TABLE OF CONTENTS
Introduction
The Long Term Condition template works alongside the LTC Review Invite process to make annual reviews performed in a patient streamlined. The template clearly lists the patients conditions, bloods that need to be taken dependent on their condition, and any outstanding work that needs to be done. The template is also dynamic on a patient and only highlights the templates that are relevant for each patient. It also has a tick box to record once the Initial Review and Follow-Up review have been completed to ensure the Invite process works smoothly.
To access the template, simply click on the following icon highlighted that appears in the patient demographic box in the top right of the patient record.
Clinicians performing the reviews will use the 'Initial Review & Tests' page to help them take the bloods and perform the initial assessment, and the 'Follow-up Review' page will be used to follow up once the blood results have been returned.
The template is broken down into the following pages:
Home
The home page acts as an index to the other pages of the template and also the view in the bottom half gives you a good overview of any relevant information that exists in the patient record, such as what tests may be required and any Conditions the patient has.
The boxes at the top allow for a quick entry of any relevant free text notes. Anything added in the 'Chronic disease administration' box will also show in the view below, so can be used for reminders or additional personalised information a practice may wish to record about the annual reviews.
There are also buttons to launch the DNA template or Reasonable Adjustments templates.
Invitations
The main window to the left hand side of this page will show information already in the patient record, and the right hand side pane will have buttons to launch various things.
The main window will show information to mainly help an admin team who perform the invitations for the LTC Recall process. For example, on the image above, we can see that the 'Month for Annual Review' when this particular patient gets called in will be May.
- Last Annual Review -
Under this heading will appear either of the two codes that get added on this template once either the bloods have been done and/or the follow-up review has been performed.
In the example above, on 1st May 2024 the Initial Assessment and bloods were done for this patient as we can see the code of "Chronic disease initial assessment (170557005)" has been added (which gets ticked on the Initial Review & Tests page).
We can also see they the patient had their follow up completed on the 15th May 2024 as the code of 'Chronic disease management annual review completed (888461000000107)' has also been added (which gets ticked on the Follow-up Review page).
That way we can see when this patient last had their annual review using the Ardens LTC Recall template.
This heading is useful as if either of those codes have been added in the current QOF year, then this patient will not appear on any of the invite searches. Therefore if whoever performs the invites wonders why a patient is not appearing on their invite searches, they can use this to see if either of these codes have been added in the current QOF year which would then explain why they aren't appearing.
| NOTE: If this is the first year using the Ardens LTC Recall process, it's very likely there will be no codes under this heading as it is doubtful these two codes would have been added outside of this template. Once the Ardens LTC Recall process has started to be used, this heading will become more accurate and start to be populated. |
- Invitations Sent -
This heading will show the last time any invitation was sent for this patient using the Ardens LTC Recall Invitations, as long as the correct invitation code has been added.
In the example above, we can see that the code of Long term condition care planning invitation (912641000000104) has been added once, on the 5th April 2025. Therefore this patient has been sent one invitation for their LTC Recalls this QOF year. This would mean that if it is three weeks after that patient has had that invite, in the example above because they have not had their Initial Review or Follow-Up Review completed this QOF year, they will be sat on the 2nd Invite searches waiting to be sent a reminder.
This heading is useful to determine how many invites a patient has had and where they might be sat in the invite searches.
The Choose LTC Review Month at the top of the right hand pane on this page allows practices to change the month this patient gets called in, if their month of birth is not suitable. For more information on this, see this guide.
There are also options to record that an ad-hoc LTC Invite has been sent to this patient, rather than performing this in bulk.
Booking
For practices that book in the patients LTC Reviews by the patient calling up after they have received their invite, the Booking page of the template can be used to easily see what conditions the patient has, as well as if the patient needs any tests or questionnaires completed. There is even a section at the bottom that will show any other appointments the patient may already have booked. From this, they can use this information to book the relevant initial LTC appointment from the information shown.
On the right hand pane are useful links - with a link to the practices Free Slot Presets (if any are set up) or the standard Free Slot Search to easily book in the appointment. There are also links to the Appointment screens and where the patients contact details can be updated.
In the bottom right red box are two tick boxes:
Declined Review - This adds the code of 'Declined invitation to attend care planning appointment' (1092841000000109 or XabVB). This code removes the patient from the invite searches for that financial year, so they will get no more invites. This can be used if a patient says they don't wish to come in for any reviews. The patient's notes will still need to checked off the back of this code being added, and any outstanding work to do dealt with (e.g. Excepted from certain QOF indicators).
Defaulted from follow-up - This adds the code of 'Chronic disease - default from follow-up' (170559008 or 6619.). This code also removes the patient from the invite searches for that financial year, so they will get no more invites. This can be used if the practice identifies a reason why they may not wish to invite this patient in for a review.
Both of the above codes remove the patient from the invite searches, so only one needs to be ticked depending on the reason why.
Pre-Assessment Questionnaire
This page of the template shows any questionnaires the patient may have filled out already, and also enables the practice to view, print or send a questionnaire electronically to the patient.
The main window is divided up between the last questionnaire the patient has filled out, and all questionnaires filled out by the patient in the last 2 years. In the example above, an Asthma questionnaire has already been completed by the patient. By clicking on the downward arrow to the left of each questionnaire will show the questions and patient answers for that questionnaire:
On the right hand pane are links to view the questionnaires and answer them within SystmOne, or a button to print the Questionnaire and give a paper copy to the patient.
The 'Send Message' button at the bottom launches the Communications Annexe and allows the patient to receive an online questionnaire. This may have been done in bulk during the invite process, but if it hasn't, one can be sent ad-hoc from here.
Initial Review
This page is designed to be used during the patients initial appointment where all their bloods are taken.
The main window will show everything relevant for the patient to perform the bloods, and ask them anything else deemed necessary at this initial appointment. The right hand pane has links to templates that are only relevant for the patient - any 'greyed out' or inactive links are not applicable to the patient.
The main window is divided up into many sections to make it easier to see what is going on with the patient. In the example above, working from the top downwards, we can see the following:
Screening
If the patient is eligible for any screening, it will appear here. Above we can see this patient is eligible for both bowel and breast cancer screening.
Wellbeing
Any wellbeing about the patient is shown here - so above we can see the patient has never smoked, but they do have some safeguarding we need to consider.
Conditions - QOF
Any QOF Conditions that the patient has will appear here. In the example above, the patient has been diagnosed with asthma, diabetes and heart failure.
Conditions - Best Practice
Any 'Best Practice' conditions that don't fall under QOF will appear here. In the example above, the patient has a diagnosis of Chronic Kidney Disease.
NOTE: Depending on whether a practice is performing reviews for QOF + IIF Conditions or QOF + IIF + Best Practice Conditions, this 'Best Practice' section could be ignored if the practice is only reviewing for QOF + IIF Conditions. |
Conditions - Other
Any 'other' conditions the patient has that do not require an annual review but may need some intervention will appear here. For example, conditions like Osteoporosis, Obesity and Depression will appear here. If it is empty, the patient has none.
Test - Blood Tests Required
As this is the Initial Review page and designed for the point in which the bloods are done with the patient, this section will show exactly what bloods are required based on the conditions the patient has. In the example screenshot above, the patient requires an FBC, HbA1c, LFT and Lipids test. They had a UE test performed within the last 2 months, so may not need this repeating.
For a list of what blood tests the template shows for each condition please see this handy guide.
| NOTE: This template is designed to be used during the patients annual review, therefore the 'Tests - Blood Tests Required' section is looking to see if these bloods have been done in the last 2 months, as to be clinically relevant for the annual review they would need to have been done in that time frame. This does not mean these bloods need to be done every 2 months. |
The - Blood test overdue: LFT (on azithromycin) - heading will appear if the patient is on any drugs that require bloods and the bloods are overdue, so these can be taken into consideration when taking the other bloods. In this case, the patient has outstanding LFT bloods that need to be done because they are taking Azithromycin.
Tests - Other Tests Required
Any other 'non' blood tests that need to be done for the patient will appear here - for example taking a patients blood pressure, pulse, spirometry etc.
WORK TO DO (as alert or overdue or not done since 1st April)
Any outstanding QOF work or any other required codes that this patient needs recording (as they haven't been done since 1st April) will appear here. This will give the clinician a good idea if anything is or isn't missing that needs to be done for the patient.
This list updates in real time - so once any of these things have been performed and coded correctly, they will disappear from this list.
In theory, if all reviews have been completed and all the correct codes have been added to the patient, this list will be empty.
Exceptions (in last 1y)
Any exceptions added to the record in the last year will appear here - for example if a patient has a Personalised Care Adjustment (PCA) code added for a certain condition e.g. Asthma, you will see it here.
Future Planning
Any future planning codes within the record will appear here - for example, things like 'For resuscitation' or 'Preferred place of care - care home'.
Follow-Up
This links to a pop up which provides functions for you to arrange a follow up with the patient by copying the suggested text and sending this via SMS or email.
This is not a mandatory function, just to aid with informing the patient of the next steps.
For example: clicking No Follow Up provides the following text:
The text in this box can be copied by highlighting the text with the mouse and copying (Ctrl + C), then click Send Email or SMS. This will launch the SystmOne Communications Annexe where you can paste the copied message and Send to the patient. Or you could choose Send Task to message another member of staff to advise the patient.
The same applies for the other follow-up functions within this pop up depending on whether or not the patient requires a follow up, choose the appropriate option.
LTC Task
Links to the SystmOne task function with a task type of LTC Review.
Initial LTC review tick box
Once the initial review has been completed for the patient and only if you are using the Ardens LTC Review Recalls process in order to invite patients for their annual review, this box will need to be ticked to record that the Initial LTC review has been completed. This will prevent the patient from receiving further invitations and is linked to a report for the staff responsible for sending invitations, to identify all patients who have had their initial review completed but have not yet completed their full review. Ticking the box adds the code 'Chronic disease initial assessment (6617.)'
If you are using any other method to recall patients, this box does not need to be ticked.
Follow-up Review
This page is designed for the nurse to record the full or follow-up review with the patient. For example, a diabetic patient who has had their initial review where bloods and urine were done but needs to see the diabetic nurse for their follow-up appointment now that the results of any tests are back.
This page is laid out in the same format as the Initial Review & Tests page showing the conditions that the patient has and the remaining work to be done within the Work to do list
Results
Results of any prior tests can be viewed by scrolling down the left side of the template; below the Work to do list. You will be able to view recent HR+ BP, weight + BMI, smoking status, current medication, future planning information and blood test results.
The right-side of the template links to all of the templates relevant to that patient. The conditions templates link to the full chronic disease template as opposed to the condensed versions within the initial review page. There is also a useful link to all of the OQF templates if needed.
Medication
This section provides links to the drug review and the specific drug monitoring templates for the medication the patient is currently taking.
Annual LTC Review tick box
Once the full annual review has been completed for the patient and only if you are using the Ardens LTC Review Recalls process in order to invite patients for their annual review, this box will need to be ticked to record that the Annual LTC review has been completed. You can use the Work to Do list to check there is nothing outstanding for the patient.
| NOTE: This box should only be ticked once ALL work has been completed for the patient. For example, a practice may have a respiratory nurse and a diabetic nurse. If the patient has been seen by the respiratory nurse for their condition but has not yet been seen by the diabetic nurse, this box should be left unticked until the patient has been seen for everything. You would be able to view this simply by looking at the work to do list and clearly seeing the diabetic work outstanding. Once all work is completed, the last person to see the patient would tick the box. |
Ticking the box will record the annual review as being completed for the current year. This will prevent the patient from receiving further invitations for the current year. Ticking the box adds the code 'Chronic disease management annual review completed (Xaagy)'
If you are using any other method to recall patients, this box does not need to be ticked.
