Chronic disease monitoring

For a number of chronic diseases, it is important to have regular checks in order to monitor the condition. This monitoring would often involve a combination of physical health checks, blood tests, and in some cases more focussed checks. At Bridge Street our chronic disease monitoring is done by a team approach between the nursing team and doctors, and would usually vary between 6 monthly and yearly checks.

The following table will provide some information on our usual follow up of the more common chronic diseases. It is important that these checks are done, as we will often link our medication reviews to these checks. It will reduce any inconvenience when it comes to ordering your medications if these checks are done on time. We would normally try and remind patients by letter if these reviews are missed.

ConditionFrequency of follow upDetailFlu jab recommended
AsthmaYearlyReview with nursing team or GP. Will require doctor review if symptoms are not controlledY
Chronic obstructive pulmonary disease (COPD)Yearly30 min nurse review including spirometry and then doctor reviewY
HypertensionAnnual check and 6 month reviewNurse review including bloods. Review by GP if identified by nursing teamY
Coronary heart diseaseAnnual review +/- 6 monthly bloodsNurse review with GP follow if identified by nursing teamY
DiabetesYearly + bloods up to 3 monthly30 min nursing team review including physical checks and bloods followed by GP follow upY
Mental healthYearly for those with significant illnessNurse appointment for physical checks +/- bloods and GP review


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