Asthma
Keep a register of patients
Diagnosed after 1st April 2006 need PEFR or Spirometry
Aged 14 – 19 and smoking status recorded
Annual review and patients must answer  if night symptoms, day symptoms and exercise related problems
Atrial Fibrillation
Keep a register of patients
Patient needs CHA2DS2-VASc in the last 12 months
Patients with  CHA2DS2-VASc  > 2 need anticoagulant
Cancer Care
Keep a register of patients
Cancer care review within 6 months of diagnosis
Chronic Kidney Disease
Keep a register of patients (over the age of 18 with CKD 3-5
COPD
Keep a register of patients
Spirometry with reversibility between 3 months before diagnosis and 1 year after diagnosis
FEV1 recorded
COPD annual review
MRC dyspnoea score
Exacerbating history
Lung function
Inhaler technique check
MRC score > 3 need O2 saturation recording
Influenza vaccination between 1st August – 31st March
Coronary Heart Disease
Keep a register of patients
BP reading < 150/90
Influenza vaccination between 1st August – 31st March
Patient needs to be taking either Aspirin / Clopidogrel or anticoagulant
Cytology
25 – 64 years of age and has had a cervical smear
Protocol in place for the management of screening (including training, recall and exception reporting)
Protocol for audit of screening and audit of inadequate samples every 2 years
Dementia
Register of patients
Face to face review of care plan
New patients have FBC UE, LFT, TFT, Gluc, B12, Folate, Calcium 12 month before or 6 months after diagnosis
Depression
Patients aged 18 or over with a new diagnosis have a review by a GP within 10 and 56 days of diagnosis
Diabetes
Keep a register of patients (over the age of 17)
Last IFCC < 59
Last IFCC <64
Last IFCC <75
Foot examination and risk classification
Last BP < 150/90
Last BP <140/80
ACEi or ARB if microalbuminuria or proteinuria
Last cholesterol < 5
Influenza vaccination between 1st August – 31st March
Referred to structured education programme within 9 months of entering register
Epilepsy
Register of patients
Hypertension
Register of patients
BP reading < 150/90
Heart Faliure
Register of patients
Needs ECHO confirmed diagnosis or coronary angio
ACEi or ARB
B Blocker (Must be bisoprolol, carvedilol or nebivolol)
Learning Disability
Register of patients
Mental Health
Register of patients with
Schizophrenia, psychoses, bipolar disorder or prescribed lithium
Needs personal health plan
Alcohol consumption
BP check
Smear (if eligible female)
Lithium check in therapeutic range
Creatinine and TSH check if on lithium
Obesity
Register of patients aged over 18 with BMI > 30
Osteoporosis
Keep a register of patients –
Age 50-74 with fragility fracture and DEXA confirmed osteoporosis
Age >75 with fragility fracture
Patients in 1) receiving treatment
Patients in 2) receiving treatment
Palliative Care
Keep a register of patients
Review patients on the palliative care register at least every 3 months
Peripheral Vascular Disease
Keep a register of patients
Patient needs to be taking either Aspirin / Clopidogrel or OTC aspirin
BP reading < 150/90
Public Health
Aged > 45 with BP recorded in the last 5 years
Aged 30-75 with CVD risk >20% on statin
Rheumatoid Arthritis
Keep a register of patients (over the age of 16)
Annual face to face review
Sexual Health
Register of women prescribed contraception
Patients given emergency contraception are given information on LARC within 1 month of the prescription
Smoking
Smoking status for anyone with
CHD / DM / CVA / BP / COPD / Asthma / Psychosis / PVD / CKD
Offer support and treatment
Smoking cessation advice
Support with literature and appropriate therapy
Sroke / Transient Ischemic Attack
Keep a register of patients
Diagnosed after 1st April 2014 and referral for investigations between 3/12 before and 1/12 after episode
BP reading < 150/90
TIA or non bleed CVA on antiplatelet or anticoagulant
Influenza vaccination between 1st August – 31st March
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