI and NSTEMI (but you don't have to worry too much about this).

  • G3 is the Read code for CHD
  • Cardiology referral is 8H44 or
  • Exercise Tolerance Test is 33B9%

Heart Failure - G58

Heart failure sounds worse than what it is. Basically it means that the heart is not pumping as well as it should and that means blood doesn't flow around the body very well and ends up making people short of breath the ankle swelling and so on. It has lots of different names because there are different types of heart failure. Most doctors use the word Congestive Heart Failure (CHF for short) or Congestive Cardiac Failure (CCF). Another type is LVF - which is short for Left Ventricular Failure. Different people have different degrees of heart failure and we doctors use something called the NYHA classification to work out how bad it is. NYHA stands for New York Heart Association.

  • G58 is the code for Heart Failure
  • Cardiology Referral is 8H44
  • Ultrasound Heart Scan is 5853
  • Echocardiogram is also 5853 or 33BD

Atrial Fibrillation - G573

Atrial fibrillation is a specific condition where the heart pumps erratically and not regularly and steadily like it should do. We get worried because the long in the long run clots can form giving rise to a stroke to a heart attack. So we put these people on blood thinning drugs to stop these clots from forming. Atrial fibrillation gets more common as you get older. Doctors often use the letters AF to refer to it because it is a bit of a mouthful. And it can only be properly diagnosed by doing an ECG heart test (the ones the nurses do with all those wise)

  • G573 is the code for Atrial Fibrillation
  • Cardiology Referral is 8H44
  • 3272 is the code for ECG:atrial fibrillation.   Always add this code with the AF code because you can't make an AF diagnosis without it.  In other words, it will have been done!

Stroke or TIA - G61

When a clot goes to the brain, it stops blood getting through and a part of the brain dies. This is called a stroke. Depending what area of the brain is shut off, the patient will often have varying degrees of speech difficulty and be paralysed down one side of the body. If the clot is dissolved quickly, then once the blood is restored to the brain, sometimes there is no damage and the brain fully recovers.  So, if a patient has stroke-like symptoms that fully recover within 24 hours, it is not a stroke but something called a TIA or Transient Ischemic Attack. If they have symptoms that are more permanent then it is likely the person has had a proper stroke. In summary, a TIA is like a mini-stroke where it recovers. And a stroke is the proper full blown thing. TIAs are worrying because although the person fully recovers, they can indicate a full-blown stroke might be on its way if nothing is done. By the way, a stroke is often referred to by medics as a cerebral vascular accident or CVA for short.

  • G61 is the code for Stroke or TIA
  • Stroke/TIA referral is 8HBJ
  • CAT scan brain is 5675
  • MRI is 569 (Nuclear Magnetic Resonance is the same thing)

 

COPD - H3

Smokers often get a condition where the lungs get stiff and are not very elastic anymore. That means that air doesn't go in and out very easily. This is called COPD, short for Chronic Obstructive Pulmonary Disease. Over the years it has had lots of different names. Others include COAD - Chronic Obstructive Airways Disease and some of you will even remember the term emphysema.

  • H3 is the code for COPD
  • Spirometry Referral is 8HRC
  • Spirometry is

COPD - H3

In astham, the lungs become tight - but this tightness is reversible (especially with inhalers).  Please remember, asthma kills - a lot of people forget that.  This is the reason why they should carry inhalers with them all the time.  You can never predict when a life threatening attack is every going to happen - even in the most mildest of asthmatics!

  • Asthma code is
  • PEFR monitoring is 66YX

Diabetes

Diabetes is a condition where the body cannot control the sugar levels in the blood very well. But it is important for the body to control the level of sugar running around in your body at any one time - too much or too little can be dangerous. In normal people it is the hormone insulin which controls the amount of sugar running around. In diabetics this insulin system doesn't work very well. In some diabetics just simply controlling the amount of sugar they get from food is enough - so they go on a diabetic low sugar diet. Others need tablets like metformin but others will need something stronger like Insulin in the form of injections. Those that are controlled by insulin injections are called Type 1 diabetics. All the other types are called Type 2.

  • C10E and C10F are the codes for Type 1 and Type 2 diabetes
  • There are lots of things to code for diabetes.  Please use the diabetes template.

Cancer diagnoses

New Cancer diagnoses - please code and then send a task to Pam Brown - because she keeps a register of new cancer patients, which the doctors also discuss at a team meeting.  Your task note might go something like: “Dear Pam, according to letter *RA12 this patient looks like they have a new cancer diagnosis: Pancreatic Carcinoma “

 

Letters - specifying who they have come from

Hi scanning & letters team, Hi scanning & letters team,
We spoke about the letters the other day and how different scanners are doing different things and how we as GPs find it difficult to find the letter we want in the masses of letters in the Systm1's Communication & Letters section - because all we can see is things like 'outpatient', 'clinic letter', 'discharge' rather than more meaningful data like 'Dermatology letter'.

It's all about what we code under the two bits - SENDER and TYPE.   So how about the following as a starter ....

For the SENDER

  • Do not select BRI or St Lukes
  • Instead, select specific department  eg Dermatology, Gynae, Respiratory etc.
  • Same rule applies to discharge letters, do not select BRI or St  Lukes but select department.
  • WHY?   Because knowing which department a letter has come from is more important than the building!

For the TYPE (of letter)...Select one of..

  • Discharge report  (not summary)
  • OOH/NHS 111 report
  • A&E
  • Ophthalmic Services - use only for GOS/Opticians Reports
  • Clinic letter  (default) - use this for most things - surgical procedures, stroke services, elderly medicine, breast services, paediatric assessment unit etc.
  • 24h BP
  • 24h ECG
  • X-ray
  • Ultrasound Scan
  • MRI
  • CT
  • Gastroscopy - use this one instead of Endoscopy (both are the same)
  • Colonoscopy
  • Cystoscopy
  • Spirometry
  • Retinal Screen
  • Doppler
  • Venogram
  • Other Test Report

So, options under SENDER should be (and this may need tidying up in S1)

  • A&E
  • Breast Services - use for screening, clinic
  • Mental Health
  • Elderly Medicine
  • General Surgery
  • Respiratory
  • Cardiac - including Acute Coronary Unit (ACU)
  • Diabetes
  • Endocrinology
  • Dietician
  • Physiotherapist
  • Orthopaedics
  • MSK
  • Dermatolology
  • Plastics
  • Maxillo-facial (nor Oral)
  • Dental
  • Medical Admissions -use for MAU (Medical Admissions Unit) or AMU (Acute Medical Unit)
  • Oncology
  • Optician
  • Ophthalmology
  • Orthopaedics - use this for trauma/fractures
  • Pain Management
  • ENT
  • Rheumatology
  • Sexual Health
  • Stroke Services - including TIA
  • Paediatrics
  • Obstetrics
  • Gynaecology
  • Urology

 

Terms and Short Hand You May Be Unfamiliar With

  • Abdominal Aorta – 5cm or more – should be followed up (the aorta is normally about 2-2.5 cm)
  • Angiogram – a test to see if blood vessels are obstructed.  Eg Coronary angiogram check the cornonaries (blood vessels which supply the heart)
  • BCC – a slow growing skin cancer called Basal Cell Carcinoma
  • BMD (Bone Mineral Density) / T scores / Z scores – this is all about bone scans and whether the patient has weak bones (a condition called osteoporosis, which is NOT the same as osteoarthritis – the latter is wearing of the bones).
  • COPD – Chronic Obstructive Pulmonary Disease (permanent lung condition, usually from smoking).
  • FESS – functional endoscopic sinus surgery – basically surgery on the sinuses.
  • Incidentally/Incidental finding – something picked up by chance
  • L3 L4 L5 S4 S5 – back problems – spine.  L1, 2, 3 etc are different levels of the spine.  Each building block of the spine has a corresponding number.
  • LUTS – lower urinary tract symptoms
  • Melanoma – a very serious skin cancer that kills people quickly if not picked up early.
  • Squamous Cell Carcinoma – can happen anywhere – often the skin, but can be any where that has a lining like the lungs or even the tongue or mouth.
  • STEMI – ST elevation Myocardial Infact = Heart Attack.
  • Vasovagal syncope – fancy name for a simple faint; not serious