Hei Hei Health Centre
Data Standards Policy
Date: 20/08/2023
Updates: 10/10/2023, 24/11/2024, 23/09/2025
Purpose:
To ensure clinical efficiency and effectiveness and compatibility with national data acquisition programmes by providing a framework for consistent, accurate use of the Practice Management System (PMS)
Policy:
Almost all data pertaining to patients should be documented using the PMS.
Where this is not possible, such as when using incompatible software, the data should be printed and scanned in to the PMS.
Specific issues:
External Communications:
Staff should generally avoid more than trivial communication by patients by email or txt.
These modes of communication are low bandwidth, prone to misinterpretation; and longer communication is best handled during an appointment whether in person or by remote services.
Where email or txt is received from patients, this should be attached to the PMS as an inbox document, and not pasted into notes. This keeps communication clear as to its source and location.
To create a suitable document, go to patient inbox / create new and paste text into the text area. Be sure to add a suitable subject eg 'email from patient'
Where text is inappropriate for inclusion in the record, remove it and include a comment that text was removed, and briefly why eg: "Text containing third part information removed"
Images sent by patients should be added as attachments using attachment manager.
Outgoing email should be sent using the PMS - create a new outbox document and email that to the patient - this will appear as a PDF attachment to an email.
Classification List:
The classification list forms a 'problem list' for the patient. Classifications in Medtech Evolution can be flagged as Long-Term (blue), Highlighted (red), Both (red) or not flagged (black)
Long-term classifications and any comments will automatically be added to referrals and should be used for any information of sufficient import to be shared in most referral letters.
ALL red classifications should also be flagged as long-term.
Some classifications should ALWAYS be in blue (smoking status, language spoken, food allergies, occupation)
Highlighted classifications should be used ONLY for significant cancers which are likely to have significant implications should they recur (eg:melanoma but not BCC) or other conditions which it is vitally important that other practitioners should consider over and above their usual level of vigilance. DO NOT use red to indicate current active problems otherwise as it diminishes the value of the warning.
Black is the place for other classifications such as past history. Things which were once relevant but are now insufficiently important to be added to a routine transfer of care. A tonsillectomy might be a good example as it has no implications for future care, but an appendicectomy might remain long-term. Where the relevance of a condition might have changed, staff are encouraged to consider changing the long-term or highlighted status of the classification appropriately.
Generally try to keep the classification list short and relevant to limit the risk that important information may be overlooked.
DO NOT use classifications to document the following, as doing so clutters the list with little to no clinical value. Do not use Dashboard to add these, instead document these in screening:
1. Alcohol use (unless a formal disorder) - guidelines vary and doing so clutters the list with little to no value - document standard drinks per week in screening instead (ALC)
2. Smoking cessation discussions - document in screening only (#SCS)
Specific classifications:
Some classifications are reserved for specific uses:
Current Smoker (Is currently using tobacco. Document cannabis separately. Vaping only does not count) document amount used where possible in average tailies per day or g per week for rollies. Ideally include "Pack years as at (date)" when updating smoking staus.
Ex-Smoker (Has previously smoked more than about 100 cigarettes in their lifetime) Document quit date or year, and pack-years smoked.
Never Smoked Tobacco (Has not smoked more than 100 cigarettes in their lifetime)
Non-Smoker - NOT TO BE USED.
Please ensure that patients have only ONE classification relating to smoking status. When status changes, please REMOVE old classifications by making them inactive.
Vaping - There are a number of classifications related to vaping. There is no agreed standard for quantification. Please ensure that patients have only ONE classification relating to vaping status. When status changes, please REMOVE old classifications by making them inactive.
Language Spoken: Primary language; other fluent languages. If English is insufficient for clear medical consultation, this should be noted. Eg: English (broken but adequate), Martian.
Occupation: Current occupation, Other current occupation; past occupations (INDUSTRIAL RISKS) eg: Secretary; Demolition specialist (ASBESTOS)
History:
The History tab is the best place to put family history.
Please try to ensure that for all patients of relevant age we record:
Family history of diabetes
Family histoy of ischaemic heart disease (over or under 60)
Family history of stroke
Family history of relevant cancers (if very high risk add as highlighted classification)
Screening:
Screening is useful for any measurements that may change AND may be relevant in future. It is very easy to search and to chart. Common choices are:
BP: Blood pressure (mmHg)
Wt: Weight (to one decimal place, cm)
Ht: Height (to one decimal place, Kg)
Waist: Waist Circumference (cm)
O2: Oxygen Saturation (%)
Pulse: Pulse Rate (BPM)
Alcohol: Document approx average standard drinks per week. 0 = NEVER drinks 1= Drinks, but 1 or fewer per week, even if only rarely.
Results which are less likely to be of future clinical use such as respiratory rate and temperature should not be placed in the screening. Document these in the clinical notes only.
DO NOT include units in measurement. These are implicit and added automatically. Doing so changes the data type from numeric to string, which makes analysis difficult and can slow referrals.
CVD Risk:
The purpose of CVD risk is to identify patients who may benefit from treatment, not to document a decimally accurate risk of heart disease.
If a patient has established cardiovascular disease (Angina, MI, CVA, Stent etc.) then document '35' (Clinically high) to indicate acknowledgement of the high risk.
If a patient is already on statin medication then document D for Discussed as there is no valid method to assess CVD risk in this group and their need has already been addressed.
Use QRisk 3 (pick Indian for high risk groups) to calculate a 10 year risk. Divide this in half and round to the nearest 5% UP. Always round up as this is a trigger for consideration only and it is better to over-trigger than under-trigger. Document the actual calculated risk in the note part of the screening entity.
Treat prediabetes as diabetes for the purposes of CVD Risk assessment.
Where patients have a family history of CVD, generally check the family history box, unless the CVD risk was in late old age.
Recalls
Recalls are covered in greater detail in the recall policy, but should contain sufficient information to permit clinical action. At minimum:
What is required.
How urgent is it (category)
Why is it required (bear in mind that patients can view this on their portal)
Incoming Correspondence:
Where appropriate, incoming correspondence should have a comment added to make it easy to find later. A moment spent now can save many moments later when searching for insurance, ACC or patient management queries.
XRays - add a comment of what the Xray is of.
Letters - A simple note of content if not implicit eg: specialty / name of specialist / area - ortho bloggs ankle
Bloods - some bloods may be drawn in series. A comment of the relevant value can save much time later, especially HbA1c and PSA (with threshold levels if apprpopriate)
Please bear in mind that comments should be short and carry relevant detail in the first 20 characters or so - this ensures that the important data is not hidden eg: "Te Whatu Ora Letter Urology Clinic" may show as "Te Whatu Ora Letter U" which is not helpful.
Medical Warnings
A medical warning should be entered for medication which, having been prescribed previously for the patient has resulted in sufficient side effects or reaction such that exceptional consideration should be exercised before re-use.
Bad experiences can thus be recorded as well as anaphylaxis. All that is required is that the patient perhaps experienced more than the usual expected side effects, or felt strongly about not taking the medication again for a documentable reason.
When properly utilised, the medical warnings capability will ensure that prescribers have to check an additional box before prescribing a medication that has an active warning related to it. There is also a warning in red in the medication selection window.
For this warning to be effective, the medication needs to be correctly classified.
DO NOT USE note only warnings UNLESS you are unsure how to classify the medication correctly, in which case please enter a note only warning and send a task to the Clinical Director to classify the medication correctly. Note only classifications ALWAYS appear in red and this dilutes the impact of the warning substantially. Single medication allergies should be recorded under 'generic group' and class allergies under 'drug class'
DO NOT record food allergies or intolerances in medical warnings - those should be in classifications as "food allergy" with a comment as to type and severity. Food allergies should usually be made 'long-term' (blue) but almost never highlighted.
When entering a medical warning, please ensure that you document the reaction as doing so will help future prescribers make appropriate decisions. Simply entering the name of a drug without further specification is unacceptable. More appropriate documentation might look like: "Metoprolol - felt awful, tired, achy" "Penicillins -checked <date> unsure of reaction. Was told allergic as a child"
DO NOT use medical warnings as a substitute for prescribing vigilance. Entries such as "Triple Whammy - avoid NSAIDS" for instance are not appropriate - prescribers should always check co-medications and classifications before issuing a new prescription. Medical warnings are there for information that is not so readily visible otherwise.
Discretion may be applied when documenting allergies to alternative products. The preference is that unless the reaction was severe these should not be included in medical warnings as doing so may reduce the impact of the warnings. It is also extremely difficult to be sure what is in the product and what has actually caused the reaction.
Where there is no record of allergies, the medical warnings tab will appear in black. If this is the case, please enquire and enter details as appropriate, including 'no known allergies' as appropriate. No Known Allergies will turn the tab blue so prescribers can see this at a glance. If the warnings tab is red, indicating a medical warning, please check that the warnings which are documented comply with this policy. Please take special care to document antibiotic sensitivities carefully as patients may otherwise miss out on useful treatments in life threatening circumstances.
Change Log:
23/09/2025 - added section on external communication
28/11/2024 - added vaping documentation
10/10/2023 - added medical warnings section.