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Standard Folder Structure                                                                               1




National Sta...
Standard Folder Structure                                                        2

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Standard Folder Structure                                                                              3


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Standard Folder Structure                                                                                                 ...
Standard Folder Structure                                                                                                 ...
Standard Folder Structure                                                                                                 ...
Standard Folder Structure                                                                                                 ...
Standard Folder Structure                                                                                    8

       ISD...
Proposed DocMan Folder List
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Rehabilitation      AP Rehabilitation Medicine         Spinal Injury Rehab                 Prosthetics       Orthotics    ...
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7. Docman National Folder structure

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Transcript of "7. Docman National Folder structure"

  1. 1. Standard Folder Structure 1 National Standard Folder Structure for DocMan Version 7. Prepared by: Neil McNeil Microtech Support Limited Head of Software Support Review date 01/8/2005 Chris McMAil Status: Version: 2.3 Date of Release: 17/2/2005 Confidentiality: The content of this document is confidential to Microtech Support Limited. No part is to be cited without the express written permission of Microtech. Copyright remains with Microtech Support and any use out- with Microtech is at the users own risk. Authorised for issue CMM/010505 WARNING – This document is uncontrolled when printed Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  2. 2. Standard Folder Structure 2 Microtech Support Limited, DocMan Standard Folder Structure Contents Page number 3 Specification 4 Folder Structure 8 ISD Speciality List 9 Guidance for Document Filing All issues concerning this Document should be raised with the Security and Communications Manager, Microtech Support Limited, Portland House, 38 Portland Road, Kilmarnock, Ayrshire KA1 2DL. (01563 530480) Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  3. 3. Standard Folder Structure 3 Microtech Support Limited Overview and Specification This document is intended to provide a standardised folder structure for the filing of scanned documents into DocMan Document System by GP Practices and other Primary Care Organisations throughout Scotland. Additionally, this document will provide guidance in filing documents by mapping the ISD Speciality List into the proposed structure. Background Microtech Support were awarded the National contract to provide DocMan Document Management Solution to GP Practices in Scotland. There are 1086 GP practices in Scotland There are 5 Clinical Software Providers in Scotland DocMan links to all the current Clinical Software Providers providing a Standard Scanning and Filing Application. There are circa 250 DocMan Installations. DocMan Version 7 will be launched at the Paperlite NUG on the 11th May. Targets The standard folder structure will be installed with DocMan Version 7. Currently when a patient moves between practices, any document which has been scanned and filed in the departing practice has to be filed in the receiving practice. In future the filing metadata will be carried with the document reducing the filing input required at the receiving practice. A prerequisite of this is the departing and receiving practices must have a similar folder structure. All practices that have DocMan installed after the 11th May will be installed with the standard folder structure. All practices that are upgraded from previous versions of DocMan will be installed with the standard folder structure and a mapping tool will be used to transfer existing filed documents into the new folder structure. Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  4. 4. Standard Folder Structure 4 SGPC and SCIMP Nationally Agreed Folder Structure Accident & Include Accident and Emergency letters Emergency Exclude GP Out of hours contacts Out of hours) General practice administrative paperwork, letters from patients, Benefits agency letters Include and requests, Insurance reports and requests. Criminal justice reports Administration Scanned clinical GP notes (Clinical) Exclude Scanned nursing notes (nursing) Employment medicals (Occupational Health) Include Allergy clinic Allergy Patch testing (dermatology) Exclude RAST results (Labs) Include Breast clinics, breast screening services Breast Plastic surgery (Plastics) Exclude Genetic clinics (Genetics) Cardiology, paediatric cardiology, cardiovascular risk factor clinics, cardiac surgery, Include Cardiology thoracic surgery, ECG, ETT Exclude Thallium scans (Imaging) Include Scanned clinical GP notes Clinical General practice administrative paperwork, letters from patients (Administration) Exclude Scanned nursing notes (nursing) Homoeopathy, chiropractic, osteopathy, herbal medicine and any other complementary Complementary Include medication. medicine Acupuncture except given as part of a physiotherapy programme or at pain clinic Exclude Acupuncture given as part of a physiotherapy programme or at pain clinic (Pain) Community dentistry; oral medicine and surgery; orthodontics oral pathology; Include Dental / Max-Fac maxillofacial surgery Exclude Plastic surgery (Plastics) Dermatology, paediatric dermatology, including patch testing and excisions carried out Include Dermatology by dermatologists Exclude Excision carried out by plastic surgeons (Plastics) Include General dietetic services as well as diabetic, nephrology and nutritional support services. Dietetics Exclude Specialist multidisciplinary obesity services (general medicine) Include Educational material given to patients, Research questionnaires and data Disease specific information sheets for patients – include in the specific disease area or genetics Education / School nursing notes (nursing) research Exclude Additional Support for Learning (Records of needs) documents and reviews (Shared services) Child protection services run jointly with social work; voluntary agencies or non-health services agencies (Shared services). Include Diabetes, endocrine, osteoporosis clinics, paediatric endocrine and diabetes Endocrine / Optician reports (ophthalmology) Diabetes Exclude Podiatry reports (podiatry) DEXA scan results (imaging) Include ENT, paediatric ENT Dental (Dental Max-Fac) ENT exclude Maxillofacial (Dental Max-Fac) Allergy clinic (Allergy) Include Medical and surgical gastroenterology, liver transplant services Gastroenterology Exclude Colostomy services (nursing) General medicine unless otherwise classified; ITU discharge reports when discharged to Include the care of a physician; Specialist multidisciplinary obesity services Otherwise classified medical specialties i.e. cardiology, dermatology, diabetology, General Medicine endocrinology, gastroenterology, geriatrics, infectious diseases, neurology, general Exclude paediatrics, renal medicine, respiratory medicine, haematology (Pathology) and rheumatology. Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  5. 5. Standard Folder Structure 5 General surgery including emergency surgical admissions unless otherwise classified; Include anaesthetic assessment clinics; ITU discharge reports when discharged to the care of a surgeon; minor surgery carried out by a general surgeon General Surgery Otherwise classified surgical specialties i.e. ENT, maxillofacial surgery, surgical Exclude gastroenterology, breast clinic, vascular surgery, plastic surgery, neurosurgery, urology or general paediatric surgery. Include Genetic clinics, family history cancer risk clinics Genetics Ongoing cystic fibrosis (respiratory) or neuromuscular services for muscular dystrophy Exclude or related inherited disorder (neurology) Include Geriatric clinics, geriatric day hospital, specialist falls clinics Geriatrics Exclude Old age psychiatry clinics Unclassified historical scans from previous systems or unclassified back scanning of Include Historical letters Exclude Any other letter Include Clinical radiology, ultrasounds, DEXA and nuclear medicine imaging Imaging Interventional radiology (vascular), EEG (neurology) Exclude Nuclear medicine laboratory results, e.g. C13 urea, Schilling tests (Labs) Include Infectious diseases, including HIV and AIDS, including paediatric infectious diseases Infectious Diseases Exclude Pulmonary tuberculosis (Respiratory) All biochemistry, haematology, bacteriology and serology results. Nuclear medicine Include laboratory results (C13 urea, Schilling tests). Blood grouping reports. Labs Radiology results nuclear medicine imaging including bone scans and DEXA (Imaging) Exclude Biopsy and post mortem results (pathology) Cervical cytology results (pathology) Neurology, neurosurgery, neurophysiology, paediatric neurology, neuromuscular, EEG, Include EMG Neurology Neuro-psychology (psychology) Exclude Spinal and head injury rehabilitation (rehabilitation) Nursing notes; district nursing, health visitors; school nursing notes; public health nursing; domiciliary venepuncture services; specialist paediatric services (not otherwise Include classified); notification of immunisations and vaccinations given in school; Macmillan nurse letters; specialist nursing services e.g. colostomy or incontinence; nurse led tissue Nursing viability (leg ulcer) clinics. Specialist outreach nursing services which would be better classified in another folder, e.g. heart failure (cardiology); cystic fibrosis (respiratory); COPD (respiratory); Exclude midwifery (obstetrics); CPN (psychiatry); diabetes (Diabetes and endocrinology) or osteoporosis (Diabetes and endocrinology) Obstetrics, including GP obstetric notes, gynaecology, gynaecology, community Include midwifery notes, specialist HRT services, fertility services, colpscopy GP family planning notes (Clinical), Cervical cytology results (pathology) Obstetrics / Well woman services (sexual health) Gynaecology Exclude Family planning services (sexual health) Psychosexual services (sexual health) Neonatal paediatrics (Paediatrics) Male infertility (urology) Occupational Include Employment medicals and reports Medicine Exclude Benefits agency and insurance reports (Administration) Medical oncology, radiotherapy, palliative care and hospice (including for reasons other Include than cancer) and haematological oncology Oncology family history cancer risk clinics Exclude surgical follow-up clinics following treatment for cancer (general surgery) respiratory medicine clinics following treatment for cancer (respiratory) Include Ophthalmology, opticians reports and orthoptic clinics, paediatric ophthalmology Ophthalmology Visual acuity reports as part of a wider occupational health assessment (Occupational Exclude medicine) Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  6. 6. Standard Folder Structure 6 Trauma and orthopaedics, paediatric orthopaedics; back pain and other services led by a Include physiotherapist as part of an orthopaedic clinic. Accident and Emergency Rheumatology Orthopaedics Sports medicine clinics Exclude Rehabilitation Prosthetics and orthotics (Rehabilitation) Back pain and other services led by a physiotherapist and not as part of an orthopaedic clinic Include GP out of hours contacts; NHS24 contacts; letters to NHS24; OOH contact with CPN’s Out of Hours Exclude Accident and Emergency General paediatric surgery and medicine; neonatal medicine; community child health; Include child protection services and assessment carried out by consultant paediatricians Specialist paediatric clinics which can be otherwise classified, e.g. cardiology, dermatology, diabetology, endocrinology, child and adolescent psychiatry, gastroenterology, infectious diseases, neurology, renal medicine, respiratory medicine, haematology (Pathology), rheumatology, ENT, maxillofacial surgery, plastic surgery, neurosurgery, or urology. Paediatrics Cystic fibrosis (Respiratory) Exclude School nursing notes (nursing) Health visitors (nursing) Child protections services run jointly with social work; voluntary agencies or non-health services agencies. (Shared services) Additional Support for Learning (Records of needs) documents and reviews (Shared services) Include Pain clinics Pain Pre-anaesthetic assessment clinics (surgery) Exclude ITU reports (general medicine or surgery) Haematology clinics (except for oncology), histopathology, biopsy reports, cervical Include cytology results Pathology Cardiovascular risk factor clinics (cardiology) Exclude Biochemistry, haematology, bacteriology laboratory results (Labs) Include Physiotherapy reports, back pain and other services led by a physiotherapist. Acupuncture, not given by a physiotherapist or as part of the pain clinic (Complementary Physiotherapy medicine) Exclude Physiotherapy clinics as part of an orthopaedic or rheumatology clinic Sports medicine clinics Include Plastic surgery; cosmetic surgery Plastics Exclude Minor surgery carried out by a general surgeon or dermatologist Podiatry and chiropody reports; podiatry biomechanical and orthotic clincs; podiatry led Include Podiatry surgical clincs Exclude Operations to feet and nails by general surgeons or orthopaedic surgeons General psychiatry; liaison psychiatry; child and adolescent psychiatry; forensic psychiatry; old age psychiatry; psychiatrist led psychotherapy, learning disability and Include community psychiatric nursing (CPN) and Community Mental Health Teams. Substance abuse services led by a psychiatrists Psychiatry OOH CPN contacts (out of hours) Psychology Exclude Substance abuse services run jointly with social work; voluntary agencies or non-health services agencies. Psychology; counselling services offered by NHS; psychologist led psychotherapy; Include neuro-psychology Psychology Counselling services offered outside the NHS Exclude Psychiatrist led psychotherapy (Psychiatry) Psychosexual services and gender identity services (sexual health) Copies of referrals made to other services, including secondary care, voluntary and non- Include Referrals health services agencies, community services, social work and AHP’s Exclude Insurance reports and requests Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  7. 7. Standard Folder Structure 7 Physical rehabilitation services, spinal injury rehabilitation services; prosthetics and Include orthotics; occupational therapy; sports medicine clinics Physiotherapy or occupational therapy as part of services better classified in another Rehabilitation speciality e.g. geriatrics Exclude Care community care projects jointly run with social work or voluntary agencies (Shared services) Include Nephrology clinics; paediatric nephrology; renal transplant and dialysis services Renal Medicine Urology clinics Exclude Dietetic services Respiratory medicine; pulmonary tuberculosis; asthma clinics; cystic fibrosis services; Include Respiratory spirometry and respiratory function results Exclude Oncology services for respiratory tumours Rheumatology clinic; rheumatology services led by a physiotherapist as part of a Include Rheumatology rheumatology clinic Exclude Sports medicine (rehabilitation) Sexually transmitted disease services; Psychosexual services; gender identity clinics; Include family planning and well woman services outside general practice including vasectomy Sexual Health HIV & AIDS (infectious diseases) Exclude Cervical cytology and smears (pathology) Colposcopy (Obstetrics / Gynaecology) Counselling services offered outside the NHS Community care projects jointly run with social work or voluntary agencies Substance misuse services run jointly with social work; voluntary agencies or non-health Include services agencies Shared Services Child protection services run jointly with social work; voluntary agencies or non-health services agencies. Additional Support for Learning (Records of needs) documents and reviews. Outreach services from the NHS in a clearly defined specialty e.g. heart failure nurses or Exclude Community Mental Health Teams Include Speech and language therapy including paediatric services Speech & When part of services run jointly with social work; voluntary agencies or non-health Language Exclude services agencies (Shared services) Urology, paediatric urology, nurse led and other prostate clinics, erectile dysfunction Include services; male infertility Urology Vasectomy (sexual health) Exclude Nurse led incontinence services (Nurses) Include Vascular surgery; interventional radiology Vascular Exclude Nurse tissue viability (leg ulcer) clinics (Nursing) If you have any queries or concerns about the nationally agreed folder structure, or simply require Guidance on document filing, then please e-mail SCIMP at the email address below" annabel.chambers@isd.csa.scot.nhs.uk Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  8. 8. Standard Folder Structure 8 ISD Speciality List A1 General Medicine F1 Obstetrics & Gynaecology T3 Mental health nurses A2 Cardiology F1A Well Woman Service T31 Community psychiatric nurses A21 Paediatric Cardiology F1B Family Planning Service T4 Mental handicap nurses A3 Clinical Genetics F2 Gynaecology T41 Community mental handicap nurses A5 Clinical Pharmacology & Therapeutics F3 Obstetrics T5 Community nurses (district nurses) A6 Infectious Diseases F31 Obstetrics Ante-Natal T6 Health visitors A7 Dermatology F32 Obstetrics Post-Natal T7 Sick children's nurses A8 Endocrinology & Diabetes G1 General Psychiatry (Mental Illness) T8 Nursery nurses A81 Endocrinology G1A Community Psychiatry A82 Diabetes G2 Child & Adolescent Psychiatry A9 Gastroenterology G21 Child Psychiatry AA Genito-Urinary Medicine G22 Adolescent Psychiatry AB Geriatric Medicine G3 Forensic Psychiatry AC Homeopathy G4 Psychiatry of Old Age AD Medical Oncology G5 Learning Disability (Mental Handicap) AF Paediatrics G6 Psychotherapy AFA Community Child Health H1 Clinical Radiology AG Renal Medicine H1A Breast Screening Service AH Neurology H2 Clinical Oncology AK Occupational Medicine H3 Nuclear Medicine AM Palliative Medicine J1 Histopathology AN Public Health Medicine J2 Blood Transfusion AP Rehabilitation Medicine J3 Chemical Pathology AQ Respiratory Medicine J4 Haematology AR Rheumatology J5 Immunology AT Medical Ophthalmology J6 Medical Microbiology & Virology AV Clinical Neurophysiology R1 Chiropodists/Podiatrists AW Allergy R11 Surgical Podiatry C1 General Surgery R2 Clinical psychologists C11 General Surgery (excl Vascular) R3 Dieticians C12 Vascular Surgery R4 Occupational Therapists C2 Accident & Emergency R41 Industrial therapists C3 Anaesthetics R5 Physiotherapists C31 Pain Management R6 Speech and language therapists C4 Cardiothoracic Surgery R7 Ambulance men/women - Accident & C41 Cardiac Surgery Emergency C42 Thoracic Surgery R8 Audio logical scientists C5 Ear, Nose & Throat (ENT) R81 Hearing aids C6 Neurosurgery R82 Audiometry C7 Ophthalmology R9 Medical physicists C8 Trauma and Orthopaedic Surgery RA Pharmacists C9 Plastic Surgery RB Physiologists CA Paediatric Surgery RC Dental hygienists CB Urology RD Dental surgery assistants CC Intensive Care Medicine RE Physiological measurement technicians D1 Community Dental Practice RF Prosthetists/orthotists D2 General Dental Practice RG Dispensing opticians D3 Oral Surgery RH Optometrists D4 Oral Medicine RJ Orthoptists D5 Orthodontics RK Diagnostic radiographers D6 Restorative Dentistry RK1 Electroencephalography D7 Dental Public Health RK2 Electrocardiography D8 Paediatric Dentistry RK3 Ultrasonics D9 Oral Pathology RK4 Nuclear medicine DA Oral Microbiology RL Therapeutic radiographers DB Dental & Maxillofacial Radiology RM Medical photographers DC Surgical Dentistry RS Dental therapists DD Fixed & Removable Prosthodontics T1 General nurses E1 General Practice T11 School nurses E11 GP Obstetrics T2 Midwifery E12 GP Other than Obstetrics T21 Community Midwifery Microtech Support Limited Portland House 38 Portland Road Kilmarnock Ayrshire KA1 2DL 31st March 2005
  9. 9. Proposed DocMan Folder List <-------------------------------------------------------------- ISD Speciality list with proposed folder ----------------------------------------------------------------------------> Accident & Emergency C2 Accident & Emergency Administration E1 General Practice Benefits Agency Insurance Reports Criminal Justice Reports Letters from Patients Allergy AW Allergy Breast H1A Breast Screening Service Breast Clinics Cardiology A2 Cardiology A21 Paediatric Cardiology C41 Cardiac Surgery RK2 Electrocardiography C4 Cardiothoracic Surgery C42 Thoracic Surgery Clinical Clinical Notes Complementary Medicine AC Homeopathy Chiropractic Osteopathy Herbal Medicine Acupuncture Dental/Max-Fac D1 Community Dental D2 General Dental D5 Orthodontics D8 Paediatric Dentistry D9 Oral Pathology DB Dental & Maxillofacial Rad RS Dental Therapists DC Surgical Dentistry RC Dental hygienists RD Dental surgery assistants DD Fixed & Removable D4 Oral Medicine D3 Oral Surgery D6 Restorative Dentistry D7 Dental Public Health DA Oral Microbiology Prosthodontics Dermatology A7 Dermatology Paediatric Dermatology Dietetics General Dietetic Services Nephrology & Nutritional Support Education Educational Material Research Questionnaires & Data Endocrine/Diabetes A8 Endocrinology & Diabetes A81 Endocrinology A82 Diabetes Osteoporosis Clinic Paediatric Endocrine & Diabetes ENT C5 Ear, Nose & Throat (ENT) Paediatric ENT Gastroenterology A9 Gastroenterology Liver Transplant General Medicine A1 General Medicine ITU Discharge to Physician Care Specialist Multidisciplinary Obesity Reports General Surgery C1 General Surgery C11 General Surgery (excl Vascular) ITU Discharge to Surgeon Care C3 Anaesthetics Minor Surgery Genetics A3 Clinical Genetics Family History Cancer Care Clinic Geriatrics AB Geriatric Medicine Geriatric Day Hospital Specialist Falls Clinic Historical Unclassified Historical Scans Unclassified Back Scanning Imaging H1 Clinical Radiology RK Diagnostic radiographers RK1 Electroencephalography RK3 Ultrasonics RM Medical Photographers RL Therapeutic Radiographers RK4 Nuclear Medicine Infectious Diseases A6 Infectious Diseases HIV AIDS Paediatric Infectious Diseases Labs Microbiology Haematology Biochemistry Blood Group Reports Serology Neurology AH Neurology AV Clinical Neurophysiology C6 Neurosurgery Paediatric Neurology Nursing General Nurses T11 School Nurses T5 Community Nurses T6 Health Visitor School Nursing Colostomy or Incontinence Vaccination Immunisation Obstetrics/Gynaecology E11 GP Obstetrics E12 GP Other than F1 Obstetrics & F1A Well F1B Family F2 F3 F31 Obstetrics Ante- T2 Midwifery Obstetrics Gynaecology Woman Service Planning Gynaecology Obstetrics Natal F32 Obstetrics T21 Community Midwifery Service Post-Natal Occupational Medicine AK Occupational Medicine Occupational Medicine Employment Medicals & Reports Oncology AD Medical Oncology H2 Clinical Oncology Ophthalmology AT Medical Ophthalmology C7 Ophthalmology RG Dispensing RH Optometrists RJ Orthoptists Opticians Orthopaedics C8 Trauma & Orthopaedic Surgery Out of Hours GP Out of Hours NHS 24 Letter to NHS24 OOH contact with CPN’s Paediatrics AF Paediatrics AFA Community Child Health CA Paediatric Surgery T7 Sick Children's Nurses T8 Nursery Nurses Pain Pain Clinics Pathology J3 Chemical Pathology J1 Histopathology J2 Blood Transfusion J5 Immunology J4 Haematology Physiotherapy R5 Physiotherapists Plastics C9 Plastic Surgery Cosmetic Surgery Podiatory R1 Chiropodists/Podiatrists R11 Surgical Podiatry Psychiatry G1 General Psychiatry G1A Community Psychiatry G21 Child Psychiatry G3 Forensic Psychiatry T31 Community psychiatric nurses T41 Community Mental Handicap Nurses (Mental Illness) G2 Child & Adolescent Psychiatry G22 Adolescent Psychiatry G4 Psychiatry of Old Age G5 Learning Disability (Mental Handicap) RK1 Electroencephalography T3 Mental health nurses Psychology G6 Psychotherapy R2 Clinical psychologists Referrals Referrals Secondary Care Referrals
  10. 10. Rehabilitation AP Rehabilitation Medicine Spinal Injury Rehab Prosthetics Orthotics Occupational Therapy Sports Medicine Clinics Renal Medicine AG Renal Medicine Nephrology Clinics Paediatric Nephrology Renal Transplant Dialysis Respiritory AQ Respiratory Medicine Rheumatology AR Rheumatology Pulmonary Tuberculosis Cystic Fibrosis Spirometry Sexual Health AA Genito-Urinary Medicine STD Psychosexual Services Gender Identity Family Planning Well Woman Services Vasectomy Shared Services Counselling outside NHS Community Care Child Protection Support for Learning Substance Misuse Speech & Language Speech & Language Therapy Urology CB Urology Prostate Clinics Erectile Dysfunction Male Infertility Paediatric Urology Vascular Vascular Surgery Interventional Radiology

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