National Care of the Dying Audit Hospitals (NCDAH) Round 3

National Care of the Dying Audit Hospitals (NCDAH) Round 3 This audit is being led by the Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians, and is supported by the Department of Health and Marie Curie Cancer Care CLINICAL AUDIT Guidance for Completing Your Clinical Audit Proformas or Matched Alternative April 2011 NCDAH Clinical Audit Coding Guidelines April 2011 1 of 21

SHOULD YOU HAVE ANY QUERIES AT ALL ABOUT COMPLETING YOUR PROFORMAS THEN PLEASE DON T HESITATE TO CONTACT OUR EVALUTIONS UNIT ON: 0151 706 2212 or email: evaluations.unit@rlbuht.nhs.uk HOURS: 9.00 5.00PM (Mon Fri) Answering Machine available if the team is unable to take your call and queries will be responded to within 2 working days Clinical Audit 1. Auditor This can be completed by any member of staff within your organisation. This person should be in a position senior enough to have access to the required information. 2. Completion of One should be completed and submitted for each completed LCP document entered into the audit. All fields must be filled in before the can be indicated as Complete and data must be submitted between 1 st April and 30 th June 2011 (final submission by Friday 8th July 2011). Sample size is a minimum of 30 completed LCPs, although hospitals are encouraged to submit as many patient data sets as possible throughout the data collection period, in order to ensure a more robust feedback of data to compare with the national benchmark. Data Protection: NCDAH Round 3 Disclaimer All care has been taken to ensure confidentiality within this electronic data submission tool, and therefore Organisations are prohibited to enter any data that may identify an organisation or patient e.g. organisation names, or patient identifiable information. All guidance must be followed for the completion of any electronic. The NCDAH data entry tool has been designed in accordance with the Data Protection Act 1998 and no patient/organisation identifiable information is needed to complete the audit. NCDAH Clinical Audit Coding Guidelines April 2011 2 of 21

CONTENTS PAGE How to identify your sample of patients 4 How to complete the Demographic Information section of your 5 6 Generic Guidance for those hospitals using LCP Generic Version 12 or matched alternative Initial Assessment Ongoing Assessment Care After Death 7 22 7 17 18 19 20 22 It is imperative that all guidance is followed strictly to ensure that the data from each individual hospital can be successfully brought together to provide feedback that is accurate and meaningful Final submission of your completed s (data collection period 1 st April 30 th June 2011) is required by 8 th July 2011, however, you should aim to enter your data consecutively from 1 st April. It is important to remember that information about the number of total deaths in your Hospital Trust for the whole 3 month data collection period will be required in order to complete the NCDAH organisational. Therefore, it is vital that you continue to collect information about the number of deaths that occur in your Hospital Trust for the whole of the data collection period. NCDAH Clinical Audit Coding Guidelines April 2011 3 of 21

How to identify your sample of patients The sample for this audit is drawn from the population of deaths supported by the Liverpool Care Pathway for the Dying Patient (LCP) generic version 12, or matched alternative occurring in your hospital in the three month period between 1 st April 2011 and 30 th June 2011 (inclusive). You should enter data into the online tool for each consecutive death supported by the LCP or matched alternative, occurring on or after 1 st April 2011 until the end of the data collection period. We have suggested a minimum sample size of 30, however organisations are encouraged to enter as many LCPs as they have during the data collection phase to ensure a robust and representative sample to compare with the national benchmark. However, as entry into the audit has been judged using the LCP or matched alternative you submitted at registration, only deaths supported by this version of the LCP should be included in the sample. Data quality: Inter-Auditor Reliability In order to assess the quality of data submitted, a second auditor from within each hospital will be required to independently code 4 patient data sets using this guidance. This data will be used to estimate how faithfully the data has been coded onto the. The separate user name and password for the submission of this data is included in the document Inter-auditor Reliability attached to the NCDAH Round 3 Data Entry and Submission email. Data Protection: NCDAH Round 3 Disclaimer All care has been taken to ensure confidentiality within this electronic data submission tool, and therefore Organisations are prohibited to enter any data that may identify an organisation or patient e.g. organisation names, or patient identifiable information. All guidance must be followed for the completion of any electronic. The NCDAH data entry tool has been designed in accordance with the Data Protection Act 1998 and no patient/organisation identifiable information is needed to complete the audit. NCDAH Clinical Audit Coding Guidelines April 2011 4 of 21

NCDAH Round 3 NCDAH Clinical Audit Proforma Coding Guidelines Demographic Information Data Item Patient Identifier Patient Age Gender Hours on LCP Month of Death Did the patient have Dementia as a co-morbidity? Primary Diagnosis Explanation It is vital that patient confidentiality and anonymity is preserved. For this reason you will need to assign a patient identifier for each submitted. Please number the s 1 30 etc, where number 1 represents the first patient death supported by an LCP or matched alternative from 1 st April 2011. This patient identifier is crucial so if queries arise during our analysis, they can be resolved quickly. We recommend that you photocopy all LCPs or matched alternatives from which data were submitted and record the relevant patient identifier on each copy. All data collected should be stored securely within a locked cabinet, to which only designated personnel have access. Using the patient s date of birth, please calculate the patient s age at time of death rounded down to the nearest whole number of years. e.g.: Patient s DOB = 10 th April 1940 Patient s DOD = 8 th April 2011 Age = 70 Please code the corresponding selection on the This should be calculated as the time between the date and time of death and the date and time recorded when the LCP or matched alternative was commenced, or where this has not been recorded, of the date and time of the first observation in the ongoing assessment). Make sure this is entered in number of hours and not in days, and also round up or down to the nearest hour, as appropriate. Eg: if the LCP or matched alternative was commenced at 10.00 hours on 24 th April 2011 and the patient died at 13.25 hours on 26 th April 2011, the number of hours that the patients care was supported by the LCP would be recorded as 51 hours (not 52 as the patient was alive for fewer than 30 minutes into the next hour). This information will allow us to calculate the length of time taken for you to collect your 30 LCPs or matched alternative, and to ensure that all data submitted is from within the appropriate time period. Please select the correct month by clicking on the appropriate selection on the. Please code Yes if the patient a diagnosis of dementia that coexists with the diagnosis of a separate, primary medical condition. The 'Primary Diagnosis' is the main illness that the patient was suffering from at the time of death, which may or may not be the same as the direct cause of death. This information will allow us to understand more about the patient sample, and in particular to calculate the percentage of patients with a cancer or non cancer diagnosis. If you have any difficulty in coding the information correctly from the LCP or matched alternative to the, please refer to the following website: The International Statistical Classification of Diseases and Related Health Problems 10 th revision 2006 (ICD-10) website: www3.who.int/icd/currentversion/fr-icd.htm NCDAH Clinical Audit Coding Guidelines April 2011 5 of 21

NCDAH Round 3 NCDAH Clinical Audit Proforma Coding Guidelines Goal Information Please pay close attention to the goal labels or descriptors rather than the goal numbers, as the numbering system used in your LCP or matched alternative may differ from that used in the. GOAL 1.1 The patient is able to take a full and active part in communication Unconscious NCDAH Round 3 Clinical Proforma SECTION 1 INITIAL ASSESSMENT Coding Guidance Goal 4: Ability to communicate in English assessed as adequate a) Patient Comatose Achieved, Variance, Unconscious on the LCP, please code Achieved, Variance, Unconscious on the online. as missing as all fields must be Coding guidelines for LCP V11: If Yes is documented on LCP V11, code Achieved on If No is documented on LCP V11, code Variance on If Comatose is documented on LCP V11, code Unconscious on If a goal has been left blank on the LCP, Missing must be coded on the online. All allowed fields must be GOAL 1.2 The relative or carer is able to take a full and active part in communication as missing as all fields must be Goal 4: Ability to communicate in English assessed as adequate b) Family/other Coding guidelines for LCP V11: If Yes is documented on LCP V11, code Achieved on If No is documented on LCP V11, code Variance on If a goal has been left blank on the LCP, Missing must be coded on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 6 of 21

GOAL 1.3 The patient is aware that they are dying Unconscious Coding Guidance Achieved, Variance, Unconscious on the LCP, please code Achieved, Variance, Unconscious on the online. Goal 5: Insight into condition assessed Recognition of dying c) Patient Comatose Coding guidelines for LCP V11: Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on If Comatose is documented on LCP, code Unconscious on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be GOAL 1.4 The relative or carer is aware that the patient is dying Goal 5: Insight into condition assessed Recognition of dying d) Relative/Carer Coding guidelines for LCP V11: Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 7 of 21

GOAL 1.5 The clinical team have up to date contact information for the relative or carer as documented below GOAL 2 The relative or carer has had a full explanation of the facilities available to them, and a facilities leaflet has been given Coding Guidance Goal 7: Identify how family/other are to be informed of patient s impending death At any time Not at night-time Stay overnight at Hospital Primary contact name:... Relationship to patient:... Tel no:... Secondary contact:... Tel no:. Coding guidelines for LCP V11: Primary and secondary contact name, relationship, telephone number has been documented clearly on the LCP in the section provided code Achieved on the online. Primary and secondary contact name, relationship, telephone number has not been documented clearly on the LCP in the section provided code Missing on the online. NB: there is no option to code Variance for this goal, as coding is dependent upon whether or not there is written information on the LCP at the point of care delivery. All allowed fields must be Goal 8: Family/other given hospital information on:- Facilities leaflet available to address: Car parking; Accommodation; Beverage facilities; Payphones; Washrooms & toilet facilities on the ward; Visiting times; Any other relevant information. Coding guidelines for LCP V11: Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 8 of 21

GOAL 3.1 The patient is given the opportunity to discuss what is important to them at this time e.g. their wishes, feelings, faith, beliefs, values Unconscious Sub goals 3.1a. Did the patient take up the opportunity to discuss what is important to them? Coding Guidance Achieved, Variance, Unconscious on the LCP, please code Achieved, Variance, Unconscious on the online. Yes, No on the LCP, please code Yes, No on the online. Goal 6: Religious/spiritual needs assessed a) with Patient Comatosed Patient/other may be anxious for self/others Consider specific cultural needs Consider support of Chaplaincy Team Coding guidelines for LCP V11: Slight wording difference but overall meaning of the goal still matches and the coding is the same. If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on If Comatose is documented on LCP, code Unconscious on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be Excluded Does not appear on LCP version 11 NCDAH Clinical Audit Coding Guidelines April 2011 9 of 21

3.1b. Was the patients religious tradition identified? GOAL 3.2 The relative or carer is given the opportunity to discuss what is important to them at this time e.g. their wishes, feelings, faith, beliefs, values Sub goal 3.2a. Did the relative/carer take up the opportunity to discuss what is important to them? Coding Guidance Yes, No on the LCP, please code Yes, No on the online. Yes, No on the LCP, please code Yes, No on the online. Excluded Does not appear on LCP version 11 Goal 6: Religious/spiritual needs assessed b) with family/other Coding guidelines for LCP V11: Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be Excluded Does not appear on LCP version 11 NCDAH Clinical Audit Coding Guidelines April 2011 10 of 21

GOAL 4.1 The patient has medication prescribed on a prn basis for all of the following 5 symptoms which may develop in the last hours or days of life GOAL 4.2 Equipment is available for the patient to support a continuous subcutaneous infusion (CSCI) of medication where required already in place not required Coding Guidance Achieved, Variance, already in place, not required on the LCP, please code Achieved, Variance, already in place, not required on the online. Goal 2: PRN subcutaneous medication written up for list below as per protocol (See sheets at back of LCP for guidance) Pain Agitation RTS Nausea and Vomiting Dyspnoea Coding guidelines for LCP V11: Medication for All 5 symptoms (pain, agitation, RTS, nausea and vomiting, dyspnoea) have been documented Yes code Achieved on the online. At least 1 symptom has been documented No, even if all the other symptoms have been documented Yes code Variance on the online. At least 1 symptom has been left blank at the point of care delivery code Missing on the online. Please remember that all symptoms have been left blank on the LCP, you must code Missing on the online. All allowed fields must be Goal 3b: Syringe driver set up within 4 hours of doctors order N/A If Yes is documented on LCP V11, code Achieved on If No is documented on LCP V11, code Variance on If N/A is documented on LCP V11, code not required on. This will be recoded by the Evaluations Unit as N/A after submission of data, and reported back separately in the NCDAH Round 3 final report. If a goal has been left blank on the LCP, Missing must be coded on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 11 of 21

GOAL 5.1 The patient s need for current interventions has been reviewed by the MDT Coding Guidance 5a: Routine Blood Tests 5b: Intravenous Antibiotics 5c: Blood Glucose Monitoring 5d: Recording of Routine Vital Signs 5e: Oxygen Therapy Commenced, Discontinued, already in place, not required etc on the LCP, please code Commenced, Discontinued, already in place, not required etc, on the online. Excluded Does not appear on LCP version 11 NCDAH Clinical Audit Coding Guidelines April 2011 12 of 21

GOAL 5.2 The patient has a Do Not Attempt Cardiopulmonary Resuscitation Order in place GOAL 5.3 Implantable Cardioverter Defibrillator (ICD) is deactivated No ICD in place Coding Guidance Achieved, Variance, No ICD in place on the LCP, please code Achieved, Variance, No ICD in place on the online. 3.4 Not for cardiopulmonary resuscitation recorded Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be 3.5 Deactivate cardiac defibrillators (ICD s) N/A Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on If N/A is documented on LCP, code No ICD in place on NB: If your version of LCP does not have an option for N/A, you must only code Achieved Variance or Missing on the online. When interpreting your data you must be careful, and scrutiny of the variance sheet must be utilized. Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 13 of 21

GOAL 6 The need for clinically assisted (artificial) nutrition is reviewed by the MDT GOAL 7 The need for clinically assisted (artificial) hydration is reviewed by the MDT GOAL 8 The patient s skin integrity is assessed Coding Guidance Excluded Does not appear on LCP version 11 Excluded Does not appear on LCP version 11 Excluded Does not appear on LCP version 11 NCDAH Clinical Audit Coding Guidelines April 2011 14 of 21

GOAL 9.1 Full explanation of the current plan of care (LCP) is given to the patient Unconscious Coding Guidance Achieved, Variance, Unconscious on the LCP, please code Achieved, Variance, Unconscious on the online. Goal 10: Plan of care explained & discussed with: a) Patient Comatosed Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on If Comatosed is documented on LCP, code Unconscious on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be GOAL 9.2 Full explanation of the current plan of care (LCP) is given to the relative or carer Goal 10: Plan of care explained & discussed with: b) Relative/Carer Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 15 of 21

GOAL 9.3 The LCP Coping with dying leaflet or equivalent is given to the relative or carer Goal 9.4 The patient s primary healthcare team / GP practice is notified that the patient is dying Coding Guidance Excluded Does not appear on LCP version 11 Goal 9: G.P. Practice is aware of patient s condition G.P. Practice to be contacted if unaware patient is dying, Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be NCDAH Clinical Audit Coding Guidelines April 2011 16 of 21

Goal a : The patient does not have pain Goal b : The patient is not agitated Goal c : The patient does not have respiratory tract secretions Goal d : The patient does not have nausea Goal e : The patient is not vomiting Goal f : The patient is not breathless Goal g : The patient does not have urinary problems NCDAH Round 3 Clinical Proforma: SECTION 2 ONGOING ASSESSMENT Guidance Goals Pain, Agitation, Respiratory Tract Secretions (RTS), Nausea, Vomiting, Dyspnoea, Micturition, Bowel Care, Medication, Clinically Assisted (artificial) Hydration; Mouth Care, Skin Integrity, personal Hygiene, physical environment, patient s psychological well-being, well-being of the relative or carer. The boxes on the LCP are split in to the same 4 hourly sections as those on the. The 4 hourly assessment times on the LCP occur at intervals starting at 04.00 and ending at 24.00. Your LCP may identify slightly different times to fit in with shift patterns locally (e.g. 03.00 to 23.00) which should be coded in the same way. The seeks information regarding the last 24 hours of the patient s life (approximately). The boxes on the are numbered 1-6 (where 1 represents the last possible assessment prior to the patient s death). In order to complete this section accurately, it is important to identify the last observation time possible prior to the time at which the patient died, and also the time the LCP was commenced where known, or date and time of first ongoing assessment. Example: LCP commenced on 09/04/11 at 0730 Patient died on 10/04/11 at 0100 Last possible observation would be 2400 on 09/04/11 Then count back a further 5 observations (6 in total) and code accordingly A (Achieved) has been recorded against a particular goal in a given time point, you should enter a 1 - Achieved into the corresponding box on the. V (Variance) has been recorded on the LCP; you should enter a 2 - Variance into the corresponding box on the. Where an assessment was possible (i.e. the patient was being supported by the LCP at the time of the assessment) but the box has been left blank, you should enter a 9 - Missing into the corresponding box on the to indicate that the goal was not documented. Where a patient was supported by the LCP for less than 24 hours there will be legitimate blank boxes in the 6 timeslots that you have previously identified. Here, you should enter a 3 Not Applicable into the corresponding box(es) on the to indicate that the patient was not being supported by the LCP at that particular time point (continued over page). LCP generic version 11, or Matched Alternative Guidance Goal a Please follow guidance for LCP generic version 12 users Goal b Please follow guidance for LCP generic version 12 users Goal c Please follow guidance for LCP generic version 12 users Goal d & E This goal on LCP V11 is combined into Nausea and Vomiting Coding guidance for LCP version 11 users: Where A has been recorded on the assessment sheet 1 (achieved) must be entered into the online for both nausea and vomiting Where V has been recorded on the assessment sheet 2 (variance) must be entered into the online for both nausea and vomiting Where nothing has been documented (assessment slot left blank) 9 (missing) must be entered into the online for both nausea and vomiting All allowed fields must be completed to allow submission of data. Goal f Please follow guidance for LCP generic version 12 users Goal g Please follow guidance for LCP generic version 12 users NCDAH Clinical Audit Coding Guidelines April 2011 17 of 21

Goal h : The patient does not have bowel problems Goal j : The patient s comfort & safety regarding the administration of medication is maintained Goal k : The patient receives fluids to support their individual needs Goal l: The patient s mouth is moist and clean Goal m: The patient s skin integrity is maintained Goal n: The patient s personal hygiene needs are met Goal o: The patient receives their care in a physical environment adjusted to support their individual needs Goal p: The patient s psychological well-being is maintained Goal q: The well-being of the relative or carer attending the patient is maintained Guidance Please ensure that you only code those entries that have been recorded correctly. For example, if a signature has been placed in the column rather than the required A or V, a code of 9 ( Missing ) must be recorded on the, as it is impossible to interpret the meaning of a signature retrospectively. Coding 1 Achieved 2 Variance 3 Patient not supported by the LCP at this time point 9 Assessment possible, but entry missing If the last possible assessment for this patient was at 24.00 hours, data coded as follows on the LCP: Section Patient 2 problem/focus Ongoing assessment Pain Goal: Patient is pain free Verbalised by patient if conscious Pain free on movement Appears peaceful Consider need for positional change Would be coded as follows on the : 04:00 08:00 12:00 16:00 20:00 24:00 A A V A 6 5 4 3 2 1 PAIN 3 1 9 1 2 1 LCP generic version 11, or Matched Alternative Guidance Excluded 12 hourly on LCP V11 Goal j Please follow guidance for LCP generic version 12 users Excluded Does not appear on LCP version 11 Goal l Please follow guidance for LCP generic version 12 users Excluded Combined under LCP V11 goal Mobility/Pressure area care, also 12 hourly. Excluded Combined under LCP V11 goal Mobility/Pressure area care, also 12 hourly. Excluded Combined under LCP V11 goal Mobility/Pressure area care, also 12 hourly. Excluded 12 hourly on LCP V11 Excluded 12 hourly on LCP V11 NCDAH Clinical Audit Coding Guidelines April 2011 18 of 21

GOAL 10 Last offices are undertaken according to policy and procedure GOAL 11 The relative or carer can express an understanding of what they will need to do next and are given the relevant written information SECTION 3 CARE AFTER DEATH Guidance box which corresponds to the information Achieved, Variance on the LCP, please code Achieved, Variance on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online box which corresponds to the information Achieved, Variance on the LCP, please code Achieved, Variance on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online LCP generic version 11, or Matched Alternative Guidance Goal 13: Procedures for laying out followed according to hospital policy Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. This combines 2 goals from LCP V11 into one overall goal in LCP V12. Both goals 15/16 are documented Yes code Achieved on At least 1 goal documented No code Variance on At least 1 goal left blank/not documented code Missing on. Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. NCDAH Clinical Audit Coding Guidelines April 2011 19 of 21

GOAL 12.1 The Primary healthcare team / GP is notified of the patient s death Guidance box which corresponds to the information Achieved, Variance on the LCP, please code Achieved, Variance on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online LCP generic version 11, or Matched Alternative Guidance Goal 12: GP Practice contacted re patient s death Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. Sub Goal 12a Grieving Leaflet Given box which corresponds to the information Yes, No on the LCP, please code Yes, No on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online Goal 18: Bereavement leaflet given Slight wording difference but overall meaning of the goal still matches, please see coding below: If Yes is documented on LCP, code Yes on If No is documented on LCP, code No on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. NCDAH Clinical Audit Coding Guidelines April 2011 20 of 21

Sub Goal 12b DWP1027 (England & Wales) or equivalent is given GOAL 12.2 The patient s death is communicated to appropriate services across the organisation Guidance box which corresponds to the information Yes, No on the LCP, please code Yes, No on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online box which corresponds to the information Achieved, Variance on the LCP, please code Achieved, Variance on the online. entry (i.e. nothing coded against a particular goal on the LCP or matched alternative goal not documented) is coded on the online LCP generic version 11, or Matched Alternative Guidance Goal 17: Necessary documentation & advice is given to the appropriate person What to do after death booklet given (DHSS) please see coding below: If Yes is documented on LCP, code Yes on If No is documented on LCP, code No on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. Goal 14: Procedure following death discussed or carried out Input patients death on hospital computer LCP V12 goal 12.2 separates the above prompt from within LCP V11 goal 14 into an overall goal. Please see coding below: If Yes is documented on LCP, code Achieved on If No is documented on LCP, code Variance on Please remember that if a goal has been left blank on the LCP, you must code Missing on the online. All allowed fields must be completed to allow submission of data. NCDAH Clinical Audit Coding Guidelines April 2011 21 of 21