Download Annual Review Clinic

Rheumatoid Arthritis Annual Review
Patient identification fields from eRecord
Surname
MRN
Forename
NHS No.
Address
Telephone Number
Date of Birth
Male / Female
Ethnicity
Date form entered :
dd/mm/yyyy
Consultant:
(Free text or drop down list from eRecord??)
Medical History
Scrolling list of free text notes (1 line per comorbidity)
Drug
Dose
Treatments – DMARDs / Biologics (if date order, most current first)
Units Frequency
Route
Date
Date
started
stopped
Code
Decimal
g/mg
Daily/Weekly/Stat/Monthly/12
Weeks/As required/Yearly
PO/SC/IM/IA
dd/mm/yyyy
dd/mm/yyyy
Reasons
for
stopping
Note
field
Monitored by: Hospital / Community DMARD Scheme / GP (delete at appropriate)
Monitoring up to date:
Y/N
Monitoring booklet with results:
Y/N
Other medications:
Scrolling list of free text notes (1 line per
treatment)
Analgesics:
Scrolling list of free text notes (1 line per
comorbidity)
Scrolling list of free text notes (1 line per
allergy/warning)
Drug Allergy:
Pain Scale:
0-10 (Decimal)
Was the patient seen in Early Arthritis Clinic?
Y/N
DAS28 Score
Tender28
Joints:
Int
(0-28)
Swollen28
Joints:
Int
(0-28)
Global
VAS:
Int
(0-100)
ESR:
Decimal
DAS28 :
Decimal
Disease
Activity:
Remission/Low
/Moderate/High
Cardiovascular Risk (25-84)
Total Cholesterol
Decimal (maybe from latest bloods on eRecord)
HDL cholesterol
Decimal
Cholesterol HDL ratio
Decimal
Triglycerides
Decimal
HBA1c
Decimal
BP
Decimal
Height (Metres)
Decimal
Weight (Kg)
Decimal
BMI
Decimal
Angina or heart attack in a 1st degree relative <60?
Y/N
Diabetes
None/Type1/Type2
CKD
Y/N
AF (Atrial fibrillation)
Y/N
Blood pressure Treatment
Y/N
Rheumatoid Arthritis
Y/N – Default in as Y ?
Smoking Status
Ex-smoker/Current Smoker
Smoking Pack Years
Decimal
Alcohol consumption [units per week]
Integer
Alcohol consumption exceeds 3 units per day
Y/N
QRISK 2 Score
Decimal
IF Q Risk 2 Score >20% please refer to GP for management of risk factors
Fracture Risk (40-90)
Previous Fracture?
Parent HIP fracture?
Secondary Osteoporosis
Femoral neck BMD (g/cm2)
FRAX Assessment (Major Osteoporotic Fracture))
FRAX Assessment (Hip Fracture)
NOGG guidance
Referred for DEXA scan?
Commenced treatment?
Y/N
Y/N
Y/N
Free text response
% (Decimal)
% (Decimal)
Red, Amber, Green
Y/N
Y/N
Known Osteoporosis
Bisphosphonate Holiday
DEXA scan 3 yearly
Y/N
Y/N
Steroid History
Intramuscular steroids – Number of doses in last 12 months
Intra-articular steroids – Number of doses in last 12 months
Has patient got a blue steroid alert card if on oral steroids?
Int
Int
Y/N
Vaccinations
Date of last flu vaccination
Date of last pneumococcal vaccination
Advised to have if not up to date
Advised to avoid live vaccines
dd/mm/yyyy
dd/mm/yyyy
Y/N
Y/N
Pregnancy / Contraception
Child bearing age on DMARDs – advised about contraception
Planning to start a family*
*Please discuss with rheumatologist
Need for Podiatry Referral
Does the patient describe issues with their feet?
Footwear
Referred to podiatry
Y/N
Y/N
Y/N
Y/N
Need for Physiotherapy Referral
Has there been a significant change in function / range of movements of joint(s)
Mobility problems requiring assessment / falls risk
Is the patient keeping active?
Referred for physiotherapy
Y/N
Y/N
Y/N
Y/N
Need for Occupational therapy Referral?
Needs joint protection advice or assessment / review of splints
Can a patient hold a pen or do up buttons?
Problems with activities identified by HAQ?
Issues with coping / mood / fatigue / stress / relationship issues
Accommodation:
Y/N
Y/N
Y/N
Y/N
House/
bungalow/flat/
sheltered/
residential/
nursing home
Living arrangements:
Alone/spouse /
partner/relative/
carer
responsibilities
Full-time / parttime / selfemployed /
student /
unemployed /
retired
Employment status:
Number of work days taken sick due to RA
Unpaid leave days due to RA
Decreased working hours due to RA
Work occupational assessment?
Int
Int
Y/N
Y/N
Given NRAS employment booklet:
Referred for occupational therapy (based upon answers or HAQ):
Y/N
Y/N
Other
Education Advice (i.e. NRAS)
Prescription advice (i.e. PPC)
Driving advice (blue badge scheme. NE mobility centre)
Early Morning Stiffness (Mins) :
Agree to help with teaching / exams / trials
X-rays hands and feet (every 2 years)
Other Measurements
ESR :
CRP:
RF Status:
CCP Status:
Negative/Positive
Negative/Positive
Mental Health
Discussed patient’s mental health and wellbeing?
HAD
Free text Notes
Free text Notes
Y/N
Int
Y/N
Y/N
Decimal (default in from DAS28 Score)
Decimal
RF Value
Decimal
CCP Value
Decimal
Y/N
Decimal
Plan
Free text notes
Name:
Updated by
(default in?)
Designation:
Free Text
Date:
dd/mm/yyyy
(default in)
Time:
Hh:mm:ss
(default in)