<p>18 Weeks Referral to Treatment Standard</p><p>Clinic Outcome Codes Recording</p><p>Issue 2.0 July 2009 Document purpose Guidance for implementation of NHS Boards’ Local Delivery Plans.</p><p>Title 18 weeks: The Referral To Treatment Standard – Clinic Outcome Code Recording Issue 2.0</p><p>Author Scottish Government Health Directorates – 18 Weeks RTT Information Delivery Team</p><p>Issue Date July 2009</p><p>Target audience NHS Staff with involvement in reducing waiting times, and Scottish Government policy leads. Circulation list NHS Board Chief Executives, SG Health Directors Description This document sets out the principles and definitions for Clinic Outcome Code Recording that will underpin the scope of the 18 weeks Referral to Treatment Standard. </p><p>Cross references “ 18 Weeks: The Referral to Treatment Standard”, Scottish Government (2008).</p><p> www.18weeks.scot.nhs.uk</p><p>Superseded docs 18 Weeks: The Referral To Treatment Standard – Clinic Outcome Code Recording Draft version</p><p>Issue 2.0 July 2009 Introduction and Background</p><p>The goal of measuring the total patient pathway remains an imperative and work should be progressed to achieve this as an improvement measure until data is robust to use for performance management purposes. This change will put greater emphasis on NHSScotland to manage the ‘gap’ between the two agreed stages of treatment measures. It is understood that a significant element of this gap is diagnostics, along with repeat OP attendances for further assessment.</p><p>A significant part of this work is the preparation of a working definition of clinic outcome codes recording and measuring treatment events. We know from the experience in health systems in England and Wales that providing such a definition is essential to allow local progress of RTT pathway development, and the implementation of measurement processes needs to include clinic outcome codes recording and measuring treatment events. We also know that such definitions are likely to require discussion and amendment. </p><p>NHS Boards must continue to progress clinical outcome recording to capture the next step in the patient journey. In doing so, NHS Boards will be acting on the recommendations made by Audit Scotland in their Report Day Surgery in Scotland, September 2008.</p><p>There is a requirement to consider the inclusion of outpatient treatments within the 9 week (IP/DC) treatment element of the journey. At present these procedures, often undertaken in an outpatient setting during a return appointment are not captured. However, regardless of treatment setting, they form part of the 18 weeks journey, and clear systems for measurement and recording must therefore be established. </p><p>The enclosed document has been developed by a working-group of the Information Delivery Team which included an extensive period of consultation with contributions from clinicians, patient representatives, NHS information and general managers, ISD and SG Health Delivery.</p><p>Further enquiries should be directed through the Programme website [email protected] or via Joyce Wardrope, Health Information Consultant, Access Support Team, Directorate of Health Delivery on [email protected]</p><p>Outpatient Clinical Outcome Recording Issue 2.0 July 2009 General Guidance for completion of Outpatient Clinical Outcome Form</p><p>One Outcome Code must be selected for every patient seen at the Outpatient Clinic (New or Return appointment).</p><p>All codes on the left hand side of the form have an outcome which will cause the patient’s clock to stop. i.e. the patient has reached the end of his / her patient pathway. This is the date on which the patient starts the treatment that is most appropriate for the patient’s disease, condition or injury.</p><p>All codes on the right hand side of the form have an outcome where the patient’s clock will continue to tick, will pause or be set back to zero waiting time.</p><p>Code Outcome for Patient – Clock Code Outcome for Patient – Clock still Stopped Ticking / Paused / Zeroed</p><p>01 Therapeutic treatment commenced / 101 Add to Waiting list for admission / OP Medical treatment prescribed by procedure – for treatment clinician today (includes for admission today) 02 Medical treatment to be prescribed by 102 Admit today for diagnostic Tests / GP diagnostic OP Procedure carried out today – awaiting results 03 Patient fitted with a medical device 103 Refer for diagnostic test today</p><p>04 Decision taken to start active 104 Refer for treatment to Nurse / AHP monitoring / watchful waiting</p><p>05 Patient declined treatment 105 Refer for investigation / treatment to another clinician - same condition Retain responsibility for patient care 06 No treatment required / Patient 106 Refer for investigation / treatment to Discharged another clinician - same condition Transfer of care to another clinician 07 Patient DNA – no further appointment 107 Return OP Appointment – continuing management pre treatment</p><p>08 Return OP Appointment - 108 Patient considering options treatment already started / complete</p><p>109 Patient DNA – further appointment </p><p>Definitions</p><p>Issue 2.0 July 2009 Outcome - Clock Stops</p><p>Code 01 : Therapeutic treatment commenced / Medical treatment prescribed by clinician today </p><p>The clock will stop on the date that therapeutic treatment commences. If therapeutic treatment commences at the outpatient appointment then the clock will be stopped. However if a course of treatment is recommended by the clinician then the clock will stop on the date of the first session of the treatment and an alternative code should be chosen. E.g. Code 104 If, at the clinic, the clinician prescribes medical treatment as the most appropriate treatment at this point in time, then the patient’s clock will stop. </p><p>Case Study 01</p><p>Mrs A is referred to the consultant led Glaucoma Service at her local hospital. At the first outpatient appointment Mrs A is examined by the ophthalmic nurse practitioner who diagnoses glaucoma and commences treatment.</p><p>Mr A attends the Renal Clinic. The clinician decides that the most appropriate treatment is to prescribe medication rather than start dialysis. </p><p>Master A is referred by his GP for assessment of a skin condition to a Dermatology Outpatient Clinic. A course of phototherapy is recommended and Master A receives his first session at the clinic. Code 01 should be used and the patient’s clock will stop. </p><p>Code 02 : Medical treatment to be prescribed by GP</p><p>This code is similar to Code 01 in that the clock will stop if the clinician decides that medical treatment is the most appropriate treatment at this point in time. Where the clinician does not prescribe the medication but advises the patient to attend their GP for the prescription, then Code 02 should be used and the clock will stop on the date the letter is sent out informing the GP of the recommended treatment. For the purposes of the Outpatient Clinical Outcome Form it is to be assumed that the letter is sent out on the same day as the clinic is held.</p><p>Case Study 02</p><p>Mrs B is referred by her GP to the Orthopaedic Department for investigation of a sore toe. The consultant advises the patient that the most appropriate treatment in this case is the application of an antifungal cream and advises the patient to attend her GP for the prescription. In this case code 02 should be used and the patient’s clock will stop on the date the letter is sent out to the patient’s GP informing him/her of this decision.</p><p>Code 03 : Patient fitted with a medical device today</p><p>Issue 2.0 July 2009 If a clinician (or Audiologist) decides at the clinic that the most appropriate treatment for the patient consists of fitting a medical device, the clock will stop on the date of the supplying and fitting of the device – rather than the date at which the patient is assessed or measured for the device. If supplying and fitting is done at this outpatient appointment then Code 03 should be used and the patient’s clock will stop otherwise the clinician will refer the patient on to the appropriate service and the clock will continue to tick - an alternative code should be used e.g. Code 104.</p><p>Case Study 03</p><p>Miss C approaches her local Audiology Service complaining that her hearing has deteriorated. She attends the Audiology Clinic where her hearing is assessed. The clinical decision is that Miss C requires a hearing aid. If Miss C is fitted and supplied with her new hearing aid at this appointment then the clock will stop otherwise the clock will continue to tick until Miss C has her new hearing aid supplied and fitted. </p><p>Code 04 : Decision taken to start active monitoring / watchful waiting</p><p>The clock will stop on the date that the decision is taken that the most clinically appropriate option for the patient is to be actively monitored over a period of time, rather than to undergo any further tests, treatments or other clinical interventions at this time. Stopping a patient’s clock for active monitoring requires careful consideration on a case-by-case basis and its use needs to be consistent with the patient’s perception of their wait. N.B. Active monitoring stops a patient’s 18wRTT clock and it will not be restarted as part of this episode of care. It should be used where a long period of active monitoring is anticipated before any further action is needed. Patient’s should not be recorded as commencing a period of active monitoring if the reason is that the patient is not medically fit to undergo treatment. In such cases the patient should be recorded as being Unavailable and the clock should be paused under the New Ways definitions of medical and social unavailability.</p><p>Case Study 04</p><p>Mr D sees the vascular surgeon and is given a diagnosis of an aortic aneurysm. At the appointment Mr D and the consultant discuss the possibility of surgery, but agree that at this stage the aneurysm is too small for surgery. Therefore Mr D agrees to commence a period of active monitoring. During this period, regular ultrasound tests will be carried out to measure the size of the aneurysm and lifestyle changes are addressed to minimise the risk of rupture to the patient. Code 04 should be used and the patient’s clock will stop.</p><p>Code 05 : Patient declined treatment</p><p>Issue 2.0 July 2009 If, at the outpatient clinic the patient declines the treatment that has been offered as being the most appropriate by the clinician, Code 05 should be used and the patient’s clock will stop. The clinician will have explained to the patient that he / she will now be discharged back to the care of the referrer. A letter should be sent to both the patient and the patient’s GP informing him / her of the patient’s decision. Should the patient change this / her mind after a period of reflection then a new referral would have to be made by the GP. If the patient has any doubts at all about proceeding with the recommended treatment then Code 108 – Patient considering options should be used.</p><p>Case Study 05</p><p>Mrs E is referred by her GP to the Orthopaedic Clinic with a painful hip. After having X-rays taken she returns to the OP Clinic and is advised by the consultant that the most appropriate treatment in her case would be a hip replacement. Mrs E, who is 80 years old, decides that she would rather manage the pain than proceed with the operation. At the outpatient appointment Mrs E informs the consultant of her decision and acknowledges the fact that she will be placed back in the care of her GP. Code 05 should be used and the patient’s clock will stop. Two months later, after having a discussion with her daughter, Mrs E contacts her GP to say that she has changed her mind and would like to go ahead with the operation. Mrs E is re-referred to the Orthopaedic Clinic for her condition to be reassessed.</p><p>Code 06 : No treatment required / Patient Discharged</p><p>If the clinician at the outpatient clinic decides that No Treatment is required or that Treatment is no longer required then Code 06 should be used and the patient’s clock will stop. The patient will then be discharged from the system and the referrer notified of this decision. Where the decision is made not to treat, but to retain clinical responsibility for the patient (for regular follow-ups etc) then it may be more appropriate to record this as active monitoring, using Code 04, which will in turn stop the clock.</p><p>Case Study 06</p><p>Mr F is referred to Oral Surgery by his dentist for the investigation of a ‘white patch’ inside his cheek.. At the outpatient appointment the consultant informs Mr F that his ‘white patch’ is harmless and the result of biting his cheek. No treatment is deemed necessary and Mr F is discharged. Code 06 should be used and the patient’s clock will stop on the date that the decision not to treat is communicated to the patient.</p><p>Code 07 : Patient DNA – no further appointment</p><p>Issue 2.0 July 2009 The patient’s clock will stop if the patient does not attend the outpatient clinic for his/her appointment and the decision is made by the clinician at the clinic to offer no further appointment. Both the patient and the referrer should be informed in writing of this decision along with the reason why the patient is being removed from the waiting list. N.B. If the clinician is undecided at the outpatient clinic whether to offer the patient a further appointment or not then the Outpatient Clinic Outcome Form should not be completed at the clinic and the patient’s notes should be put to the side along with the form. When a decision has been reached the Outpatient Clinic Outcome Form should then be completed.</p><p>Case Study 07</p><p>Miss G is referred by her dentist to the Orthodontic Clinic at her local hospital for consideration of treatment to correct squint teeth. Miss G fails to attend her outpatient appointment. After considering the options the consultant decides that Miss G should not be given a further appointment. In this case Code 07 should be used and the patient’s clock will stop. Miss G should be removed from the waiting list and both patient and referrer should be notified in writing of the patient’s removal from the waiting list and why. The patient may be re-referred by the original referrer and a new appointment offered but waiting time will start from the date the new referral is received.</p><p>Code 08 : Return OP Appointment - treatment already started / complete</p><p>If a patient returns to an outpatient clinic for a review after treatment has already been started / completed then Code 08 should be used. N.B. The patient’s clock will already have stopped on the date that treatment commenced. However, a Clinical Outcome code must be applied for every patient attending the clinic.</p><p>Case Study 08</p><p>Mr H was referred to his local hospital by his GP in August. He was diagnosed by a consultant physician as suffering from Diabetes in September and placed on appropriate medication at that time. In October he received a letter inviting him to attend a Retinopathy Clinic in April the following year. The patient’s clock stopped in September when active treatment commenced. Subsequent elective care by the patient’s consultant will be scheduled appropriate to the ongoing management of his chronic disease and a new clock will not be started. Code 08 should be used for any subsequent appointments relating to the patient’s condition up until the time the patient is discharged in which case Code 06 should be used. </p><p>Outcome - Clock Still ticking / clock paused / clock zeroed</p><p>Issue 2.0 July 2009 Code 101 : Add to Waiting List for admission for treatment / OP procedure – for treatment (includes for admission today)</p><p>The patient’s clock will continue to tick if the clinician decides at the outpatient clinic appointment that the most appropriate treatment for managing the patient’s condition involves a procedure or treatment as an inpatient, day case or outpatient. The patient should be added to the waiting list and the patient’s clock will continue to tick. If the patient is admitted for treatment straight from clinic as either an inpatient or daycase then the clock will continue to tick until the patient is admitted.</p><p>Case Study 101</p><p>Master J is referred by his GP to the ENT Clinic for investigation of frequent nose bleeds. The clinician at the outpatient appointment decides that the best way to treat the patient’s epistaxis is by cauterizing the nasal passages. In this case code 101 should be used and the patient’s clock will continue to tick. Normally, the clinician would have added the patient to the Return Outpatient Waiting List for an Outpatient Procedure but as Master J is a nervous 7 year old boy, the clinician decides to add his name to the daycase waiting list to have the procedure done under a general anaesthetic. </p><p>Mr J is referred by his GP to the Surgical OP Department for investigation of a suspected hernia. When Mr J presents himself at the clinic, he is in severe pain and the clinician realises that his condition has deteriorated to the extent that Mr J requires to be admitted that day for urgent hernia surgery. In this case, code 101 should be used and the patient’s clock will continue to tick until he is admitted to the appropriate surgical ward.</p><p>Code 102 : Admit today for diagnostic Tests / Diagnostic OP Procedure carried out today – awaiting results</p><p>Code 102 should be applied and the patient’s clock will continue to tick if the patient is admitted directly from the outpatient clinic for a diagnostic test. Similarly, if a Diagnostic procedure has taken place at the outpatient appointment and the clinician requires to see the results before deciding whether a further appointment is necessary or not, the patient’s clock will continue to tick until the patient either starts the treatment that is decided to be that most appropriate for the patient or the patient is informed that no treatment is required..</p><p>Case Study 102</p><p>Mrs K is referred by her GP to the Urology Department of her local hospital. At the outpatient appointment the clinician performs a Cystoscopy with biopsy. Mrs K will have to wait for the results of this procedure before knowing whether any treatment is required or not. Code 102 should be used and the patient’s clock will continue to tick.</p><p>Mr K is referred by his GP to a General Medicine Clinic at his local hospital with abdominal pain. At the outpatient clinic the physician decides that the best course of action is to admit Mr K today as a daycase in order that a colonoscopy can be performed by a gastroenterologist. Code 102 should be used and the patient’s clock will continue to tick until the results of the diagnostic test are known.</p><p>Code 103 : Refer for diagnostic test</p><p>Issue 2.0 July 2009 The patient’s clock will continue to tick if the clinician decides at the outpatient clinic appointment that the patient must undergo a diagnostic test as an inpatient, day case or outpatient before the most appropriate treatment for managing the patient’s condition can be decided.</p><p>Case Study 103</p><p>Rev L is referred by his GP to the Rheumatology Outpatient Clinic with a stiff neck. After examination, the consultant decides that Rev L requires an X-ray of his neck before a diagnosis can be made. Code 103 should be used and the patient referred to Radiology. The patient’s clock will continue to tick.</p><p>Code 104 : Refer for treatment to Nurse / AHP</p><p>Code 104 should be applied if, at the outpatient clinic appointment, the clinician decides that the most appropriate course of action is to refer the patient to a Nurse or AHP for treatment of the patient’s condition. (This includes fitting of some medical devices and some therapeutic treatments.)</p><p>Case Study 104</p><p>Master M suffers from mild cerebral palsy. He is referred to the Orthopaedic Clinic by his GP. The Orthopaedic consultant decides at the outpatient clinic that Master M would benefit from wearing a splint on his leg. The clinician refers Master M to the Orthotic Department for assessment and measurement. Code 104 should be used and the patient’s clock will continue to tick until the orthotist has fitted Master M with his new orthosis. </p><p>Code 105 : Refer for investigation / treatment to another clinician - same condition Retain responsibility of Care </p><p>The clock will continue to tick if the clinician decides at the outpatient clinic appointment to refer the patient to another clinician for investigation / treatment of the same condition while continuing to be the clinician responsible for the care of the patient. </p><p>Case Study 105</p><p>Mrs N is referred by her GP directly to Audiology with a suspected hearing loss. At her Audiology appointment the audiologist decides to refer Mrs N to a consultant in ENT because Mrs N has an ear infection which requires investigation before a hearing assessment can be carried out. Code 105 should be used and the patient’s clock will continue to tick. Responsibility for care of the patient will not be transferred to the ENT consultant as the audiologist still has to investigate the suspected loss of hearing for which Mrs N was referred.</p><p>Code 106 : Refer for investigation / treatment to another clinician - same condition Issue 2.0 July 2009 Transfer of care to another clinician</p><p>The clock will continue to tick if the clinician decides at the outpatient clinic appointment to transfer the responsibility of care for the patient to another clinician – for the same condition. Note : The clinician may be transferring the care of the patient to someone in the same NHS Organisation that is better informed to make the decision relating to the most appropriate treatment of the patient’s condition or the clinician may be transferring the care of the patient to another NHS Organisation better equipped to treat the patient.</p><p>Case Study 106</p><p>Miss O attended her GP after an onset of severe headaches. Her GP decided to refer her to a consultant physician at the local hospital. Miss O attended the outpatient clinic where the physician referred Miss O for a CT scan of the head. At the return outpatient appointment the physician informs Miss O that she is going to transfer the care of Miss O to a consultant neurologist who would be better advised on how to treat Miss O’s condition. At this clinic Code 106 should be used and the patient’s clock will continue to tick.</p><p>Code 107 : Return OP Appointment – continuing management pre treatment</p><p>The clock will continue to tick if the clinician decides at the outpatient clinic appointment that a further outpatient appointment is required before a diagnosis can be made or before deciding on the most appropriate treatment for the patient’s disease, condition or injury. Alternatively, the consultant may already have decided on the most appropriate treatment for the patient and the patient is already sitting on a waiting list waiting to be admitted for that treatment. In the meantime further appointments may be required for the consultant’s continuing management of the patient’s symptoms prior to treatment.</p><p>Case Study 107</p><p>Mrs P has been a strict vegetarian for many years and suffers from pernicious anaemia. Her 4 year old daughter is beginning to show symptoms of the disease and her GP decides to refer her to the Medical Paediatrician at her local hospital for further investigation. At the outpatient clinic appointment the paediatrician takes bloods and requests that a further appointment be made for a review of the results and to repeat the tests if necessary. In this case code 107 should be used and the patient’s clock will continue to tick.</p><p>Mr P is already sitting on the inpatient waiting list for a knee replacement. His consultant has decided that during the period of wait for his operation, Mr P should return to the outpatient department every 2 weeks for a review of his condition and if necessary have steroid injections administered to relieve his painful symptoms. In this case Code 107 should be used and the patient’s clock will continue to tick until Mr P is admitted for his surgical procedure.</p><p>Code 108 : Patient considering options</p><p>Issue 2.0 July 2009 If, at the outpatient clinic appointment, the clinician discusses the most appropriate treatment for the patient’s condition and the patient requests time to consider the available options, then the patient’s clock will be paused and Unavailability should be applied from the date of the outpatient clinic appointment. If after the period of indecision the patient decides to go ahead with the treatment, then the clock should restart from the date the patient informs the hospital of his / her decision. The patient should then be added onto the appropriate waiting list for treatment. If the patient decides not to go ahead with the treatment then the clock (and the period of Unavailability) should stop from the date the patient informs the hospital of this decision. A letter should be sent out to both the patient and the GP informing him / her of the patient’s decision</p><p>Case Study 108</p><p>In Case Study 05, after discussing the various options with her consultant, Mrs E made the decision at the Orthopaedic Outpatient Clinic appointment not to have her hip replaced but to manage the pain herself and her clock was duly stopped. Instead of making this decision right away, Mrs E could have asked the consultant for some time to consider the options. In this case Code 108 should be used and the patient’s clock should be paused during the period of indecision.</p><p>Code 109 : Patient DNA – further appointment </p><p>The patient’s clock will be zeroed if the patient does not attend the outpatient clinic for his/her appointment and the decision is made by the clinician at the clinic to offer a further appointment. N.B. If the clinician is undecided at the outpatient clinic whether to offer the patient a further appointment or not then the Outpatient Clinic Outcome Form should not be completed at the clinic and the patient’s notes should be put to the side along with the form. When a decision has been reached the Outpatient Clinic Outcome Form should then be completed.</p><p>Case Study 109</p><p>Miss Q is suffering periodic pains in her side and is referred by her GP to see a medical paediatrician at her local hospital. Miss Q fails to attend her outpatient appointment. The paediatrician decides that Miss Q should be given a further appointment. Code 109 should be used and the patient’s clock will be set to zero from the date of the DNA’d appointment. The original referral received date remains. The DNA should be verified with the patient by letter or telephone with a letter being copied to the patient’s GP.</p><p>Issue 2.0 July 2009</p>