4 Patients

The patient list is sorted so that patient records needing your attention (based on the information in the Status columns) are listed at the top. The list then continues alphabetically.

If you have an extensive list of patients, you can change the number of patients shown per page (up to 300).

If you cannot find the patient you are looking for immediately on the list, you can search for them using the search box provided.

To search for patients, you can enter a first name, last name or Medicare Number. For example, if the only information you had about a patient was a surname, such as ‘Celeste’, you could type ‘Celeste’ in the search box and among the results returned you would find the patient, Gabriel Celeste.

Click Search without entering anything in the search box to display all listed patients.

A green dot to the left of a patient’s name indicates that you are that patient’s PCP. Clicking Show Primary Care Provider Patients Only displays the patients for whom you are the PCP. Depending on your role, you may be able to change a patient’s PCP on the patient’s health record if you wish (see 4.2.1.2 Changing a Patient’s Primary Care Provider).

If you are logging in to cdmNet for the first time, you may not have any patients. This may be because you have not uploaded any patient information from cdmNet Desktop, or you may not yet have been assigned to any patients by a PCP.

If you cannot find a patient’s name, this could mean one of two things:

Clicking a patient’s name displays the patient’s health record (see 4.2 Patient Health Record). For Primary Care Providers and Care Plan Creators, if you have not yet created a health record for this patient, clicking their name displays the create health record page (see 4.1 Creating a Patient’s Health Record).

4.1 Creating a Patient’s Health Record

When you want to create a health record for a patient, you can upload their medical history and clinical information from your clinical desktop software (Best Practice or MD3) to cdmNet, using cdmNet Desktop (see the cdmNet Desktop User Guide for more information). cdmNet displays the following page.

If you are a Care Plan Creator uploading a patient record onto cdmNet, you are prompted to select a Primary Care Provider. If the PCP you select is participating in a cohort, an additional checkbox appears asking whether the patient consents to being part of the Diabetes Care Project. If in doubt, leave this box un-ticked; cdmNet Support can add the patient to the cohort any time before the Care Plan is created.

You must obtain the patient’s consent to share their health record in order to continue (unless they are a Test Patient).

Once you have created the patient’s health record, the patient receives a notification from cdmNet with a username and temporary password they can use to log in to cdmNet.

4.1.1 Test Patients

If you tick the ‘Is the patient a test patient?’ box, the patient is marked as a Test Patient. This means that notifications will not be sent to the care team linked to the patient.

Marking patients as test patients is recommended for testing and experimental purposes for Primary Care Providers and Care Plan Creators, particularly if you are new to cdmNet. Once you have marked a patient as a test patient, you cannot turn them back into a normal patient. (However, you can always delete that test patient and upload the patient record onto cdmNet again if you created a test patient in error for a real patient.) You can turn off the test patient option in your Preferences (see Chapter 7.1).

If you marked a patient as a Test Patient, cdmNet indicates this on the patient’s health record with the following red bar, with the option of deleting the patient.

4.2 Patient Health Record

When viewing the health record for a patient who does not have a care plan, the main green navigation bar contains five sections to choose from. They are:

When viewing the health record for a patient who does have a care plan, there are two additional sections in the navigation bar. They are:

Clicking a patient’s name in your patient list to view their health record automatically opens the Contacts section.

If a patient does not yet have a care plan, Primary Care Providers and Care Plan Creators can click Create Care Plan to initiate one (see Chapter 9 Creating Care Plans). This link is available on all pages.

4.2.1 Contacts Page

On the Contacts page Primary Care Provider and Care Plan Creators (only) can:

When viewing the health record for a patient who has a care plan, this page also lists the Care Team Details.

4.2.1.1 A Patient’s cdmNet Number and Card

The ‘cdmNet Number’ is a unique number identifying the patient’s record within cdmNet. Click View cdmNet Card to display a printable card containing this number and a barcode, for use in conjunction with third-party systems that integrate with cdmNet.

4.2.1.2 Changing a Patient’s Primary Care Provider

To change a patient’s Primary Care Provider, click Change Primary Care Provider. cdmNet displays the following page.

Select the Primary Care Provider you wish to assign by clicking the page numbers at the top of the list if necessary until you find them.

4.2.2 Health Summary Page

A patient’s health summary page contains the information uploaded from the Primary Care Provider’s or Care Plan Creator’s clinical desktop software (Best Practice or MD3).

On a patient’s Health Summary Page, Primary Care Providers and Care Plan Creators (only) can:

Any items that you may wish to add or edit about a patient’s Current or Past History, Current Medications, Adverse Reactions and Immunisations records must be done and uploaded via the Primary Care Provider’s or Care Plan Creator’s clinical desktop software (Best Practice or MD3).

4.2.3 Measurements Page

A patient’s measurements page contains information about the patient’s clinical measurement history and how it relates to their care plan.

There are five main categories of measurements. They are:

Targets only appear on this page if the patient has a care plan. The main point of the measurements page is to keep track of the history of measurements and review how well the patient is progressing to achieve the targets.

On this page, all providers can:

If the PCP or CPC had any of the relevant data for a particular measurement type on their clinical desktop software (Best Practice or MD3), you should find it that it has been uploaded into the appropriate fields in the Measurements Page.

If you are a Primary Care Provider or a Care Plan Creator, you can also add data to the Measurements page by clicking Upload XML Record and selecting the appropriate XML file if you do not wish to add it manually.

The Self Monitoring category is primarily for patients who wish to enter measurements they took themselves (for example, readings from a home blood sugar level monitor). However, as a provider, you can also enter measurements on their behalf if they are not confident or comfortable with doing it themselves. You can see who entered particular measurements by hovering your mouse pointer over a measurement value to display such information in a ‘tooltip’.

4.2.3.1 Adding New Measurements

To add new measurements to a category, click the Add New Measurements link to the right of the category. cdmNet displays a screen like the following, where you can add the appropriate information accordingly.

4.2.3.2 History

The History screen contains more history of measurement values than is displayed on the main Measurements Page.

Clicking History in the Actions column of a measurement category also allows you to enter measurement values of the particular measurement type you selected.

In the above example of weight history, you can see three historical measurements for the Date Range selected. Click a measurement to select it. The middle measurement is selected and highlighted in yellow with the tooltip displaying more information about the measurement value. Select a particular historical measurement on this page, then click a link in the Actions column to edit or delete it if you wish.

To add a new measurement value on the same page, click Add New under the Actions column. cdmNet then displays the following page.

You can add the appropriate Value and any Notes in the boxes provided. Any notes you enter in this page will only be displayed in the tooltip on the Measurements page when you hover your mouse over that particular measurement value; they will not appear on the patient’s Progress Notes page.

4.2.4 Planning Page

The Planning page only appears in a patient’s navigation bar if a care plan has been created (see Chapter 9 Creating Care Plans).

The purpose of the Planning page is to set tasks and goals, tailoring them to suit the individual patient in order for them to manage their condition(s).

The content and composition of a patient’s planning page varies depending on the condition(s) they have and your association with that patient.

There is a general template of planning, consisting of five main categories. They are:

On this page, you can:

(See 4.2.4.2 Creating and Editing Appointments)

In addition, PCPs and CPCs can:

(For more information on the context in which you might do these things, see Chapter 9.2 Modifying Care Plans)

Care Plans consist of goals (column on the left) and tasks to achieve them (Task column next to Goal column). There are providers responsible for seeing tasks through (Responsible column) and the frequency of the tasks to be undertaken.

Tasks	Indicates
Green	The task is your responsibility.
Yellow	Your attention may be required for this task, or you may need to check the information cdmNet has generated.
Red	There is a problem that needs resolution (for example, an overdue task).
Not highlighted	The task may be the patient’s responsibility. Or, The task has already been assigned to another provider.

Note that only Primary Care Providers and Care Plan Creators can assign providers to tasks. Care Team Members cannot assign themselves to tasks, regardless of their speciality and association with a patient.

4.2.4.1 Adding Goals and Tasks

This functionality is only available to PCPs and CPCs.

To add a new goal, click Add Goal to the right of the category title to which the goal applies.

Adding a pre-defined goal also adds the corresponding set of pre-defined tasks associated with it.

You can add a custom goal if you cannot find an appropriate goal in the pre-defined goal list. To do this, click the New Goal radio button and fill in the appropriate details in the boxes provided.

You can add tasks to particular goals where you see fit by clicking Add Task in the actions column.

Just as you can add custom goals, you can add custom tasks by clicking the New Task radio button and filling in the appropriate details in the boxes provided.

You can edit tasks by clicking the task name under the Task column and edit the task accordingly.

Tasks require responsible parties assigned to them. To select a responsible party for a task you are creating, click Change. If you wish to amend a responsible party for an existing task, click the responsible party name. cdmNet displays the following Edit Responsible Party screen.

You can assign a single speciality to a task without needing to select a specific provider. To do this, select the Speciality Only radio button and find your selected speciality in the drop down list. When you choose a single speciality, you can also record appointments and generate Allied Health Referral forms for that speciality (see 4.2.6 Documents Page).

Ticking the ‘Display preferred providers only’ box restricts the search results to display the PCP’s preferred providers only.

From here, you can also register a new provider on their behalf if you cannot find them in cdmNet. To do this, click Register a New Provider and fill in the appropriate details in the boxes provided (see Figure 38). As long as you are able to provide accurate contact information, the new provider should receive a notification with a username and temporary password with which they can use to log into cdmNet in future.

When you have selected the provider for a task, you can assign them to all tasks that the previous provider was assigned to, or assign them to unassigned tasks with that provider’s speciality. You can do this by ticking the ‘Assign to all tasks’ box when it becomes available after you select a provider.

Tasks also require a set frequency. You can set the frequency when you add tasks and then alter them by clicking their frequency in the How Often column. You can also set a fixed frequency (days, weeks, months and years) and limit the repetitions by ticking the tick box. cdmNet calculates the number of times the repetitions occur when you set the fixed frequency and tick the box.

4.2.4.2 Creating and Editing Appointments

You can change the next date without setting a specific appointment for when a task needs to be undertaken. Under the Next column, click the downward triangle next to the due date, the options of changing the next date and adding appointments (or adding measurements if clicking in the Biomedical category) are displayed.

You can change the next date for a task up to five years in the future. When there is no specific party assigned to a task, you can only change the next date.

Clicking the calendar icon next to Date displays a date and time calendar where you can set a specific date and time for appointments.

4.2.4.3 Seeing Changes

After a GPMP has been approved, if any changes have been made to the care plan (for example, assigning a different provider to a task or changing a task’s frequency), a pink change bar appears next to the modified area. Hover the mouse over the pink change bar to view information on a tooltip as to what the change was.

Any modifications made to a care plan will also be indicated by a red Modified mark on the top right of the page. The PCP or CPC can accept the modifications by clicking Accept All Changes at their discretion.

4.2.5 Care Team Page

The Care Team page only appears in a patient’s navigation bar if a care plan has been created (see Chapter 9 Creating Care Plans).

This page contains the list of the Care Team members (individual providers and organisations) that are involved in a particular patient’s care plan.

On this page, you can:

When a TCA has been distributed (see 9.4 Care Team TCA Agreements), the Care Team Members need to agree to participate. If/when they have, a grey thumbs-up icon appears next to their name.

As a PCP or CPC, you can add agreements from Care Team Members on their behalf, provided that you have consulted with them on the matter. To do this, click Add Agreement, and tick the box that confirms it.

(Similarly, when a TCA Review is in progress, the Care Team members need to agree to it and as the PCP or CPC, you can add agreements on behalf of Care Team members. TCA Review agreements appear as a thumbs-up with a green tick above it.)

4.2.6 Documents Page

The Documents page has the following sections:

Depending on the status of the patient’s record, not all of these sections are shown all the time.

If the patient does not have a care plan, only the Uploaded Documents section appears.

If you wish to upload a document that you feel is relevant to a patient, clicking Upload Document allows you to select a document to upload onto a patient’s health record. (Note that all other providers associated with a patient can also view any document you upload.)

Clicking the file name in the File column opens a new window displaying the content of the document. You can also click View in the Actions column to view the document in a new window.

Clicking the description of the file in the Description column allows you to change the description of any document you uploaded.

You can download a document by clicking Download in the Actions column.

You can also delete any documents that you have uploaded by clicking Delete in the Actions column.

If the patient has a care plan, the Current Care Plan section shows the Care Plan and Patient Summary.

The Approved Care Plans section displays all approved GP Management Plans, Team Care Arrangements, GPMP Reviews and TCA Reviews (Medicare items 721, 723 and 732).

When a document has not yet been approved (such as GPMP or TCA) a Drafts section is displayed, containing the related documents.

The Annual Cycles of Care section displays any approved annual cycle of care documents.

The Supporting Documents section contains documents that accompany the care plan, including Allied Health Forms, Dental Referrals and Home Medicines Review Referral Form (900).

(In order to create a Home Medicines Review Referral the patient’s care plan must include the domiciliary medication management review task in the Correct Use of Medications goal (in the Medications category of the Planning page). For more information about adding goals and tasks to the care plan see Chapter 4.2.4.1 Adding Goals and Tasks.)

These documents will only be available when the TCA has been approved. When supporting documents are already available for the current year, Primary Care Providers and Care Plan Creators can create new or modify existing supporting documents (where available) to prepare for the following year and future needs of the patient by clicking Create/Modify Supporting Document.

4.2.7 Progress Notes Page

The Progress Notes page is where everyone involved in the patient’s care (including the patient themselves) can make notes about the patient’s progress. The page also displays information about when major milestones (such as GPMPs, TCAs and reviews) related to the patient’s care plan occurred.

Note that you cannot edit or delete notes once they have been added.

Clicking Show Detailed Timeline displays the full list of notes and notifications, including GPMP approvals, the details of TCA agreements from care team members, and so on.

When someone adds new progress notes, the green navigation bar indicates that new notes have been added.

You will also find a notification mark next to the name of the patient on your patient list when new progress notes have been added.

[*] Note that Medication Notes are different from the Progress Notes section (see Chapter 4.2.7 Progress Notes Page)