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ℹ️Introduction
This article explains how to set up, review, maintain, and update the Continuity of Care RAG Status using the Ardens resources within SystmOne. By the end of this guide, you will understand how to identify patients requiring review, maintain the registers, and record or update a patient’s RAG status.
Background
The Continuity of Care RAG model helps practices identify and manage patients according to their level of continuity need using a Red, Amber, Green (RAG) approach.
The Ardens resources support practices by:
Identifying patients who require a RAG status
Highlighting patients needing review
Providing alerts and templates within the patient record
Supporting ongoing register maintenance and data quality
How Ardens Can Help
Ardens has developed a number of Continuity of Care resources to support patient segmentation and the ongoing management of each group. These resources enable prioritisation, regular review, and the updating of RAG status as required.
For an overview of the resources, including background and clinical context, please refer to the Continuity of Care RAG - Overview support article.
⚙️Initial Setup
To set up the practice to use the Continuity of Care RAG model and ensure clinicians can begin recording the RAG status.
Review Patients with no RAG Status Recorded
Access Clinical Reporting > Arden's Ltd > Registration > Continuity of Care I Registers
Highlight the three 'Predicted' reports and the 'RAG status: Recorded - 4. Unknown | Not recorded' report and then press the green triangle icon above the list of reports to run all highlighted reports.
Prioritise the Predicted reports. These identify patients who have not had a RAG status recorded within the last 12 months.
At this stage, you may want to prioritise which staff members will review the complex patients (red and amber status) and those in general good health (green status). Once decided, select the required report, right click and select 'Show Patients'.
To record a RAG status for the patient once reviewed, access the patient record and click on the Continuity of Care patient status alert either under the patients name in the top right, or on the patient home screen. This will either be a green, amber or red circle, or a blue circle if the RAG score hasn't been recorded.
In the Update RAG status section, select the appropriate status.
Click OK and save the patient record.
🚦RAG Status Reviews
We recommend practices review and maintain the Continuity of Care registers monthly.
Register Maintenance
Access Clinical Reporting > Arden's Ltd > Registration > Continuity of Care I Registers.
Highlight the appropriate reports and click on the green triangle to run the reports.
Continue to action the Predicted reports and RAG status: Recorded - 4. Unknown | Not recorded report.
Update patient RAG status as appropriate.
Data Quality
Access Access Clinical Reporting > Arden's Ltd > Registration > Continuity of Care I Data Quality
Highlight all reports by clicking on the dotted square icon above the reports, and then click on the green triangle icon next to this to run all highlighted reports.
For the top three reports (Record RAG Status as not previously recorded but predicted):
These patients have never had a RAG status recorded.
Review the record and update the RAG status (follow the same steps as Initial Setup).
For the bottom three reports (Review RAG status as recorded XX but predicted):
Review each patient and decide whether the suggested RAG status should be recorded.
Review RAG Status
Access Clinical Reporting > Arden's Ltd > Registration >Continuity of Care I Review
Highlight all reports by clicking on the dotted square icon above the reports, and then click on the green triangle icon next to this to run all highlighted reports.
Advise clinicians to complete a clinical review for these patients and update the RAG status accordingly.
📋Updating RAG Status
For clinicians to record the patient's current RAG status in line with best practice guidance.
Via a Template
Open the patient record and and press F12.
Search for 'Continuity of Care' in the search box.
Click on the template to launch it. Alternatively, drag the template onto the left hand side to store it as a favourite template for your log in.
Review the current RAG status displayed.
In the Update RAG status section, select the appropriate status.
Click OK and save the patient record.
Via a Patient Status Alert
Open the patient record.
The current RAG status is displayed as an icon under the patient name in the top right, or on the patient home screen. This will either be a green, amber or red circle, or a blue circle if the RAG score hasn't been recorded.
Either choose 'Action' or click on the coloured circle under the patients name to open the Continuity of Care Ardens template.
Update the RAG status if required and save.
🔎Viewing RAG Status
To ensure all practice staff can easily view a patient’s current RAG status.
The current RAG status is displayed as an icon under the patient name in the top right, or on the patient home screen. This will either be a green, amber or red circle, or a blue circle if the RAG score hasn't been recorded.
❓FAQs
How often should the Continuity of Care searches be reviewed?
We recommend practices review the registers and data quality searches monthly.
What does the “UNKNOWN” RAG status mean?
This indicates that a patient has not yet had a Continuity of Care RAG status recorded.
🏫 Additional Learning
To further your understanding of the risk stratification tools and how to make the most of Ardens resources:
For an overview of the resources, including background and clinical context, please refer to the Continuity of Care RAG - Overview support article
Watch our Continuity of Care webinars for EMIS Web and SystmOne
Book training for your GP Practice, PCN or ICB
Contact our Support Team for support in real time