Allied Health Professions Core Data Standards

Transcription

1 For reference only Do Not Use For more information contact: Allied Health Professions Core Data Standards Comprising data standards devised and/or recommended by NHS Scotland National Clinical Dataset Development Programme November 2005 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: to: NCDDPsupportteam@isd.csa.scot.nhs.uk Website:

2 Document control Superseded documents Not Applicable Document history Date Version Comments Status Consultation Document Final Post-Consultation Edits Draft Submission to NCDDP Board Final Content Changes from Consultation Document New data item added: Objective Outcome {AHP}, Objective Outcome (Patient) {AHP}, Unavailability Times Data item removed: Professional Outcome Rating {AHP}, Patient Outcome Rating {AHP} Data item name & definition changed: Date Appointment Created, Values/sub-values added: Allied Health Profession, Patient Contact Type {AHP}, Caseload Status {AHP}, Referred To {AHP}, Discharge Reason {AHP} Sections re-ordered Changes Forecast None Reviewed by Members of the NCDDP AHP Core Data Standards Working Group (Appendix 1) Issue control Authors: Contributor(s): Target Group: Distribution: Related documents: NCDDP Support Team NCDDP AHP Core Data Standards Working Group Any agency or individual involved in the collection, processing or use of patient information and any other relevant public sector bodies See list at end of paper Consultation AHP Core Data Standards Generic Data Standards 3 - Consultation Allied Health Professions Core Data Standards Page 2

3 Contents SECTION 1 - OVERVIEW & BACKGROUND... 4 Overview...4 Allied Health Professions Core Data Standards...4 Background to NCDDP...5 Generic Data Items...5 Clinical Terminology...6 Date Recording...6 SECTION 2 - AHP CORE DATA STANDARDS Demographics and Personal Information...7 Generic Data Items Associated Professional Details...8 B01: Allied Health Profession...8 Generic Data Items Referral Information...10 C01: Health Problem/Issue {AHP}...10 C02: Date 1 st Appointment Created...11 C03: Unavailability Dates...11 C03A: Unavailability Times...11 C04: Unavailability Days of the Week...12 C05: Assessed Priority of Appointment...12 Generic Data Items Background Information...14 Generic Data Items First Contact Information...15 E01: Outcome of First Contact...15 E02: Patient Contact Type {AHP}...15 Generic Data Items Caseload Management...17 F01: Objective(s) {AHP}...17 F02: Caseload Status {AHP}...18 F03: Referred to {AHP}...19 F04: Number of Care Plans Delivered...20 F05: Discharge Reason {AHP}...21 F06: Objective Outcome {AHP}...22 F07: Objective Outcome (Patient) {AHP}...22 Generic Data Items Acronyms and Abbreviations...24 APPENDIX 1 - WORKING GROUP MEMBERSHIP APPENDIX 2 - ICF CODE APPENDIX 3 - DISTRIBUTION LIST Allied Health Professions Core Data Standards Page 3

4 Overview Section 1 - Overview & Background The Electronic Community Health Information Project (echip) established by the Scottish Executive Health Department commissioned the development of Allied Health Professions (AHP) Core Data Standards for NHS Scotland in order to ensure a national approach to the collection of clinical and non-clinical data items relating to AHPs. The aim is to ensure inter-compatibility of national clinical information systems and support the implementation of an electronic integrated health record. National data standards will also support data sharing with other agencies through agreed protocols. A multi-disciplinary Clinical Working Group, established in October 2004 and supported by the National Clinical Dataset Development Programme (NCDDP) Support Team in Information Services (ISD), carried out the development of these AHP data standards. The AHP Core Data Standards will: Define common data items recommended for collection in a wide variety of clinical settings Support the exchange of patient information between healthcare providers Support the consistent recording of patient information throughout NHS Scotland It is important to emphasise that these are data standards rather than a dataset. This means that the individual data items included in this document are not required to be recorded together in a single clinical information system. However, where it is considered appropriate to record a particular data item as part of a person s record of care, the information should be recorded in accordance with the nationally agreed standard. We are now asking for feedback from the wider clinical community in order to ensure that these data standards are fit for purpose and ready for inclusion in the national Health and Social Care Data Dictionary. We invite all interested organisations and individuals to take part in this consultation by completing the attached Consultation Response Form and then returning it to NCDDPsupportteam@isd.csa.scot.nhs.uk. Comment on all or a part of the document is welcome. Some background information on the NCDDP and AHP Core Data Standard development can be found below. If you require further information, please go to our Clinical Dataset and/or AHP echip websites or contact liz.mitchell@isd.csa.scot.nhs. Allied Health Professions Core Data Standards The membership of the AHP Core Data Standards Clinical Working Group is shown in appendix 1. This group agreed the inclusion of individual data items using the following criteria: Is the data item required by AHPs in the care of patients? Will it prevent unnecessary duplication of data recording? Would most patients expect this data item to be available/shared? Allied Health Professions Core Data Standards Page 4

5 Phase one of this work is presented here and extensions to this work is ongoing with considerations of disease specific extensions such as AHP stroke data standards and discipline specific such as podiatry data standards. Simultaneously to the consultation, a National Census of the nine participating AHP s (approximately 8,500 clinicians) will take place using AHP Core Data Standards which describe AHP caseloads. This will practically test the usability and usefulness of these data standards across the disciplines and country. Once consultation is complete the AHP Core Data Standards will be submitted to the NCDDP Programme Board for formal approval as a national standard, and subsequently passed to the ehealth National Clinical Information Steering Group and the NHS Scotland Information Standards Group for endorsement. Once approved the AHP Core Data Standards will be freely and widely available through publication in the Health and Social Care Data Dictionary. It is expected that the AHP Core Data Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national datasets to facilitate the implementation of the integrated care records across NHS Scotland. These standards will: Support direct patient care, by reflecting current best practice guidance Facilitate effective communication between health care professionals Improve data quality and support secondary data requirements where possible including data to support clinical governance Be freely and widely available through publication in the web based Health & Social Care Data Dictionary Incorporate agreed national clinical definitions and implement national terminology Be UK compatible where possible The programme was established by the Chief Medical Officer in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-health Strategy. More information can be found on our website. Generic Data Items Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by wider Generic Data Standards clinical working groups and approved as national data standards for NHS Scotland. The AHP Core Data Standards working group selected several generic data items for inclusion in their standards. These data item s name and definition are listed in this document for information. The detail of these existing standards are available by contacting barbara.iwinska@isd.csa.scot.nhs.uk and will shortly be published on the web based Health and Social Care Data Dictionary. Allied Health Professions Core Data Standards Page 5

6 Generic Data Standards Phase 3 is undergoing development and will be consulted upon shortly. If you would like to participate in the Generic Standards Phase 3 consultation, please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that clinical information systems will record clinical data using this international standard. It is intended that the NCDDP Support Team will develop recommended SNOMED CT specifications as part of the data standards and datasets it supports. This work will commence once SNOMED CT tools become available. Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include date stamping as standard functionality, therefore the AHP Core Data Standards do not deal with this issue. In many clinical situations, the date of an event, investigation, etc. is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The AHP Core Data Standards do not include standards for recording dates, though the date format for storage and management within a system should conform to the Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. Allied Health Professions Core Data Standards Page 6

7 Section 2 - AHP Core Data Standards 1. Demographics and Personal Information GENERIC DATA ITEMS Data Item Community Health Index (CHI) Number Structured Name Person Birth Date Person Current Gender Address (BS7666) Postcode UK Telephone Number Internet Address Registered GP Practice Code GP General Medical Council (GMC) Number Associated Person* Definition The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. An ordered sequence of person name elements such as title, forename(s) and family name. The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned). A collection of data describing the addressing of locations The code allocated by the Post Office to identify a group of postal delivery points. A number, including any exchange or location code, at which a person or organisation can be contacted in the UK by telephonic means. The string of characters that identifies an addressee's post box on the Internet. General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and single-handed practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board. (SMR) The GMC (General Medical Council) number is the personal identification number issued to each doctor in the UK by the General Medical Council. Associated person(s) include(s) people who have a significant involvement or relationship with the client/patient (e.g. main carer, next of kin, key holder, emergency contact etc) in a non-care professional capacity. *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 7

8 2. Associated Professional Details B01: ALLIED HEALTH PROFESSION Main source of standard: Health Professions Council ( Definition: The recognised Allied Health Profession (AHP) with which the healthcare professional is registered. Recognised Allied Health Professions are those groups of clinicians who belong to the Health Professions Council. Format: 2 characters Codes and values: Code Value 01 Arts Therapy 02 Dietetics 03 Occupational Therapy 04 Orthoptics 05 Physiotherapy 06 Podiatry 07 Radiography & Radiotherapy 08 Prosthetics / Orthotics 09 Speech and Language Therapy 10 Biomedical Scientists 11 Operating Department Practitioners 12 Paramedics 13 Clinical Scientists 98 Other GENERIC DATA ITEMS Data Item Associated Professional* Associated Professional Role* Associated Professional Identifier* Associated Professional Group* Associated Professional Employing Organisation* Associated Professional Base of Service* Definition Those who are involved with the care recipient in a professional care capacity e.g. consultant, social worker, occupational therapist, etc. The role(s) with regard to a particular client/patient and the care context carried out by the professionals (e.g. Named Nurse, Key Worker). The unique identifier issued to all Health and Social care professionals by their professional regulatory body. The recognised professional group to which the care professional belongs. The organisation, body or agency, which currently employs the associated care professional in relation to the role they are fulfilling. Any building or set of buildings where NHS services are based in Scotland. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, care Allied Health Professions Core Data Standards Page 8

9 homes and schools (local authority and otherwise). Each location has a location code (formerly institution code). Locations may also include community centres and leisure centres. *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 9

10 3. Referral Information C01: HEALTH PROBLEM/ISSUE {AHP} Common names: Reason for referral; Presenting problem; Presenting complaint Definition: The reason(s) for the patient requiring involvement with health care professionals. These may include any problem or issue affecting the patient s health and/ or wellbeing. Includes physical, emotional, psychological symptoms, signs and diagnoses; impairment or limitation of body structure or function; impairment or limitation of the patients activities and ability to participate in life situations; and issues relating to their physical, social and attitudinal environment. Format: ICD10 or OPCS4 code, ICF Grouping or Read version 2 code In the future all health problems and issues should be recorded using SNOMED CT and codes. Codes and values: To be developed for specific AHP clinical datasets Attributes: May include any attributes or qualifiers available in the national standard clinical classifications and terminologies, namely IDC10, ICF, OPCS4, Read version 2 or SNOMED CT. For example: Laterality: Severity: Chronicity: Left, right, bilateral Mild, moderate, severe Acute, chronic, recurrent Further information: Health problems and issues may be identified at any point during the patient s involvement with the health care professional. They will often be identified in a referral at which point they may be referred to as the reason for referral or during initial assessment when they may be described as the presenting problem or presenting complaint. However additional health problems and issues may be identified at any stage in the patient s journey of care, for example during treatment or follow-up. Drop-down lists of codes and terms (values) for common health problems and issues can be developed within the context of specific clinical data standards/ datasets. Ideally, IT systems for AHPs should include functionality to enable automatic generation of the ICF high-level grouping code required for summary information from the clinical term entered. Examples of health care problems and issues are: bilateral muscle weakness, chronic left foot ulcer, recurrent falls, failure to thrive, lack of self-esteem, damp housing. Where an IT system is currently unable to implement the appropriate clinical terminology(ies) within its functionality, it would be possible to record health problems and issues using free text. This is not recommended as a long term option. Recording guidance: It is recommended that IT systems incorporate a clinical terminology browser to facilitate recording of appropriate data on health problems Allied Health Professions Core Data Standards Page 10

11 and issues. The browser should allow selection and display of clinical terms on the user interface whilst storing, managing and transferring such data by the corresponding clinical code. C02: DATE 1 ST APPOINTMENT CREATED Definition: The date on which the first appointment was produced and communicated to the patient. Format: 10 characters (CCYY-MM-DD) Further information: It is assumed that when an appointment is created, the process of communicating that appointment to the patient will be instigated on the same day. This is not necessarily the same as the date on which the patient then receives that communication, which depends on the communication method used. C03: UNAVAILABILITY DATES Common names: Unavailability period Definition: Any date(s) and/ or range(s) of dates during which the patient is unavailable for an appointment or admission. Format: 10 characters (CCYY-MM-DD) Related data items: Availability Status Code Unavailability Days Unavailability Times Recording guidance: IT systems should allow for the recording of multiple unavailability dates and/ or ranges of dates. Where the patient is unavailable for a range of days, the first date entered should be the unavailability start date and the second date entered should be the unavailability end date. C03A: UNAVAILABILITY TIMES Definition: Any morning/afternoon during which the patient is unavailable for an appointment or admission. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 am Before 12 noon 02 pm After 12 noon Allied Health Professions Core Data Standards Page 11

12 Related data items: Unavailability Dates Unavailability Days of the Week C04: UNAVAILABILITY DAYS OF THE WEEK Common name: Unavailability days Definition: The day(s) of the week on which the patient is unavailable for an appointment or admission. Format: 2 characters Codes and values: Code Value 01 Monday 02 Tuesday 03 Wednesday 04 Thursday 05 Friday 06 Saturday 07 Sunday Sub Data Items Start Date End Date Related data items: Availability Status Code Unavailability Dates Unavailability Times Recording guidance: IT systems should allow for the recording of multiple unavailability days. This is only required if Availability Status Code is A, e.g. if a patient cannot attend a podiatry appointment on Mondays, Wednesdays or Fridays because they are scheduled to have dialysis on these days. C05: ASSESSED PRIORITY OF APPOINTMENT Common name: Assessed Priority Main source of standard: Derived from SMR Data Standards Referral Category Definition: The priority status of the patient with respect to the urgency of the appointment they should be given as assessed by the care professional. Format: 2 characters Codes and values: Allied Health Professions Core Data Standards Page 12

13 Code Value Explanatory Notes 01 Urgent For clinical reasons, a patient requires an appointment at the earliest possible opportunity. 02 Soon For clinical reasons, a patient requires an earlier appointment than they would receive if given the next available routine appointment. 03 Routine A patient requires the next available routine appointment. 04 Not Recorded 96 Not applicable 99 Not known Further information: This may be different from the urgency assessed by the person making the referral (as recorded in Urgency of Referral). The Assessed Priority is reached by the care professional receiving the referral assessing the information in the referral and may be supplemented by further information, e.g. where the patient completes a pre-appointment screening questionnaire, telephone triage. GENERIC DATA ITEMS Data Item Availability Status Code* Clinic Code* Clinic Name* Date Referral Received* Referral Source* Referral Type* Definition A patient s circumstances which affects the normal scheduling of a patient s appointment(s), Day Case and Inpatient admissions or Home Visit. A code assigned locally to identify a clinic session or group of clinic sessions. A name assigned locally to identify a clinic session or group of clinic sessions. The date on which a referral is first received by a care service or professional, either via letter, electronic communication or verbally. One of a group of organisations, professionals and other individuals who make a referral to a healthcare professional, service or organisation. Specification of whether a referral relates to a new health problem for the service receiving the referral or one already known to that service together with a brief description of the level of service requested by the referrer. *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 13

14 4. Background Information GENERIC DATA ITEMS Data Item Significant Medical History* Recent Prescribed Medication Record Patient Allergies, Intolerances and Adverse Reactions Allergies* Definition An illness, injury or associated health care problem, which relates to a single episode of care. Record of acute prescription information for the last 30 days, repeat prescription information that has not been stopped. Excludes alternative medication. A record of a patient s allergic or other adverse reactions or intolerances to a therapeutic substance, food or other substance. *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 14

15 5. First Contact Information E01: OUTCOME OF FIRST CONTACT Definition: The result of the initial encounter with the patient, whether it be face-toface contact, by telephone or by questionnaire. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Accepted onto active case load 02 Added to waiting list for e.g. as a result of a call or triage next appointment 03 Full Assessment achieved 04 Partial Assessment achieved 05 Care Plans agreed 06 Care Plans not agreed 07 Onward Referral 08 Referred back to e.g. inappropriate referral referrer 09 Discharged Related data items: Caseload status {AHP} Referred To {AHP} Number of Care Plans Discharge Reason {AHP} Discharge Type Discharge Destination Recording guidance: More than one option may be selected. E02: PATIENT CONTACT TYPE {AHP} Common Name: Patient Contact Location {AHP} Definition: The type of environment where the patient is routinely seen by the AHP. Format: 3 characters Allied Health Professions Core Data Standards Page 15

16 Codes and values: Code Value 01 Hospital Inpatient A Inpatient Daycare Explanatory Notes A patient who occupies an available staffed bed in a hospital and either does not remain overnight, or at admission is not expected to remain overnight 02 Outpatient B A B Inpatient Overnight NHS Premises Non-NHS Premises A patient who occupies an available staffed bed in a hospital and either remains overnight, or at admission is expected to remain overnight All NHS locations where patients do not reside and they generally come to staff, e.g. hospital outpatient, day care clinics, health centre clinics etc All Non-NHS locations where patients do not reside and they generally come to staff, e.g. schools, prisons etc 03 Domiciliary All patients seen in their current place of residence e.g. own home, residential home, care home and temporary home. 98 Other 99 Not known GENERIC DATA ITEMS Data Item Date of First Contact* Professional Diagnosis* Definition The date of first contact between a patient and an individual healthcare professional for the purpose of care. The diagnosis made by an appropriate clinician in relation to the health problems and issues experienced by the patient. A diagnosis is made by: evaluating the patient s history; the signs and symptoms; and the results of clinical assessments and investigations. *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 16

17 6. Caseload Management F01: OBJECTIVE(S) {AHP} Main source of standard: CEN European Standards for Health Informatics: ETC251. Definition: A desired ultimate achievement of a programme of care. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Counsel To engage in supportive listening with the patient, e.g. empathise, re-assure or support. 02 Diagnose Only used where no intervention is required and no other objective has been enacted, for example where a professional opinion is required as part of a multidisciplinary team or as a second opinion, e.g. assess, evaluate or needs analysis. 03 Educate To teach the patient specific skills in the management of their condition, e.g. communicate, liaise, reinforce or retrain. 04 Enablement / Facilitation In relation to a problem presented, to the AHP will assist in making the problem easier for the patient but not necessarily curing the patient, e.g. facilitate change, self-caring and self-management; motivate, empower, maintain/sustain, manage or crisis intervention. 05 Maximise Potential To help the patient achieve their maximum potential, where a cure is not possible, e.g. rehabilitate. 06 Resolve To help the patient reach a level which is within normal limits for their chronological age / pre-morbid state, e.g. cure, increase, improve, reduce, relieve symptoms, promote or treat. 07 Screen / Triage Select if a screening questionnaire (written / verbal) has been completed by the patient and the care professional s analysis is that the patient does not need to be seen or can be given advice and discharged, e.g. self-referral or telephone triage. This should not be used where patients continue on to a programme of care. 08 Prevent To reduce risk of worsening, or exacerbation of secondary complications arising from an existing problem. 09 Supply / Repair Equipment 98 Other 99 Not known Allied Health Professions Core Data Standards Page 17

18 Further information: AHP programmes of care, address problems and issues identified by the patient and AHP. These problems and issues will be resolved by the provision of one or more care plans, which will include referral, triage or screening, assessment, agreement and delivery of care plans and possibly discharge (which for some patients may be at death). Recording guidance: More than one option may be selected. F02: CASELOAD STATUS {AHP} Definition: The management stage and frequency of input within the AHP s Duty of Care. Format: 3 characters Codes and values: Code Value Explanatory Notes 01 New Referral An Unknown Case on waiting list for 1 st consultation 02 Known case Inactive involvement, e.g. on waiting list for 1 st appointment post triage (this is not a new referral) 03 Diagnosis / problem intervention Currently being assessed or diagnosed 04 Current active intervention A More than once per day B C Daily More than once per week D Weekly E Fortnightly F 3 weekly G Monthly H 6 weekly I 2 monthly J Quarterly K 6 monthly L Other 05 Review An appointment to allow the health professional to evaluate progress of and/or intervene with a patient undertaking an autonomous programme of management, awaiting the effect of an intervention or needing to have a series of interventions to achieve the aims of the programme of care. e.g. formal assessment with intervention if required Allied Health Professions Core Data Standards Page 18

19 06 Patient Initiated Review 07 Monitor as required 08 On discharge pending list A B C D E Monthly Quarterly 6 Monthly Annually Other An review appointment which is generated by a patient who manages their own condition without intervention The process of determining the status of a patient in respect of the condition for which they are under a programme of care. Monitoring can be face to face or remote but does not necessarily imply intervention. e.g. observation, regulate, record or control. This is a time-limited period where no active interventions are scheduled during which the patient has the right to initiate a return to active intervention. At the end of this period the patient will automatically be discharged. 09 Discharged This links to Discharge Reason 98 Other F03: REFERRED TO {AHP} Definition: The professionals, organisations or services a patient may be referred to for the purpose of further investigation and/or ongoing care. Format: 3 characters Code and values: Code Value Sub Sub- value Code 01 Nursing A Health Visitor B District Nurse C Practice Nurse D Family Health Nurse E Treatment Room Nurse F Clinical Nurse Specialist G Liaison Nurse H Community Psychiatric Nurse I Community Learning Disabilities Nurse 02 Midwifery A Community Midwife B Midwife 03 Dental 04 General Practice 05 Acute Services A ENT Allied Health Professions Core Data Standards Page 19

20 06 Mental Health 07 Pathology 08 Surgical 09 Social Care 10 Extended Scope Practitioner 11 AHP (Allied Health Professional) 12 Consultant AHP (Allied Health Professional) 13 Radiology 14 Clinical Psychologist 98 Other 99 Not known A B C D E F G H I J A B C D E F G H I J Arts Therapies Dietetics Occupational Therapy Orthoptics Physiotherapy Podiatry Diagnostic Radiography Prosthetics Orthotics Speech and Language Therapy Arts Therapies Dietetics Occupational Therapy Orthoptics Physiotherapy Podiatry Diagnostic Radiography Prosthetics Orthotics Speech and Language Therapy Further information: The patient must be active on the AHP s caseload status at the time of onward referral. Thereafter, they may or may not remain active on the caseload status and may or may not be discharged from the service. If they are discharged it does not mean that their health problem/issue no longer exists but rather that it is being dealt with by another professional. Recording guidance: More than one option may be selected. F04: NUMBER OF CARE PLANS DELIVERED Main Source of standard: Derived from NHS Connecting for Health Data Dictionary Definition: The number separate plans invoked for the treatment or health care provided to a patient within an episode of care, e.g. a stroke patient may have many care plans to deal with the varying impairments detected such as pain, immobility, Allied Health Professions Core Data Standards Page 20

21 co-ordination, balance etc. Each impairment would necessitate an individual care plan. Format: 2 numeric Related data items: Health Problem/Issue {AHP} Further information: As an example, a stroke patient may have many care plans to deal with the varying impairments detected such as pain, immobility, co-ordination, balance etc. Each impairment would necessitate an individual care plan. Each CARE PLAN must be a plan relating to one and only one episode of care. It may be in the context for the provision of one or more services. F05: DISCHARGE REASON {AHP} Definition: The reason why care is discontinued. Format: 2 characters Codes and values: Code Value 01 Maximum benefit gained 02 Patient did not attend 03 Patient unable to attend/ could not attend 04 Patient stopped attending 05 Care no longer required 06 Inappropriate referral 07 Care transferred to other agency 08 Discharged because of abusive behaviour towards a member of staff 09 Discharged by another Profession before intervention complete 10 Planned course of intervention complete 11 Non-compliance 12 Deceased 98 Other 99 Not known Related data items: Objective Outcome {AHP} Objective Outcome (Patient) {AHP} Recording guidance: Where further information is required for Other, a free text field should be provided by the system. Allied Health Professions Core Data Standards Page 21

22 F06: OBJECTIVE OUTCOME {AHP} {A Definition: Achievement of agreed goals in relation to the original objectives. From the AHP s perspective at the end of an episode of care or at an agreed review point Format: 2 characters Codes and values: Code Value 01 Objective achieved 02 Objective partially achieved 03 Objective not achieved 98 Other 99 Not known Related data items: Objective(s) Discharge Reason {AHP} Recording guidance: Only one option should be recorded. F07: OBJECTIVE OUTCOME (PATIENT) {AHP} {A Definition: Achievement of agreed goals in relation to the original objectives. From the patients/guardians perspective at the end of an episode of care or at an agreed review point Format: 2 characters Codes and values: Code Value 01 Objective achieved 02 Objective partially achieved 03 Objective not achieved 98 Other 99 Not known Related data items: Objective(s) Discharge Reason {AHP} Recording guidance: Only one option should be recorded. Allied Health Professions Core Data Standards Page 22

23 GENERIC DATA ITEMS Data Item Discharge Type* Definition The outcome of an attendance or series of attendances with a healthcare service in connection with a specific complaint. The type of location to which a patient is discharged or transferred following an episode of care. Discharge Destination* *This item is still being developed in Generic Standards Phase 3 and may change. If you would like to receive a copy of the consultation document for these standards please contact NCDDPsupportteam@isd.csa.scot.nhs.uk. Allied Health Professions Core Data Standards Page 23

24 7. Acronyms and Abbreviations AHP Allied Health Professions/ Professional CHI Community Health Index echip Electronic Community Health Information Project GMC General Medical Council ICD International Classification of Diseases ICF The International Classification of Functioning, Disability and Health ISD Information Services NCDDP National Clinical Dataset Development Programme OPCS Office of Population Censuses and Surveys SMR Scottish Morbidity Record SNOMED-CT Systemized Nomenclature of Medicine-Clinical Terms Allied Health Professions Core Data Standards Page 24

25 Appendix 1 - Working Group Membership Membership of AHP Core Data Standards Clinical Working Group Margaret Hastings (Chair) Liz Mitchell (Facilitator) Rhian Morgan (Developer) Eilidh Fletcher Alison Smith Avril Farquhar Barbara Iwinska Brian Brockie Chris Upton Duncan MacFarlane Fiona Smith Hasmukh Pankhania Hazel Dykes Jamie Quin Jim Cannon John M c Conway Ken Andrew Lesley Burnett Lorna Grant Lorna Ramsay Maggie Stobie Mary Parham AHP Information Development Officer Scottish Executive Health Department Primary Care Division AHP Advisor, NCDDP Information Services, NHS National Services Scotland Data Development Officer, NCDDP Information Services, NHS National Services Scotland Data Development Officer, NCDDP Information Services, NHS National Services Scotland Lead AHP Workload Project, (seconded OT) Scottish Executive Health Department Primary Care Division Orthoptist, Wishaw General Hospital, NHS Lanarkshire Projects Manager, NCDDP Information Services, NHS National Services Scotland Physiotherapy Manager Roodlands Hospital, NHS Lothian Superintendent Physiotherapist Aberdeen Royal Infirmary, NHS Grampian AHP Advisor to echip NHS Glasgow Physiotherapy Manager Gilbert Bain Hospital, NHS Shetland Head of Laboratory Services Balfour Hospital, NHS Orkney Head of Therapy Services D & G Royal Infirmary, NHS Dumfries & Galloway Head of Podiatry Gartnavel Royal Hospital, NHS Glasgow Radiographer, Victoria Hospital, NHS Fife Podiatry Services Manager NHS Ayrshire & Arran Executive Professional Officer for the British Association of Prosthetists and Orthotists Head of Physiotherapy, Adult LD Service NHS Tayside Superintendent Physiotherapist Stirling Hospital, NHS Forth Valley Clinical Lead NCDDP Information Services, NHS National Services Scotland Superintendent Physiotherapist Borders General Hospital, NHS Borders Prof Leader in Physiotherapy Royal Northern Infirmary, NHS Highland Allied Health Professions Core Data Standards Page 25

26 Michele Mackintosh Peter M c Crossan Philomena Reid Rob Packham Sheena Ogilvie Stephen Moore Tricia Mitchell Professional Lead Dietetics, Lomond & Argyll, NHS Argyll & Clyde Head of Podiatry Cleland Hospital, NHS Lanarkshire Dietetics Monklands Hospital, NHS Lanarkshire Therapy & Rehabilitation Manager Queen Margaret Hospital, NHS Fife Assistant Lead Occupational Therapist Royal Hospital for Sick Children, Edinburgh (to July 2005) Head of Podiatry Western Isles Hospital, NHS Western Isles Lead Speech & Language Therapist Borders General Hospital, NHS Borders Allied Health Professions Core Data Standards Page 26

27 Appendix 2 - ICF Code The International Classification of Function, Disability and Health Code (ICF code) 1, published by the World Health Organisation, is a new coding system which will be used to classify the patient s health problem/issue data item C05. ICF code (b) b1 b2 b3 b4 b5 b6 b7 b8 (s) s1 s2 s3 s4 s5 s6 s7 s8 (d) d1 d2 d3 d4 d5 d6 d7 d8 d9 (e) e1 e2 e3 e4 e5 (x) ICF Descriptions Body function Mental functions Sensory functions and pain Voice and speech functions Functions of the cardiovascular, haematological, immunological & respi systems Functions of the digestive, metabolic and endocrine systems Genitourinary and reproductive functions Neuromusculoskeletal and movement-related functions Functions of the skin and related structures Body structure Structures of the nervous system The eye, ear and related structures Structures involved in voice and speech Structures of the cardiovascular, immunological and respiratory systems Structures related to the digestive, metabolic and endocrine systems Structures related to the genitourinary and reproductive systems Structures related to movement Skin and related structures Activities and participation Learning and applying knowledge General tasks and demands Communication Mobility Self-care Domestic life Interpersonal interactions and relationships Major life areas Community, social and civic life Environmental factors Products and technology Natural environment and human-made changes to environment Support and relationships Attitudes Services, systems and policies Unable to match to an ICF code 1 World Health Organisation (2001). International Classification of Functioning, Disability and Health. Allied Health Professions Core Data Standards Page 27

28 STEP 1: choose one of the categories b, s, d, e, x: Does the patient s overriding health problem issue originate in an impairment or limitation of: (b) Body function Physiological function of the body system. (s) Body structure Anatomical part of the body e.g. organs, limbs and their components. (d) Activities and participation Activity is the execution of a task or action by an individual. Participation is involvement in a life situation. (e) Environmental factors These make up the physical, social and attitudinal environment in which people live and conduct their lives. (x) Unable to match to an ICF code Choose this category if there is no appropriate ICF code. STEP 2: Choose the most appropriate code within the category above. For example to code back pain; the back is a body structure but the main concern to the patient is the level of pain. This means that the pain takes priority and the code will be b2, made up of Body function code b plus Sensory functions and pain sub code 2. Allied Health Professions Core Data Standards Page 28

29 Appendix 3 - Distribution List AHP ehealth Leads AHP Networks in Scotland Allied Health Professions Forum-Scotland Associated Chiropodists and Podiatrists Union Association of Clinical Scientists (ACS) Association of Operating Department Practitioners (AODP) British Association of Arts Therapists British Association of Drama therapists British Association of Occupational Therapists British Association of Professional Music Therapists British Association of Prosthetists & Orthotists British Chiropody & Podiatry Association British Dietetic Association British Medical Association British Orthoptic Society British Paramedic Association Chartered Society of Physiotherapists Clinical ehealth Leads College of Occupational Therapists Community Nurses Network Electronic Clinical Communication Implementation (ECCI) Electronic Community Health Information Project (echip) Health & Social Care Information Centre, Datasets Development Programme (England) Health Protection Scotland Information Services (ISD) Information Standards Group Institute of Biomedical Science Institute of Chiropodists & Podiatrists National Services Division NHS Board Chief Executives NHS Board Directors of Public Health NHS Connecting for Health NHS Health Scotland NHS Quality Improvement Scotland NHS24 Open Scotland Information Age Framework (OSIAF) Royal College of General Practitioners (Scotland) Royal College of Nursing (Scotland) Royal College of Physicians Royal College of Physicians and Surgeons Glasgow Royal College of Physicians, London Royal College of Radiologists Royal College of Speech and Language therapists Royal College of Surgeons Queen Margaret University College Robert Gordon University SCI Programme Board Scottish Clinical Information Management Practice (SCIMP) Allied Health Professions Core Data Standards Page 29

30 Scottish ehealth Nursing Forum Scottish Executive Centre for Change and Innovation Scottish Executive Data Standards Branch Scottish Intercollegiate Guidelines Network Society & College of Radiographers Society of Chiropodists & Podiatrists UK Data Standards Forum Voluntary Health Scotland NCDDP Reference & Working Groups AHP Core Data Standards Community Nursing Core Data Standards NCDD Programme Board Allied Health Professions Core Data Standards Page 30