Diabetes Year of Care
Care Planning Results Letter
(Version 2)
Implementation & User Guide
- SystmOne –
Produced by Carol McTurk, Head of PRIMIS Informatics, NHS Cumbria on behalf of the Year of Care programme
Vision Diabetes YOC Upgrade © v2 September 2011
SystmOne Diabetes YOC Guide © V3.2 April 2012
Contents:
Page:
Introduction
3
Instructions
1.
Diabetes Care Planning Results Letter – Outer page
4
2.
Adding the Diabetes Care Planning Results Letter – Outer Page
4
3. Creating the Diabetes Care Planning Results Letter - Inner Page
7
4. Creating and printing the Diabetes Care Planning Results Letter - Inner Page 18
Attachment

Diabetes Care Planning Results Letter – Outer page
Using Goals via SystmOne ‘Goals’ templates
22
Reporting on SystmOne template recorded Goals
27
SystmOne Diabetes YOC Guide © V3.2 April 2012
Introduction
1. Introduction
The aim of this document is to support practices with the installation and use of tools to
support the Diabetes Year of Care process on SystmOne.
The guidance supports the use of the ‘Diabetes Care Planning Results Letter’ in the
desired format and includes a way of populating the results letter with individual patient
results, as well as providing instructions on the use of the SystmOne Goals Template.
Current SysmOne functionality does not allow an ideal solution to the merging of
relevant patient clinical data into the ‘Diabetes Care Planning Results Letter’ in
the desired format and so these instructions include details of how to address
these issues.
Version 3 replaces all other versions. It has been updated to incorporate the new
HbA1c (IFCC) reporting method.
Practices will need to remove all previous Diabetes Year of Care documents, and
replace them with documents produced using these instructions.
Instructions
These new instructions involve building the Diabetes Care Planning Results Letter
‘inner pages’ on the practice system. Patient results can then be merged onto this
document. The document is then printed onto the pre-printed ‘outer page’ document.
Attachment
This is the Diabetes Care Planning Results Letter outer page document and needs to
be imported onto the practice system.
Using Goals via SystmOne ‘Goals’ templates
This section details how to record and review goals and action plans using the goals
template.
Reporting on SystmOne template recorded Goals
This section details how to report on goals and action plans from the goals template.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Instructions
1. Diabetes Care Planning Results Letter – Outer page
See separate attachment
2.
Adding the Diabetes Care Planning Results Letter – Outer Page
Save the separately attached Diabetes Care Planning
Results Letter - Outer Page document on to your
Desktop.
In Office 2003, go to File in the menu bar and select
“Save As” and then “Save Attachments”. Choose
“Desktop” in the left hand panel and then click “Save”.
In Office 2007, click on the Office button in the top-left
corner, select “Save As” and then “Save
Attachments”. Choose “Desktop” in the left hand panel
and then click “Save”.
First, follow the route Setup
> Referrals & Letters >
*New* Word Letter
Templates, as shown here.
SystmOne Diabetes YOC Guide © V3.2 April 2012
When the Letter template
window appears, click on
“New Template”.
Then choose “Import an
existing Word document”
and click OK.
Using the Select Document
window, navigate to your
Desktop where the Diabetes
Care Planning Results Letter
– Outer Page document is
held.
Highlight the document and
click Select.
SystmOne Diabetes YOC Guide © V3.2 April 2012
When the document has
been imported, complete the
New Word Template
window.
Remember to complete the
description and to add the
appropriate category by
clicking the New Category
button.
In the New Template
Category window, add a
category of Care Planning.
Complete the template by
selecting an icon and
clicking OK.
SystmOne Diabetes YOC Guide © V3.2 April 2012
3. Creating the Diabetes Care Planning Results Letter - Inner Page
This document details how to create a Creating the Diabetes Care Planning Results
Letter - Inner Page using letter template functionality within SystmOne.
It is helpful to work electronically from this document, to allow the copying and
pasting of text.
You must be a system administrator to create letters in SystmOne:
a) Click on the Setup Menu, select the sub menu Referrals and Letters, and then
click *New* Letter Templates
b) The Letter Templates window will open. Select the New Letter Template button.
Click the Printer Settings and ensure that the document is set to Landscape
Then name the document and add it to an appropriate category for example “Care
Planning”.
Template name
Category
Sub-category
Icon
Number of
copies to print
DYOC Patient Goal Results
DYOC Care Planning (create by New Category if needed)
Leave blank
Select an icon of your choosing from the list of available
icons
This will usually be 1
c) To begin the letter, select the
Table tool and set the first
table to 3 columns and 6
rows.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Right-click on the table to get the
drop-down menu from which you
choose Table properties.
In the Table Properties window,
highlight each column in turn and
right-click to Amend width. Set
Column 1 to 50, Column 2 to 20
and Column 3 to 30. Click OK to
confirm the property changes.
In the first row of the table put the headings “Measurements that affect your
future risk of health problems”, “Latest results” and “Questions, thoughts,
ideas”. Please set font to Arial 14 and bold. For the remaining rows in the
table enter the following under the first column:
Diabetes Control: Your HbA1c is an overall measure of glucose control over
the past 8 - 10 weeks. A level of 48-53 mmol/mol is associated with the lowest
risk of complications. (press ‘return’ key – to enter a blank line)
Blood Pressure (BP): A target blood pressure of below 130/80 lowers the
risk of complications (a target of below 125/75 is used if you have kidney
disease). (press ‘return’ key – to enter a blank line)
Cholesterol and Blood Fats: Lowering your cholesterol can reduce the risk
of heart attacks and strokes. Treatment to lower cholesterol is recommended
in diabetes for all people over 40 years. For other people, treatment depends
on your overall risk. The target cholesterol is less than 4 mmol /L. (press
‘return’ key – to enter a blank line)
Weight: Being overweight increases the risk of many medical conditions
including heart disease, arthritis and premature death. It can also make your
diabetes and blood pressure more difficult to control. (press ‘return’ key – to
enter a blank line)
SystmOne Diabetes YOC Guide © V3.2 April 2012
Smoking: Smoking causes problems with your health in many ways but it is
particularly damaging in people with diabetes. (press ‘return’ key – to enter a
blank line)
Now create another table with 2 columns and 1 row. In the first column, enter:
Mood: How you feel could make a big difference to your diabetes. What are
your answers to these questions:
During the last month, have you been bothered by feeling down, depressed or
hopeless?
During the last month, have you had little interest or pleasure in doing things?
In the second column, enter “Your thoughts:” in Bold
Now create a third table with 3 columns and 5 rows. Right-click on the table to
get the drop-down menu from which you choose Table properties.
In the Table Properties window, highlight each column in turn and right-click to
Amend width. Set Column 1 to 50, Column 2 to 20 and Column 3 to 30. Click
OK to confirm the property changes
In the first row, put the headings “Your annual screening checks”, “Last
Screening Date” and “Questions, thoughts, ideas”. Set the font to Arial 14 and
bold.
For the remaining rows in the table enter the following under the first column –
Kidney Tests: Your kidneys are tested by looking at two tests.
1. An early morning urine test (Albumin/Creatinine Ratio). ACR results are
better if under 3.0.
2. A blood test (eGFR). Ideally the higher the eGFR the better. Normally
eGFR should be over 90. (press ‘return’ key – to enter a blank line)
Eyes: Your eye check looks for any changes to tiny blood vessels at the back
of your eye. This may be done at a different time to the other checks. Your
last screening was done on: (press ‘return’ key – to enter a blank line)
Feet: Your feet check detects if you have problems with circulation or the
feeling (sensation) in your feet. Your last screening was done on:
(press ‘return’ key – to enter a blank line)
Go back and highlight in BOLD the first word/words of each heading– as
above.
SystmOne Diabetes YOC Guide © V3.2 April 2012
After entering the headings and
their explanation, then in the list
of available mail-merge fields,
choose the Clinical sub-section.
Now set up the mail merge variables in the first table.
For Diabetes Control: click in
the second column, double click
on “Numerics” in the list of mail
merge variables. Now click on
the “Graph” icon and type
“XaPbt” in the Search and click
the Search button, highlight
HbA1c target level - IFCC
standardised and click OK.
From the Filters tab, select the filter “Last X items” from the drop down menu, then click
“Add filter option” selecting add only the last 2.
From the Output tab (shown below), select the “Display type” of Text, the Fields of
Consultation date and Numeric reading and type “Nothing recorded” in the “If the
output is empty show” field.
Finally click OK.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Repeat the above method for
Row
Cholesterol and Blood Fats
Weight:
Read code
XE2eD
22A..
For Smoking, select “Diagnoses” from the available mail-merge fields. Click on the “Any
of these” choice and choose “Tobacco smoking behaviour” by clicking on the red R and
entering the Read Code “Ub0oo” (You, bee, zero, oh, oh) and click Search and click
OK.. Remember to tick “Including child codes”.
SystmOne Diabetes YOC Guide © V3.2 April 2012
From the Filters tab, select the filter “Last X items” from the drop down menu, then click
“Add filter option” selecting add only the last 1.
From the Output tab (shown below), select the “Display type” of Text, the Fields of
Consultation date and Read Code Description and type “Nothing recorded” in the “If
the output is empty show” field.
Finally click OK.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Return to the Blood Pressure row, click in the second column and double-click on Latest
BP.
Now you have set up the mail merge variables in the first table.
Repeat the method (shown earlier for obtaining Cholesterol results) to insert the Kidney
test results in the third table.
Kidney Tests: ACR
Kidney Tests: eGFR
XE2n3
XaK8y
For Eyes, click in the second cell of the Eyes row and double-click on “Diagnoses” from
the available mail-merge fields. In the Constraints tab choose “RET: Retinal screening
codes” from the cluster selection.
SystmOne Diabetes YOC Guide © V3.2 April 2012
From the Filters tab, select the filter “Last X items” from the drop down menu, then click
“Add filter option” selecting add only the last 1.
From the Output tab (shown below), select the “Display type” of Text, the Field of
Consultation date and type “Nothing recorded” in the “If the output is empty show”
field.
Finally click OK.
Nothing recorded
For Feet, click in the second cell of the Feet row and double-click on “Diagnoses” from
the available mail-merge fields. In the Constraints tab choose “PP: Peripheral pulse
codes” from the cluster selection.
SystmOne Diabetes YOC Guide © V3.2 April 2012
From the Filters tab, select the filter “Last X items” from the drop down menu, then click
“Add filter option” selecting add only the last 1.
From the Output tab (shown below) select the “Display type” of Text, the Fields of
Consultation date and type “Nothing recorded” in the “If the output is empty show”
field.
Finally click OK.
Nothing recorded
SystmOne Diabetes YOC Guide © V3.2 April 2012
The template (first 2 columns) should now be as follows.
If there are any entries in the header.
These need to be removed. First, click the Header button.
On the Amend Header window, just highlight the fields that are shown in turn and press
the Delete key to remove the entry. Click OK to change the header.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Once finished, finally click Ok.
Check that the patients name and date of birth are on the right hand side of the footer.
In the left hand column delete ‘date’ and ‘NHS Confidential patient information’
SystmOne Diabetes YOC Guide © V3.2 April 2012
4. Creating and Printing the Diabetes Care Planning Results Letter - Inner Page
This document details how to print out the Creating the Diabetes Care Planning
Results Letter - Inner Page; the document should then be printed onto the Diabetes
Care Planning Results Letter – Outer Page and then sent to the patient.
Please note all patients’ details are fictitious as this is shown in a TEST PATIENT
scenario.
-
-
Browse to the relevant patient and select Communications and letters (or
Letters) node from the clinical tree on the left hand side of the screen.
Next click on the little envelope to create a new letter.
Within the “New Letter Wizard” dialogue box, select the sender as this
organisation and the recipient as the patient.
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-
The “New Letter” dialogue box will open, select a letter type and then choose the
DYOC Patient Goal Results from SystmOne templates.
-
Click “Write Now”
Your letter should now be completed with the relevant information inserted where
appropriate. You can now Print a copy for the patient and Save Final Version
into the patient’s record.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Due to changes within SystmOne some practice have found that too many results have
been merged into the latest results column, if this happens delete older results and
ensure that only the latest 2 are kept in Diabetes Control, Cholesterol and blood fats,
Weight and Kidney test sections
If you find that your document goes on to 2 pages you may need to delete some of the
line spacing entered previously (such as)
You will now need to manage the manual printing of the results. Place the pre-printed
Diabetes Results Care Planning Letter – Outer Page in the manual feed of your
printer.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Initially to find out which way works for your print set-up, you may need to experiment
with how the pre-printed page should be loaded. First try laying the pre-printed page
face down on the manual feed with the top edge nearest the front of the printer, this
usually is the correct way although your printer may be slightly different.
SystmOne Diabetes YOC Guide © V3.2 April 2012
Using Goals via SystmOne ‘Goals’ templates

Agree and record the patient’s new goals by selecting the New Goal button from the
LTC - Care Planning - Consultation template.
This will open the Goal Setting screen, such as this one:

Set the goal importance and using the patient’s own words complete the objective
and reason of the patient’s new goal.
SystmOne Diabetes YOC Guide © V3.2 April 2012

Assign the goal to a category using the drop down box. Select the type of goal.

If indicated, set the target of the goal using a numeric value or a read code. The goal
may be achieved when a particular numeric value is reached (weight, BP etc) or
when a particular Read code applies (Ex Smoker)

Add the Action Plan which the patient would like apply to achieve their goal.

Using the patient’s own words type what action the patient would like to take to
achieve their goal and define its category from the list. The categories can be added
to if required (this provides both the exact wording that reflects the patient’s specific
goals and actions and could be inserted in a post consultation ‘care plan’, whilst also
enabling categories to be ‘counted’ and used for commissioning, audit, etc.).

If the patient’s method truly cannot be met, for example there are no accessible
SystmOne Diabetes YOC Guide © V3.2 April 2012
WeightWatchers classes then select the tick box, Action Plan cannot be met and
record why in the free text box that appears.
NB: Please note that it is extremely important that clinicians select this tick box if the
method cannot be met as commissioners within the PCT need to be able to identify met
and unmet needs to enable them to commission these methods.
SystmOne Diabetes YOC Guide © V3.2 April 2012

Goals are displayed in the Goals view, which you can access by selecting the Goals
node from the clinical tree. Active goals are displayed this can be changed using the
drop down menu, to display all goals, parked goals and past goals.
SystmOne Diabetes YOC Guide © V3.2 April 2012

The following options are available if you right-click on a Goal:
Option
Description
View Details
View full details about the selected goal. The View Goal dialog
allows you to:



Graph Target
Value
manage the methods associated with the goal
mark the goal as achieved or abandoned
park (temporarily shelve) the goal
Allows you to view a graph of relevant readings for the selected
goal (goals that have a numeric Read code as a target only).
Note: If the selected goal has associated numeric readings, these
are also displayed in the form of a graph in the lower right-hand
corner of the Goals view.
Add Method
Add a method to the selected goal.
Amend
Objective
Amend the goal objective and reason (active and parked goals
only).
Amend
Priority
Amend the priority given to the goal.
Park Goal
Temporarily suspend or shelve the goal due to the patient's
circumstances. Parked goals can be reactivated at any time.
Unpark Goal
Reactivate a parked goal.
Goal Achieved Mark a goal as having been achieved.
Goal
Abandoned
Mark a goal as having been abandoned.
New Goal
Create a new goal.
Show Journal
Entry
View the associated Journal entry for the selected goal.
Problems
To link the currently selected goal to one of the active problems
listed, select the appropriate entry from the sub-menu. A tick is
displayed beside each linked problem in the sub-menu.
SystmOne Diabetes YOC Guide © V3.2 April 2012

To make multiple amendments to Goals, right click on the goal and select View
Details
View the details of the Goal
Add and amend the methods
set for achieving the Goal
Mark the Goal as achieved,
abandoned or park it
SystmOne Diabetes YOC Guide © V3.2 April 2012
Reporting on SystmOne template recorded Goals
1. Create a new report in Clinical Reporting to
report on Goals.
1.
2. Give a clear name to the report e.g. “Goals
for NHSK” . Possibly create a new category
too.
SystmOne Diabetes YOC Guide © V3.2 April 2012
3. Click on “Goals” in the left hand list and click
only “Has a Goal” in the right hand panel.
SystmOne Diabetes YOC Guide © V3.2 April 2012
4. Click on “Join to one report” in the left hand
list and click “Select report” in the right hand
panel.
SystmOne Diabetes YOC Guide © V3.2 April 2012
4. On the “Select Report” window, open up the
System Wide reports. Scroll down to and
open up the latest QOF reports. Select the
Diabetes group and then the Diabetes
Register. Now click OK.
SystmOne Diabetes YOC Guide © V3.2 April 2012
5. Making sure that the choice is “Only report
on patients found in ..........”, click OK.
You have now created a report for patients
on the diabetic register with one or more
goals.
Run the report.
SystmOne Diabetes YOC Guide © V3.2 April 2012
6. When you have created and run the report,
right-click on it and select Breakdown
Results from the drop-down menu.
8. In Breakdown, choose the NHS Number
from Demographics, all of the options in
Goals and the Registered Practice ID in
Registration. Now click on Refresh.
7. In Breakdown, choose the NHS Number
from Demographics, all of the options in
Goals and the Registered Practice ID in
Registration. Now click on Refresh.
9. Now produce a spreadsheet by clicking the
spreadsheet (CSV) icon.
SystmOne Diabetes YOC Guide © V3.2 April 2012