Hospice Patient Records - Features

Patient Records    

- personal details, diagnoses, allergies

- medical contacts (GP, District Nurse, Hospital Consultant, Social Worker, etc)

- Patients' understanding of their situation

- details of death, including causes

Patients' Carers

- personal details, next of kin, emergency contacts

- Carers' understanding of Patient's situation                             

- Carers' details may be made available for Bereavement Support

Patient Care Services

...eg Day Care, Home Care, In-Patients, Out Patient clinics – whatever services you provide, called whatever you name them

Patient Care Episodes

- records viewed by status, per Day (Day Care) or per Nurse (Home Care) or per Clinic (Out-Patients)

- responsibility for Patient (nurse and consultant)   

- details of referrals, assessment, acceptance, admission, and discharge

- log of attendances, visits, appointments; also phone calls ... showing planned contacts, outcome, and comments

- bulk entry of planned attendances and bulk update of actual attendances

Care Service Reports for day-to-day management of each service

- lists of Patients, selective lists

- patients expected on 1 day or in 1 week   

- attendance reports: summaries, lists for 1 day or for 1 patient

- waiting lists

- Patient reports covering each episode of Care

- movement reports (referrals, starts, discharges, deaths)

- reminder lists when reviews are due

Care Episode features

- you  define the Care Services that your Hospice offers

- some Care Services may follow the Day Care pattern with attendances, activities, transport arrangements, capacity levels

-  other  Care Services may follow the Home Care pattern, with  visits, tasks (or types of visits)

- In-Patient services provide details of admissions, beds occupied, etc, and have provision for notes and comments

- Out-Patient clinics - and you may have several - record expected appointments and actual appointments

- Care episodes are locked at discharge, for security reasons (but may be unlocked under controlled circumstances)

Non-Patient Support Services

- covering a variety of services offered to Carers, family members, potential patients

- facilities available are similar to those available for Patient Care services

- reports available for each support service, as well as all support services together

Patient Reports

- Patient Data Report: ie. the "front sheet" of a Patient's file, showing details, and a summary of care-episodes

- Patient Episode Report: showing Patient details for one care service, including a list of attendances

- lists of Patients: current Patients, deceased Patients, birthdays

Management and Statistical Reports

- care Service Management summary - for each service for a period of time

- period statistics: progress over time

- summary report for all Care Services, inc Waiting lists

- Minimum Data Set statistics for the National Council, and supporting schedules

- referrals analysis: by source, GP, area, age/sex, objectives, etc

- deaths analysis: by cause(s) of death, age/sex, time since referral, etc

Selective Statistical Reports

- comparing a selection of Patients with all Patients

- user-defined selections

- statistical profiles, diagnosis analysis, survival analysis

Permanent Records

ReadyRiter RRH5 contains a few fixed records, for example …

- ICD10 Diagnostic Codes: but you can select which codes you use

- Ethnic Group Codes: but you can select the summary or detailed version

But most permanent records in ReadyRiter RRH5 are user-defined: referral reasons, referral sources, locations, relationships of Carers, staff jobs, staff members, professional contacts (GPs, District Nurses, etc), Out-Patient Clinics, non-patient Support Services

Minimum Data Set

ReadyRiter RRH5 complies with the requirements of the Minimum Data Set, published by the National Council for Hospice & Palliative Care Services, as revised with effect from April 2008

Diversity Monitoring

ReadyRiter provides the wherewithal to record and report on all elements of Diversity (age, gender, ethnicity, etc - most of which may be switched off if not required)