Download EMIS User Guide 2

MEDICAL RECEPTION STATION SANDHURST
PROTOCOL FOR USE OF EMIS
PRIMARY HEALTH CARE
INFORMATION SYSTEM (PHCIS)
INTRODUCTION
1.
The aim of this protocol is to direct how the EMIS PHCIS is used at MRS RMAS.
The protocol complements the EMIS training package provided by the Defence Medical
Services Training Centre (DMSTC) and should be read in conjunction with the user guides
produced by DMSTC. This protocol is installed on all practice computers as an icon on the
Desktop. Amendments, especially Read codes, will only be made by the SMO.
2.
All users are to receive EMIS training, including locums and temporary nursing staff
who are to be instructed in the use of the system by the Practice Manager (System
Administrator). This guide provides basic guidance for use of the system.
HEALTH AND SAFETY
3.
The Practice Manager is nominated as the MRS Health and Safety officer. He is to
conduct Risk Assessments in accordance with MOD and Academy policies.
4.
All new users of the EMIS system are to have a Display Screen Equipment (DSE)
Work Station assessment carried out and MOD Form 1054 completed. All safety information
is to be displayed either attached to or near that workstation.
1
EMIS Protocol 20 June 2017
LEVEL OF ACCESS
5.
The following levels of access are to be applied:
a.
The Practice Manager is designated System Administrator (SA) and is to have
Level 6 access, as is the Senior Medical Officer (SMO), who is the System Manager.
b.
The Receptionist is the Appointments Manager and requires Level 5 access.
c.
The Dispenser is required to access stock control and so requires Level 5 also.
d.
Doctors other than the SMO, physiotherapists, all nurses and all CMTs are to
have Level 4 access.
e.
Permanent clerical staff other than the Receptionist are to have Level 4 access.
f.
Temporary clerical staff are to be given Level 3 access.
LOGGING ON AND LOGGING OFF
6.
All users not familiar with the system are to be provided with a User Guide by the
Practice Manager (SA). The following is a brief guide to logging on:
Step
1
2
3
4
5
6
7
Action
Switch on computer
Ctrl, Del, Return to log on
Type in password
Press RETURN
Type in WORK at UCI prompt
Type in your user code then RETURN
Type in password, then RETURN
8
At end of session type CU to change
user, or CD to close down
Remarks
Usually your initials
Unique to user. Practice Manager
(SA) is to ensure passwords changed
at the beginning of each term
2
EMIS Protocol 20 June 2017
REGISTERING PATIENTS
7.
All patients must be registered on the computer, whether as temporary or permanent.
There will be many occasions when patients consult before their full medical record has
arrived; this is catered for by the system. Those registering patients must do so in accordance
with the EMIS guide produced by DMSTC. Addresses are to be entered for military staff as
follows:
House name/No
Street
Village/station
Town
Tel No
Course number (e.g. CC 013) or PS or DS
Company name in full then Coy (e.g. Alamein Coy) for cadets;
44 Sqn, GDC, Ac HQ, or MRS for permanent staff; leave blank
for Directing Staff. Army Medical Directorate entered as AMD.
RMAS, FASC or CTC
Camberley
Home telephone number or other contact number is essential
.
APPOINTMENT SCHEDULES
8.
The Receptionist as Appointments Manager is to generate sessions as directed by the
SMO or deputy. The Cadets’ Medical Officer as Deputy SMO is responsible for producing
the doctors’ rota and so will usually produce this information for medical officers. Matron
will produce the information for the Treatment Room (and nurse run clinics) and the
Superintendent Physiotherapist for the physiotherapists.
3
EMIS Protocol 20 June 2017
9.
Appointments.
a.
As a default setting, all appointments are 10 minutes in length. Appointments
are made by typing AP when in the main “Patient Management” menu and selecting
the appropriate session holder.
b.
The Duty MO for the session is to have alternate appointments categorised as
urgent only. This will be annotated in text as URGENT. These slots can only be
filled by nurses or CMTs after they have assessed the patient; they are not available to
the Receptionist. Sick Parade slots are similarly indicated as such. These have to be
cancelled by the nurse or CMT making the appointment, and then the patient’s name
booked in. If the medical officer or other session holder is unavailable for that
particular time, then these appointments will be BLOCKED (--------------) (type B).
c.
Double appointments (i.e. 20 minutes for the patient, rather than 10) may be
made by any user, but must be annotated as such by double appt being entered in text
in the 10 minute slot immediately following that in which the patient’s name appears
(type T then type text). When booking appointments, all patients should be asked if
they would like to make a regular 10 minute appointment, or whether they feel a
longer appointment will be necessary.
d.
Cervical smears, Y list reviews and medicals (except boxing medicals, which
are 10 minute appointments) are as a default always double appts. In this situation,
type T and enter y list review, PULHHEEMS, etc. Medical Board appointments are
always 40 minutes. 30 mins are needed for minor ops and IUD fittings. IUD fittings
must also be booked into the Practice Sister’s appts; minor ops must be booked in
treatment room appointments as well as the doctor concerned.
e.
Other appointments may also be blocked, usually by the Receptionist at the
request of the clinician holding that session. In this situation dotted lines will appear
in that slot. Such appointments may only be unblocked with the permission of that
session holder.
f.
The Receptionist, doctors, nurses and CMTs may make appointments directly
in the physiotherapists’ sessions. Note that there are three physiotherapists, named as
session holders (use linked screens). As for all patients, blocked appts must NOT be
unblocked except by the physio. Referral forms are not required, provided full details
are on the consultation notes. Enter as a Referral: Referral to Physiotherapist Read
Code 8H77.
10.
The appointment schedules are to be backed up by the Receptionist on disc at the end
of each working day Monday to Friday, discs rotating on a weekly basis.
4
EMIS Protocol 20 June 2017
DATA ENTRY
TOP TIP:
When entering data in more than one screen press
F3 to transfer function
11.
MR Page.
a.
The Medical Record (MR) page is to be used for all entries when the patient is
not consulting (i.e. results, reports from consultants etc). It is especially important that
ALLERGIES are entered (from MR screen, type B)1, plus other essential information
including for example Hepatitis B risk.
b.
Results of xrays, blood tests etc are to be entered by typing V for Values and
Investigations and then A for Add. Then chose the appropriate line (e.g. Z for CK –
creatine kinase level). ECGs will also be recorded here.
c.
Immunisations are entered via MR screen by typing I for Immunisations2.
Choices are listed; type T for Template then D for Service Immunisations..
d.
Reports from consultants must always have been seen by a medical officer.
The data will then be entered onto EMIS by nursing staff as indicated by the doctor.
Space in the MR sector is limited to two lines of text, and so only essential
information will be recorded (highlighted by the doctor). The original will be filed in
the patient’s notes; when hardware becomes available the letter will be scanned into
EMIS. The clinical information is to be entered by typing E for Diseases and
Operations and then A for Add data. The problem is then added via Read Codes as
described below, with further text as highlighted by the MO. Where invited to add as
a problem, do so. The MO will have indicated if the problem is Significant or not.
e.
Nurses carrying out new civilian patient registrations (all new patients other
than cadets should be offered a new patient check with the nurse) must generate the
beginnings of a summary on this first contact. This can be amended once the patient’s
records arrive. Similarly, the medical officers carrying out initial medicals will
complete details on the military (blue) summary card. This must be entered on the
computer when this is generated later that day by nursing or data entry staff. Any entry
on the summary card is Significant. Clinical data from new notes and registration
medicals for both military and civilians is entered from the MR screen via H for
Health Screen. The most recent immunisations must also be entered.
f.
Administrative contacts are made via the MR page. Generally the entry will be
headed Administration (Read Code 9…..).
1
The letter B is not immediately visible when the MR screen is entered; it is among those found by entering Q.
However, even in the first screen typing B will bring the person entering data to the Allergies screen.
2
I for Immunisations is not on front screen, but typing I will bring the Immunisation screen up.
5
EMIS Protocol 20 June 2017
12.
CM Page.
a.
The Consultation Mode (type CM from the main screen) is to be used by
doctors, nurses and medics for all patient contacts, including telephone advice. It must
NOT be used for entering results, reports etc as this will generate a consultation
statistic (i.e. make our consultation rate appear much higher than it actually is).
b.
During sessions, clinicians will have the appointments page selected (type AP).
As the patient arrives at Reception, the cursor must be moved to that patient’s name on
the appt list and A typed. When the session holder calls the patient in they are then to
enter S on their appointment list. Pressing RETURN will then bring that patient’s
notes onto the screen. When the patient leaves type L .
c.
When invited to select the Place of consultation, the default setting should be
MRS RMA Sandhurst for doctors’ consulting rooms. Press F4 to chose the place that
you are consulting (e.g. Treatment Room) if this does not appear as default.
d.
All terminals should as a default be configured to show the Brief Summary on
entering CM. Summaries are updated via the MR screen.
e.
To enter CM from MR, select C for Consultations and then A for Add. The
Problem Title will be highlighted. Press RETURN and define the problem by entering
a Read Code from the list below. No other codes are acceptable.
TOP TIP:
When reviewing a patient with an ongoing problem,
select L - Patient’s Problem List. The list of problem
titles already used will be displayed. For a new
problem, type D – Problem Titles. This leads to the
MRS RMAS list of Read Codes. When in Additional
typing J brings you to Morbidity Index for entering
Additional codes
f.
In order that injuries can be attributed to the activities that caused them, the
doctor must enter the relevant code in the Additional field as described in para 16
below, but only once (usually the first occasion they present). Patients seen for
review must have the Read Code Patient reviewed entered as an Additional field. On
y list recommendation Read Code Medical evaluation for rehab is entered as an
Additional field. This is most easily entered by typing J for Morbidity index; choices
are listed.
g.
If the patient has a further problem type N - next problem.
6
EMIS Protocol 20 June 2017
h.
The consultation must be saved by pressing F8 - File, F5 - swap patient, or
F10 - Appointments. These keys may ONLY be pressed when on the CM screen. For
military patients you will then be prompted to detail fitness for duty. Press F8 to exit.
7
EMIS Protocol 20 June 2017
13.
Coding – responsibilities of doctors, nurses and medics.
a.
If patients are seen by nurses or medics and then immediately referred to a
medical officer (i.e. the usual procedure during Sick Parade) then the “Problem Title”
must be competed by the nurse/medic as seen by practice nurse Read Code 9N22, or
by CMTs as Combat Medical Technician Read Code TRISCO22. The medical
officer will then complete the problem title, disposal etc. Details of the condition are
typed in as free test in history. The Light Duties screen which will be displayed on
typing F8 to file can be bypassed in this case by typing F9.
b.
If the patient is given treatment by the nurse or medic, and/or is seen later that
day, the following day or later, then the nurse or medic must enter the code for
problem as below (plus days light duties etc). In this situation the Light Duties screen
which will be displayed on typing F8 to file, is completed as appropriate. If the
problem is to be entered by the nurse then usually it will be entered as Minor unless
the nurse or CMT considers that it is definitely Significant.
c.
For recording procedures such as taking blood, stay in CM but enter X for
Xray/lab requests and then one of the choices listed, e.g. W for Blood sample sent to
lab. Similarly, if an X ray is requested type X for Xray/lab requests then X for Xray.
d.
In summary, if the medical officer sees the patient in the same session as the
nurse or CMT then this is in effect one consultation. If the doctor sees them later, then
there are two consultations.
14.
Read Codes. Read Codes are to be used during consultations, or as Problems on the
MR page, entering one of the following choices as “Problem Title”. The aim is to ensure that
for Service personnel there is consistency in data entry. This is in order to maximise the
accuracy of morbidity returns, and to ensure accuracy when undertaking searches and audits.
The Read Codes used in the practice will need to be reconsidered from time to time, but only
via amendments to this EMIS Protocol by the SMO.
8
EMIS Protocol 20 June 2017
J97
1
1
2
3
3
3
3
3
3
3
3
4
4
5
5
51
5
6
6
6
6
7
7
7
7
Description
Read Code
Remarks
INFECTIOUS AND TROPICAL DISEASE
Intestinal infectious diseases
A0
Incl diarrhoea and vomiting
when likely to be infective or
due to food poisoning
Typhoid and paratyphoid fever
A01
Proven cases
Genitourinary symptoms
1A
Sexually transmitted diseases,
epididymo-orchitis and pelvic
inflammatory dis (not thrush)
Temperature symptoms
165
If cause not known – Pyrexia
of Unknown Origin (PUO)
Bacterial Meningitis
F00
Tuberculosis
A1
Malaria
A84
Leptospirosis risk exposure
65PC
Infectious mononucleosis
A75
Rubella
A56
Rubella antib present - immune
4393
Rubella a/b low – not immune
4395
Other infectious and parasitic
AD
If notified also enter Read
disease
Code 9G1 in Additional field
Foreign travel advice
67E
PSYCHIATRIC PROBLEMS
Alcohol problem drinking
E23-2
Alcohol abuse
Suspected drug abuse
1J1
Incl CDT positive
Overdose of drug
SL-5
Self harm by overdose
Suicide+self-inflict.in.-SII
TK
Other self harm
Stress reaction causing mixed
E284
Stress reaction, including
disturbance of emotion/conduct
marital discord, bereavement
and situational anxiety
Mental state
6652
All other psychiatric conditions
including depression (exact
symptoms free text)
EYES AND ENT PROBLEMS
Acute and subacute iridocyclitis
F440
Incl repeated episodes
Glaucoma
F45
Closed fracture zygoma
S0241
Enter in Additional field the
cause of injury.
Eye symptoms
1B8
All other eye disorders incl
conjunctivitis and corneal FB
Otitis media NOS
F52z
Impedance audiometry
3136
Audiometry review
Allergic rhinitis
H17
Hay fever
ENT symptoms
1C-1
Other disorders of ENT
including sore throat and acute
or chronic tonsillitis
9
EMIS Protocol 20 June 2017
J97
81
82
82
82
82
82
82
82
9
9
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
Description
Read Code
Remarks
RESPIRATORY SYSTEM
Acute nasopharyngitis
H00
URTI – colds
Acute lower respiratory tract
H062
LRTI – significant coughs esp
infection
with sputum; bronchiolitis in
babies and pneumonia
Influenza like illness
H27z-2
Severe cases only (bedded
down)
Influenza
H27
Only those proven on serology
as influenza
Asthma
H33
Incl occupational asthma
Pneumothorax
H52
Croup
H044
Children and babies
Lung cancer
B22z-1
Other resp system diseases
H5
DIGESTIVE SYSTEM
Tooth symptoms
191
Oral cavity, salivary glands and jaw J0
Including # jaw (add injury
diseases
mechanism in Additional field)
Jaundice - symptom
1675-1
Cirrhosis and chronic liver disease
J61
Other liver disorders
J63
Incl porphyria
Hepatitis B surface antig +ve
43B4
Hepatitis risk
Hepatitis B immune
43B2
Epigastric pain
1972
Incl dyspepsia and reflux
Acute pancreatitis
J670
When diagnosed
Abdominal pain
1969
Incl low abdo pain. Enter
associated vomiting as free text
Gastric ulcer
J11
Duodenal ulcer
J12
BMI 25 – 29 overweight
22K4
BMI to be recorded
Obesity
C380
BMI > 30
Emergency appendicectomy
7700-1
All appendicectomies
Cholecystectomy
7810-1
Incl laparoscopic
Inguinal hernia
J30
Incl repair operations
Femoral hernia
J31
Incl repair operations
Neoplasm of unspecified nature of
BA00
All GIT cancers
digestive system
Constipation
19C
Haemorrhoids
G84
Inflammatory Bowel Disease
J4-2
Crohn’s Disease and Ulcerative
Colitis
Digestive system diseases NOS
Jz
All other gastro-intestinal
problems incl irritable bowel
syndrome and vomiting when
cause not likely to be infective
10
EMIS Protocol 20 June 2017
J97
12
12
12
12
12
12
12
12
12
12
131
132
132
132
132
132
132
132
132
132
132
132
132
Description
Read Code
Remarks
CERVICAL NEOPLASIA SCREENING
Cervical neoplasia screen
6859
Smear recall (use template; In
CM type T then O then C)
Ca cervix screen - up to date
6856
Smear up to date
Ca cervix screen - offered
6852
Smear offered
Ca cervix screen – not wanted
6853
Smear declined (incl NSA)
No smear – benign hysterectomy
685H
Cervical smear status unknown
685E
Cervical smear non responder
6857-1
Cervical smear taken
7E2A2
Cervical smear: negative
4K22
Cervical smear negative
Ca cervix screen – no result yet
685A
When smear taken elsewhere
Ca cervix screen – wanted
6854
Smear to be taken elsewhere
Ca cervix screen abnormal
685C
OBSTETRICS AND GYNAECOLOGY
General contraceptive advice
611
Including condoms and caps
Post-coital contraception
61A
Oral contraceptive
614
As template
Depot contraceptive
61B
IUD contraception
615-2
Sterilisation counselling
6775
Pregnancy care
62-3
All obstetric care
Cancer of ovary
B440-1
Fertility problem
1AZ2
Gynaecological history
15
All other gynae problems
including miscarriage and TOP
SKIN DISEASE
Atopic dermatitis/eczema
M111
Incl occupational eczema
Blisters
SD-3
Acne
M2610
Psoriasis unspecified
M1610
Pilonidal sinus/cyst
M06
Cutaneous cellulitis
M08
Impetigo
M05
Pruritus
M18
Fungal infection of skin
AB0-1
Incl athlete’s foot and
ringworm
Fungal nail infection
AB01-3
Other local infections of skin and
M07
Other skin infections including
subcutaneous tissue infections
warts, scabies and head lice
Suspected skin cancer
1J0G
Other skin and subcutaneous tissue M2
Other skin problems including
disorders
non specific rashes, lipomas
and sebaceous cysts
11
EMIS Protocol 20 June 2017
J97
14
14
14
14
14
15
15
15
16
16
16
16
16
16
16
16
16
16
16
16
17
17
18
18
18
18
18
Description
Read Code
Remarks
MUSCULO-SKELETAL PROBLEMS AND INJURIES
Internal derangement of knee
N07
Suspected or proven, including
effusion (the operation itself is
coded as below as a Significant
Problem on Summary)
Therapeutic arthroscopy knee
7K35-1
Meniscal repairs, ACL etc
Anterior knee pain
N094W
Chondromalacia patellae etc
Knee sprain
S54-1
All knee symptoms when no
internal derangement
Housemaid’s knee
N2225
Prepatellar bursitis
Low back pain
N142-1
Incl sciatica
Intervertebral disc disorders
N12
When proven
Back pain, unspecified
N145-2
Incl thoracic back pain
Musculoskeletal disease NOS
Nz
Other musculoskeletal system
problems not otherwise coded
Compartment syndrome
SK0y-2
Shin splint
8D58
Incl medial tibial syndrome
Stress fracture
S3z2
Incl tibial stress #. Enter in
Additional - cause of injury.
#Ankle
S34
Additional - cause of injury.
Ankle sprain
S550
Incl fibular fracture
Achilles tendinitis
N2174
#Bones unspecified
S3z
Other fractures
Lateral epicondylitis - elbow
N2132
Tennis elbow
Medial epicondylitis – elbow
N2131
Golfer’s elbow
Dislocation or subluxation of
S41
When specifically diagnosed
shoulder
Sprain shoulder/upper arm
S50
All other shoulder problems
incl rotator cuff syndrome
COMPLICATIONS OF MEDICAL CARE AND HEALTH CARE POLICY
[X]Complications of medical and
U6
Complication of medical care.
surgical care
Alternatively code - Additional
Medical counselling
677
Incl health care policy issues
and health promotion
Formal complaint about medical
9U0
care
CARDIOVASCULAR SYSTEM
Acute myocardial infarction
G30
Including past history
Angina pectoris
G33
Heart diseases
G-3
Other heart problems, incl
significant heart murmurs and
congenital heart disease
Cardiovascular symptoms NOS
18ZZ
Other CVS problems including
INNOCENT heart murmurs
Hypertensive disease
G2
Incl BP monitoring
12
EMIS Protocol 20 June 2017
J97
Description
Read Code
Remarks
BLOOD, ENDOCRINE, IMMUNOLOGICAL PROBLEMS AND POISONING
18
Anaemia
D21z
all types, less sickle cell
18
Sickle cell anaemia
D106
18
Blood/blood forming organ NOS
Dz
All other blood disorders
18
Deep vein thrombosis
G801-1
Code if no PE
18
Pulmonary embolism
G401
Including if due to DVT
18
Patient immunocompromised
2J30
Including patient HIV positive
18
Total splenectomy
78401
18
Diabetes
C10
Use template for reviews
18
Disorders of thyroid gland
C0
18
Anaphylactic shock
SN50
Allergy to be entered
18
Other endocrine gland diseases
C1
Incl Addison’s dis, pituitary
18
Tired all the time
1683
Not if due to depression
18
Accidental poisoning by drugs
T8
Not for attempted suicide
CHILD HEALTH
Child health care NOS
64Z
Routine CHS and perinatal
conditions and visits
68N1
Immunisations up to date
68NU
No record of immunisations
Chromosomal anomalies
PJ
Incl Down’s syndrome
Speech or language development
E2F3
disorder
Specific delays in development
E2F
Other specific delay
Mixed development disorder
E2F5
All other developmental
problems and syndromes
Cystic fibrosis
C370
Accidental poisoning by drugs,
T8
medicines and biologicals
Physical injury to child
SN552-2
Accident or NAI
Child at risk
13IF
On PHCT meetings list
Child at risk-case conference
9F2
On At Risk Register
Enuresis
1A22
[D]Convulsions, febrile
R0030
Children
NEUROLOGICAL PROBLEMS
18
Head injury
S646
NOT Code S64-3. Enter in
Additional the cause of injury.
18
Had a fit
1B63
Not known epileptic
18
Had a collapse
1B65
Unknown cause (also fol
exercise if temp < 39o)
18
Epilepsy
F25
18
Multiple sclerosis
F20
18
Headache
1B1G
Less migraine
18
Migraine
F26
18
Nerve/spinal cord injuries
SJ
Additional - cause of injury.
18
Accident – diving pressure
TE22
Incl barotrauma
18
Nervous system diseases
F-2
Other neuro problems
13
EMIS Protocol 20 June 2017
J97
18
18
18
18
18
18
18
18
18
18
18
18
18
20
20
20
20
20
20
20
20
20
23
23
23
-
-
Description
Read Code
Remarks
UROLOGICAL PROBLEMS
Proteinuria
4678
Berger’s IgA or IgA nephropathy
K0326
Haematuria
K197
Calculus of kidney
K120
Calculus of ureter
K121
Suspected UTI
1J4
Recurrent urinary tract infection
K190-1
Incl reflux
Chronic renal failure
K05
Incl post transplant
Polycystic kidney
PD1-3
Other urinary system diseases
K1
BREAST DISORDERS
Breast disorders NOS
K3z
All breast problems other than
lump or cancer
Breast lump symptom
1A8
Malignant neoplasm of the female
B34
May include male breast cancer
breast
HEAT AND COLD INJURY
Heat syncope/collapse
SN21
All heat injuries (>39o )
Sunburn
M1271
Heat effects NOS
SN2z
Incl prickly heat
Hypothermia - accidental
SN16
Hypothermia
Frostbite of face
SN10
Frostbite of hands
SN11
Frostbite of feet
SN12
Immersion (trench) foot
SN14
NFCI
Other reduced temperature eff
SN1y
INJURIES AND TREATMENT ROOM PROCEDURES
Operations and procedures
7-3
Incl minor ops, joint injections
and aspirations, and suturing
Post operative monitoring
893
Accidental cut, puncture,
TA0
Wounds
perforation, haemhorrage – medical
care
[D]Burning of skin
R0201
Nursing care - dressing
8C15
All dressings and ROS
Vaccinations
65-4
Cryotherapy
7M07z-1
Treatment for warts/verrucae
Seen by practice nurse
9N22
For other nursing procedures
and also for use by nurses
when referring to MO
Combat medical technician
TRISCO22 For other procedures by also
for use by CMTs when
referring to MO
14
EMIS Protocol 20 June 2017
15.
Referral. Nurses will frequently refer to medical officers, and the doctors will refer
to a number of agencies. The following codes are to be used:
Description
Seen by practice nurse
Read Code
9N22
Combat medical technician
TRISCO22
Referral to GP
Refer to hospital casualty
Referral to hospital OPD
Referral to Physiotherapist
Seen by physiotherapist
Refer to midwife
Refer for physiology investign
Referral for further care
8H62
8HC
8HD
8H77
9N28
8H74
8HR
8H
Remarks
For other nursing procedures and also for
use by nurses as Problem Title when
referring to MO on Sick Parade
Other procedures by medics and also for
CMTs as problem Title when refer to MO
Referral to MO
All emergency admissions and opinions
Outpatient referrals
All physio consultations
Only for INM referrals
Other referrals
16.
Reports and Returns. The following must be added in the “Additional” field if they
are not recorded as the main Problem Title while in Consultation Mode. This is essential for
morbidity reporting . These may be accessed by typing J for Morbidity index.
J97
-
Description
Did not attend
Read Code
9N4
-
Letter encounter
9N33-1
19
9N31
13X
9G1
T1
20
Telephone encounter
History of foreign travel
Infectious disease notification
Motor vehicle traffic accidents
(MVTA)
Active exercise
20
Endurance exercise
8E75
20
Physical exercise NOS
8E7Z
21
TG10
22
23
Accidentally struck by or against
person or object in sports
Injury from war operations
Accident-struck object/person
23
-
Assault – unspecified means
Medical evaluation for rehab
TLxz
3861
8E72
TP
TG1
15
EMIS Protocol 20 June 2017
Remarks
All military pers who fail to attend
without reason are to be reported
If details from letter entered
during a consultation
With PUO if susp tropical disease
F Med 85 to be completed
Injuries when due to RTAs
Injuries sustained during military
field training exercises
Injuries sustained on endurance
training including competitions
Injuries sustained during PT other
than endurance
Injuries when due to sport
Injuries when due to hostile action
Inj sustained in bks from
accidents
Injuries due to other causes.
OMMB completed for y list
J97
-
Description
Patient reviewed
Read Code
6A
Remarks
Must be completed for all
subsequent attendances for the
same problem
17.
Templates should be used wherever possible. The following are especially important
(enter as Summary from CM to enter MR screen – do not use “Template entry” in CM):
MR
H
T
Description
Health Screen
Template entry
Templates to use
Registration for both military and civilian patients
R - Asthma clinic and MO reviews
C - Child health care
G - Diabetes
J - Essential Hypertension
O - Obstetrics and Gynaecology (including A for antenatal
and W for Well Woman Clinic)
Y - Armed Forces medical personnel (Type C for template for
Other Personnel) for use with all military medicals
18.
Run ups will be entered onto the computer by nurses and CMTs from the MR screen,
and using the appropriate Template entry as above (type T for Template). The doctor will
initially be in CM mode and will record the consultation using only one of the following Read
Codes as “Problem Title” and then will switch to the MR screen by typing S for Summary:
Description
Retirement
medical exam
Employment
medical exams
Read Code
6943
Pre-employment
medical exam
Armed forces
medical exam
6941
Boxing medical
Diving medical
HGV drivers
Parachuting
Insurance
medical exam
6931
6933
9EK
6935
696
694
6994
Remarks
Discharge medicals for those leaving the Army (less
those who have Medical Boards – use Code 694).
Medical Boards only (incl those for discharge). After
entering Read Code 694 in CM, type S for Summary
and then T for Template; continue template entry started
by nurses/CMTs – use Z to enter PES.
Incl MOD Guard Force.
All other military medicals seen by MO including
routine PULHHEEMS and officer cadets’ initial and
final medicals (Service medical). Data entry for initial
(first term) medicals is by nursing staff, or additional
data entry staff as available. After entering Read Code
6994 in CM, type S for Summary, T for Template, Y for
Armed Forces medical exam and then C for Other
personnel; continue template entry above started by
nurses/CMTs – use Z option for completing PES.
16
EMIS Protocol 20 June 2017
Description
Medico-legal
Signed
Read Code
69B
Remarks
……………………… (SMO)
Date
17
EMIS Protocol 20 June 2017
20 June 2017
QUICK GUIDE TO EMIS FOR NURSES AND CMTs
DATA ENTRY (MR SCREEN)
Registration
H FOR Health Screen to enter data from newly arrived notes
or following Registration for military and civilian patients
Results
V for Values and Investigations and then A for Add.
Immunisations
I for Immunisations3. Then type T for Template then D for
service Immunisations.
Reports – data entry
E for Diseases and Operations and then A for Add data. Add
problem via Read Codes as EMIS protocol, with further text
as indicated by MO.
Seen by nurses or medics “Problem Title” is seen by practice nurse Read Code 9N22,
and then immediately
or Combat Medical Technician Read Code TRISCO22.
referred to MO (Sick
Details are typed in as free test in history. F8 to file then
Parade)
bypass light duties screen - F9.
Treated by nurse or
Read Code as EMIS protocol (plus days light duties - F8 to
medic
file then complete light duties screen)
MEDICALS AND HEALTH PROMOTION CLINICS (MR SCREEN)
Description
Templates to use
T for Template entry R - Asthma clinic and MO reviews
on MR screen
C - Child health care
G - Diabetes
J - Essential Hypertension
O - Obstetrics and Gynaecology (including A for antenatal and W
for Well Woman Clinic)
Y - Armed Forces medical personnel (Type C for template for Other
Personnel) for use with all military medicals
SICK PARADE CONSULTATIONS AND REFERRALS (CM SCREEN)
Description
Seen by practice nurse
Read Code
9N22
Combat medical technician
TRISCO22
Referral to GP
Refer to hospital casualty
Refer to physiotherapist
Refer to midwife
8H62
8HC
8H77
8H74
3
Remarks
For other nursing procedures and also for
use by nurses as Problem Title when
referring to MO on Sick Parade
For other procedures by medics and also
for use by CMTs as problem Title when
referring to MO as above
Referral to MO
All emergency admissions and opinions
I for Immunisations is not on front screen, but typing I will bring the Immunisation screen up.
18
EMIS Protocol 20 June 2017