Diabetes Foot Care Extension Dataset
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Draft Diabetes Foot Care Extension Dataset Diabetes Foot Care Extension Dataset Consultation Document February 2006 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7053 Email to: [email protected] Website: http://www.clinicaldatasets.scot.nhs.uk/
Transcript of Diabetes Foot Care Extension Dataset
Draft Diabetes Foot Care Extension Dataset
Diabetes Foot Care Extension Dataset
Consultation Document
February 2006
National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7053 Email to: [email protected] Website: http://www.clinicaldatasets.scot.nhs.uk/
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Contents 1. Patient Administration and Demographics ..................................... 5 Patient Administration and Demographics Table........................................................................5
2. Ethnic, Cultural and Diversity.......................................................... 6 Ethnic, Cultural and Diversity Table............................................................................................6
3. Socio-Environmental Details ........................................................... 6 Socio-Environmental Details Table.............................................................................................6
4. General Medical Practitioner Details................................................ 7 General Medical Practitioner Details Table.................................................................................7
5. Associated Person Details................................................................ 8 Associated Person Details Table................................................................................................8
6. Associated Professional Details....................................................... 9 Associated Professional Details Table........................................................................................9
7. Diagnosis Details ............................................................................... 9 Diagnosis Details Table ..............................................................................................................9
8. Care Episode Administration Details ............................................. 10 Care Episode Administration Details Table ..............................................................................10 8.1 Appointment Type {Diabetes} .............................................................................................10
9. Vascular Assessment..................................................................... 11 Vascular Assessment Table .....................................................................................................11 9.1 Diabetes-related Amputation ..............................................................................................11 9.2 Date of Amputation of Lower Limb......................................................................................11 9.3 Intermittent Claudication .....................................................................................................12 9.4 Previous Vascular Intervention (Lower Limb) .....................................................................12
10. Neurological Assessment ............................................................. 13 Neurological Assessment Table ...............................................................................................13 10.1 Loss of Protective Sensation ............................................................................................13 10.2 Neurotips Assessment......................................................................................................13 10.3 Neurothesiometer Assessment.........................................................................................14 10.4 Painful Neuropathy ...........................................................................................................14
11. Risk Factors ................................................................................... 16 Risk Factors Table....................................................................................................................16 11.1 Previous Ulceration...........................................................................................................16 11.2 Structural Abnormality.......................................................................................................16 11.3 Ability to Self-care (Foot Care)..........................................................................................16
12. Risk Category................................................................................. 18 Risk Category Table .................................................................................................................18
13. Action.............................................................................................. 18 Action Table..............................................................................................................................18 13.1 Type of Educational Advice Given ....................................................................................18
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14. New Ulcer Assessment Data......................................................... 19 New Ulcer Assessment Data Table ..........................................................................................19 14.1 Foot Ulcer Number............................................................................................................19 14.2 Ulcer Treatment Start Date ...............................................................................................19 14.3 Ulcer Treatment End Date ................................................................................................20 14.4 Estimated Duration of Ulcer ..............................................................................................20 14.5 Foot Ulcer Causative Factors ...........................................................................................20 14.6 Anatomical Location..........................................................................................................21 14.7 Aspect of Foot...................................................................................................................21 14.8 Specified Location of Ulcer ...............................................................................................22 14.9 Previously Ulcerated at this Site .......................................................................................23 14.10 Previous Ulcer Number(s)...............................................................................................23 14.11 Foot Wound Classification (The University of Texas) .....................................................23
15. Foot Ulcer Management ................................................................ 25 Foot Ulcer Management Table .................................................................................................25 15.1 Date of Assessment (Foot Ulcer)......................................................................................25 15.2 Condition of Ulcer Bed......................................................................................................25 15.3 Condition of Ulcer Surrounding Skin.................................................................................26 15.4 Foot Ulcer Exudate Volume ..............................................................................................26 15.5 Foot Ulcer Exudate Type ..................................................................................................27 15.6 Frequency of Pain (Foot Ulcer).........................................................................................27 15.7 Severity of Pain (Foot Ulcer).............................................................................................27 15.8 Foot Ulcer Odour ..............................................................................................................28 15.9 Wound Infection................................................................................................................28 15.10 Osteomyelitis ..................................................................................................................28 15.11 Foot Ulcer Depth.............................................................................................................29 15.12 Foot Ulcer Length ...........................................................................................................29 15.13 Foot Ulcer Width .............................................................................................................30 15.14 Undermining Wound .......................................................................................................30 15.15 Foot Ulcer Photograph Taken.........................................................................................30 15.16 Foot Ulcer Dressing Type ...............................................................................................31 15.17 Foot Ulcer Dressing Category.........................................................................................31 15.18 Foot Ulcer Dressing Name..............................................................................................31 15.19 Pressure Management Footwear....................................................................................32 15.20 Debridement Type ..........................................................................................................33 15.21 Date of Next Appointment...............................................................................................33 15.22 Foot Ulcer Management Follow-up.................................................................................33
16. Medication ...................................................................................... 35 Medication Table.......................................................................................................................35 16.1 Current Antibiotic Therapy (Foot Ulcer) ............................................................................35
17. Foot Ulcer Management Evaluation ............................................. 36 Foot Ulcer Management Evaluation Table................................................................................36 17.1 Date of Outcome (Foot Ulcer Management).....................................................................36 17.2 Duration of Treatment (Foot Ulcer) ...................................................................................36 17.3 Foot Ulcer Outcome..........................................................................................................36 17.4 Vascular Surgical Intervention ..........................................................................................37 17.5 Footwear...........................................................................................................................37 17.6 Review Date......................................................................................................................38
18. Outcomes....................................................................................... 38 Outcomes Table........................................................................................................................38
19. Date ................................................................................................ 38
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Date Table ................................................................................................................................38
Appendix 1 - Membership of the Diabetes Foot Care Extension Working Group..................................................................................... 39
Appendix 2 - Consultation Distribution List ...................................... 40
Appendix 3 - Consultation Response ................................................ 41
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1. Patient Administration and Demographics
Patient Administration and Demographics Table Data Item Definition Format & Field Length Structured Name1 - Person Title - Person Family Name - Person Given Name - Person Preferred Forename - Previous Person Family Name
An ordered sequence of person name elements such as title, forename(s) and family name.
35 characters (each)
Person Full Name1 (Unstructured)
This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements.
70 characters
Person Current Gender
A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned).
1 character
Person Birth Date
The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate.
10 characters (CCYY-MM-DD)
CHI Number
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.
10 characters
Address (BS7666) 2
A collection of data describing the addressing of locations.
See Government Data Standards Website
UK Postal Address2 Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines).
5x35 characters
Postcode2
The code allocated by the Post Office to identify a group of postal delivery points.
8 characters
UK Telephone Number A minimum standard is provided for holding a UK STD code. An extended set of component parts is provided for systems to hold more information.
35 characters
Internet Email Address The string of characters that identifies an addressee's post box on the Internet.
255 characters
Person Marital Status An indicator to identify the legal marital status of a person.
1 character
Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary.
1 It is recommended that Structured Name should be used in all new IT systems. Person Full Name (Unstructured) should only be used in legacy systems, which should migrate to use of Structured Name in due course. 2 It is recommended that Address (BS7666), which is a structured address, should be used in all new IT systems. Unstructured UK Postal Address plus Postcode should only be used in legacy systems, which should migrate to use of Address (BS7666) in due course.
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2. Ethnic, Cultural and Diversity
Ethnic, Cultural and Diversity Table Data Item Description Format & Field Length Ethnic Group (Self-Assigned) A statement made by the service user
about their current ethnic group. 3 characters
Note: The above data item has already been approved and is available in the Health & Social Care Data Dictionary.
3. Socio-Environmental Details
Socio-Environmental Details Table Data Item Description Format & Field Length Occupation The current and/ or previous relevant
occupation(s) of the patient/ client, as described by them.
75 characters
Note: The above data item has already been approved and is available in the Health & Social Care Data Dictionary.
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4. General Medical Practitioner Details
General Medical Practitioner Details Table Data Item Definition Format & Field Length GP General Medical Council Number
The GMC (General Medical Council) number is the personal identification number issued to each doctor in the UK by the General Medical Council.
8 characters
Registered GP Practice Code
Each GP practice in Scotland is identified by a unique GP practice code.
6 characters
Address (BS7666) A collection of data describing the addressing of locations.
see Government Data Standards website
UK Postal Address Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines).
5x35 characters
Postcode The code allocated by the Post Office to identify a group of postal delivery points.
8 characters
Structured Name - GP Title - GP Family Name - GP Given name
An ordered sequence of person name elements such as title, forename(s) and family name.
35 characters
Person Full Name (Unstructured)
This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements.
70 characters
Start date The date on which a process or period of validity commences.
10 characters (CCYY-MM-DD)
End date The date on which a process or period of validity terminates.
10 characters (CCYY-MM-DD)
Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary.
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5. Associated Person Details
Associated Person Details Table Data Item Definition Format & Field Length Associated Person People who have a significant
involvement or relationship with the client/patient (e.g. main carer, next of kin, key holder, emergency contact, etc). This includes professionals who are not involved in the care of the client/patient e.g. accountant, lawyer.
Detailed in this table
Structured Name - Title - Surname/ Family Name - First Forename
An ordered sequence of person name elements such as title, forename(s) and family name.
35 characters
Person Full Name (Unstructured)
This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements.
70 characters
Address (BS7666) A collection of data describing the addressing of locations.
see Government Data Standards website
UK Postal Address Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines).
5x35 characters
Postcode The code allocated by the Post Office to identify a group of postal delivery points.
8 characters
Telephone Number A minimum standard is provided for holding a UK STD code. An extended set of component parts is provided for systems to hold more information.
35 characters
Associated Person Role A description of the particular involvement(s) with/ function(s) fulfilled by an associated person towards the client/ patient.
3 characters
Relationship to Client/ Patient The relationship of an Associated Person to the client/patient.
3 characters
Start Date The date on which a process or period of validity commences.
10 characters (CCYY-MM-DD)
End Date The date on which a process or period of validity terminates.
10 characters (CCYY-MM-DD)
Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary.
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6. Associated Professional Details
Associated Professional Details Table Data Item Definition Format & Field LengthAssociated Professional Associated Professionals are
those individuals who are involved with the client/ patient in a professional capacity e.g. consultant, social worker, occupational therapist, etc.
Detailed in this table
Structured Name - Title - Surname/ Family Name - First Forename
An ordered sequence of person name elements such as title, forename(s) and family name.
35 characters
Person Full Name (Unstructured)
This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements.
70 characters
Address (BS7666) A collection of data describing the addressing of locations.
see Government Data Standards website
UK Postal Address Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines).
5x35 characters
Postcode The code allocated by the Post Office to identify a group of postal delivery points.
8 characters
Associated Professional Identifier
The unique identifier issued to all health and social care professionals by their professional regulatory body.
8 characters
Associated Professional Group The recognised professional group to which the care professional belongs and in which they are employed.
3 characters
Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary.
7. Diagnosis Details
Diagnosis Details Table Data Item Definition Format & Field Length Date of Diagnosis {Diabetes Mellitus}‡
For Consultation – see Diabetes Core 7 characters (CCYY-MM)
Diabetes Mellitus Type‡ For Consultation – see Diabetes Core 3 characters ‡ Further information on these data items can be found in the Diabetes Core Data Standards.
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8. Care Episode Administration Details
Care Episode Administration Details Table Data Item Definition Format & Field Length Location Code†
This is the reference number of any building or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client's home.
5 characters
Health Record Identifier†
The hospital patient identifier is a code, which uniquely identifies a patient on the main index of a hospital (i.e. within the hospital health records system).
14 characters
Clinic Code† A code assigned locally to identify a clinic session or group of clinic sessions.
15 characters
Clinic Name†
A name assigned locally to identify a clinic session or group of clinic sessions.
50 characters
Contact Status† A record of whether or not the patient/ client attended for their appointment or was present for a planned home visit.
2 characters
Appointment Type {Diabetes} For Consultation 2 characters † The above data items have already been approved and are available in the Health & Social Care Data Dictionary.
8.1 Appointment Type {Diabetes} Definition: Indicates whether the person’s appointment is a first (new) appointment or review (return/ follow-up) appointment.
Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 First e.g. new appointment. 02 Review e.g. return or follow-up appointment.
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9. Vascular Assessment
Vascular Assessment Table Data Item Definition Format & Field Length Amputation of Lower Limb (Personal history) {Diabetes}‡
For Consultation – see Diabetes Core 2 characters
Diabetes-related Amputation For Consultation 2 characters Date of Amputation of Lower Limb
For Consultation
10 characters (CCYY-MM-DD)
Foot Pulse Status‡
For Consultation – see Diabetes Core 2 characters
Intermittent Claudication For Consultation 2 characters Previous Vascular Intervention (Lower Limb)
For Consultation
2 characters
‡ Further information on these data items can be found in the Diabetes Core Data Standards.
9.1 Diabetes-related Amputation Definition: Records whether or not the amputation is diabetes related. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Attribute: Laterality Left Right
Related data item: Amputation of Lower Limb (Personal History) {Diabetes}
9.2 Date of Amputation of Lower Limb Definition: The date of the patient’s amputation of forefoot or part of the lower limb. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A
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Related data items: Amputation of Lower Limb (Personal History) {Diabetes} Amputation of Lower Limb (Diabetes Related)
9.3 Intermittent Claudication Definition: Records whether or not intermittent claudication is present. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Attribute: Laterality Left Right
9.4 Previous Vascular Intervention (Lower Limb) Definition: Records whether or not there is a history of some attempt at re-vascularisation such as bypass operation, angioplasty, vascular reconstruction or lumbar sympathectomy. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Attribute: Laterality Left Right
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10. Neurological Assessment
Neurological Assessment Table Data Item Definition Format & Field Length Foot Sensation to Monofilaments‡
For Consultation – see Diabetes Core 2 characters
Loss of Protective Sensation For Consultation 2 characters Neurotips Assessment For Consultation 2 characters Neurothesiometer Assessment For Consultation 2 characters Painful Neuropathy For Consultation 2 characters
‡ Further information on this data item can be found in the Diabetes Core Data Standards.
10.1 Loss of Protective Sensation Definition: Records whether or not the patient has loss of protective sensation in the foot, using a monofilament. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 00 No Foot sensation to monofilaments in the right foot
and foot sensation to monofilaments in the left foot = greater than or equal to 8 sites.
01 Yes Foot sensation to monofilaments in the right foot and foot sensation to monofilaments in the left foot = less than 8 sites.
Further information: Loss of Protective Sensation is defined as foot sensation to monofilaments in less than 8 sites if both feet are present, or less than 4 sites if only one foot is present.
10.2 Neurotips Assessment Definition: Ability to determine the presence or absence of a sharp or blunt sensation when neurotip is applied to the plantar surface of the hallux. Format: Characters Field length: 2
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Codes and values: Code Value Sub-
code Sub-value
00 Not Done A Present 01 Done B Absent
Attribute: Laterality Left Right Further information: Neurotip (sometimes contained within a neuropen) assesses pain perception. In random order the sharp or blunt end of the neurotip should be pressed against the plantar surface of the hallux and patient asked to distinguish between painful and non-painful. Failure to distinguish correctly constitutes a positive test result (Paisley A.N. et al. Diabetic Medicine 200, 19:400-405).
10.3 Neurothesiometer Assessment Definition: The average of three Neurosthesiometer readings (expressed in volts) at which the patient has vibration sense. Format: Characters (nn) Field length: 2 Codes and values: N/A Attribute: Laterality Left Right
10.4 Painful Neuropathy Definition: Record of whether or not the patient has symptoms present that are due to peripheral neuropathy. Format: Characters Field length: 2 Codes and values: Code Value 00 Absent 01 Present 99 Not Known
Attribute:
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Laterality Left Right Further information: Neuropathic pain manifests as shooting pains in the legs, burning pains in the legs, pain in the legs during walking and burning pain in the calves at night.
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11. Risk Factors
Risk Factors Table Data Item Definition Format & Field Length Foot Callus Status‡ For Consultation –see Diabetes Core 2 characters Prevalent Ulcer Status‡ For Consultation –see Diabetes Core 2 characters Previous Ulceration For Consultation 2 characters Structural Abnormality For Consultation 2 characters Foot Deformity Status‡ For Consultation –see Diabetes Core 2 characters Ability to Self-care (Foot care) For Consultation 2 characters
‡ Further information on these data items can be found in the Diabetes Core Data Standards.
11.1 Previous Ulceration Definition: Records whether or not the patient has had previous ulcers. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Related data item: Prevalent Ulcer Status
11.2 Structural Abnormality Definition: Records whether or not there is any structural or functional change in either foot, which causes localised increases in pressure. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
11.3 Ability to Self-care (Foot Care) Main source of standard: SIGN 55 Management of Diabetes: A National Clinical Guideline.
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Definition: Records whether or not the patient is able to self-care for their feet. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 00 No Unable to self-care for foot due to significant visual
impairment or physical disability (e.g. stroke, gross obesity).
01 Yes Able to self-care for foot. Further information: Ability to self-care refers to patients who are unable to reach their feet or who have poor vision and cannot provide regular monitoring and maintenance (e.g. toenail cutting, or filing).
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12. Risk Category
Risk Category Table Data Item Definition Format & Field Length Diabetic Foot Risk Status‡ For Consultation – see Diabetes Core 2 characters Podiatry Service Type‡ For Consultation – see Diabetes Core 2 characters
‡ Further information on these data items can be found in the Diabetes Core Data Standards.
13. Action
Action Table Data Item Definition Format & Field Length Type of Educational Advice Given
For Consultation 2 characters
Referred To {Diabetes}‡ For Consultation – see Diabetes Core 2 characters ‡ Further information on this data item can be found in the Diabetes Core Data Standards.
13.1 Type of Educational Advice Given Definition: Records the method used to give the educational advice. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 Verbal 02 Written This could be in various media such as paper, video,
cassette, CD, CDROM, DVD and website details.
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14. New Ulcer Assessment Data
New Ulcer Assessment Data Table Data Item Definition Format & Field Length Foot Ulcer Number For Consultation 4 characters Ulcer Treatment Start Date For Consultation 10 characters (CCYY-
MM-DD) Ulcer Treatment End Date For Consultation 10 characters (CCYY-
MM-DD) Estimated Duration of Ulcer
For Consultation 2 characters
Foot Ulcer Causative Factors
For Consultation 2 characters
Anatomical Location (Foot Ulcer Location 1)
For Consultation 2 characters
Aspect of Foot (Foot Ulcer Location 2)
For Consultation 2 characters
Specified Location of Ulcer (Foot Ulcer Location 3)
For Consultation 2 characters
Previously Ulcerated at this Site
For Consultation 2 characters
Previous Ulcer Number(s) For Consultation 4 characters Foot Wound Classification (The University of Texas)
For Consultation 2 characters
14.1 Foot Ulcer Number Definition: Records the identifier of the foot ulcer. Format: Characters Field length: 4 Codes and values: N/A Related data items: Ulcer Treatment Start Date Ulcer Treatment End Date Estimated Duration of Ulcer
14.2 Ulcer Treatment Start Date Definition: Records the start date of treatment for the new ulcer. Format: Characters (CCYY-MM-DD) Field length: 10
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Codes and values: N/A Related data items: Foot Ulcer Number Ulcer Treatment End Date
14.3 Ulcer Treatment End Date Definition: Records the date the ulcer is resolved. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A Related data items: Foot Ulcer Number Ulcer Treatment Start Date
14.4 Estimated Duration of Ulcer Definition: A record of how long the ulcer had been present before the patient presented at the clinic. Format: Characters Field length: 2 Codes and values: Code Value 01 <7 Days 02 1 Week to 4 Weeks 03 1 Month to 3 Months 04 >3 Months 99 Not Known
Related data item: Foot Ulcer Number
14.5 Foot Ulcer Causative Factors Definition: Underlying factors which have resulted in ulceration. Format: Characters Field length: 2 Codes and values:
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Code Value 01 Pressure 02 Ischaemia 03 Traumatic Penetration 04 Self Treatment 98 Other 99 Not Known
Recording guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Foot Ulcer Causative Factors.
14.6 Anatomical Location Common name: Foot Ulcer Location 1 Definition: The anatomical location of the ulcer on the foot. Format: Characters Field length: 2 Codes and values: Code Value 01 Calcaneum 02 Metatarso-phalangeal joint 03 Midtarsal 04 Longitudinal Arch 05 Malleolus 06 Toe(s) Specified 98 Other
Attributes: Laterality Left Right Related data items: Aspect of Foot Specified Location of Ulcer Recording guidance: Where ‘06 – Toe(s)’ or ‘98 – Other’ are recorded, systems may be configured to include a text box to allow specification of the Anatomical Location.
14.7 Aspect of Foot Common name: Foot Ulcer Location 2 Definition: The location aspect of the wound on the foot. Format: Characters
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Field length: 2 Codes and values: Code Value 01 Dorsal 02 Plantar 03 Anterior 04 Posterior 05 Apex 06 Web Space 07 Subungal 08 Medial 09 Lateral 10 Interphalangeal Joint 98 Other
Related data items: Anatomical Location Specified Location of Ulcer Recording guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Aspect of Foot.
14.8 Specified Location of Ulcer Common name: Foot Ulcer Location 3 Definition: The specified location of the ulcer on the foot. Format: Characters Field length: 2 Codes and values: Code Value 01 1 02 2 03 3 04 4 05 5
Related data items: Anatomical Location Aspect of Foot
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14.9 Previously Ulcerated at this Site Definition: Records whether or not there has been a previous ulcer at the same site as new ulcer. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Recording guidance: This item should be automatically generated by the system.
14.10 Previous Ulcer Number(s) Definition: The identifiers of previous ulcers at the same site as new ulcer. Format: Characters Field length: 4 Codes and values: N/A Recording guidance: This item should be automatically generated by the system.
14.11 Foot Wound Classification (The University of Texas) Main source of standard: Diabetic Foot Wound Classification System, The University of Texas San Antonio. Definition: The Texas classification of the foot wound. Format: Characters Field length: 4 Codes and values: Code Value Explanatory Notes 01 A0 Pre- or Post-ulcerative Lesion Completely Epithelialized. 02 A1 Superficial Wound, Not Involving Tendon, Capsule or Bone. 03 A2 Wound Penetrating to Tendon or Capsule. 04 A3 Wound Penetrating to Bone or Joint. 05 B0 Pre- or Post-ulcerative Lesion Completely Epithelialized with
Infection.
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06 B1 Superficial Wound, Not Involving Tendon, Capsule or Bone with Infection.
07 B2 Wound Penetrating to Tendon or Capsule with Infection. 08 B3 Wound Penetrating to Bone or Joint with Infection. 09 C0 Pre- or Post-ulcerative Lesion, Completely Epithelialized with
Ischaemia. 10 C1 Superficial Wound, Not Involving Tendon, Capsule or Bone with
Ischaemia. 11 C2 Wound Penetrating to Tendon or Capsule with Ischaemia. 12 C3 Wound Penetrating to Bone or Joint with Ischaemia. 13 D0 Pre- or Post-ulcerative Lesion Completely Epithelialized with
Infection and Ischaemia. 14 D1 Superficial wound, not involving tendon, capsule or bone with
infection and ischaemia. 15 D2 Wound Penetrating to Tendon or Capsule with Infection and
Ischaemia. 16 D3 Wound Penetrating to Bone or Joint with Infection and Ischaemia.
Further information: The University of Texas, San Antonio, Diabetic Foot Wound Classification System uses a system of wound grade and stage to categorise wounds by severity. Wounds are graded by depth (Grades 0, 1, 2 & 3). Within each wound grade, there are 4 stages: clean wounds (A), non-ischaemic infected wounds (B), ischaemic wounds (C) and infected ischaemic wounds (D). Sources: (i) Armstrong DG et al. Diabetes Care 1998; 21: 855-859 and (ii) Lavery, LA et al. Journal of Foot Ankle Surgery 1996; 35: 528-531.
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15. Foot Ulcer Management
Foot Ulcer Management Table Data Item Definition Format & Field Length Date of Assessment (Foot Ulcer)
For Consultation 10 characters (CCYY-MM-DD)
Condition of Ulcer Bed For Consultation 2 characters Condition of Ulcer-Surrounding Skin
For Consultation 2 characters
Foot Ulcer Exudate Volume For Consultation 2 characters Foot Ulcer Exudate Type For Consultation 2 characters Frequency of Pain (Foot Ulcer)
For Consultation 2 characters
Severity of Pain (Foot Ulcer)
For Consultation 2 characters
Foot Ulcer Odour For Consultation 2 characters Wound Infection For Consultation 2 characters Osteomyelitis For Consultation 2 characters Foot Ulcer Depth For Consultation 2 characters Foot Ulcer Length For Consultation 3 numeric (nnn) Foot Ulcer Width For Consultation 3 numeric (nnn) Undermining Wound For Consultation 2 characters Foot Ulcer Photograph Taken
For Consultation 2 characters
Foot Ulcer Dressing Type For Consultation 2 characters Foot Ulcer Dressing Category
For Consultation 2 characters
Foot Ulcer Dressing Name For Consultation 2 characters Pressure Management – Footwear
For Consultation 2 characters
Debridement Type For Consultation 2 characters Date of Next Appointment For Consultation 10 characters (CCYY-
MM-DD) Actions Taken- Foot Ulcer Management
For Consultation 2 characters
15.1 Date of Assessment (Foot Ulcer) Definition: The date on which the assessment of the ulcer took place. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A
15.2 Condition of Ulcer Bed Definition: The condition of the tissue in the ulcer bed.
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Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 Epithelialising Shows evidence of a pink margin to the wound or
isolated pink islands on the surface. 02 Granulating Contains significant amounts of highly vascularised
granulation tissue, generally red or deep pink in colour. 03 Sloughy Contains a layer of viscous adherent slough, generally
yellow in colour. 04 Necrotic Covered with devitalised epidermis, frequently black in
colour. Recording guidance: IT systems should allow for the recording of multiple Condition of Ulcer Bed types.
15.3 Condition of Ulcer Surrounding Skin Definition: The condition of the skin tissue surrounding the ulcer. Format: Characters Field length: 2 Codes and values: Code Value 01 Normal 02 Fragile 03 Macerated 04 Callus 05 Erythematous 06 Anhydrotic 07 Blistered
Recording guidance: IT systems should allow for the recording of multiple categories.
15.4 Foot Ulcer Exudate Volume Definition: The graded volume of foot ulcer exudate excreted. Format: Characters Field length: 2
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Codes and values: Code Value Explanatory Notes 00 None 01 Light Small stain on dressing. 02 Moderate Dressing only is wet through. 03 Heavy Dressing and secondary dressing are wet. 04 Copious Dressing and bandage are wet.
Related data item: Foot Ulcer Exudate Type
15.5 Foot Ulcer Exudate Type Definition: The type of exudate excreted from the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 Serous Clear fluid. 02 Sanguinous Bloody. 03 Sero-sanguinous Clear and bloody. 04 Purulent Pus.
Related data item: Foot Ulcer Exudate Volume
15.6 Frequency of Pain (Foot Ulcer) Definition: The frequency of pain related specifically to the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Intermittent 02 At Dressing 03 Continuous
Related data item: Severity of Pain (Foot Ulcer)
15.7 Severity of Pain (Foot Ulcer) Definition: The grade of severity of the pain related specifically to the foot ulcer.
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Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 01 Mild Patient able to tolerate without analgesia. 02 Moderate Patient able to tolerate with analgesia. 03 Severe Patient does not have relief with analgesia. 04 Unable to Evaluate Patient unable to communicate.
Related data item: Frequency of Pain (Foot Ulcer)
15.8 Foot Ulcer Odour Definition: The occurrence of an odour being expelled from the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Only on Dressing Change 02 Extends Beyond the Ulcer
15.9 Wound Infection Definition: Records any clinical signs of an infection being present in the wound. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Local Infection 02 Cellulitis
Recording guidance: IT systems should allow for the recording of multiple Wound Infection categories.
15.10 Osteomyelitis
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Definition: Records whether or not there is any osteomyelitis present. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
15.11 Foot Ulcer Depth Definition: The maximum tissue depth of the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value 01 Pre- or Post-lesion 02 Superficial 03 To Tendon or Capsule 04 Penetrating to Bone or Joint
Related data items: Foot Ulcer Length Foot Ulcer Width Further information: The depth should be described in terms of the tissue involved in the ulcer base.
15.12 Foot Ulcer Length Definition: The maximum length of foot ulcer in millimetres. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Related data items: Foot Ulcer Depth Foot Ulcer Width
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15.13 Foot Ulcer Width Definition: The maximum width of foot ulcer in millimetres. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Related data items: Foot Ulcer Depth Foot Ulcer Length
15.14 Undermining Wound Definition: Records whether or not the wound is undermining. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Further information: An undermining wound is described as an area of tissue destruction underneath intact skin that can slow the wound healing process.
15.15 Foot Ulcer Photograph Taken Definition: Records whether or not a photograph has been taken of the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value 00 No 01 Yes
Related data item: Foot Ulcer Number Recording guidance: Photographs taken can be stored in and retrieved from the system.
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15.16 Foot Ulcer Dressing Type Definition: Records whether the dressing is primary or secondary. Format: Characters Field length: 2 Codes and values: Code Value 01 Primary 02 Secondary
15.17 Foot Ulcer Dressing Category Definition: Records the dressing category of the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value 01 Non-adherent 02 Foam 03 Antimicrobial 04 Hydrofibre 05 Alginate 06 Hydrocolloid 07 Hydrogel 08 Non-sterile to Secure 09 Vapour Permeable Adhesive Film 10 Silicon 11 Deodorising 12 Modulating Matrix 13 Tulle Gras 98 Other
Related data item: Foot Ulcer Dressing Name Recording guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Foot Ulcer Dressing Category.
15.18 Foot Ulcer Dressing Name Definition: Records the name of the dressing of the foot ulcer. Format: Characters
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Field length: 2 Codes and values: Code Value Code Value 01 Mepitel 25 Hydrocoll 02 Melolite 26 Granuflex 03 Non-adherent Ultra 27 Duoderm 04 Melolin 28 Combiderm 05 Telfa 29 Comfeel 06 Allevyn Lite 30 Intrasite 07 Allevyn 31 Purilon 08 Allevyn Adhesive 32 Nu Gel 09 Allevyn Heel 33 Tubegauze 10 Lyofoam 34 Tubifast 11 Lyofoam Extra 35 Conforming 12 3M Foam Adhesive 36 Soffban 13 Biatain 37 Surgifix 14 Tielle 38 Opsite 15 Aquacel AG 39 Mepilex 16 Acticoat 40 Mepilex Lite 17 Actisorb 41 N-A Ultra 18 Actisorb Silver 42 Carboflex 19 Iodosorb 43 Promogran 20 Iodoflex 44 Bactigras 21 Inadine 45 Jelonet 22 Aquacel 46 Honey tulle 23 Kaltostat 98 Other 24 Seasorb
Related data item: Foot Ulcer Dressing Category Recording guidance: IT systems should allow for the recording of multiple Foot Ulcer Dressing names. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Foot Ulcer Dressing Name.
15.19 Pressure Management Footwear Definition: The type of footwear used for Pressure Management. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Own Footwear 02 Prescriptive Footwear 03 Trauma Shoe
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04 Darco Boot 05 IPOS Boot Rearfoot 06 IPOS Boot Forefoot 07 Prafo Boot 08 Air Cast 09 Scotch Cast 10 Total Contact Cast 98 Other
Recording guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Pressure Management Footwear.
15.20 Debridement Type Definition: The type of specified debridement used on this occasion. Format: Characters Field length: 2 Codes and values: Code Value Explanatory Notes 00 None Debridement is not necessary on this
occasion. 01 Physical 02 Chemical 03 Larvae
Further information: Debridement is the process of removing non-living tissue from pressure ulcers, burns and other wounds.
15.21 Date of Next Appointment Common name: Date of Next Contact Definition: The date on which the next planned appointment is scheduled to take place between a patient/ client and individual care professional for the purpose of care. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A
15.22 Foot Ulcer Management Follow-up Definition: Any specific actions taken to contribute to the foot ulcer management.
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Format: Characters Field length: 3 Codes and values: Code Value Sub-Code Sub-Value 00 None 01 Swab Taken
A Antibiotics B Plain X-Ray C Vascular Intervention D MRI E Isotope Bone Scan
02 Refer For
F Surgical Debridement A Specialist Foot Team B Orthopaedic Surgeon
03 Refer To
C Orthotist 04 Admit to Hospital 98 Other
Recording guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Foot Ulcer Management Follow-up.
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16. Medication
The NCDDP is continuing to further develop generic data standards with relevant clinicians and agencies in order to ensure that they are appropriate across all disciplines and specialities. This will include data standards developments for medication, allergies, intolerances and adverse reactions and risk indicator. If you would like to receive a copy of these standards once they reach consultancy stage, please contact the NCDDP Support Team.
Medication Table Data Item Definition Format & Field Length Current Antibiotic Therapy (Foot Ulcer)
For Consultation 2 characters
16.1 Current Antibiotic Therapy (Foot Ulcer) Definition: Records the antibiotics currently prescribed to the patient for treatment of the foot ulcer. Format: Characters Field length: 2 Codes and values: Code Value Code Value 01 Amoxycillin 18 Imipenem 02 Cefoxitin 19 Itraconazole 03 Ceftazidime 20 Levofloxacin 04 Ceftriaxone 21 Linezolid 05 Cephalosporins 22 Metronidazole 06 Ciprofloxacin 23 Miconazole 07 Clarithromycin 24 Minocycline 08 Clindamycin 25 Ofloxacin 09 Co-amoxiclav 26 Piperacillin 10 Daptomycin 27 Rifampicin 11 Doxycycline 28 Tazobactam 12 Erythromycin 29 Teicoplanin 13 Etrapenem 30 Terbinafine 14 Flucloxacillin 31 Trimethoprim 15 Fusidic Acid 32 Vancomycin 16 Gentamicin 98 Other 17 Griseofulvin
Recording guidance: List to be maintained and updated centrally by SCI-DC. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Current Antibiotic Therapy (Foot Ulcer)
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17. Foot Ulcer Management Evaluation
Foot Ulcer Management Evaluation Table Data Item Definition Format & Field Length Date of Outcome (Ulcer Management)
For Consultation 10 characters (CCYY-MM-DD)
Duration of Treatment (Foot Ulcer)
For Consultation 3 numeric (nnn)
Foot Ulcer Outcome For Consultation 2 characters Vascular Surgical Intervention
For Consultation 2 characters
Footwear For Consultation 2 characters Review Date For Consultation 10 characters (CCYY-
MM-DD)
17.1 Date of Outcome (Foot Ulcer Management) Definition: The date on which a final outcome of the ulcer is specified. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A
17.2 Duration of Treatment (Foot Ulcer) Definition: Records the duration (in weeks) of the treatment the patient received. Format: Numeric (nnn) Field length: 3 Codes and values: N/A Recording guidance: This item is derived from Treatment Start Date (new foot ulcer) and Date of Outcome (Ulcer Management).
17.3 Foot Ulcer Outcome Definition: Records the outcome of the foot ulcer. Format: Characters Field length: 2
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Codes and values: Code Value 01 Healed Ulcer 02 Chronic Ulcer 03 Lost to Follow-up 04 Amputation 05 Patient Deceased
Related data item: Foot Ulcer Number
17.4 Vascular Surgical Intervention Definition: Specifies the type of vascular surgical intervention, if any. Format: Characters Field length: 2 Codes and values: Code Value 00 None 01 Angiogram 02 Angioplasty 03 Lumbar Sympathectomy 04 Vascular Reconstruction 99 Not Known
17.5 Footwear Definition: Records the type of footwear used by the patient. Format: Characters Field length: 2 Codes and values: Code Value 01 Own Footwear 02 Bespoke with TCI 03 Stock with TCI 04 Stock 05 Bespoke with AFO
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17.6 Review Date Definition: The date of the next scheduled contact between the patient and the care professional, team or service. This is a date planned for the future and may not necessarily happen. Format: Characters (CCYY-MM-DD) Field length: 10 Codes and values: N/A
18. Outcomes
Outcomes Table Data Item Definition Format & Field LengthPerson Death Date
The date on which a person died or is officially deemed to have died, as recorded on the Death Certificate.
10 Characters (CCYY-MM-DD)
Note: The above data item has already been approved and is available in the Health & Social Care Data Dictionary.
19. Date
Date Table Data Item Definition Format & Field LengthDate
The day, month, year and century, or truncated combination of these elements, of an event.
10 characters (CCYY-MM-DD, CCYY-MM or CCYY)
Note: The above data item has already been approved and is available in the Health & Social Care Data Dictionary.
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Appendix 1 - Membership of the Diabetes Foot Care Extension Working Group Graham Leese (chair) Alison Rodgers David Wylie Duncan Stang Fay Crawford Florence Reid John McCall Kathleen Spence Les Hogarth Margaret Hastings Suzanne Ralston Richmond Davies Scott Cunningham Fiona Black Amanda Logue
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Appendix 2 - Consultation Distribution List Diabetes Managed Clinical Networks (Scotland) NCDDP Stakeholders • Centre for Change & Innovation (CCI) • Clinical eHealth Leads • Health & Social Care Information Centre, Datasets Development Programme (England) • Improving Mental Health Information Programme • Information Services Division, NSS • Information Standards Group • NHS Quality Improvement Scotland • 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 Surgeons • Scottish Care Information (SCI) • Scottish Clinical Information Management Practice (SCIMP) • Scottish Executive Data Standards Branch • Scottish Intercollegiate Guidelines Network • Scottish Executive Health Department NCDDP Diabetes Clinical Working Groups • Diabetes Core • Diabetes Secondary Care Extension • Diabetes Paediatric Extension • Diabetes Specialist Nursing Extension • Diabetes Dietetics Extension • Diabetes Retinopathy Extension • Diabetes Foot Care Extension
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Appendix 3 - Consultation Response
We value your opinion. These data standards have been developed to support the work of clinicians. Therefore, we need your input.
We welcome suggestions for amendments, improvements and feedback on any issues. Below are some of the key things we would like you to consider when reviewing the data standards:
The definitions of data items – are they clear and fit for purpose? The formats of data items (e.g. free text or pick list, field length) The content of code sets – any codes that are superfluous or missing?
All comments are welcome, whether they be on all or part of the data standards and are positive or negative. Name: Title/Designation: Organisation: Telephone No: E-mail:
Diabetes Foot Care Extension Dataset Consultation feedback Data Item Have you reviewed this data item? (Y/N)
Details of any suggested alterations, additions or clarifications
8. Care Episode Administration Details 8.1 Appointment Type {Diabetes}
9. Vascular Assessment of Foot 9.1 Diabetes-related Amputation
9.2 Date of Amputation of Lower Limb
9.3 Intermittent Claudication
9.4 Previous Vascular Intervention (Lower Limb)
10. Neurological Assessment of Foot 10.1 Loss of Protective Sensation
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Consultation feedback Data Item Have you reviewed this data item? (Y/N)
Details of any suggested alterations, additions or clarifications
10.2 Neurotips Assessment
10.3 Neurothesiometer Assessment
10.4 Painful Neuropathy
11. Risk Factors 11.1 Previous Ulceration
11.2 Structural Abnormality
11.3 Ability to Self-care (Foot Care)
13. Action 13.1 Type of Educational Advice Given
14. New Ulcer Assessment Data 14.1 Foot Ulcer Number
14.2 Ulcer Treatment Start Date
14.3 Ulcer Treatment End Date
14.4 Estimated Duration of Ulcer
14.5 Foot Ulcer Causative Factors
14.6 Anatomical Location
14.7 Aspect of Foot
14.8 Specified Location of Ulcer
14.9 Previously Ulcerated at this Site
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Consultation feedback Data Item Have you reviewed this data item? (Y/N)
Details of any suggested alterations, additions or clarifications
14.10 Previous Ulcer Number(s)
14.11 Foot Wound Classification (The University of Texas)
15. Foot Ulcer Management 15.1 Date of Assessment (Foot Ulcer)
15.2 Condition of Ulcer Bed
15.3 Condition of Ulcer Surrounding Skin
15.4 Foot Ulcer Exudate Volume
15.5 Foot Ulcer Exudate Type
15.6 Frequency of Pain (Foot Ulcer)
15.7 Severity of Pain (Foot Ulcer)
15.8 Foot Ulcer Odour
15.9 Wound Infection
15.10 Osteomyelitis
15.11 Foot Ulcer Depth
15.12 Foot Ulcer Length
15.13 Foot Ulcer Width
15.14 Undermining Wound
15.15 Foot Ulcer Photograph Taken
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Consultation feedback Data Item Have you reviewed this data item? (Y/N)
Details of any suggested alterations, additions or clarifications
15.16 Foot Ulcer Dressing Type
15.17 Foot Ulcer Dressing Category
15.18 Foot Ulcer Dressing Name
15.19 Pressure Management Footwear
15.20 Debridement Type
15.21 Date of Next Appointment
15.22 Foot Ulcer Management Follow-up
16. Medication Prescribed 16.1 Current Antibiotic Therapy (Foot Ulcer)
17. Foot Ulcer Management Evaluation 17.1 Date of Outcome (Foot Ulcer Management)
17.2 Duration of Treatment (Foot Ulcer)
17.3 Foot Ulcer Outcome
17.4 Vascular Surgical Intervention
17.5 Footwear
17.6 Review Date
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Any additional views, comments or suggestions (especially on data items that might be missing): Please e-mail to: [email protected] OR Post hard copies to NCDDP Support Team
Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB
THANK YOU FOR YOUR VALUABLE CONTRIBUTION These standards will now be reviewed and presented to our clinical Programme Board for approval. Once approved, they will be published on the web based Health & Social Care Data Dictionary (www.datadictionary.scot.nhs.uk/) and implemented across Scotland.
