G.P.Report.

Waiting for DLA Tribunal Date & woud also like to see the booklet.

Thanks
Kriss

will send a copy to the web site and see if they can post it, it covers 6 things and gives gps advice I could change the pdf to a text file and see how it posts

kriss wrote:

Waiting for DLA Tribunal Date & woud also like to see the booklet.

Thanks
Kriss

changed from PDF to TEXT


Advice to GPs completing
Disability Living Allowance
Factual Reports



Contents

General..................................................2
Specific.................................................2
GPFR examples for specific

condit............................................................3

1. Asthma / COPD / other respiratory

conditions.........................................................3
2. Ischaemic heart

disease..............................................................3
3. Musculoskeletal conditions such as arthritis / back pain

etc....................................4
4. Mental health

conditions................................................................5
5. Epilepsy or loss of

consciousness.......................................................................5
6. Childhood

problems......................................................................6









Advice to GPs completing DLA and AA
Factual Reports





General

1. Record relevant information only as this will help us and make it much easier for you.

2. Write down facts rather than opinion.

3. Remember your patient may have a copy of the report and read what you have
written.

4. Your report should be based upon your knowledge of the patient and the medical
records. It is not necessary to interview the patient, as any information they provide,
especially with regard to mobility and self care may not necessarily be objective.




Specific

1. Date you last saw the patient. If no recent contact with patient please include where and when seen by other health care professional if relevant in your report.

2. Diagnosis – relevant diagnoses only needed and it is helpful to number the
conditions if there are several.
3. Severity – mild, moderate or severe according to numbered conditions at 2. State also if well-controlled if appropriate, e.g. Diabetes.

4. Variability – this is helpful in very variable conditions, e.g. 3 courses of
prednisolone in last 12 months.

5. Examination findings – facts are very helpful, such as:

• Peak flow/spirometry in asthma or COPD

• Results of exercise test in angina (Bruce Protocol)

• Normal or abnormal joint movements, extent of any joint swelling/deformity.
• Summary of any relevant information in hospital letters


6. Medication – level of painkillers and inhalers very useful

7. Self-care – write what you know, e.g. rose unaided from a chair in the surgery, no bending difficulty noted, had an OT assessment recently.

8. Ability to get around – write fact not opinion. Good examples would be:

• Walks slowly with marked right-sided limp using walking stick

• Not breathless or very breathless when attends surgery for routine check
• Normal balance and gait on (date).


9. Conclusion – this section is not asking for an opinion but rather to add something
relevant, e.g. in severe depression has suicidal ideas or psychotic features. If there

is
treatment planned such as a hip replacement this is useful information here.





GPFR examples for specific conditions

1. Asthma / COPD / other respiratory conditions



• Diagnosis? Any other associated conditions?
• Severity? Whether mild moderate or severe?
• Symptoms: whether breathlessness at rest /mild exertion such as talking / or on
moderate exertion?
• Is he/she under hospital care? Details if possible
• Clinical findings such as:
Chest examination

PEFR: Expected

Most recent PEFR

Is there any variations from previous recordings?

Lowest recorded PEFR when? Etc.


• Spirometry results if available
• Treatment:
Inhalers Which inhalers

Are inhalers regularly requested? If not

When was the last script?

Nebulisers and or oxygen used at home?

Oral steroid courses in the last 6 to 12 months

Is there a history of hospitalisation for acute attack?


• Functional ability if known re: selfcare and mobility




2. Ischaemic heart disease



• Diagnosis and any other associated conditions?
• Severity whether it is mild / moderate or severe?
• Symptoms
Anginal attacks

How frequent?

When do they occur i.e. are they associated with mild, moderate or
severe exertion?

Does GTN help?

Shortness of breath

Is it present?

Is it on mild, moderate or severe exertion?

Is there any evidence of heart failure?


• Is he/she under hospital care?
• Is there any history of repeated attendance at A&E or inpatient admissions due to
chest pain?



• How was diagnosis of IHD made? Was it only clinical or on investigations? What
investigations? Results of the investigations such as ECG / ECHO / exercise test
(Bruce Protocol)


• Treatment
Medications / dose / frequency

Are prescriptions regularly ordered?

Are they effective?

Has he/she had any surgical treatment or any planned in future for IHD? If yes which
procedure?


• Functional ability re self care and mobility ( if known)




3. Musculoskeletal conditions such as arthritis / back pain etc



• Diagnosis: If arthritis type such as OA / rheumatoid etc
If back pain – is it mechanical or prolapsed disc, etc


• Symptoms and clinical findings that are recorded in GP records and or in hospital
letters

Important for us is:

For arthritis: Which joints affected?

Severity of affected joints?

Any deformity?

Any other clinical findings?

Exacerbations and flare ups / how often & how bad?

For backache: Pain / variability / duration of acute exacerbations and
severity

Is there any radiation of pain?

Is there any neurological deficit or muscle wasting?

Range of movements of spine / SLR


• Results of important investigations such as MRI scan
• Hospital treatment: any
Physio?

Occupational therapist? Any aids provided?

Back pain clinic attendance?

Counselling / clinical psychologist?

Neurologist or rheumatologist attendance?

Has any of above helped?


• Any planned future surgical treatment? Such as: is he/she waiting for hip or
knee replacement? If so when referred to hospital?
• Medications: What? Dose? Frequency? Are regular scripts ordered? Does
medications help pain etc?
• Is there any history of falls recorded? If yes any hospital attendance?
• Any aids used?
• Functional effects on self care and mobility (if known)







4. Mental health conditions



• Diagnosis
• How long these conditions present?
• Severity is it mild, moderate or severe?
• Day to day variations reported to GP or any other health professionals (if known)
• Any recorded history of suicidal thoughts / intent / attempts in the past? If yes

when?
How?
• Any self harm episodes?
• Is there or has there been any history of self neglect?
• Is he/she aware of dangers? Has he/she got an insight into his problems and
surroundings?
• Is there any confusional state or disorientation or lack of concentration / motivation
etc? Is he/she capable of self medicating? If no, why not?
• Is there any history of psychiatric hospitalisations? If yes were they voluntary or
compulsory under mental health acts?
• Is he/she under secondary care? Who? How often?
• Medications: type / dose / frequency /how administered / side effects / is it

effective
• Are regular scripts being ordered? If not when was the last prescription issued?
• Any other supervisory or attention related activity required or given that has been
recorded in GP records or hospital letters


• Any other problems — other than mental health?




5. Epilepsy or loss of consciousness



• Is there any history of fits or such symptoms?
• Diagnosis e.g. Grand Mal (major), petit mal / absence siezures / syncope etc
• How was the diagnosis made? Is it confirmed by EEG or on history alone?
• Is he/she under hospital care? Under which specialist? How often seen there? When
was he/she last seen?
• Is there any warning before the fit? Type and how long before it occurs?
• Frequency of fits as recorded in GP notes and/ or as per hospital letters
• Any injuries recorded after the fits? Any history of attendance at A&E post fits and
resultant falls?
• Any hospitalisation? Any history of status epilepticus?
• Treatment:
Medications which? Frequency? Any recent change in medication type or dose?

If yes any benefit in control? What?

Any future proposed changes in medications planned?


• Date of last fit as per GP records and / or hospital letters
• Any other associated other conditions e.g. mental health?







6. Childhood problems



It is very important to remember that when children’s claims are assessed it

is based on the facts that the need for attention and / or supervision should

be in excess of what one would normally expect in another child of similar age

without claimed medical conditions.



What we need to know most of the time is:

• Diagnosis
• If it is related to behavioural problems e.g. ADHD / autism / Aspergers syndrome /
learning difficulties etc then who made the diagnosis?
• Is he/she attending a specialist? Which? How often?
• Is he/she at a normal school or at a special needs school?
• Is he/she on medications? If yes then is it effective?
• Are there any reported behavioural problems? If yes give details
• Any injuries related to the conditions claimed?
• Any hospitalisations?
• Any other conditions such as incontinence (if dry before) / any known night time
medications such as creams etc
• Anything else you may consider useful which may be relevant to the claim?

Can I just point out that it makes life an awful lot easier for the mods if you simply post a link. We don't see any of the line or paragraph breaks and if you post it, we read it. That was a very long post to read through, word for word, without any breaks. I have deleted shorter posts before now for being too long. If you post more threads this length and I am the one that picks them up for moderation, I will delete them and invite you to post a link.

Survivor wrote:

Can I just point out that it makes life an awful lot easier for the mods if you simply post a link. We don't see any of the line or paragraph breaks and if you post it, we read it. That was a very long post to read through, word for word, without any breaks. I have deleted shorter posts before now for being too long. If you post more threads this length and I am the one that picks them up for moderation, I will delete them and invite you to post a link.

I have not got a link or I would have course posted it I have a copy of the booklet on pdf not sure where it came from i was going to email the document to steve but he did not answer my post and as 4 people had now asked to see it I thought I should let them see it

Hi all,

This article on the site gives a link to the GP Factual report form guidance that Dave has reproduced:

GPs warned not to discuss DLA with patients

Steve