Recording Outcomes including Procedure & RTT Codes

From the OP BASIC MENU select RECORD OUTCOME (H O O A) and enter the patient number or details. Check you have the correct patient and enter Type Ay and press the return key to Accept any changes.

Attended?, - Enter Y or N depending on whether the patient attended and press the return key.

Care Stage, - This field may be pre-filled. Pressing the F1 key will display a code list.
Note: If a procedure has been performed during the outpatient attendance this must be recorded. The codes MUST be entered in the order they appear on the outcome form .

Reason for Referral, - This field may be pre-filled. Pressing the F1 key will display a code list.
Note: If a procedure has been performed during the outpatient attendance this must be recorded. The codes MUST be entered in the order they appear on the outcome form .

At Care stage, enter 2 for Treatment, and Reason for referral, enter 2 for a specific Procedure.

Once entered the letters P C will populate the bottom right data field.

Outcome, - Enter the code indicated on the outcome form. Pressing the F1 key will display a code list.

Time of Arrival - May be entered here if not previously entered.

Time seen, - Enter if required.

Grade of Staff, - Enter the code for the appropriate person who reviewed the patient. Pressing the F1 key will display a code list.

If no procedure has been performed Type Ay and press the return key to Accept any changes.

If a procedure has been performed, press the return key over P C and enter the code indicated on the outcome form.

Once all of the codes have been entered return to Coding complete and Enter Y for Yes, then press the return key.

Type Ay and press the return key to accept the procedure codes. You will then be returned to the outcome screen.

Type Ay and press the return key to accept again.

The following MUST be completed with the relevant RTT code as indicated by the clinician on the outcome form. This is to ensure the Trust is able to monitor that the patients’ care is completed within the Referral to Treatment pathway guidelines.

Local RTT Outcome Code, - enter the code indicted on the outcome.

Press the return key to return through the Related RTT Outcome and Date fields.

Type Ay and press the return key to accept the RTT code.

Warning – if you press the F3 key to exit out of the RTT screen before accepting a code, none of the outcome will have been recorded.

If the outcome was Further Appointment or Add to Follow-up Pending List, you will be taken to the next screen.