Assessment of New Clients
Policy Code: POL 1
Date: 06/06/2014
Updated 11/10/2021, 28/11/2024
Purpose:
To improve the quality of care given to new clients by:
Ensuring an up to date history and set of examinations is available when the client meets the doctor for the first time.
Ensuring an adequate time is booked for an initial consultation.
Initial consultation to be 30 minutes where feasible at the price of a 15 minute consultation,
Providing an opportunity for health promotion activity to be discussed with a member of the clinical team outside of the normal time constraints.
Reducing the stress on medical staff by managing time more efficiently.
Responsible Staff:
Implementation: Practice Nurses, Reception Staff
Action: All Staff
Audit: None
Audit:
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Training Resources:
None
Linked Policies:
None
Enabling Resources:
None
Policy:
Upon enrolment, all new clients over 20 years of age should be offered a discussion with the Practice Nurse. Those under 60 years of age should book for 15 minutes, those 60 and older for a half-hour.
The Receptionist shall:
Account for the service as a NPA (new patient assessment) account item.
Encourage but not coerce clients to accept the service.
Wherever possible, ensure that the New Patient Assessment takes place immediately before the client sees the doctor. There is little value in performing the assessment after a consultation.
The Practice Nurse shall:
Welcome the client to the practice and ask how we can help them.
Record basic observations including Blood Pressure, Height, Weight and Waist Circumference. If appropriate, a peak flow and oxygen saturation should be considered.
Record appropriate classifications including: Smoking status, operations, major medical problems.
Offer smoking cessation support, if appropriate.
Record family history including: Diabetes, IHD, Stroke.
Record medication sensitivities.
Record immunisation status.
Arrange opportunistic screening if appropriate – eg: smear, urine dip, blood sugar.
If the client is on medication and is not certain which, or at what dose, contact their pharmacy to ascertain the most current medication list. This is usually more accurate and much faster than speaking to the previous medical practice. Nurses should without prescribing authority should not enter medication onto the computer system. A note on paper is more appropriate.
Discuss specific health concerns – it may be possible for the problem to be dealt with then and there, especially as most extended medical consults involve the management of chronic disease. Otherwise, the nurse shall ensure an appropriate amount of time is booked with the doctor. Usually, 15 minutes will suffice but if the problem is complex, book half an hour.
If time allows, discuss general health promotion activity.
Conditions usually requiring half an hour with the doctor include:
Any mental active mental health problems.
Clients taking more than 5 regular medications.
Upon receipt of non-electronic record forms:
Most patients have only an electronic record, however some practices still send paper notes.
If there are no electronic notes, then a doctor or NP should review the paper notes, otherwise, these are to be scanned into the record as 'old notes' and then passed to the practice nursing team who will ensure that immunisation and allergy records are transferred from paper to the electronic record as appropriate. They will also check the old records to ensure that all diagnoses of clinical relevance are entered into the electronic record. After this, the physical file can be destroyed.
Change Log
28/11/24
Changed NEWP code for billing to current use NPA
Changed wording of paragraph about non-paper records.
11/10/2021
Added explanation of handling of paper records.
06/06/2014
Minor changes to wording.
Addition of requirement to offer smoking cessation support.