patient journey through the health system
DESCRIPTION
The journey of a remote indigenous Australian through the health system just to get to town for a renal checkup from Bhavini Patel, Chief Pharmacist Royal Darwin Hospital and NICS FellowTRANSCRIPT
remote clinic receives outpatient appointment request
INFORMATION CREATION/
UPDATE
PROCESSES
STAFF ROLES
PATIENT NEEDS/
PRACTICE GUIDELINES/
POLICIES
PATIENT MOVEMENT
MEASURE-MENTS
20.RECEIVE RENAL
SERVICES REFERRAL*1A/B
CKD Nurse
- Past Medical Hx- Bloos Results- Medications- HRN/DOB-Correct Name *
Written referral
Verbal referral
21.CREATE/UPDATE
PATIENT FILE
CKD Nurse
22.COMPLETE
REFERRAL TO NEPHROLOGIST
(if GFR <30)
CKD Nurse
Written referral*2
RAM database
Excel S/S
RDU Patient File
23.COMPLETE
REFERRALS TO OTHER SERVICES
CKD Nurse
SW,WDM,Diet,A&A etc
Written referrals??*2
*2: Added to DB? Std letters? What info do they need?
24.MAKE NEPHROLOGY
CLINIC APPT
Ward Clerk
*1A: Length of Referral Validity*1B: Approp Referral Doco Not always received
CARESYS (JCCB)
Excel S/S
25.FAX APPT DETAILS TO HOME CLINIC
Request bloods, Meds (if first
ref)Neph Referral Recent Bloods??
26.RETRIEVE
BIOCHEMISTRY RESULTS
RDU Patient File
JADECARE
WESTERNS*4
*4: Lab Test Feed currently manual
CKD Nurse
RDU Patient File
Hosp File
Or Fax
Ward ClerkCKD Nurse
Written referral
CKD Nurse
clinic organises transport
Nephrologist
INFORMATION CREATION/
UPDATE
PROCESSES
STAFF ROLES
PATIENT NEEDS/
PRACTICE GUIDELINES/
POLICIES
PATIENT MOVEMENT
MEASURE-MENTS
27.COMPLETE PT
REQUEST FORM*5
Community Patient File
PAT Form
PATS
PATS ELIGIBILITY
Escort Permitted?
*5: Long waits, shortage of accom, Pt perception >DNA (educ), Comm
with clinic WHEN??
28.ADVISE PATIENT/RS OF TRANS/ACCOM
DETAILS
CKD Nurse
*6: 2 x clinic/wk (Mon/Thur 1pm-4:30
HIGH DNA
RDU Patient File
Hosp Patient File
JADECARE
30.CONDUCT
NEPHROLOGY CLINIC *6
+
Ward Clerk
31.RECEIVE ADJUNCT
SERVICE APPT TIMES AND ORGANISE
PATIENT TRANSPORT
RDU File
CKD Nurse
RDU File
CKD Nurse
32.FOLLOW-UP BLOOD
REQUESTS
PT Forms
29.PATIENT ARRIVES IN
TOWN
GP/DMO/SpecO/R/P
Nurse/AHW
Nurse/AHW
CKD Nurse
Or Fax
>RenalServP1 NephClinicP1>
journey through renal clinic
INFORMATION CREATION/
UPDATE
PROCESSES
STAFF ROLES
PATIENT NEEDS/
PRACTICE GUIDELINES/
POLICIES
PATIENT MOVEMENT
MEASURE-MENTS
NephrologistCKD Nurse
30.3.DETERMINE NEED
FOR OTHER ADJUNCT SERVICES/
INTERVENTIONS*8A/B/C
*8A:-Dietician -Social Worker-PD - Ultrasound-Iron infusions -Mapping-Bloods -Renal Biopsy-Darwin
NephrologistCKD Nurse
30.1.CONDUCT PATIENT
EXAM
RDU Patient File
Hospital Patient File
CARPA
Interpreter Req?
NephrologistCKD Nurse
30.2.PROVIDE PATIENT
EDUCATION*7A
Existing Education Material*7B
*7A: -Fistula Formation-Dialysis options-Medication/s-Bloods req-Preventative measures-Precautions-Info on future appts *8B:
-Dietician (on call-page)-Social Worker No links curr. est. (on call_page too)-Move clinics to Flynn Dr
NephrologistCKD Nurse
30.4.CONFIRM FOLLOW-UP APPT WITH PATIENT
*9
Nephrologist
30.5.WRITE UP PATIENT
NOTES
Hosp File
30.6.PREPARE REFERRALS
(as per 20.3)
Hosp File
Referrals Letters *10
*7B: Build demo arm
*8C: Transport an issue if move to Flynn Drive
*9:Comm Clinic not currently advised of next appt. Possibly intro patient appt card that patient is told to give to comm clinic?
JADECARE
*10:No std referrals currently
CKD Nurse
RDU Patient File
>RenalServP2 NephClinicP2>
Nephrology Clinic Letter
journey through renal clinic
30.7.SEND CLINIC LETTER
and REFERRALS
Hosp File
Fax/email to Comm Clinic/CKD Nurse/
Other involved services
INFORMATION CREATION/
UPDATE
PROCESSES
STAFF ROLES
PATIENT NEEDS/
PRACTICE GUIDELINES/
POLICIES
PATIENT MOVEMENT
MEASURE-MENTS
CKD Nurse
30.8.WRITE UP CLINIC NOTES & FILE *11
RDU File
*11 Duplicate paperwork
CKD Nurse
30.9.CONFIRM REFERRAL /INTERVENTION APPTS
MADE
Ward ClerkNephrologist
CKD Nurse
RDU File
Or Fax
>NephClinicP1 RenalServP2>
RAM database
Excel S/S
Nephrology Clinic Letter