Download Mental Health - Dementia, Dataset (Word).

OP MH Dementia Dataset
1.1
1.2
1.2a
1.3
Data Item
Person Demographics
NHS NUMBER
LOCAL PATIENT
IDENTIFIER
ORGANISATION CODE
(LOCAL PATIENT
IDENTIFIER)
CASE NUMBER
Description
See NHS Data Dictionary
See NHS Data Dictionary
1.4
LOCAL AUTHORITY
CODE
PERSON FAMILY NAME
1.5
PERSON GIVEN NAME
See NHS Data Dictionary
1.6
PATIENT USUAL
ADDRESS
POSTCODE OF USUAL
ADDRESS
See NHS Data Dictionary
1.7
1
Used to uniquely identify the patient
who is the subject of the dataset.
Used to uniquely identify the patient
within a health care provider
See NHS Data Dictionary
The unique number assigned to
a person when they are formally
recognised as a social service
user and have a case opened for
them.
The identifier of a local authority
within the UK
See NHS Data Dictionary
1.3a
Purpose
See NHS Data Dictionary.
Codes and Classifications
See NHS Data Dictionary
See NHS Data Dictionary
an5
Used to uniquely identify the patient
who is the subject of the Dataset
within a local authority care provider
an10 (up to 10 characters)
an4 nnaa
Identifies that part of a person's name
that is used to describe family, clan,
tribal group, or marital association.
Identifies the forename or given name
of a person.
Identifies the address details for the
person at their usual address
See NHS Data Dictionary
See NHS Data Dictionary
See NHS Data Dictionary
See NHS Data Dictionary
Version No: 1.2
Date Updated: March 2005
1.8
PRESENT ADDRESS
1.9
POSTCODE OF
PRESENT ADDRESS
1.10
PERSON BIRTH DATE
1.11
PERSON GENDER
CURRENT
See NHS Data Dictionary
1.12
ETHNIC CATEGORY
See NHS Data Dictionary.
1.13
GP NAME (NAME OF
REGISTERED OR
REFERRING GMP)
GMP (CODE OF
REGISTERED OR
REFERRING GMP)
ORGANISATION NAME
(GP PRACTICE)
See NHS Data Dictionary
1.14
1.14a
1.15
CODE OF GP
PRACTICE
(REGISTERED GMP)
2
This is the ADDRESS nominated
by the PATIENT, with ADDRESS
ASSOCIATION TYPE of Present
address’
The POSTCODE of the
ADDRESS nominated by the
PATIENT with ADDRESS
ASSOCIATION TYPE 'Present
Address’.
See NHS Data Dictionary
Identifies the address details for the
person at their present address where
this is different from their usual
address
See NHS Data Dictionary
PATIENT USUAL ADDRESS
See NHS Data Dictionary
POSTCODE
Additional identifier for the person who
is the subject of the dataset. Also
required for the calculation of age. To
enable the provision of case mix
indicators.
Identifies the phenotypical gender
classification that currently applies to
the person.
Records the ethnicity of a person, as
specified by the person.
Identifies the name of the person’s
general medical practitioner
See NHS Data Dictionary
See NHS Data Dictionary.
Identifies the unique code for the
person’s general medical practitioner
See NHS Data Dictionary
The name of the GP practice for
the GMP who has either
registered or referred the
PATIENT
See NHS Data Dictionary
Identifies the name for the person’s
general medical practitioner
Max an255
Identifies the unique practise code for
the person’s general medical
practitioner
See NHS Data Dictionary
See NHS Data Dictionary
See NHS Data Dictionary
See NHS Data Dictionary
Version No: 1.2
Date Updated: March 2005
1.16
ORGANISATION CODE
(PCT OF GP PRACTICE)
See NHS Data Dictionary
1.17
ORGANISATION CODE
(CODE OF PROVIDER)
See NHS Data Dictionary
1.18
ORGANISATION CODE
(CODE OF
COMMISSIONER)
See NHS Data Dictionary
3
Identifies the unique code of the
See NHS Data Dictionary
Primary Care Trust responsible for the
GP practise at which the person is
registered.
Identifies the unique code of the
See NHS Data Dictionary
ORGANISATION providing the care to
the patient.
Identifies the unique code of the
See NHS Data Dictionary
ORGANISATION commissioning the
care for the patient.
Version No: 1.2
Date Updated: March 2005
2.
2.1
2.2
2.3
Dementia Needs Assessment
DATE OF LAST
The date of the last Routine
ROUTINE HEALTH
Health Check
CHECK
DATE OF NEEDS
The date the memory
ASSESSMENT
assessment was conducted
(MEMORY LOSS)
ASSESSMENT
A summary of the person’s
(MEMORY LOSS)
memory loss needs and
circumstances captured within a
Single Assessment Process
n8 (with 2 spaces): ccyy-mm-dd
Patients with dementia should be
diagnosed as early as possible in the
disease trajectory. Routine health
checks for older people should screen
for dementia
Simple mental state tests should be
used in primary care
Business Requirement 1
2.4
NEEDS ASSESSOR
(MEMORY LOSS)
4
The person responsible for the
memory loss needs and
circumstances assessment.
Business Requirement 1
n8 (with 2 spaces): ccyy-mm-dd
n2
National Codes:
01 – Need being addressed
02 – Need not being addressed
03 – No current need
99 – Unknown
Text
Captured as text in each domain
group of SAP
Version No: 1.2
Date Updated: March 2005
3.
3.1
3.2
3.3
3.4
3.5
Dementia Cognitive Assessment and Clinical Diagnosis
ASSESSMENT DATE
The date on which the cognitive
(COGNITIVE
functions and memory of the
FUNCTIONS AND
person were assessed using the
MEMORY)
identified assessment scale
ASSESSMENT SCALE
USED
(COGNITIVE
FUNCTIONS AND
MEMORY)
The assessment scale used to
determine the person’s cognitive
functions and memory
ASSESSMENT SCORE
(COGNITIVE
FUNCTIONS AND
MEMORY)
DATE (PHYSICAL
EXAMINATION)
The assessment score achieved
by the person in relation to their
cognitive functions and memory
PRESENTING
SYMPTOM (S)- possible
repeat group
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 2
Link to primary care – tests are
commenced here
Business Requirements 2 and 4
Date of examination, to provide
evidence that a physical
examination of the person was
carried out
Symptoms recorded at diagnosis
of dementia
n8 (with 2 spaces): ccyy-mm-dd
To capture other symptoms that may
present in addition to memory loss
Business Requirement 3
5
an2
01 – MMSE (Mini-Mental State
Examination)
02 – Short orientation-memoryconcentration test of cognitive
impairment (6 items)
03 – Gujarati version of MMSE
95 – Own local tool
96 – No Tool
97 – Other
Alpha numeric
Format to be defined. Free text
or coded list. To be agreed from
behavioural/ mood /psychosocial
Assessment info
Version No: 1.2
Date Updated: March 2005
3.6
3.7
DATE (Symptom first
recorded) Repeat group
linked to 1.8a
DIAGNOSIS (ENDURING
IMPACT ON NEEDS
ICD)
3.8
DIAGNOSIS (ENDURING
IMPACT ON NEEDS
Read)
3.9
DIAGNOSIS (ENDURING
IMPACT ON NEEDS
Snomed)
3.10
DIAGNOSIS DATE
(DIAGNOSIS)
6
First date that each symptom
from 1.8a recorded
A medical diagnosis that
potentially has an enduring
impact on the health and social
care needs of the person
A medical diagnosis that
potentially has an enduring
impact on the health and social
care needs of the person
A medical diagnosis that
potentially has an enduring
impact on the health and social
care needs of the person
The date the on which the
diagnosis was made
n8 (with 2 spaces): ccyy-mm-dd
The clinical diagnosis of dementia and
types of dementia should be based
upon a standardised system such as
ICD-10,Read codes or Snomed
an6 (see also appendix c of SAP
Dataset)
Attempts should be made to specify
clinical sub-typing such as; Alzheimer’s an6 (see also appendix c of SAP
disease, Vascular Dementia, DLB
Dataset)
Frontal lobe Dementia, Normal
Pressure Hydrocephalus etc.
an6 (see also appendix c of SAP
Business Requirements 3 and 6
Dataset)
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 5
Version No: 1.2
Date Updated: March 2005
Referral to Specialist Services
4.1
DATE (PRESENTING
SYMPTOMS)
4.2
REFERRED ON? (TO
SPECIALIST SERVICE)
The date the presenting
symptoms were first recorded
same as field recorded under diagnosis n8 (with 2 spaces): ccyy-mm-dd
see 2.5
To capture whether the person
was referred onto a specialist
Business Requirement 8
To capture those cases who are or
who are not referred on for specialist
services
Business Requirement 8
4.3
4.4
DATE (REFERRAL TO
SPECIALIST SERVICE)
DATE (SEEN BY
SPECIALIST SERVICE)
The data a referral was made to
a specialist service
The date the person was seen
be a specialist service
Easy, early and informative referral
should be made to a specialist service
if dementia suspected or confirmed.
Also provides data on the time
between referral and first appointment
n2
National Codes:
01 Yes
02 No
99 Unknown
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 8
7
Version No: 1.2
Date Updated: March 2005
4.5
REFERRAL SOURCE
Source of referral to specialist
service
To provide information on sources of
referral to specialist services
Business Requirement 9
4.6
REASON (FOR
REFERRAL)
8
The reason the person was
referred to the specialist service
Business Requirement 9
to be confirmed
e.g.: from Data Dictionary used
for MH Care Spell
00 General Medical Practitioner
01 Self
02 LA Social Services
03 A&E
(04 Employer, 05 Education)
06 Police
07 Other clinical specialty
08 Carer
09 Courts
10 Probation Services
11 High Security
12 Medium Security
13 Other
(20 Temporary transfer from MH
Unit, 21 Permanent transfer MH
Unit)
Codes to be used as
appropriate?
n2 (suggested professional
roles):
01= Psychiatrist
02= Mental health nurse
03= Social worker
04= Psychologist
05= Occupational therapist
06= Other allied health
professional
07= Other
Version No: 1.2
Date Updated: March 2005
4.7
4.8
4.9
SERVICE TYPE
The type of service the person
was referred to the specialist
service for
Business Requirement 8
PERSON ROLE IN
ORGANISATION
(FIRST SPECIALIST)
The professional role of the
person making the first specialist
assessment
Business Requirement 9
REFERRAL TYPE
Referral type required (other
relevant professional)
9
Business Requirement 9
n2 (suggested professional
roles):
01= Psychiatrist
02= Mental health nurse
03= Social worker
04= Psychologist
05= Occupational therapist
06= Other allied health
professional
07= Voluntary Service
08= Other
n2 (suggested professional
roles):
01= Psychiatrist
02= Mental health nurse
03= Social worker
04= Psychologist
05= Occupational therapist
06= Other allied health
professional
07= Other
n2 (suggested professional
roles):
01= Psychiatrist
02= Mental health nurse
03= Social worker
04= Psychologist
05= Occupational therapist
06= Other allied health
professional
07= Other
Version No: 1.2
Date Updated: March 2005
4.10
4.11
4.12
REFERRAL DATE
ASSESSMENT DATE
ASSESSMENT
LOCATION
Date referred to other health care
professional
Date assessed by other relevant
professional
Location where the other health
professional conducted
assessment
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 9
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 9
To monitor where assessments are
undertaken
Business Requirement 9
4.13
DATE DISCUSSED
10
Date on which the case is
discussed at the MDT (Multi
Disciplinary Team)
free text or coded, if coded an2
e.g. NHS Data Dictionary
01 Health Site (General
Occurrence)
02 Home
03 Delivery Place
04 Health Site at the start of
Health Care Activity
05 Health Site at end of Health
Care Activity
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 9
Version No: 1.2
Date Updated: March 2005
4.14
4.15
4.16
4.17
4.18
4.19
DATE SEEN
(SPECIALIST SERVICE)
DATE (OF SPECIALIST
EXAMINATION)
DATE (NEURO
PSYCHOLOGICAL
ASSESSMENT)
DATE (SOCIAL
ASSESSMENT)
DATE (BRAIN SCAN)
SERVICE TYPE
(REFERRED TO)
11
The date the person is seen by
the specialist service
The date the specialist
examination is conducted
The date a Neuro Psychological
assessment is conducted
Patients referred to a specialist service n8 (with 2 spaces): ccyy-mm-dd
should have a comprehensive
assessment including medical
n8 (with 2 spaces): ccyy-mm-dd
assessment, neuro psychology and
social, supported by neuro imaging
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 10
The date a social assessment is
conducted
The date a brain scan is
conducted
Specialist service the person is
referred to
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
To be Confirmed
Codes required for specialist
services, DD Codes are for GMS
Services or for service type
requested only values are
1 Advice/consultation
2 Specific procedure
3 Other
Version No: 1.2
Date Updated: March 2005
5.
5.1
5.2
5.3
5.4
DEMENTIA - SPECIALIST TREATMENTS
START DATE
The date that anti dementia
(ANTI DEMENTIA
drug(s) were described
DRUGS)
START DATE
This needs discussion –which
(OTHER DRUGS)
other drugs are to be recorded
and if so are they to be coded by
type e.g. anti psychotic or actual
name?
START DATE
The start date that the non
(BEHAVIOUR
professional carers received
MANAGEMENT)
behaviour management support
and advice
START DATE
The start date that the patient
(INDIVIDUAL
received individual counselling
COUNSELLINGPATIENT)
12
n8 (with 2 spaces): ccyy-mm-dd
Specialist treatments that are offered
should be recorded
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 11
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Version No: 1.2
Date Updated: March 2005
6.
6.1
6.2
6.3
DIAGNOSIS REALTED SERVICES
DATE (DEMENTIA
The date that the person is
DIAGNOSIS
informed of the diagnosis
DISCUSSED WITH
PATIENT)
DATE (DEMENTIA
The date that the dementia
DIAGNOSIS
diagnosis is discussed with
DISCUSSED WITH
another person who has a
SIGNIFICANT OTHER)
significant relationship to the
patient
DATE (Re DVLA
The date the person is advised
ADVICE)
re their responsibility to the
DVLA
6.4
DATE (Re ADVICE
POWER OF ATTORNEY)
The date the person is given
information about the options of
appointing a Power of Attorney
6.5
DATE (Re ADVANCED
DIRECTIVES)
6.6
DATE (Re SERVICES)
The date the person receives a
consultation wherein they are
given the opportunity to discuss
advanced directives
The date the person receives a
consultation including advice
regarding the appropriate
services that are available to
them including 24hr crisis
support
13
To monitor that there is a record of
whom has been informed of the
diagnosis
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 12
n8 (with 2 spaces): ccyy-mm-dd
To monitor that patients are advised re n8 (with 2 spaces): ccyy-mm-dd
the impact of their condition with regard
driving
Business Requirement 13
To monitor that patients are informed
re the options regarding the
appointment of powers of attorney
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 14
General issue re older peoples
datasets
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 15
General issue re older peoples
datasets
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 16
Version No: 1.2
Date Updated: March 2005
7.
7.1
DEMENTIA - DRUG TREATMENT
ANTI DEMENTIA DRUG
Has the person been prescribed
PRESCRIBED?
an anti dementia drug?
To monitor use of anti dementia drugs
Business Requirement 17
7.2
PRESCRIBING SOURCE
(ANTIDEMENTIA DRUG)
The originating source of the
prescriber of the anti dementia
drug
To monitor the prescribing source
patterns for anti dementia drugs
Cholinesterase inhibitors should be
prescribed by a specialist in elderly
care/old age psychiatry/neurology for
mild and moderate AD where the mini
mental state examination is above 12
points, following full assessment in a
specialist clinic
Business Requirement 17
7.3
PROFESSIONAL ROLE
IN ORGANISATION
(PRESCRIBING
SOURCE)
14
This is the role in the
organisation of the prescribing
source.
Identifies contact details for the
prescribing source
n2
National Codes:
01 Yes
02 No
99 Unknown
Suggested codes
The following types of
ORGANISATION may act as
HEALTH CARE PROVIDERS:
a. GP Practice
b. NHS Trust
c. Registered non-NHS
Provider
d. Unregistered non-NHS
Provider
e. Primary Care Trust
f. Care Trust
g. Local Authority Social
Services
h. Other agencies
Max an 255
Version No: 1.2
Date Updated: March 2005
7.4
START DATE (ANTI
DEMENTIA DRUGS)
The date the person was
prescribed anti dementia drugs
To monitor prescribing of anti dementia n8 (with 2 spaces): ccyy-mm-dd
drug therapies
Business Requirement 17
7.5
DEMENTIA DRUG
PRECRIBED
The actual anti dementia drug
prescribed for the person
7.6
ASSESSMENT DATE
(COGNITIVE FUNCTION
AND MEMORY)
The date on which the cognitive
functions and memory of the
person were assessed using the
identified assessment scale.
7.7
ASSESSMENT SCALE
USED (COGNITIVE
FUNCTIONS AND
MEMORY)
The assessment scale used to
determine the person’s cognitive
functions and memory
7.8
ASSESSMENT SCORE
(COGNITIVE
FUNCTIONS AND
MEMORY)
The assessment score achieved
by the person in relation to their
cognitive functions and memory
15
note Are these to be tracked separately
from cholinesterase inhibitors?
To monitor the prescribing patterns of Should these drugs be grouped
anti dementia drug therapies
by type or classified so that a
coding structure can be created.
Business Requirement 17
Would need to include other/not
known. Otherwise Max an 255
To monitor time period between
n8 (with 2 spaces): ccyy-mm-dd
cognitive function and prescription of
anti dementia drug therapy
Business Requirement 17
To monitor use of specific assessment an2
scales in respect of memory and
01 – MMSE (Mini-Mental State
cognitive function
Examination)
02 – Short orientation-memoryBusiness Requirement 17
concentration test of cognitive
impairment (6 items)
03 – Gujarati version of MMSE
95 – Own local tool
96 – No Tool
97 – Other
To monitor the person’s cognitive
Alphanumeric?
impairment relative to therapies used
Business Requirement 17
Version No: 1.2
Date Updated: March 2005
7.9
DATE (ASSESSED IN A
SPECIALIST CLINIC)
7.10
DATE (START DATE
CHOLINESTERASE
INHIBITORS)
Cholinesterase inhibitors should be
prescribed by a specialist in elderly
care/old age psychiatry/neurology for
mild and moderate AD where the mini
mental state examination is above 12
points, following full assessment in a
specialist clinic
The start date that the
cholinesterase inhibitors
treatment began
Business Requirement 18
Patients prescribed cholinesterase
inhibitors should be reviewed 2 to 4
months after the initiation of treatment
n2 (suggested types):
01= Memory clinic
02= Consultant out-patient clinic
03= Nurse-led clinic
04= Other
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 19,20
7.11
7.12
7.13
REVIEW DATE
(CHOLINESTERASE
INHIBITORS)
REVIEW ASSESSMENT
SCALE USED
(COGNITIVE
FUNCTIONS AND
MEMORY)
The date the patient prescribed
cholinesterase inhibitors was
reviewed
The assessment scale used to
determine the person’s cognitive
functions and memory
REVIEW ASSESSMENT
SCORE (COGNITIVE
FUNCTIONS AND
MEMORY)
The assessment score achieved
by the person in relation to their
cognitive functions and memory
16
n8 (with 2 spaces): ccyy-mm-dd
To monitor use of specific assessment an2
scales in respect of memory and
01 – MMSE (Mini-Mental State
cognitive function
Examination)
02 – Short orientation-memoryBusiness Requirement 20
concentration test of cognitive
impairment (6 items)
03 – Gujarati version of MMSE
95 – Own local tool
96 – No Tool
97 – Other
To monitor the person’s cognitive
Alphanumeric?
impairment relative to therapies used
Business Requirement 20
Version No: 1.2
Date Updated: March 2005
7.14
7.15
7.16
7.17
7.18
SIX MONTH REVIEW
DATE
(CHOLINESTERASE
INHIBITORS)
DATE (RESTART DATE
CHOLINESTERASE
INHIBITORS)
ASSESSMENT SCALE
USED (COGNITIVE
FUNCTIONS AND
MEMORY)
The date the patient prescribed
cholinesterase inhibitors was
reviewed
ASSESSMENT SCORE
(COGNITIVE
FUNCTIONS AND
MEMORY)
DATE (END DATE
CHOLINESTERASE
INHIBITORS)
The assessment score achieved
by the person in relation to their
cognitive functions and memory
The re-start date that the
cholinesterase inhibitors
treatment began
The assessment scale used to
determine the person’s cognitive
functions and memory
The date that the cholinesterase
inhibitors treatment ended.
Patients who continue on
cholinesterase inhibitors should be
reviewed by MMSE score, global,
functional and behavioural
assessments every six months.
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 20,21
To monitor use of specific assessment an2
scales in respect of memory and
01= MMSE (Mini-Mental State
cognitive function
Examination)
02= Short orientation-memoryBusiness Requirement 21
concentration test of cognitive
impairment (6 items)
03= Gujarati version of MMSE
04= Chinese
95= Own local tool
96= No Tool
97= Other
To monitor the person’s cognitive
Alphanumeric?
impairment relative to therapies used
Business Requirement 21
Cholinesterase inhibitors should be
n8 (with 2 spaces): ccyy-mm-dd
discontinued as per national guidance.
The threshold for discontinuing is
currently a mini mental score of 12, but
this may change
Business Requirement 21
17
Version No: 1.2
Date Updated: March 2005
7.19
REASON
(CHOLINESTERASE
INHIBITORS STOPPED)
The reason why the
cholinesterase inhibitors
treatment was ended.
To monitor prescribing patterns for
cholinesterase inhibitors relevant to
cognitive function assessments
Business Requirement 21
7.20
ASSESSMENT SCORE
(COGNITIVE
FUNCTIONS AND
MEMORY)
The assessment score achieved
by the person in relation to their
cognitive functions and memory
at the end of the cholinesterase
Inhibitors treatment
The date on which the cognitive
functions and memory of the
person were assessed using the
identified assessment scale.
7.21
ASSESSMENT DATE
(COGNITIVE FUNCTION
AND MEMORY)
7.22
NEEDS ASSESOR
(MEMORY LOSS)
This is person undertaking the
memory/cognitive function test.
7.23
DATE (RE START DATE
CHOLINESTERASE
INHIBITORS)
The date that the cholinesterase
Inhibitors treatment was re
started.
7.24
REVIEW DATE
(GENERAL DRUG
REVIEW)
The date the person’s general
drugs were reviewed
To monitor the person’s cognitive
impairment relative to therapies used
Reason codes to be created
e.g.
01 Patient unable to cooperate
02 Patient refused
03 MMSE Score indicates
withdrawal
04 Not Known
Alphanumeric?
Business Requirement 21
To monitor time period between
cognitive function and prescription of
anti dementia drug therapy and the
cessation of the drug treatment
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 21
Identifies contact details for the
Max an 255
memory/cognitive function assessment Should the needs assessor
details be captured per review
Business Requirement 21
and start etc of cholinesterase
inhibitor treatments?
To monitor instances of CI treatment
n8 (with 2 spaces): ccyy-mm-dd
being restarted
Business Requirement 21
All patients on 4 or more antipsychotics n8 (with 2 spaces): ccyy-mm-dd
or benzodiazepines drugs should be
reviewed every 6 months
Business Requirement 21
18
Version No: 1.2
Date Updated: March 2005
7.25
7.26
7.27
7.28
DATE OF REASSESSMENT OF
NEEDS
PROFESSIONAL ROLE
(PERSON REVIEWING
GENERAL DRUGS)
DATE OF 75+ ANNUAL
ASSESSMENT
NEUROLEPTIC USE
19
The date the needs of the person
was assessed once the drugs
were stopped
This is the role of the person
conducting the review of the
patient’s general drugs.
The date that an annual review
was made of a person who is
75+ years old
Type of Neuroleptic medicine
prescribed
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 21
Max an 255
Business Requirement 21
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 22
Text (or n2 coded list?)
Business Requirement 22
Version No: 1.2
Date Updated: March 2005
8.
8.1
ACCESS TO OTHER SERVICES/FACILITIES
DATE (CONSULTATION The date the person received a
RE AVAILABLE
consultation explaining the
SERVICES)
various services available to
patients and carers including 24
hour support
8.2
REFERRAL DATE
(HOSPITAL PROVIDER
SPELL)
The date the person was referred
for a Hospital based provider
spell
8.3
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
This is the role in the
organisation of the referring
source for the hospital facilities.
20
To monitor good practice in advising
patients and carers of available
services. This requirement should also
be monitored via the organisational
audits
There should be access to Inpatient
facilities if required
Business Requirement 23
Identifies role and contact details for
the referring source
n8 (with 2 spaces): ccyy-mm-dd
Note: On SAP data items
regarding services capture the
following codes:
n2
National Codes:
01 –Support/ service currently
provided
02 – Support/service pending
03 - Support/Service not
currently provided
99 – Not Known,
Referral dates are not captured
but the date the service was
started or planned to start for
pending services is collected,
end dates are not captured,
should this affect what is
collected for MH?
n8 (with 2 spaces): ccyy-mm-dd
Max an 255
Version No: 1.2
Date Updated: March 2005
8.4
8.5
START DATE
END DATE
The start date that the person
attended a hospital based spell
The end date that the person
completed a hospital based spell
8.6
REFERRAL DATE (DAY
TREATMENT)
The date the person was referred
for a day treatment provider spell
8.7
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
START DATE
(DAY TREATMENT)
This is the role in the
organisation of the referring
source for the day treatment.
The start date that the person
attended a day treatment based
spell
8.9
END DATE (DAY
TREATMENT)
The end date that the person
completed a day treatment
based spell
8.10
REFERRAL DATE
(PLANNED RESPITE
FACILITIES)
The date the person was referred
for planned respite facilities
8.8
Monitor time between referral and
admission for hospital based
facilities/treatment
Business Requirement 23
Monitor the period of time that the
patient utilised hospital based
facilities/treatment
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 23
There should be access to day
treatment facilities if required
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 23
Identifies role and contact details for
the referring source
Max an 255
Monitor time between referral and
admission for Day Treatment based
facilities/treatment
Business Requirement 23
Monitor the period of time that the
patient utilised day treatment based
facilities
Business Requirement 23
Monitor the uptake of respite facilities
which should be available if required
for persons with dementia
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 24
21
Version No: 1.2
Date Updated: March 2005
8.11
8.12
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
This is the role in the
organisation of the referring
source for the planned respite
facilities.
START DATE (PLANNED The start date that the person
RESPITE)
was admitted for respite care
8.13
END DATE (PLANNED
RESPITE)
The end date that the person
completed a planned respite care
stay
8.14
REFERRAL DATE
(EMERGENCY RESPITE
FACILITIES)
The date the person was referred
for emergency respite facilities
8.15
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
8.16
START DATE
(EMERGENCY RESPITE
STAY)
This is the role in the
organisation of the referring
source for the emergency respite
facilities.
The start date that the person
was admitted for emergency
respite care
8.17
END DATE
(EMERGENCY
RESPITE)
The end date that the person
completed an emergency respite
care stay
Identifies role and contact details for
the referring source
Max an 255
Monitor time between referral and
admission for planned respite care
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 24
Monitor the period of time that the
patient utilised planned respite care
facilities
Business Requirement 24
Monitor the uptake of emergency
respite facilities which should be
available if required for persons with
dementia
Business Requirement 24
Identifies role and contact details for
the referring source
Monitor time between referral and
admission for planned respite care
Business Requirement 24
Monitor the period of time that the
patient utilised planned respite care
facilities
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Max an 255
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 24
22
Version No: 1.2
Date Updated: March 2005
8.18
8.19
8.20
8.21
8.22
8.23
REFERRAL DATE
(PLANNED
INTERMEDIATE CARE
FACILITIES)
The date the person was referred
for planned intermediate care
facilities
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
This is the role in the
organisation of the referring
source for the planned
intermediate care facilities.
START DATE (PLANNED The start date that the person
INTERMEDIATE CARE
was admitted for planned
STAY)
intermediate care
END DATE (PLANNED
INTERMEDIATE CARE
STAY)
REFERRAL DATE
(EMERGENCY
INTERMEDIATE
FACILITIES)
The end date that the person
completed a planned
intermediate care stay
The date the person was referred
for emergency intermediate care
facilities
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
This is the role in the
organisation of the referring
source for the emergency
intermediate care facilities.
23
Monitor the uptake of planned
intermediate care facilities which
should be available if required for
persons with dementia
Business Requirement 25
Identifies role and contact details for
the referring source
Business Requirement 25
Monitor time between referral and
admission for planned intermediate
care spells
Business Requirement 25
Monitor the period of time that the
patient utilised planned intermediate
care facilities
Monitor the uptake of emergency
intermediate facilities which should be
available if required for persons with
dementia
Business Requirement 25
Identifies role and contact details for
the referring source
n8 (with 2 spaces): ccyy-mm-dd
Max an 255
(this data item was not included
in business requirements)
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Max an 255
Business Requirement 25
Version No: 1.2
Date Updated: March 2005
8.24
8.25
START DATE
(EMERGENCY
INTERMEDIATE CARE
STAY)
END DATE
(EMERGENCY
INTERMEDIATE CARE
STAY)
The start date that the person
was admitted for emergency
Intermediate care
Monitor time between referral and
admission for planned Intermediate
care
The end date that the person
completed a emergency
intermediate care stay
Business Requirement 25
Monitor the period of time that the
n8 (with 2 spaces): ccyy-mm-dd
patient utilised emergency Intermediate
care facilities which should be available
for persons with dementia
Business Requirement 25
Monitor the uptake of 24 hour crisis
support services which should be
available if required for persons with
dementia
8.26
REFERRAL DATE (24
HOUR CRISIS
SUPPORT)
The date the person was referred
for 24 Hour Crisis Support
services
8.27
PROFESSIONAL ROLE
IN ORGANISATION
(REFERRING SOURCE)
8.28
START DATE (24 HOUR
CRISIS SUPPORT
SERVICES)
This is the role in the
organisation of the referring
source for the 24 hour crisis
support services
The start date that the person
used 24 hour crisis support
services
8.29
END DATE (24 HOUR
CRISIS SUPPORT
SERVICES
The end date that the person
stopped using 24 hour crisis
support services
n8 (with 2 spaces): ccyy-mm-dd
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 25
Identifies role and contact details for
the referring source
Max an 255
Business Requirement 25
Monitor time between referral and
admission for planned respite care
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 25
Monitor the period of time that the
patient utilised 24 hour crisis support
services
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 25
24
Version No: 1.2
Date Updated: March 2005
8.30
24 HOUR SUPPORT
CRISIS SUPPORT
SERVICE USED
The actual service(s) that the
person or their carers used
Monitor uptake of specific 24 Hour
support services
Business Requirement 25
8.31
KEY WORKER / CARE
CO-RDINATOR
25
Professional role of key worker
or care coordinator
Is this appropriate as a further
repeat group and if so would it be
useful to collect information
regarding the specific services
used by the patient/carer? A
classification or coding structure
is required.
Max an255
Business Requirement 25
Version No: 1.2
Date Updated: March 2005
9.
9.1
ACCESS TO BENEFITS
ATTENDANCE
ALLOWANCE
Identifies if the person is in
receipt of an attendance
allowance
These allowances taken as an
indicator of benefits received and are
not meant to be all inclusive
Business Requirement 26
9.2
DISABILITY LIVING
ALLOWANCE (CARE)
Identifies if the person is in
receipt of a disability living
allowance for care.
9.3
DISABILITY LIVING
ALLOWANCE
(MOBILITY)
Identifies if the person is in
receipt of a disability living
allowance for mobility
9.4
INVALID CARE
ALLOWANCE (CARE)
Identifies if the person is in
receipt of an invalid care
allowance benefit.
Business Requirement 26
Note parking badge is also included in
the business requirements but these
have been deleted from the benefits
section on SAP. They are collected in
SAP 4.21a/b/c
n2
National Codes:
01 Yes
02 No
99 Unknown
n2
National Codes:
01 Yes
02 No
99 Unknown
n2
National Codes:
01 Yes
02 No
99 Unknown
Business Requirement 26
26
Business Requirement 26
n2
National Codes:
01 Yes
02 No
99 Unknown
Version No: 1.2
Date Updated: March 2005
CARE PACKAGE
10.1
DATE (CARE
PACKAGE AGREED
WITH PATIENT)
10.2
HEALTH & SOCIAL
CARE RESOURCES
The date the individual care
package is agreed with the
patient
The health and social care
resources made available
To monitor good practice with respect
to individual care packages
Business Requirement 27
An individual care package is
developed that reflects health and
social care needs of the patient
according to the Single Assessment
Process
Business Requirement 27
10.3
10.4
10.5
n8 (with 2 spaces): ccyy-mm-dd
n2 (suggested classifications):
01= Home care
02= Day care
03= Respite care
04= Residential care
05= Hospital care
06= Other
(these are not mutually
exclusive)
? 01 SAP
02 CPA
MANAGEMENT
AGREEMENT
NOT SURE OF THE PURPOSE OF
THIS ITEM?
DATE (CARE
PACKAGE REVIEWED)
Business Requirement 27
To monitor good practice with regard to n8 (with 2 spaces): ccyy-mm-dd
review of the person’s care package
DATE (CARE
PACKAGE AGREED
WITH CARER)
The date the package of care is
reviewed
The date the individual care
package is agreed with the
patient’s carer
Business Requirement 27
To monitor good practice with respect
to individual care packages
Note: Carers assessment noted on
business requirements but this is
captured on SAP 2.121/2.122,
3.23/3.24,3.25
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 29
27
Version No: 1.2
Date Updated: March 2005
10.6
HEALTH & SOCIAL
CARE RESOURCES
(CARER)
The health and social care
resources made available
10.7
DATE (CARE
PACKAGE REVIEWED
- CARER)
The date the package of care is
reviewed
10.8
COPY OF CARE PLAN
ON GP FILES?
Whether a copy of the care plan
is held on the GP files
10.9
DATE OF
KEYWORKER
COPY OF CARE PLAN
SIGNED BY THE
SERVICE USER
The date when the keyworker
was appointed
Whether the patient has signed
the care plan
COPY OF CARE PLAN
SIGNED BY THE
CARER
Whether the Caret has signed
the care plan
10.10
10.11
28
An individual care package is
developed that reflects health and
social care needs of the carer
according to the single assessment
process
? Classification of codes or free
text
Business Requirement 29
To monitor good practice with regard to n8 (with 2 spaces): ccyy-mm-dd
review of the Carer’s care package
Clinical co-morbidity what should
Business Requirement 29
be collected, see Business
requirements?
Monitor the proportion of GPs with
n2
copies of care plans for all their
National Codes:
patients who should have one
01 Yes
02 No
Business Requirement 32
99 Unknown
n8 (with 2 spaces): ccyy-mm-dd
Business Requirement 33
Proportion of CPA care plans with
n2
severe mental illness signed by the
National Codes:
service user
01 Yes
02 No
99 Unknown
Proportion of CPA care plans with
n2
severe mental illness signed by the
National Codes:
Carer
01 Yes
02 No
99 Unknown
Version No: 1.2
Date Updated: March 2005
10.12
CARER HAS OWN
CARE PLAN
29
Whether the Carer of someone
with enhanced CPA also has
their own written care plan
Proportion of Carers of people with
advanced CPA care plans also have a
care plan themselves
n2
National Codes:
01 Yes
02 No
99 Unknown
Version No: 1.2
Date Updated: March 2005
Community related/Epidemiological
11.1 PERSON LIVES ALONE? Whether the person with
diagnosed dementia is living
alone
11.2
PERSON LIVES WITH
FAMILY/CARERS?
Whether the person with
diagnosed dementia is living with
family or carers
11.3
IS THE PERSON A
CARER THEMSELF?
Whether the person with
diagnosed dementia is already
providing carer support to
another person themselves
30
To monitor numbers of older people
with dementia in the locality living
alone and with family carers
Business Requirement 30,31
n2
National Codes:
01 Yes
02 No
99 Unknown
n2
National Codes:
01 Yes
02 No
99 Unknown
n2
National Codes:
01 Yes
02 No
99 Unknown
Version No: 1.2
Date Updated: March 2005
11.4
ETHNIC CATEGORY
The ethnicity of a PERSON, as
specified by the PERSON.
To monitor the ethnicity of older
persons with diagnosed dementia
Business Requirement 34
an2
National Codes:
White
A British
B Irish
C Any other White background
Mixed
D White and Black Caribbean
E White and Black African
F White and Asian
G Any other mixed background
Asian or Asian British
H Indian
J Pakistani
K Bangladeshi
L Any other Asian background
Black or Black British
M Caribbean
N African
P Any other Black background
Other Ethnic Groups
R Chinese
S Any other ethnic group
Z Not stated
Reference:
Office of National Statistics
(ONS) 2001 Population Census.
31
Version No: 1.2
Date Updated: March 2005
12.
12.1
OTHER
LAST DAYS/HOURS OF
LIFE
12.2
YOUNG ONSET
DEMENTIA
32
To monitor best practice
More discussion required as to
what data items could practically
be captured here?
To be advised
Version No: 1.2
Date Updated: March 2005