Download HoNOS65+ Score Sheet - Southern Health NHS Foundation Trust

HoNOS 2009/10
HoNOS65+ Score Sheet
Patient Forename
Ward / Team Base Name
Patient Surname
Service Type (please circle)
Inpatients/ CMHT/ CRHT/ AOT/ EIP/ Day Services
Date of Birth
Gender
NHS number
Postcode
Consultant Name
Rater 1 Name (& Profession)
Rater 2 Name (& Profession)
Key
NB. Rate preceding fortnight or “condition at discharge” for acute services.
0 = No problem, 1 = minor problem-requiring no action, 2 = Mild problem but definitely present, 3 = Moderate, 4 = Severe,
U = Not known (avoid using if possible)
Sheets with more than 2 unknown items will be returned
Last date of rated period here dd/mm/yyyy
Rating Setting ID 1) Hospital Admission, 2) Hospital Review 3) Hospital Discharge
4)Community Initial Assessment 5) Community Review 6) Community Discharge
7) Outpatients Initial Assessment 8) Outpatients Review 9) Outpatients Discharge
10) Crisis team admission 11) Crisis team discharge 12) Liaison Assessment 13) other (specify)
1) Overactive, aggressive, disruptive or agitated behaviour
0-4
2) Non-accidental self-injury
0-4
3) Problem drinking or drug taking
0-4
4) Cognitive Problems
0-4
5) Physical illness or disability problems
0-4
6) Problems with hallucinations and delusions
0-4
7) Problems with depressed mood
0-4
8) Other mental or behavioural problems (0-4)
Rate 0 for no problem
Specify single most severe disorder A – J
Not rated elsewhere
A) phobic, B) anxiety, C) obsessive-compulsive, D) Stress, E) dissociative,
F) somatoform, G) eating, H) sleep, I) sexual, J) other (specify)
0-4
A-J
9) Problems with relationships
0-4
10) Problems with activities of daily living
0-4
11) Problems with living conditions
0-4
12) Problems with occupation and activities
0-4
Total
Primary Diagnosis 1) Dementia, 2) Delirium, 3) Substance Misuse - Drug 4) Substance
Misuse - Alcohol 5) Schizophrenia/ Schizoaffective Disorder 6) Bipolar 7) Depression 8) Eating
Disorders 9) Borderline Personality Disorder 10) MCI
(mild cognitive impairment) 11) Other (specify) e.g. Anxiety
1-11