PDF layout for Send Consultation Report use case
Purpose
The PDF layout defines the requirements of the document layout and detailed information about data that is used to populate the document.
Requirements
Requirements are given below which define how the PDF is populated for this use case:
| GPCM-SD-086 | the provider system MUST include all data entered by the clinician at the sender practice into the 'Clinical notes [notes]' section of the PDF document. This includes all free text, clinical/SNOMED CT codes, dm+d codes and any other data entered relating to the consultation |
| GPCM-SD-087 | data MUST be displayed in a format that matches how the consultation is displayed on screen or when printed |
| GPCM-SD-088 | the provider system MUST include in the message all attachments relating to the consultation |
| GPCM-SD-089 | where the system does not have a concept of a consultation in its architecture, then the provider system MUST consider all data asserted about the patient for a specified date as part of the same consultation (this follows the same model as GP2GP) |
| GPCM-SD-090 | the layout and content of the PDF MUST conform to the template and logical field model contained in the Layout section below |
| GPCM-SD-091 | the version number MUST be displayed in the PDF in the relevant field and within the Subject of the MESH .CTL file |
| GPCM-SD-098 | version 1 is the original report, each subsequent report that relates to the same consultation MUST increment by 1 |
| GPCM-SD-102 | if the patient has requested that the consultation is confidential then the following data items MUST NOT be sent in the PDF: Clinical Notes, Clinician, Surgery Tel No., Surgery Email, Place of consultation |
| GPCM-SD-133 | if the local system supports setting individual data items as confidential, then each item flagged as confidential MUST contain the warning text Confidential item when sent in the consultation report |
| GPCM-SD-134 | if multiple data items are flagged as confidential, the warning text Confidential item MUST be repeated for each item |
Layout
The PDF below defines the expected document layout. If your browser is not compatible and unable to display the PDF, please right click and select “Save as” to download, or use this link to get the PDF directly.
Field descriptions
The following describe each of the fields used in the PDF:
| Field name | Description | Confidential item |
|---|---|---|
Version [x] |
The version of the consultation report sent. | |
Number of related documents |
The number of documents attached to the message - for example, pain point diagram, ECG, photo. These will be all documents recorded on the GP system that are linked to the consultation. | |
Page [x] of [y] |
The page number and total pages of the PDF. | |
Surname, Forename(s), Title |
The surname, forename(s) and title of the patient. Format all names in the document as follows: SURNAME <uppercase>, Forename(s), (Title)This may wrap over multiple lines depending on the length of the name. |
|
D.O.B. |
The date of birth of the patient in the format DD-Mmm-YYYY . |
|
NHS no. |
The NHS Number of the patient in the format ### ### ####. |
|
Gender |
The gender of the patient. | |
Tel No. |
The patient’s contact telephone number(s). Format all telephone numbers in the document as follows: Area Code <space> Local Number [‘x’ Extension Number] For local numbers with more than six digits include a space before the final four digits. |
|
Current Tel No. |
If the patient is currently staying at a temporary location, the number(s) for contacting the patient at that location. If the patient is not at a temporary location this will be blank and the ‘Current Tel No.’ label will not be shown. | |
Home/Registered Address |
The registered address of the patient, presented line by line, including post code. This may wrap over multiple lines depending on the length of the address. | |
Current Address |
If the patient is currently staying at a temporary location, the address of that location. If the patient is not at a temporary location this will be blank and the ‘Current Address’ label will not be shown. | |
Clinical Notes |
All data entered by the clinician at the sending practice into the ‘Clinical notes [notes]’ section of the PDF document. This includes all free text, clinical/SNOMED CT codes, dm+d codes and any other data entered relating to the consultation. This data must be displayed in a format that matches how the consultation is displayed on screen or when printed. Where the entire consultation has been set to confidential the data from the consultation is not displayed. It is replaced by the text The details of this consultation have been set as confidential. Where individual items in the consultation have been set to confidential those items are not displayed and replaced by the text Confidential item. |
x |
Date of consultation |
The date and time of the patient’s appointment at the GP practice in the format DD-Mmm-YYYY hh:mm. |
|
Date consultation letter sent |
The date and time the consultation report was sent by the practice in the format DD-Mmm-YYYY hh:mm. |
|
Clinician |
The full name and role of the treating clinician for the consultation. Where the consultation has been set to confidential the data from the consultation is not displayed. | x |
Consultation surgery Tel No. |
The main telephone number of the practice available for other GP practices. Where the consultation has been set to confidential the data from the consultation is not displayed. | x |
Consultation surgery email |
The main email address of the practice. Where the consultation has been set to confidential the data from the consultation is not displayed. | x |
Place of consultation |
The name of the practice and the town specified in its full address. Where the consultation has been set to confidential the data from the consultation is not displayed. | x |
