Yes, the QRISK2 looks at clinical information within the patients records and can be saved to the patients journal without a consultation but all patients with a risk score of ≥20% who are currently not treated with a statin or have a contraindication/allergy/intolerance  recorded should be invited in for a further review. The list of the remainder patients should have their records reviewed by a clinician to ensure there is no further action (this can be completed by either a GP, Nurse Practitioner or Practice Nurse)


The patient may have a second entry of Hypertension in their clinical record. There should only be one entry of the diagnosis with a ‘New Episode’ attached to the Read code, if a duplicate entry is made again this will reactivate the reminders for the newly diagnosed Hypertensives

No, the guidance clearly states that it is a primary care face to face review. The review is about the patients wellbeing looking at the:

Discussing DMARS, if relevant

Need for referral for surgery, if relevant

Effects the disease is having on their life, for example work and education

The need to organise appropriate cross-referral within the MDT


You would also need to use the Clopidogrel  contraindicated as the system is looking for both Aspirin or an alternative anti-platelet

CTV 3:    XaJ6Y     Clopidogrel contraindicated

Version 2: 8I2K.    Clopidogrel contraindicated

The indicator is not just looking for a QRISK2 in the preceding 12 months. The patient sitting in work to do will have had a risk of =>20 recorded in their records but have yet been treated with a statin or had a therapy exclusion code entered if a statin is not appropriate. If you record an exclusion, the patient will no longer sit in that indicator and you will be back to zero patients. Excluding a patient will remove them.

Yes, the exclusion for the first three months is to allow practices to arrange the patients care pathway and to call them in, as with any other exclusion if you achieve the indicator it will be superseded. Remember the indication is not just about the diagnosis but also about the therapy prescribed. Without a prescription for a statin having been issued, the patient will not appear in the achieved.

The register is made up of patients with a new diagnosis of hypertension in the preceding 12 months who don’t have specific pre-existing conditions. This is then adjusted in the indicator to exclude certain age groups and to include patients who specifically have CVD risk assessment (QRISK2) scores >= 20% in the preceding 12 months. Your 49 patients are the newly diagnosed Hypertensives but they will not all fulfil the criteria.

It could be one of three reasons why you have zero patients for CVD-PP001.

  1. The patients have a QRISK2 score in their clinical record but all are below 20%.
  2. The patients do not fall within the criteria of 30yrs – 75 yrs with no pre-existing CHD, Diabetes, Stroke and/or TIA.
  3. Not all the patients have a QRISK2 score saved to their records. This would mean you have not identified those patients with a risk =>20%. This can be done through reviewing of the patients notes. It does not have to be a face to face consultation to record the score but you will need to call the patient in to discuss the results if appropriate. Many clinicians also open the clinical tool but forget to press the save button especially on SystmOne as the button is not obvious!

I would suggest you score a new QRISK2 in the patients record to assess if their risk has changed. This potentially could identify a patient who requires a statin.

Yes the nurse is able to do a Dementia review during her visit.  It is important she documents what the review covered on the patient’s record when recording it as a home visit.

When the patient was initially referred to the memory clinic it was to confirm the diagnosis of Dementia as correct, so the answer would be to back date the diagnosis to the time you referred.

Please note – DEM005 – screening blood tests patients diagnosed in the current QOF year – 1st April – 31st March.

The business rules are now looking back 18 months to ensure patients who are diagnosed at the beginning of the QOF year will fulfil the blood screening criteria

With DM014 ‘education for newly DM patients, in the preceding 1 April – 31st March’, the indicator is looking back 21 months from 31st March 2016. This is in line with the ‘data set rules’ guidance.

This will carry over all patients who were not achieved last year. Also it appears that all those who refused last year are asking for a new entry of refusal for this year! This has been passed over to the NHS Employers for re-consideration.

This means that you will have to re-enter the patient’s wishes again if their diagnosis was on or after the 1st July 2014 and they refused the offer. I would suggest you back date to April of this year the refusal code with free text – patient declined within the QOF criteria see entry on xxxxx’ but ensure when entering the Read code it is within nine months of the diagnosis

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