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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