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Clinical Process - Nurse / ATSIHW Clinic

Acknowledgement of IUIH

We would like to thank the Institute of Urban Indigenous Health (Queensland) for sharing their clinic workflows which are the framework for these workflow pages.
These workflows are intended as a guide only, to show how you might use MMEx to efficiently manage patients and workload.

This section aims to set out a process that makes best use of MMEx in managing each patient’s Care Plan Activities and Recalls in a scenario where patients are routinely seen by the Nurse or ATSIHW before they see the Doctor. When a patient arrives, clinic nursing/health worker staff should undertake the following process in MMEx as part of their ‘consult’.

Patient Details

Search for the Patient and open their record. From the Patient Widget click on the required item from the Patient Details column

Select one of the listed items and the tabs for all will appear:

  • Check and where necessary update these using the relevant tabs:
    • Demographics
    • Next of Kin
    • Family Relations
    • Other Family History
    • Social History
    • Consent (Eg. Is Closing the Gap Consent current?

For more information about Patient Details click here

Clinical Details
  • From the Patient Widget click on an item from the Clinical column to update the below:
    • Risk Factors (Smoking Alcohol Other Drugs)
    • Alerts
    • Allergies

Click on the ATSI Pathway (see diagram below) to view where the patient is at in their annual journey of care

For more information about the Healthcheck Pathway see here

If Management Plan tab is visible from the Navigator, open to view the latest GPMP/TCA/Review

Add Progress Note (remember to add Reason for Contact). Select relevant Progress Note Template to enter information / observations.

Add Observations from The Navigator or the To Do List from the Patient Demographic header

More information about Observations is available here

Check the Medical History and ensure that all relevant information is evident. This field filters through to Letter Writer templates for referrals to external services. Click Add History to update where necessary. Right click on an item to Edit or Archive history items.

Care Plans

Ensure that all appropriate ‘Care Plans’ have been added.
Care Plans in MMEx are a set of Guidelines that provide recommended best practice care /management of certain conditions. All patients should have LIFETIME SURVEILLANCE (Female/Male; Aboriginal/Non-Aboriginal) Care Plan. In effect the Lifetime Surveillance is a well-persons recommended life time schedule of health activities. Do NOT archive unless there is a duplication.

  • Click Add New Care Plan to add additional plans
  • Care Plans can be Archived if no longer relevant

Additional information about Care Plans is available here.

Open the To Do List.

Check the Tasks section Action or Complete and Archive outstanding Tasks

Click on the Care Plan Activities Tab

From this tab you can action / complete Overdue Care Plan Activities. Clicking on Expand allows you to Mark Completed an activity and enter information directly about the Activity

Check the Mark Completed box
Click Save Selected Activities box at the top of the screen.
NOTE - If this box is not clicked the Care Plan will not be updated. You can complete/enter information regarding ALL Care Plan Activities from WITHIN the Care Plan Activities tab of the To Do List.
Information can be entered from the day you see patient (TODAY), and for information obtained previously, by selecting Specify Date.
Updating information within the Care Plan Activities tab of the To Do List updates the patient's Care Plan.

Returning to the Care Plan tab, select View All Activities.

You will see that the activity ‘completed’ in the To Do List / Care Plan Activities section has marked the activity as complete (ie green), and when the activity is next scheduled (blue). Hovering the mouse over the Legend in the top right corner shows what completion status each colour represents

Where the overdue activity is a GPMP, Health Check or Allied Health visit, arrange for Reception to book the patient in (before the patient leaves the clinic).
Where overdue activities are pathology items, ask the patient if they are willing to have bloods done today. Note in the progress notes and inform the Doctor.

When you have finished checking and updating, return to Progress Notes by selecting either Clinical Summary from the Navigator, or Clinical Summary from the Patient Widget, to add any additional information.

Click Close Patient from the Patient Widget drop down arrow to close the record.

manual/workflows_clinicnursehw.txt · Last modified: 2019/06/30 23:39 by sarahb