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Mr New has just moved into the area covered by Dr Smith’s practice and on the advice of some local work colleagues has decided to use Dr Smith as his GP for the five year period he believes he will be working in this location before being promoted and re-located elsewhere. As he has had a cold for the last few days which has now ‘gone to his chest’ and is associated with a quite painful cough he decides to ring for an appointment for later that day.

Dr Smith’s receptionist takes the call, notes that Mr New is a new, long term patient, and allocates a 30 minute appointment slot for later that day. [A] The receptionist also takes the opportunity to gather the basic demographic data needed by the practice computer system to register Mr New as a patient of the practice. [B]

Mr New later arrives at the practice, and, while waiting to see the doctor, is able to complete his registration details with the receptionist, and also work through an interactive questionnaire that captures much of his basic historic medical data which can be reviewed and verified during the consultation. [C]

Mr New is soon in to see Dr Smith, and explains that that pressing problem is the chest cold and that he feels some treatment is required. Dr Smith then proceeds to record, and code, the reason for this encounter as chest cold which is then stored in the patient record. After a full examination, while confirming and refining the information gathered with the electronic questionnaire, Dr Smith concludes the only significant acute problem is the chest infection, but also notes that Mr New’s blood pressure is marginally elevated for a patient under 40 (145/90) and resolves to set up regular surveillance on this by scheduling six monthly BP checks and encouraging Mr New to try to get a some regular exercise, lose a little weight and try to reduce the amount of added salt in his diet. [D] Dr Smith has a patient education brochure on borderline high blood pressure and, after adding a few comments of his own, prints this out for Mr New to take with him. [E] Dr Smith is able to quickly and easily record the findings of the history and examination in the Electronic Health Record [F] and uses electronic images, stored on the computer, to record the examination findings. [G]

Mr New then asks should he have an antibiotic for his cold. Dr Smith opens the antibiotic prescribing guidelines and confirms that if a patient has purulent sputum that a course of Augmentin Forte is appropriate. He then moves to the prescribing module. In doing all these actions the system has kept Mr New as the current patient and his details are automatically used to populate the prescription form. [H] Dr Smith decides to prescribe Doxycycline, is shown that Mr New has no recorded allergy to this drug, confirms with the patient that this is the case and automatically selects the standard PBS pack size and strength for a single course in an adult male. [I]

Dr Smith asks Mr New where he would like the prescription filled, and Mr New says he has noticed a pharmacy close to his work so that one would be fine. Dr Smith then prints the prescription, signs it and sends an electronically signed copy to the pharmacist. [J] In the background the drug has been evaluated by Dr Smith’s computer system for potential interactions with Mr New’s other treatment and Mr New and his doctor have been shown the total cost of the treatment and how much Mr New would have to pay at the pharmacist.

Dr Smith concludes the consultation with creation of an invoice [K] which is given to Mr New by the receptionist and Mr New goes to the pharmacy to find his prescription ready and waiting for him to pay for and collect. [L]

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