Last review date 03/02/2023
The Asylum Seeker & Refugee Health Assessment template can be accessed by going to Auto Consultations > ardens GENERAL > Refugee Health Assessment.
It can also be added to your F12 Favourites for quick access.
The template is split into several tabs across the top, to make it easier to navigate to the area you wish to complete:
The home tab allows you to record the top level codes for the assessment - including the code to say you have done a Refugee examination., as well as key background information, communication needs, carer information, sharing consents and special notes. Remember, blue stars are DES payment codes and yellow stars are LES payment codes.
Next to the Encounter drop down is a button that takes you to a 'New Patient Questionnaire' which allows you to complete a questionnaire for the patient using the SystmOne Questionnaire functionality. You can also send this questionnaire via the 'Communications Annexe' by clicking on the button to the right of the Questionnaire button.
Vitals & Lifestyle
This tab allows you to record specific vitals & lifestyle codes for the patient, including heart rate, weight, height, BMI as well as a smoking status and alcohol intake. There is also a link to the AUDIT-C score you can perform, next to the AUDIT-C numeric box. There are also links to leaflets on Weight, Exercise, Smoking and Alcohol next to each section - just click on the blue hyperlink to open these.
This page allows you to add extra medical history information to the patient record. The top 'History' section has a view of all the current Active Major & Minor codes that are recorded in this specific record. If there is anything missing, then it can easily be added by clicking on one of the 'R' buttons above this view, and searching for the relevant code. These can then be backdated by choosing the specific date in the date box to the right of the code you just selected. The 'Current Health Issues' allows you to free text in any other physical and mental health issues they may be experiencing.
Just like the previous page, this allows you to view any current Family History codes that maybe recorded in the record. Add any that are missing by clicking on the 'R' button above the view to add a new Family History code. If there is nothing to add, or you are happy with anything new you have added, you can click the 'Current family history checked & correct' tick box to record you have checked this with the patient.
This tab allows you to give advice on the relevant Cancer Screening options that maybe applicable to them. Ticking in the relevant boxes will record you have advised them on these particular things, and there is a button to the right of each option that takes you to the specific Cancer Screening template to record further information.
Medication & Allergies
The top view shows all the current medication that is recorded in the patient record - listed under sub headings of 'Current Acutes', 'Current Repeats' and 'Previous Meds'. This view is interactive, and you can right click on any of the drugs listed to perform further actions, such as 'Issue', 'Stop' or 'Amend Medication' dependent on your access rights. There is a button above this box to add a 'New Repeat Template' to the patient record if there is anything missing.
The box below allows you to view any Allergies that are currently recorded in the patient, and if any are missing, allows you to add them by clicking on the 'Record Allergy or Sensitivity' button.
Here you have two drop downs to record any likely contraception or Pregnancy codes if applicable for the patient. There is also a button to go to the Contraception template to record more information if appropriate.
Like the previous tabs, the main view will show you which Vaccinations are currently recorded in the patient record. If any are missing, then new ones can be added by clicking on the 'Record Vaccination' button. There are also boxes to code if all vaccinations are up to date, and the ability to access the 'Follow Up' template to record any necessary follow up.
This page will allow the appropriate staff member to record any top level sensitive codes that may be applicable for the patient - including codes for Human trafficking, Modern Slavery, Sexual abuse etc. There is also a link to the Safeguarding template to record more information.
This tab provides various resources that might be useful for both the patient and clinician. It is possible to text any web links to the patient by highlighting the link, copying with Ctrl + C, clicking 'Send Message' and then pasting into the Communications Annexe by pressing Ctrl + V.