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You are here: Home / Resources / SystmOne Resource Centre / SystmOne Specialties / Learning Disabilities

Learning Disabilities

Accessing CDRC resources on SystmOne

To access the below resources you will need to be a member of the DCS group on SystmOne. To do this, please follow the instructions on the CDRC SystmOne Access webpage.

CDRC SystmOne resources to support the care of patients with Learning Disabilities

Reports

Learning Disability Quality Improvement Reports

CDRC’s Case Finding reports can be useful to help validate your Learning Disability (LD) register.

These reports are located in the folder CDRC Quality > Learning Disability

? LD 1M Case Findin -Newl Included on OOF Code Lists after 2020 # 
? LD 1 a Case Finding - Removed from OOF Code Lists after 2020 # 
? LD 1 3 Case Finding- Code that might indicate 
? LD 1 Case Finding - Code that might indicate LD (excludes autism) #
Report NameReturns
? LD 1.1 Case Finding – Newly included on QoF Code Lists after 2020 # Patients that were added to the register in 2020 when the code list was updated 
? LD 1.2 Case Finding – Removed from QoF Code Lists after 2020 # Patients that were removed from the register in 2020 when the code list was updated 
? LD 1.3 Case Finding – Code that might indicate LD #Patients with a code that might suggest LD who are not on the LD register 
? LD 1.4 Case Finding – Code that might indicate LD (excludes autism) #As for 1.3 but not including autism 

CDRC’s Health Check reports will identify patients who have had/ not had their annual review health check.

The reports to identify patients who have yet to have a check or opt out are subdivided into reports of those likely to be at ‘higher risk’.  The criteria for higher risk are: 

  • Not had a health check for 2 years 
  • BMI <19 or >40 
  • More than one non-LD long term condition 
  • On antidepressants, antipsychotics, anxiolytics, gabapentinoids, hypnotics, lithium, opioids 
  • On medication where appropriate monitoring is significantly overdue
  • Has a LTC with features of concern
  • Has a PEG or history of aspiration pneumonia 
National PSC MedSIP Programme

The below searches have been developed to support the current Medicines Safety Improvement Programme (MedSIP) relating to “Helping people with a learning disability, at risk of behaviour that challenges, to avoid harm from psychotropic medicines.” however they are freely available to use by anyone.

These resources have been developed in collaboration with Health Innovation East Midlands, Health Innovation West Midlands and NHS England Medicines Safety Improvement team. The reports will identify people with a learning disability (without an SMI) on an antipsychotic within the relevant date parameters

Long-term Antipsychotic Prescribing Metric – One off Retrospective Search

Retropsective Data Point Reports have been developed which allow you to view trends of antipsychotic prescribing in your LD (without SMI) patients over the previous 2 years (June 2023 – June 2025).

These reports only need to be ran once and reported back to your local MedSIP Programme lead.

The SystmOne Retrospective Reports SOP can be found below:

MedSIP SystmOne Retrospective Reports SOP V1

Long-term Antipsychotic Prescribing Metric – Monthly Searches & Oral Risperidone Equivalent Analysis Tool

The following two reports need to be ran on a monthly basis from July 2025 onwards:

  • ? LD 4.1 – LD (without SMI)
  • ? LD 4.11 – Issued antipsychotics last month AND prior 3 months (without SMI)

They are located in the CDRC Quality > Learning Disability folder:

In addition to running these two reports; you will also need to use the pre-defined data output “MedSIP Antipsychotic Output” to extract data from SystmOne and save it into the MedSIP Oral Risperidone Equivalence Tool V2 to report on the total Oral Risperidone Equivalence.

The following SOP will explain how to use the pre-defined data output to extract the required data into the MedSIP Oral Risperidone Equivalence Tool V2:

MedSIP SystmOne Antipsychotic Prescribing Monthly Search and ORE Analysis Tool SOP V2

The below .zip contains the contents of the MedSIP Oral Risperidone Equivalence Tool V2:

MedSIP Oral Risperidone Equivalence Tool V2Download

For SystmOne users who are not a member of the DCS Organisation Group you will need to develop the pre-defined data output in your own system. The following SOP and video demonstration will explain how to develop this data output in SystmOne:

MedSIP SystmOne Report Output for the ORE Analysis Tool SOP V1

Video Demonstration on how to create the data output, MedSIP Antipsychotic Output, on SystmOne:

Templates

Learning Disability CDRC Template

How to Access

With the Patient record retrieved, in the lower left hand corner there is a search bar, type in ‘Learning Disabilities CDRC’ and select the following template:

Alternatively, press F12 and type in ‘Learning Disabilities CDRC’ in the search bar, this will return the aforementioned template.

Learning Disability Template

The Learning Disability template is split into two main parts: 

  1. A section where current information about the patient can be viewed and updated – below 
  2. A section to facilitate a structured annual review in line with the LD Annual Review as set out in the DES national specification 

The LD health check has been completely updated to integrate with other DCS care planning modules such as dementia, palliative care, avoiding unplanned admission etc. 

The Learning Disability Home Page provides a quick overview of the patient’s LD diagnosis codes, the date of the last LD review and action plan.  There is a button to start the annual LD review.  A link has been left to the old review template for those practices who wish to stick to that. 

Learning Disability 
Diagnosi> and Grading 
LD Specific Syndrome Check 
Reasonable Adjustment 
D Annual Review - National Specification 
This patient is on the LD register 
18 May 2012 on learning disability register (SNOMED: 416075005) 
LD Grading - NOT GRADED 
Reasonable Adjustments 
LD Health Assessment 
08 Apr 201g 
Learning disabilities annual health assessment (XaL3Q) (SNOMED: 1 gg751 0000001 00) 
LD Health Action Plan

The Relationships Page is the same as all other care planning templates, providing details of relatives and carers and their details. 

Machine generated alternative text:
Guidan 
Relationships 
Is I AlAc 
rofessiona 
Current Carers 
Family Relationships 
lg May 2014 Next Of Kin 
Name 
Additional Information 
Other Important Contacts 
Record Relationship 
Only relatives who are 
next of kin will be 
included in the printed 
repot Ifyou want other 
contact details to appear 
on the printed care plan 
record them below 
Other Important Contacts 
Mrs Jo Bloggs 
Next Of Kin 
Power of Attorne 
Niece 
Consent to share information with third party 
07 Nov 2015 Consent gi en to share patient data with specified 3rd p 
Record consent to share medical information with specified individuals here: Include all the 
people who currently have an 'information sharel If consent has been removed, record this 
here also 
Info sharing 
Consent gi en to share medical information with Niece Jo 
Bloggs 
Sack 
Notes 
Consent given to share medical information with Niece 
Jo Bloggs 
Next

The Professionals Page is customised to provide greater prominence to relevant professionals such as psychiatrists, CPNs, social workers and care coordinators. 

The Psychiatry Professionals and Social Worker Details buttons open screens that display more detailed information about these professionals, including previous relationships. 

Machine generated alternative text:
Guidance Relationships Professionals 
Current Care Co-ordinator 
Current Specilaist Nurse 
MCA 
Action Plan 
Diagnosis 
Guidanc 
Optometrist 
Mrs See YouWell 
01 234534567 
Spectacle Street Optician 
Next 
07 Nov 2015 
Name 
Work Contact 
Description 
Record Relationship 
07 Nov 2015 
Name 
Work Contact 
Description 
Community Psychiatric N 
Psychiatrist 
Mr Hamish McDougal 
01 234567Bg 
Derwent Clinic 
Current Psychiatrist 
07 Nov 2015 
Name 
Telephone 
Description 
Dr Jones Evans 
01 234567Bgo 
Derwent Clinic 
Current Social Worker 
Record Care Co-ordinator 
Record Specialist Nurse 
Record Communty Psychiatric Nurse 
Record Psychiatrist 
Record Social Worker 
Sack 
Psychiatry Professionals Details 
Social Worker Details

The MCA Page is identical to other care planning templates allowing users to view and amend information about power of attorney, IMCAs, advanced directives etc. 

idance Relationships Professiona MCAI ction Plan Diagnosis Guidan 
I cel 
LPA Welfare 
r Has appointed person with personal welfare LPA (MCA 2005) 
Has apnt persn persnl welf LPA auth life sust decns MCA 2005 
Record Power of Attorney 
Alz Soc- Patient Information Sheet LPAs 
LPA applicabilitv- checklist 
Independent mental capacty advocate instructed 
Record Independent Mental Capacty Act Advocate 
Standard authorisation deprivation of liberty MCA 2005 given 
O Death after DOCS 
Advanced directive 
Advanced Decision to Refuse Rk- proforma for F 
Advanced Decision to Refuse Rk - checklist 
Click here to complete MCA 1 and 2 form about best interest decisions 
Decidina Riaht Guidance 
Power of Attorney (health) Correct Codes 
11 Jun 2015 Has appointed person with personal welfar„ 
Other Power of Attorney Codes 
Advocate Correct Codes 
21 Apr 2016 
Independent mental capacity advocate instructed (Xapgk) 
Other Advocacy Codes 
DOLS order Given 
21 Apr 2016 
Standard authorisation deprivation of liberty MCA 2005 given„ 
Other DOLS Information 
correct ADRT Codes 
21 May 2014 Has AORT (advance decision to refuse treatment) (MCA 2005) (XaYld) 
Notes 
see entry dec 2012 
Other ADRT Information 
New 'Mental Han

The Action Plan Page provides the ability to view and amend the current action plan and to record any other important information. 

Relationships 
Action Planning 
Guidance 
When will this be reviewed? 
Professionals 
MCA 
Action Plan I 
LD Other important information 
Heath NeedGoaI/Action Planning 
New 'Care Plan' Word letter from this organisation 
Recent Care Plans 
02 Nov 2016 Care Plan to Miss Golden 
ACTON PLAN 
LD heath action plan completed 
LD heath action plan declined 
Sack 
Diagnosis Guidanc 
Other Important Information 
Health Need/Goal/Action Planning 
07 Nov 201520 03 
Entered by 
Heatth Need 1 
FORBES: Gareth (Dr) (General Medical Practitioner) 
Describe the health need 
When last reviewed? 
Goal 
Action 
Who helps? 
When will it be reviewed? 
Heatth Need 2 
Describe the health need 
When last reviewed? 
Goal 
Action 
Who helps 
Stop smoking 
December 2015 
Cut down to less than 5 cigarettes per day by March 201 7 
Only buy one packet of cigarettes per week 
Dad 
March 2017 
Lose weight 
December 2015 
Lose 4 pounds 
Walk to the shop every day to buy a newspaper 
Your dad and the shopkeeper 
December 2016

If the panels on the right are blank, click on the relevant button on the left to start a new action plan or ‘other important information’ 

If the panels already contain information that you wish to amend or update, right click anywhere in that panel, choose Copy Questionnaire, then choose Copy Comments.  

Complete the questionnaire then click Save Final Version when completed.  You can record up to 8 different health needs. 

for future Édt!ing 
- Heath Need I 
- Heath Need 2 
3 - Heath Need 3 
- Heath Need 4 
S - Heath Need S 
- Heath Need 6 
- Heath Need 7 
- Heath Need 8 
Save Final Version 
Cancel 
Health Need 1 
Describe the health need 
Stop smoking 
2 When last reviewed? 
December 2015 
Goal 
Cut down to less than 5 cigarettes per day by March 201 7 
4 Action 
Only buy one packet of cigarettes per week 
5 Who helps? 
Dad 
6 When will it be reviewed? 
March 2017 
Next Section

To create a paper document to give or email to the patient, click 

L? New 'Care Plan' Word letter from this organisation

Then choose Write Now. A prepopulated Action Plan will be created.  An example action plan can be found here LD Action Plan 

Previous Action Plans can be viewed from the Communications and Letters Node or by right clicking on the Recent Care Plans panel and choosing View Content.  

Recent Care Plans 
02 Nov 201 6 Care Plan to Miss Golden 
View Details 
View Content 
Letter Sent 
A end Content 
Describe tr 
When I st 
ACTON PLAN 
LD heath action plan completed 
LD heath action plan declined 
Amend Details 
Expon 
Send via NHSmaiI 
prnt 
Link to Appointment 
Amend Notes

The Diagnosis Page shows the definition of learning disability.  There is a LD Register inclusion checklist with a panel to show the last time this was completed.  The <–Expand button can be used to show the full details of the most recently completed checklist. 

Guidance Relationships 
Diagnosis 
Professionals 
MCA Action Plan 
Diagnosis 
Guidance 
Resources and Links 
Learning disability is defined in Valuing People (and The Same as You) as the presence of: 
A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence) 
AND - a reduced ability to cope independently (impaired social/adaptive functioning) 
AND - which started before adulthood (1 8 years), with a lasting effect on development 
The definition encompasses people with a broad range of disabilities It includes adult with autism who also have learning disabilities, but not people with a higher level 
autistic spectrum disorder who may be of average or above average intelligenc4 The presence of an Intelligence Quotient below 70, should not in isolation, be used in 
deciding whether someone has a learning disabilit/ 
The definition does not include all those people who have a 'learning difficulty' 
Factors which MAY indicate no learning disability 
• Normal development until other factors impact (before 1 8) 
• Diagnosis of ADHD, dyslexia, dyspraxia or Asperger's 
• Successfully attended a mainstream education facility without support 
• Gained qualifications (GCSE and/or A Levels) 
• Able to function socially without support 
• Independently manage their financial commitments 
• Able to drive a car 
• Contact with mental health services 
• Recorded IQ above 70 
• Communication difficulties due to English as a second language 
Factors which MAY indicate learning disability 
• Record of delayed development/diffculties with social functioning & daily living 
before the age of 13 
• Requires significant assistance to undertake activities of daily living (eating & 
drinking, attending to personal hygiene, wears appropriate clothing) and/or with 
social/ community adaptation Social problem solving/reasoning) 
NS need for assistance may be subt14 
• Presence of all three criteria for LD Impairment of intellectual functioning/social 
adaptive functioning and age of onset 
• Range of information presenting a picture of difficulties in a number of areas of 
function, not explainable by another 'label' 
• Contact with specialist Learning Disability consultant 
• Attendance at specialist education facility for people with intellectual delay 
0 
LD Register Inclusion Tool Checklist 
Learning Disability LD Register Inclusion Tool 
17 Oct 2020 05:40 
<--Expand 
Entered by 
FORBES, Gareth (Dr) (General Medical Practitioner) 
Learning Disability Register - Inclusion Tool 
Learning Disabilty codes 
On learning disabilty register
8 
I - Learning Disabilty Register - Inclusion Tool 
Learning Disability Register - Inclusion Tool 
- Does the person have difficuties wth: 
This is a checklist for GPs to assist them in identifying a person with a learning disability 
• This is not a diagnostic tool so always apply sound clinical judgement 
• The aim of this tool is to identify' people who would benefit from being on the GP practice's 
Learning Disability register 
• Inclusion on the register does not mean that the person will automatically be eligible for 
specialised learning disability services - that decision is based on needs 
Did person attend any special schools or were they statemented in mainstream school? 
Do they have an educational health care plan 
@ Yes 
O No 
O Not known 
Is there a diagnosis of a learning disability/mental handicap in any notes? IQ under 70 
(please refer to read code list of definite and potential diagnosis of a learning disability) 
O Yes 
@ No 
O Not known 
Is the person known to the Learning Disability Service? 
@ Yes 
O No 
O Not known 
Is the person under the care of a consultant psychiatrist for learning disabilities? 
O Yes

Learning Disability Annual Review CDRC Template

How to Access

With the Patient record retrieved, in the lower left hand corner there is a search bar, type in ‘Learning Disability Annual Review CDRC’ and select the following template:

Alternatively, press F12 and type in ‘Learning Disability Annual Review CDRC’ in the search bar, this will return the aforementioned template.

Learning Disabilities Annual Review

The Learning Disability Annual Review part of the template facilitates a structured annual review.

The Core Data Page allows recording of key measurements and lifestyle advice 

Core Data 
Pulse 
Pulse Rhythm 
Weight 
Height 
SocialjPaeds Rels Profs 
Routine Care 
Kg 
Screening Tests O 
blems Summary Meds Health Exam Action Plan 
DCS BP (latest with monitoring requirements view has no data for patient A 
Height 
Waist circumference 
Kg (10 08 Apr 201g 
1 65 m (5 
08 Apr 201 g 
2411 Kg/ma 
08 Apr 201g 
No numeric rex 
Waist circumference 
Advice given about weight management 
Dietary advice 
Refer to weight manageny 
Exercise 
Brief intervention for physical activty completed 
7 sep 2017 
7 sep 2017 
7 sep 2017 
08 Apr 201 g 
1 oct201g 
Alcohol intake 
Dietary advice (8CA4J (SNOMED: 1 1 81 6003) 
Advice given about weight management [XaX5F) (SNOM 
Brief intervention for physical activity completed (XaPjx) ( 
Enjoys moderate exercise (1 384) (SNOMEO: 1 6063200 
Never smoked tobacco (XEOoh) (SNOMED: 266g1 g005) 
Refer to exercise progrm 
Smoking Status 
Smoking cess readiness 
Smoking cessation advice 
Smoking Referral 
Record Teetotal 
Alcohol intake 
Alcohol Intervention 
Alcohol Referral 
Lifestyle Programme 
18 unitsmeek 
Record AUDIT Score 
LlntsMV 
02 Mar 2020 
08 Apr 201 g 
Alcohol use disorder identificatn test conn 3 
Audit Full Screen - not recorded 
02 Mar 2020 
Brief intervention for excessive alcohol consumptn comm 
No Healthy Lifestyle Programme Information Recorded 
ap Detailed 
Weight Detail 
Exercise Det 
Smoking Det 
Alcohol Detai 
Lifestyle Pru

The Social/Paeds Page allows viewing, recording and editing of key social information such as accommodation, carers, employment and schooling. 

Core Data SocialjPaeds Rels 
Social 
ChangeMew Housing Details 
profs 
Routine Care 
Screening 
Tests 
Overview 
History Seworugs Problems Summary Meds 
Other household members not recorded 
Not recorded as housebound 
Health Exam 
Action Plan 
08 Apr 201g Lives in own home (1 (SNOMED: 160g43002) 
Notes 
With parents 
Has a Carer - View/Amend Details 
Is a Carer - View/Amend Details 
Employment - View/Amend Details 
Record School 
birth to 25 education, heath and care plan 
Paediatrics Team Details 
NO clear record of having a carer 
Not recorded as a carer of others 
OSA 
201g 
Occupation 
08 Apr 201g 
Notes 
Pan-time employment (1308) (SNOMED: 1 aog04001) 
occupation history rxalev) (SNOMED: sg4704008) 
Princes trust 
DCS Paediatrician InvoVement view has no 
St Bede's Catholic Comprehensive School And Sixth Form College, Lanc 
Consett Road 
Lanchester 
Durham OH,' ORO 
started: lg sep 2012

The Relationships Page allows recording of key family and friend relationships. 

Core Data SocialjPaeds 
Record Relationshg 
Emergency contact details 
Reis 
profs 
Routine Care Screening Tests 
Family Relationships 
Date of Birth 
Overview 
History 
Seworugs 
Problems 
Mother 
Summary 
Meds 
Health Exam 
Action Plan 
og Apr 1 gag 
No emergency contact details recorded

The Professionals Page is customised to provide greater prominence to relevant professionals such as psychiatrists, CPNs, social workers and care coordinators. 

The Psychiatry Professionals and Social Worker Details buttons open screens that display more detailed information about these professionals, including previous relationships. 

Machine generated alternative text:
Guidance Relationships Professionals 
Current Care Co-ordinator 
Current Specilaist Nurse 
MCA 
Action Plan 
Diagnosis 
Guidanc 
Optometrist 
Mrs See YouWell 
01 234534567 
Spectacle Street Optician 
Next 
07 Nov 2015 
Name 
Work Contact 
Description 
Record Relationship 
07 Nov 2015 
Name 
Work Contact 
Description 
Community Psychiatric N 
Psychiatrist 
Mr Hamish McDougal 
01 234567Bg 
Derwent Clinic 
Current Psychiatrist 
07 Nov 2015 
Name 
Telephone 
Description 
Dr Jones Evans 
01 234567Bgo 
Derwent Clinic 
Current Social Worker 
Record Care Co-ordinator 
Record Specialist Nurse 
Record Communty Psychiatric Nurse 
Record Psychiatrist 
Record Social Worker 
Sack 
Psychiatry Professionals Details 
Social Worker Details

The Routine Care Page allows recording of information about dental and optometrist care, communication requirements, functional skills such as ADLs and recommended vaccinations. 

Core Data SocialjPaeds 
Not registered wth a dentist 
Registered wth dentist 
Last seen by dentist 
Record Dentist 
Not able to access optometrist 
Under care of optometrist 
Last seen by optician 
Record Optometrist 
Reis 
profs 
Routine Care 
Screening 
Tests 
Overview History Seworugs 
Problems 
Summary Meds 
Dentist 
Health Exam 
Action Plan 
Current Dentist 
08 Apr 201g 
Organisation 
Description 
Stanley Health Centre 
Stanley Health Centre 
Current Optician 
No clear record of any specific communication needs 
Communication Requirements 
Functional Skills 
Vaccination Details 
Consider Hepatitis 8 Vaccination in patients in shared accommodation 
or those who use day centres or schools for severe learning disability 
More detailed information 
08 Apr 201g 
08 201g 
08 201g 
01 oct201g 
No speech problem (1 agl (SNOMEO: 1 622g3002) 
Hearing normal (1 Cl 1 J (SNOMEO: 1 6233g002) 
Impaired vision 61_) (SNOMEO: ag7540003) 
Normal vision (668k) (SNOMED: 4508g002) 
Consider the Following Vaccines 
No record of any Hep B vaccination

The Screening Page shows relevant information for key screening programmes 

Core Data SocialjPaeds Rels Profs 
Heath education - breast examination 
Breast screening is offered 
Every 3 years from 50 to 70 
Mammography offered 
Breast Screening 
Cervical screening is offered 
25-4g every 3 years 
50-64 every 5 years 
Routine Care 
Screening 
Tests 
Overview History Seworugs Problems Summary 
Last Breast Screening Result 
Breast Cancer Screening Exceptions 
Not Applicable 
Latest Bowel Screening Information 
Meds 
Health Exam 
Action Plan 
-65 if not done since 50 or recently abnormal 
Cervical screening verbal invitation 
Cervical Cancer Screening 2m 
Bowel screening is offerel 
One off sigmoidoscopy at 50 
Then FOB testing every 2 years from 60 to 74 
screening programme 
acsp Dcs 
Diabetes UK score Dcs 
Detailed CVD Risk Information 
Consider fracture risk assessment 
Estimated Diabetes UK Score is low OR assessed recently 
Haemoglobin Alc level- IFCC numeric 
Under 25 - screening not normally indicated 
QRlSK2 cardiovascular disease 1 Oy No numeric rm 
DCS Fracture Risk Assessment Overview view has no data for patient A

The Tests Page shows any tests that might be indicated based on current medication, long term conditions, recent results and screening recommendations. 

Tests to Consider 
DCS Tests To Consider view has no data for patient

The information in the sections above could largely be obtained by administration staff and/or health care assistants.  Subsequent information is likely to need more experienced clinical input. 

The Overview Page displays some key information 

LEARNING DISABILITY REVIEW 
n sis and Grading 
LD Specific Syndrome Check 
Change SCR Consent 
ChangeMew 3rd Party Consent 
LD Consent to Share 'Mh Screening Services 
MCADOLSAMCA etc 
Safeguarding Children 
Safeguarding Aduts 
This patient is on the LD register 
18 May 2012 on learning disability register (SNOMED: 416075005) 
LD Grading - NOT GRADED 
SCR Core data is shared (implied consent) 
SCR Additonal data not shared - no record of SCR preference 
2g Apr 2020 
Consent given to share patient data with specified 3rd party IXaNwR) (SNOMED: 31 gg51 00m A 
LD - LD Screening Services Sharing Consent view has no data for patient 
There is no clear record of an appointed 'MCA 
There is no clear record that affairs are under court jurisdiction 
Not currently recorded as subject to a DOLS order 
No clear information about advanced decision recorded 
Safeguarding Summary 
No clear information to suggest there is current cause for concern

The History Page prompts the user to record a structured history using a questionnaire that expands to request more details automatically, if any issues are raised.  Click Save Final Version once completed.   

The most recent results of this history are displayed on the right hand panel. 

ome 
Relatives 
Professionals 
Dentisuoptician 
History 
roblems Summary Meds Sex Health Exam MCA Screening Action Plan Guidance Resources 
LD Health Check History 
Entered by 
04 Jan 2017 20 03 
FORBES: Gareth (Dr) (General Medical Practitioner) 
LD Heath Check History 
Cardiovascular and respiratory 
Is there any breathlessness? 
Is there a significant problem with 
coughing? 
Any additional information about 
coughing 
Is there any problem with sputum 
production or haemoptysis? 
Is there any chest pain? 
Are there any palpitations 
Nutrition and gastro 
Are there any feeding problems? 
Is there any dyspepsia? 
Is there any dysphagia? 
Is there abdominal pain? 
Is there any diarrhoea? 
Is there any constipation? 
Additional constipation information 
Yes 
cough for 4 weeks 
Yes 
Yes 
Has been struggling for months
Cardiovascular and respiratory 
- Nutrtion and gastro 
Gentiour inar y 
Neur o 
Cardiovascular and respiratory 
11 
Is there any breathlessness? 
@ yes 
Severity of breathlessness 
r Breathlessness on strenuous exertion 
r Breathlessness on moderate exertion 
r Breathlessness on mild exertion 
Shon of breath dressing 
Any additional information about breathlessness 
Is there a significant problem with coughing? 
Yes 
Is there any problem with sputum production or haemoptysis? 
Yes 
Is there any chest pain? 
Yes 
Are there any palpitations 
Yes 
Next Section

The Sex/Drugs Page allows recording of relevant information 

Sex 
Heath education - testicular examination 
Sexually active 
Currently not sexually active 
Never sexually active 
Heath education - sexual heath 
General contraceptive advice 
Advice about risks of unprotected sex 
At risk of sexual abuse 
At risk of sexual exploitation 
Not currently trying to conceive 
Trying to conceive 
Drugs 
Has never misused drugs 
Misused drugs in past 
Misuses drugs 
Lifestyle advice regarding drug misuse 
Most Recent Sexual Activity Information 
Most Recent AcMce 
Latest Pills 
Latest Implants and Depot 
Latest Coils 
Latest Emergency Contraception 
Conception Planning 
Drug Misuse

The Problem or Summary Pages (depending on practice preference) display the most recent problem lists which can be amended or updated by right clicking on the various entries. 

ome Relatives Professionals Dentisuoptician 
Active Problems 
q Asthma (833m) 
Adverse reaction to penicillins UJOO) 
q Type Il diabetes mellitus CX40J5) 
peanut allergy (Xal no) 
Epilepsy (F 25„) 
q Depressive disorder OXOOSO) 
q Patient currently pregnant (621 
Scheduled to End 
Inactive Major Problems 
Myocardial infarction CX200E) 
Tonsillectomy (7530) 
History 
Problems 
05 Jan 2018 
Summary 
Meds 
Sex Health Exam MCA Screening Action Plan 
05 Nov 2005 
Ongoing 
2g Dec 2005 
Ongoing 
01 Feb 2006 
Ongoing 
16 Mar 2006 
Ongoing 
og Jul 2013 
Ongoing 
og Jul 2013 
Ongoing 
11 May 2016 
05 Jan 2018 
05 Jun 2013 
05 Jul 2013 
og sep 2014- 
og sep 2014 
Guidance 
Resource

The Meds Page shows current medication 

ome Relatives Professionals 
Current Repeats 
Metformin 850mg tablets 
Codeine 30mg tablets 
One dose to b. 1 pre-filled dis 
Dentisuoptician 
Senna Z5mg/5ml oral solution sugar free 
History 
Problems 
Summary Meds I Sek 
Health Exam MCA Screening 
take one twice tablet 
take one 4 tinm 
28 tablet 
2x5ml spoon 
Action Plan 
Guidance 
Resource 
17 Mar 2015 
20 Jan 2016 
20 Jan 2016 
Never 
Exenatide 5micrograms/ff02ml solution for injection 1 
Recent Acutes 
Latest Medication 
10 Feb 2015 Medication review done (XaF8d) 
Medication review done 
2ml pre-filled dis

The Health Exam Page facilitates a structured examination based on the Cardiff model. 

Examination 
GENERAL 
O'E - colour pale 
C) Lymphadenopathy absent (X 
Lymph Nodes 
Clubbing 
Jaundice 
C) O'E - lymphadenopathy (2C3 
o 
No finger clubbing (XaQwh) ( 
C) O'E - hands - finger clubbing 
o 
No jaundice ('13292) 
C) O'E - jaundiced colour 
ABDOMEN 
Abdo mass 
Liver 
Spleen 
o 
O'E - abl mass not palpated 
C) O'E - abdominal mass palpate„ 
C) O'E - liver not palpable (2SGI 
C) O'E - liver palpated 
C) O'E - spleen not palpable (2C 
C) splenomegaly (2CS„) ( 
CARDIOVASCULAR 
Oedema 
Head Sounds 
oedema not present (22 
C) OE oedema (XE1h6) (SNO 
C) O'E - head sounds normal (2 
o 
Hean sounds abnormal (Xa7 
Rectal (consider) 
Scrotal (consider) 
rectal examination - NAD (2SQI J (SBC 
O - PR - rectal mass (2503) (SNOMED: 1 
O - PR-rectum full of faeces (2506) (SNO 
C) On rectal examination of prostate no abnor 
O 
OYE - PR - prostatic swelling (XE2rJ) (SNOM 
C) O'E - PR - prostate tender (XaCJd) (SNOMä 
O - testicles normal (2656) (SNOMED: 16 
C) On examination testes abnormal (XaP6s) (S 
RESPIRATORY 
Cyanosis 
Tachypnoea 
Breath Sounds 
Vvheeze 
cyanosis not present ( 
cyanosis (XaY81) (SNO 
C) O'E - tachypnoea (2353) (S 
C) O'E - breath sounds normal ( 
C) 
O'E - breath sounds abnormm„ 
C) Vvheeze absent (XaCHg) (SBC 
C) O'E - expiratory wheeze (23 
SKIN 
BREAST 
Breast 
OTHER 
o 
Skin assessment (Clal SCI) (S 
o 
O'E - no breast lump palpable 
C) O'E - breast lump palpated (X 
C) O'E - nipple normal (26CI J ( 
C) O'E - retraction of nipple (26 
Any other examination findings

The Action Plan Page provides the ability to view and amend the current action plan and to record any other important information. 

Action Planning 
Reasonable Adjustment 
Complete Action Plan Information 
Preview and print care plan 
Recent Care Plans 
ACTON PLAN 
LD heath action plan completed 
LD heath action plan declined 
'Learning disabilities annual heath assessment 
LD annual heath assessment declined 
Reasonable Adjustments 
DCS Health need/action/goal planning (includ TPP) view has no data for patient

If the panels on the right are blank, click on the relevant button on the left to start a new action plan or ‘other important information’ 

If the panels already contain information that you wish to amend or update, right click anywhere in that panel, choose Copy Questionnaire, then choose Copy Comments.  

Complete the questionnaire then click Save Final Version when completed.  You can record up to 8 different health needs. 

for future Édt!ing 
- Heath Need I 
- Heath Need 2 
3 - Heath Need 3 
- Heath Need 4 
S - Heath Need S 
- Heath Need 6 
- Heath Need 7 
- Heath Need 8 
Save Final Version 
Cancel 
Health Need 1 
Describe the health need 
Stop smoking 
2 When last reviewed? 
December 2015 
Goal 
Cut down to less than 5 cigarettes per day by March 201 7 
4 Action 
Only buy one packet of cigarettes per week 
5 Who helps? 
Dad 
6 When will it be reviewed? 
March 2017 
Next Section

To create a paper document to give or email to the patient, click 

L? New 'Care Plan' Word letter from this organisation

Then choose Write Now. A prepopulated Action Plan will be created.  An example action plan can be found here LD Action Plan 

Previous Action Plans can be viewed from the Communications and Letters Node or by right clicking on the Recent Care Plans panel and choosing View Content.  

Recent Care Plans 
02 Nov 201 6 Care Plan to Miss Golden 
View Details 
View Content 
Letter Sent 
A end Content 
Describe tr 
When I st 
ACTON PLAN 
LD heath action plan completed 
LD heath action plan declined 
Amend Details 
Expon 
Send via NHSmaiI 
prnt 
Link to Appointment 
Amend Notes

Additional Resources

Learning Disability Action Plan

The LD Action Plan, prepopulates information from the LD template.  The plan can then be further customised in the grey boxes (or anywhere else) 

Machine generated alternative text:
GP Surgery 
My Health Plan 
My name is Miss Golden Phoenix Patient- 
TestPatient 
I live at 
1 Troy Road 
Horsforth 
eeds 
est Yorkshire 
SIB 5TN 
y Telephone number 07918 91 1181 
7918 911181 
he person to talk to in an emergency about 
rs Jo Bloggs Niece 
r Hamish McDougal Community Psychiatric 
urse 0123456789 
My GP is Dr. Gareth Forbes 
Leadgate Surgery, 
Watling Street, 
Leadgate, 
Consett DH8 6DP 01207 583555
Machine generated alternative text:
What I do that affects my health 
Smoking 
The most recent information about this is. 
I would like to reduce my smoking: Yes 
Alcohol 
No 
How much do I drink every week? 0 Units/Week 
More than 14 units a week is likely to be bad for 
my health 
I would like to reduce my drinking: Yes 
Healthy diet 
My weight is 68 Kg 
I eat healthy food: Yes 
I would like to eat more healthy food: 
Yes 
No 
Exercise 
I would like to do more exercise 
n Non 
Yes
My dentist is: 
Name 
OUT, Ripem (Mr) 
My optician is: 
Name 
Address Telephone 
Address Telephone 
YOUWELL, See (Mrs) 
Other things I would like to talk about. 
My last health checks were: 
04 Jan 
2017 
Learning disabilities 
annual health assessment 
Dr Gareth 
Forbes 
My next health check will be:

Quality Improvement

The following resources will help with quality improvement related to care of patients with a learning disability 

RCGP Toolkit – https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/health-check-toolkit.aspx 

2020 QoF QI Template Download
QOF-audit-templateDownload

NHS Tool for quality checking LD Health Checks: 

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/647512/Auditing_health_checks_tool_for_people_with_learning_disabilities.pdf

The following searches can be used to complete the information needed in the documents above 

LD Audit la/b - LD alla es 
LO Audit lc- LD -1 4} 
LD Audit 3a- LD -1 4y- AHC done in last year 
LD Audit 3b - LD -1 4y- AHC declined in last year 
LD Audit 3b(i) - LD -1 4} - AHC not done nor declined in last year 
LD Audit 3i- LD -1 4y- Care plan done in last year 
LD Audit 3i(i) - LD -1 4y- Care plan declined in last year 
LD Audit 3i(ii) - LD -1 4y- Care plan not done nor declined in last year 
LD Audit 4a Proportion of population in SAME category 
LD Audit 4b Proportion of LD population in SAME category 
LO Audit 5 - LO and ONACPR 
LD Audit 6M LD and Influenza vaccination last financial year 
LD Audit 61 LD and Influenza vaccination this year

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