Physiotherapy DRAFT Extension Dataset

For reference only – Do Not Use For more information contact: [email protected]

Physiotherapy Extension Dataset

November 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/

mailto:[email protected]

http://www.clinicaldatasets.scot.nhs.uk/

Physiotherapy Data Standards

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Contents Contents........................................................................................2

Overview & Background.............................................................. 4 Overview........................................................................................ 4

Background to NCDDP ................................................................ 5

Clinical Terminology ....................................................................6

Date Recording.............................................................................6

In Context ......................................................................................6

1. Care Plan...................................................................................7 Care Plan Table ...........................................................................................................7 1.01 Care Plan Identifier ..............................................................................................7 1.02 Care Plan Type ....................................................................................................8 1.03 Problems Identified {Physiotherapy} ....................................................................9 1.04 Underlying Cause of Condition {Physiotherapy} ................................................13 1.05 Problems Goal Setting {Physiotherapy} .............................................................14 1.06 Intervention Planned {Physiotherapy} ................................................................14 1.07 Care Plan Discontinued Date.............................................................................17 1.08 Care Plan Status ................................................................................................17 1.09 Care Plan Discontinued Reason ........................................................................17

2. Care Delivery...........................................................................19 Care Delivery Table ...................................................................................................19 2.01 Date Intervention(s) Started ...............................................................................19 2.02 Date Intervention(s) Ended ................................................................................19 2.03 Intervention Date................................................................................................19 2.04 Intervention {Physiotherapy} ..............................................................................20 2.05 Intervention Not Given Reason ..........................................................................21

3. Consent ...................................................................................23 Consent Table............................................................................................................23

4. Discharge Summary...............................................................24 Discharge Summary Table.........................................................................................24 4.01 Date of First Assessment ...................................................................................24 4.02 Date of Last Intervention ....................................................................................25 4.03 Discharge Summary Forwarded To ...................................................................25 4.04 Outstanding Issues ............................................................................................25 4.05 Discharge Summary Author ...............................................................................26

5. Appointments ......................................................................... 27 Appointments Table ...................................................................................................27 5.01 Attendance Record ............................................................................................27

6. Ethnic, Cultural and Diversity ............................................... 29 Ethnic, Cultural and Diversity Table ...........................................................................29

7. Socio-Environmental..............................................................30 Socio-Environmental Table ........................................................................................30

8. Lifestyle Risk Factors ............................................................31


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Lifestyle Risk Factors Table .......................................................................................31

9. Basic Health Measurements.................................................. 32 Basic Health Measurements Table ............................................................................32

10. Risks and Alerts ................................................................... 32 Risks and Alerts Table ...............................................................................................32

11. Medications and Devices Record ....................................... 32 Medications and Devices Record Table.....................................................................32

12. Medication Concordance..................................................... 33 Medication Concordance Table .................................................................................33

Appendix 1 – AHP eHealth Working Group ............................. 34 Appendix 2 – Physiotherapy Working Group .......................... 35 Appendix 3 - Consultation Distribution List ............................ 36


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Overview & Background Overview 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. An AHP Clinical Working Group was established in October 2004 to develop these standards, supported by the National Clinical Dataset Development Programme (NCDDP). Following the publication of the AHP Core Data Standards in December 2005, 11 discipline-specific AHP Extension Data Standards were commissioned and a Physiotherapy Clinical Working Group was established to progress this work. It is important to understand that these are data standards, not a dataset. This means that the individual data standards included in this document need not all be recorded together in clinical systems but, where it is considered appropriate to record a particular data item as part of a person’s care record, it should be recorded in accordance with the nationally agreed standard. Some background information on the NCDDP and the Physiotherapy Data Standards development can be found below. If you require further information, please go to our Clinical Dataset website or contact [email protected].

The Physiotherapy Extension Dataset will:

• Support the care process for patients requiring Physiotherapy services by enabling use of appropriate and relevant information

• Facilitate communication of information about patients requiring

Physiotherapy services amongst healthcare professionals involve

• Support agreed information sharing with other relevant agencies including local authorities, social care and voluntary services and health care groups involved in the use of Physiotherapy services.

• Agree a national approach to recording of Physiotherapy information,

ensuring consistency in the way data is formatted regardless of the clinical system in use

• Improve health information for patient care, professional practice,

clinical governance and workforce management purposes • Facilitate the availability of information to avoid unnecessary

admissions

http://www.show.scot.nhs.uk/clinicaldatasets/HaveYourSay.htm



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We are now asking for feedback from the wider clinical community in order to ensure that the Physiotherapy 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 [email protected]. Comments on all or a part of the document is welcome. AHP eHealth Data Standards The membership of the AHP eHealth Working Group is shown in Appendix 1 and membership of the Physiotherapy Clinical Working Group in Appendix 2. The latter group agreed the inclusion of individual data items using the following criteria:

1. That the data item is required to prevent duplication of data recording. 2. That the data item is one which would be used by Physiotherapy

professionals to ensure appropriate patient care, if justified by clinical need.

3. That the data item is currently shared or will possibly or probably be shared in the future amongst healthcare professionals.

Following consultation, the Physiotherapy Data Standards will be submitted to the NCDDP Programme Board, the eHealth National Clinical Information Steering Group and subsequently the NHS Scotland Information Standards Group, for formal approval as a national standard. The Physiotherapy Data Standards will then be freely and widely available through publication in the Health and Social Care Data Dictionary. As far as possible they are UK compatible. It is recommended that these data standards should 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



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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 Standards Data standards that 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 Physiotherapy Working Group identified several generic data items for inclusion in their standards. These data items’ names and definitions are listed in this document for information. The detail of these existing standards are published on the web-based Health and Social Care Data Dictionary or by contacting [email protected]. Clinical Terminology The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms (SNOMED-CT). 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. Date Recording It is good record-keeping practice to always 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 Physiotherapy 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 date format for storage and management within a system should conform to the 6Government 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. In Context All tables at the beginning of each section include data items previously published in the Health and Social Care Data Dictionary, and some that are currently being developed as part of other data standards. Only the name and definition are displayed for these.

http://www.show.scot.nhs.uk/clinicaldatasets/

http://www.datadictionary.scot.nhs.uk/


http://www.isdscotland.org/isd/collect2.jsp;jsessionid=4D6B7C00CF11FBA38676F209BAC56B2E?pContentID=1265&p_applic=CCC&p_service=Content.show&

http://www.isdscotland.org/isd/collect2.jsp;jsessionid=4D6B7C00CF11FBA38676F209BAC56B2E?pContentID=1265&p_applic=CCC&p_service=Content.show&



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1. Care Plan Care Plan is a plan of the treatment or health care to be provided to a patient within a care spell (Derived from NHSIA). More than one care plan may be required. Each Health Problem/Issue should have a separate Care Plan.

Care Plan Table Data Item Definition Care Plan Identifier For Consultation Care Plan Type For Consultation Problems Identified {Physiotherapy} For Consultation Underlying Cause of Condition {Physiotherapy}

For Consultation

Bodily Location of Injury † The location of the body part of the injury responsible for occasioning the attendance of the person at the health care facility

Problems Goal Setting {Physiotherapy}

For Consultation

Objective(s) {AHP} † A desired ultimate achievement of a programme of care.

Objective Outcome {AHP}† 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

Objective Outcome (Patient) {AHP}† 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

Intervention Planned {Physiotherapy} For Consultation Care Plan Discontinued Date For Consultation Care Plan Status For Consultation Care Plan Discontinued Reason For Consultation 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.

Patient Contact Type† The type of environment where the patient is routinely seen by the AHP.

Contact Category† A description of whether the care professional contact occurs with the client/patient(s) themselves or another person on behalf of the client/ patient.

Contact Mode† A record of the manner and/or setting of the contact. Contact Type† An indication of whether a contact for the purpose of

care and/or assessment is with an individual client/ patient or more than one person.

†The above data items have already been approved and are available in the Health & Social Care Data Dictionary.

1.01 Care Plan Identifier Definition: An automatically generated number which identifies the specific care plan, relating together CHI and health problem/issue. Format: Characters




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Field Length: up to 98 Codes and Values: N/A Recording Guidance: IT systems should configure this item so every care plan belonging to a specific patient can be uniquely identified. Related items: CHI, Patient’s Name, Health Problem Issue, Care Plan Type

1.02 Care Plan Type Common Name(s): Type of Care Plan Definition: A description of the specific type of care plan delivered. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Uni-disciplinary Care Plan Care is provided by one Allied Health

Profession only 02 Multi-disciplinary Care Plan Care is provided across two or more Allied

Health professions 03 Multi-agency Care Plan Care is provided by two or more agencies – e.g

by an Occupational Therapy department and a Local Authority Social Work Department

98 Other 99 Not known Sub-Data Items: Agreed Date (Format: CCYY-MM-DD) Start Date (Format: CCYY-MM-DD) End Date (Format: CCYY-MM-DD) Review Date (Format: CCYY-MM-DD) Care Plan Author (Format: As Associated Professional) Related Data Items: Care Plan Discontinued Reason, Care Plan Identifier Recording Guidelines: Each care plan should have only one care plan type.


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1.03 Problems Identified {Physiotherapy} Main Source of Standard: NHS ISD AHP Census (September 2005) Definition: A record of the specific problems/issues affecting the patient identified by professional assessment {pertaining to a particular involvement with care services}. Format: Characters Field length: Minimum 18 Codes and values: Code Value Sub

code Sub Value

00 None A Pain B Parasthesia C Anaesthesia D Pins & Needles E Hypersensitivity F Visual Function G Hearing Function H Tenderness J Sensory Delay

01 Sensory function & Pain

K Sensory A Decreased Mobility In Joint/S B General Mobility C Hypermobility D Instability In Joint/S E Weightbearing F Dislocation In Joint/S G Subluxation In Joint/S H Soft Tissue Sprain J Soft Tissue Tear K Muscle Weakness L Muscle Imbalance M Soft Tissue Rupture N Inflammation P Effusion Q Oedema R Muscle Spasm S Contractures T Scar Tissue U Scar V Burn W Wound X Infection

02 Musculo-skeletal

Y Swelling A Breathlessness B Reduced Physical Endurance

03 Respiratory

C Reduced Aerobic Capacity


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D Fatigability E Crepitus F Consolidation G Breathing H Reparatory Rate J Respiratory Rhythm K Respiratory Depth L Cough M Haemoptysis N Hyperventilation A Unconscious B Increased Tone C Flaccidity D Decreased Tone E Involuntary Movements F Balance G Co-Ordination H Hemiplegia J Paraplegia K Monoplegia L Triplegia M Adverse Neural Tension N Ataxia P Gross Motor Function

04 Neurology

Q Seizure/S A Urinary Retention B Stress Incontinence C Urgency D Mix Incontinence E Double Incontinence F Incontinence Nos G Haematuria

05 Genitourinary & Reproductive

H Childbirth A Temperature Increased B Temperature Decreased C Weight Increased D Weight Decreased E Developmental Delay F Premature Baby G Healing Delay H Vomiting

06 Body functions

J Appetite A Oedema B Blood Supply Increased C Blood Supply Reduced D Obstruction E Haematemesis F Hypertension G Hypotension H Lymphodeama J Postural Hypotension K Dizziness

07 Circulatory

L Palpitations


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A Leg Length Discrepancy B Scoliosis C Kyphoisis D Lordosis E Congenital Abnormality F Amputation G Acquired Abnormality H Joint Replacement J Other Body Structure

Replacement/Transplant K Tall L Short

08 Body Structure

M Perforation A Walking B Standing C Moving & Handling D Wheelchair E Splints, Supports Etc F Footwear

09 Equipment

G Seating A Lying B Kneeling C Squatting D Sitting E Standing F Bending G Trasferring Oneself H Lifting J Carrying K Fine Use Of Hands L Walking/Gait M Toileting N Eating P Dressing Q Household Tasks R Employment S Educational T Social U Moving & Handling V Postural Maintenance W Climbing Stairs

10 Functional Activities

X Writing A Vulnerable Adult 11 At Risk B Vulnerable Child A Speech 12 Voice & Speech Function B Language Delay A Education B Security C Relationships D Occupation

13 Social

E Employment 14 Cognitive Problems 15 Perceptual Problems


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16 Social/Behavioural Problems

17 No Physiotherapy Problems

18 Other non Physiotherapy Problem - specify

98 Unknown 99 Other Physiotherapy

Problem

Attributes: Laterality Right Left Bilateral Midline Chronicity Chronic Acute Recurrent Severity Mild Moderate Severe Position Lower Upper Anatomical site SNOMED-CT should be used to identify anatomical sites. Related data items: Health Problem Issue {AHP}, Problems Goal Setting {Physiotherapy}, Intervention Planned {Physiotherapy}, Underlying Cause of Condition {Physiotherapy} Further information: This data item can cover any problem or issue relating to a patient/client’s life. Lists of commonly used terms for these problems identified may require further development either at local user level or nationally as part of ongoing data standard development work e.g. Common recurring problems as a result of Stroke could be developed within AHP Stroke data standards. It must also be recognised that this list will not cover all problems that may be identified at an assessment/screening as problems may be uncovered that fall out with the scope of a specific discipline but these problems may also require to be recorded in the care plan. A mechanism should be available to search the appropriate terminology and classifications to select the correct value, for example using a clinical terminology browser. Recording guidance:


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IT systems should allow for recording of multiple options. In the future all problems identified will be recorded using SNOMED Clinical Terms.

1.04 Underlying Cause of Condition {Physiotherapy} Common Name: Aetiology Definition: A record of the underlying cause/aetiology of a condition or problem. Format: Characters Field length: Minimum 18 Codes and values Code Value Sub-code Sub-value 00 None Lists of aetiologies will be developed for each dataset. All appropriate aetiologies should be recorded using the appropriate clinical terminology or classification

98 Other - specify 99 Not known Attributes: Chronicity

Chronic Acute Recurrent Severity Mild Moderate Severe Related data items: Problems Identified {Physiotherapy} Further information: Each dataset will develop a list of aetiologies specific to it. An example of an underlying cause of a condition is a bacterial infection which could be the underlying cause of Pneumonia. The underlying cause of dysphagia may be a stroke or cerebral palsy. A mechanism should be available to search the appropriate terminology and classifications to select the correct value, for example using a clinical terminology browser. Recording guidance: IT systems should allow for recording of multiple options. In the future all underlying aetiologies will be recorded using SNOMED CT terms and codes.


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1.05 Problems Goal Setting {Physiotherapy} Definition: The intended achievement for an individual problem or group problems identified and agreed as part of the specific AHP assessment and documented within the care plan. Goals must be realistic, meaningful, achievable and measurable. Format: Characters Field Length: 64 Codes and values: Code Value Explanatory Notes 00 None No Goal Setting agreed. SCT specific code(s)

SCT specific term(s) for agreed Goal Setting

Specific Goal Setting agreed in the patient care plan.

98 Other, specify Goal Setting planned that has no SNOMED term 99 Not known Each problem or group of problems identified within the care plan may require more than one goal. Attributes: Timescale Code Value

01 Short term 02 Medium term 03 Long term Related Items: Problems Identified {Physiotherapy}, Intervention Planned {Physiotherapy}. Further Information: Until SNOMED is available in systems the Codes and values within Objective (s) {AHP} should be used and linked to ICF to give measurable Goals. In future developments specific models of measuring goals may be required by disease specific group and there must be the functionality to incorporate these e.g. Therapy Outcome Model, Goal Attainment Scaling and TELER. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Goal Setting.

1.06 Intervention Planned {Physiotherapy} Common Name(s): Planned Intervention


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Definition: Any activity which is planned to be undertaken to maintain or potentially improve a patient/client’s state of health and well-being, relieve distress or reduce risk. Format: Characters. Field Length: 3 Codes and values: Code Value Sub-code Sub-value Explanatory notes 00 None 01 Acupuncture 02 Advice/Education 03 Carer Joint Session 04 Cryotherapy

A Ultrasound B Tens C Interferrential D Pulsed Short Wave E Short Wave Diathermy F Infra-red Heat pad etc G Muscle stimulator H Combined

Ultrasound/Interferrential

05 Electrotherapy

J Other electrotherapy 06 Group Therapy 07 Home Visit 08 Hydrotherapy 09 Injection Therapy 10 Issue of Equipment

A Body Part B Equipment

11 Maintenance

C Other maintenance 12 Manipulation 13 Manual Handling

training

14 Manual Therapy 15 Mobilisation 16 Onward Referral 17 Pacing

A Standard package e.g. Mcconnels exs B Tailor made

18 Personal Exercises

C Other Personal Exercises A Advanced gait & balance B Gait C Lower Limb focal D Sitting balance E Standing balance F Stepping G Transfer H Upper limb focal J hand K back L neck M knee

19 Rehabilitation

N ankle


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P hip Q Other Rehabilitation

20 Relaxation 21 Repair of

equipment

22 Respiratory intervention

23 Riding A Manual B Mechanical/Electrical

24 Traction

C Other traction 98 Other, specify 99 Not known Lists of commonly used terms for these interventions may require further development either at local user level or nationally as part of ongoing data standard development work e.g. Common recurring interventions as a result of Stroke could be developed within AHP Stroke data standards. It must also be recognised that this list may not cover all interventions so a mechanism should be available to search the appropriate terminology and classifications to select the correct value, for example using a clinical terminology browser. Related Items: Health Problem Issue {AHP}, Problems Identified {Physiotherapy}, Problems Goal Setting {Physiotherapy}, Underlying Cause of Problem {Physiotherapy} Sub Data Item: Responsibility for implementing intervention: Code Value

01 Patient 02 Carer 03 Physiotherapist 04 Physiotherapy Assistant 05 Technical Instructor 06 Student Physiotherapist 07 Patient’s family/friend/guardian 98 Other Recording guidance: If the implementer is: • the patient: name and contact details are available from the Patient

Administration and Demographics data. • a healthcare professional: the healthcare professional should be recorded as

an Associated Professional (Generic data) from which their name and contact details will be available.

• any other (including assistant, instructor and student): these should be recorded as Associated Person(s) (Generic data) from which their name and contact details will be available.

Systems must allow for recording of multiple occurrences of a specific planned intervention. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the intervention.


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1.07 Care Plan Discontinued Date Definition: The date on which a care plan is discontinued. Format: Date (CCYY-MM-DD) Field Length: 10 Codes and Values: N/A Related Data Items: Care Plan Identifier Care Plan Discontinued Reason Further Information: Discontinuing the particular care plan of a patient is not the same as discharging that patient from care.

1.08 Care Plan Status Definition: An Indicator of the care plan progress. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Completed 02 Ongoing 03 Discontinued Related Data Items: Care Plan Discontinued Reason Further Information: Discontinuing the particular care plan of a patient is not the same as discharging that patient from care. Recording Guidance: Systems should default to entering ’02- Ongoing.’

1.09 Care Plan Discontinued Reason Definition: The primary reason for discontinuing with the care plan. Format: Characters Field Length: up to 3 Codes and values:


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Code Value Sub-

codes Sub-values Explanatory Notes

01 Patient’s circumstances changed

02 Plan not meeting patient’s needs

03 Patient progress faster than anticipated

04 Patient progress slower than anticipated

A NHS same B NHS different

05 Care Transferred to another agency

C Other agency 06 Patient moved outwith area 07 Patient stopped attending Patient fails to attend

given appointments 08 Non-compliance e.g. patient refused to

complete prescribed exercises

09 Patient discharged before completed

10 Patient Deceased 11 No contact with patient Patient given option of

making further appointment but hasn’t made contact

98 Other 99 Not known Related Data Items: Care Plan Discontinued Date, Care Plan Status Further Information: Discontinuing the particular care plan of a patient is not the same as discharging that patient from care. Recording Guidance: Only one reason can be selected. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the Care Plan Discontinued Reason.


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2. Care Delivery

Care Delivery Table Data Item Definition Date Intervention(s) Started For Consultation Date Intervention(s) Ended For Consultation Intervention Date For Consultation Intervention {Physiotherapy} For Consultation Intervention Not Given Reason For Consultation

2.01 Date Intervention(s) Started Definition: The date a particular intervention or series of interventions began. Format: Date Field Length: 10 Codes and Values: N/A Sub Data Items: Verification level: Code Value

0 Actual 1 Not known

2.02 Date Intervention(s) Ended Definition: The date a particular intervention or series of interventions ended. Format: Date Field Length: 10 Codes and Values: N/A Sub Data Items: Verification level: Code Value

0 Actual 1 Not known

2.03 Intervention Date Common Name(s): Date of Intervention


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Definition: Actual date when the intervention took place Format: Date Field Length: 10 Codes and Values: N/A

2.04 Intervention {Physiotherapy} Definition: Any activity which has been undertaken to maintain or potentially improve a patient/client’s state of health and well-being, relieve distress or reduce risk. Format: Characters. Field Length: 3 Codes and values: Code Value Sub-code Sub-value Explanatory notes 00 None 01 Acupuncture 02 Advice/Education 03 Carer Joint Session 04 Cryotherapy

A Ultrasound B Tens C Interferrential D Pulsed Short Wave E Short Wave Diathermy F Infra-red Heat pad etc G Muscle stimulator H Combined

Ultrasound/Interferrential

05 Electrotherapy

J Other electrotherapy 06 Group Therapy 07 Home Visit 08 Hydrotherapy 09 Injection Therapy 10 Issue of Equipment

A Body Part B Equipment

11 Maintenance

C Other maintenance 12 Manipulation 13 Manual Handling

training

14 Manual Therapy 15 Mobilisation 16 Onward Referral 17 Pacing

A Standard package e.g. Mcconnels exs B Tailor made

18 Personal Exercises

C Other Personal Exercises A Advanced gait & balance 19 Rehabilitation B Gait


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C Lower Limb focal D Sitting balance E Standing balance F Stepping G Transfer H Upper limb focal J hand K back L neck M knee N ankle P hip Q Other Rehabilitation

20 Relaxation 21 Repair of

equipment

22 Respiratory intervention

23 Riding A Manual B Mechanical/Electrical

24 Traction

C Other traction 98 Other, specify 99 Not known Further Information: Lists of commonly used terms for these interventions may require further development either at local user level or nationally as part of ongoing data standard development work e.g. Common recurring interventions as a result of Stroke could be developed within AHP Stroke data standards. It must also be recognised that this list may not cover all interventions so a mechanism should be available to search the appropriate terminology and classifications to select the correct value, for example using a clinical terminology browser. Recording guidance: Systems must allow for recording of multiple occurrences of a specific intervention. In the future all problems will be recorded using SNOMED Clinical Terms.

2.05 Intervention Not Given Reason Common Name(s): Reason Intervention Not Given Definition: The principal reason why a planned intervention did not take place. Format: Characters Field Length: up to 3 Codes and Values: Code Value Sub code Sub value 00 No Reason Given 01 Not Indicated Best practice guidance and/or local


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protocols do not recommend A Patient unfit B Clinical assessment indicates other

management C No intervention required

02 Clinical decision

Z Other A Did Not Attend B Could Not Attend C Patient Attended but could not stay D Patient Late for Appointment E Patient attended wrong day F Patient with another clinician G Patient otherwise engaged H No access

03 Patient unavailability

Z Other 04 Staff unavailability 05 Building unavailability 06 Equipment unavailability 07 Transport unavailability 08 Patient died 95 Patient declined 98 Other 99 Not known Recording Guidance: Only one reason to be recorded. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the reason.


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3. Consent

Consent Table Data Item Consent Subject {Physiotherapy} Consent Status Consent Not Given Reason Consent Declined Reason (Patient/Carer) Consent Type Consent Date Consenting Party Consent Withdrawn Date Consent Withdrawn Reason Chaperoning Required

The AHP working groups have devised a set of data items and standards on the subject of Patient Consent. However the subject of Consent is a complex and potentially sensitive area and reaches not only into all clinical areas across NHS Scotland, but also beyond into shared care between health and other agencies (e.g. social care). There are also legal implications to be taken into account. The NCDDP intends to address the development of data items for Consent in a generic, global fashion to ensure that the data items and standards developed can be used to reflect aspects of consent across all clinical areas and beyond. Liaison and consultation will take place with appropriate agencies and bodies (e.g. the Medical Defence Union, the Scottish Executive etc) and the resulting draft data standards will be widely consulted upon in the usual way. For your information, a list of data items devised by AHPs is provided.


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4. Discharge Summary It is invisaged that some, or all, of this information will be automatically generated in an Electronic Health Record episode of care discharge summary.

Discharge Summary Table Data Item Definition Date of Discharge† The date on which a patient is discharged from

a particular episode of care Date Ready for Discharge† The date on which a hospital inpatient is

clinically ready to be discharged or moved on to the next stage of care

Date of First Assessment For Consultation Date of Last Intervention For Consultation Discharge Reason {AHP}† The reason why care is discontinued. Objective Outcome {AHP}† 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.

Objective Outcome (Patient) {AHP}† 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.

Discharge Summary Forwarded To For Consultation Outstanding Issues For Consultation Discharge / Transfer To† The type of location to which a patient is

discharged or transferred following an episode of care.

Discharge Type† The outcome of an attendance or series of attendances with a healthcare service in connection with a specific complaint.

Discharge Letter to Follow¥ Records whether a formal discharge letter is to follow.

Discharge Summary Author For Consultation Patient/Clients Comments¥ Records any relevant comments by the service

user pertaining to their care. Arrangements for Aftercare Comments¥ Records any further comments relating to the

aftercare arrangements. ¥The above data items are currently subject to consultation and as a result may be amended. †The above data items have already been approved and are available in the Health & Social Care Data Dictionary.

4.01 Date of First Assessment Definition: The date of the first assessment during a particular care episode. Format: Date Field Length: 10 Codes and Values: N/A




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4.02 Date of Last Intervention Common Name: Date of Last Treatment; Date of Last Appointment Definition: The date on which the final planned intervention in a particular care episode took place. Format: Date Field Length: 10 Codes and Values: N/A

4.03 Discharge Summary Forwarded To Definition: The name and contact details of the healthcare professional to whom the discharge summary was forwarded following discharge. Format: As Associated Professional(s) (this can be found in the Generic Data Standards section of the Health & Social Care Data Dictionary). Field Length: As Associated Professional(s) As Associated Person(s) Codes and Values: N/A Further Information: The discharge summary may be forwarded to more than one professional / person.

4.04 Outstanding Issues Definition: A record of unresolved problems not addressed in this episode of care essential to those viewing the discharge summary and not specified elsewhere. Format: ICD10 or OPCS4 code, ICF Grouping or Read version 3 code. In the future all health problems and issues should be recorded using SNOMED CT and codes. Field Length: minimum 18 Codes and values: Code Value Explanatory Notes 00 None No outstanding issues SCT specific code(s)

SCT specific term(s) for outstanding issues

Specific unresolved problems following an episode of care.

98 Other, specify Outstanding issues which have no SNOMED term. 99 Not known Recording guidance: Systems must allow for recording of multiple issues which are outstanding.


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Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the issue(s).

4.05 Discharge Summary Author Definition: The name and contact details of the healthcare professional who composed the discharge summary for this particular episode of care. Format: As Associated Professional(s) (this can be found in the Generic Data Standards section of the Health & Social Care Data Dictionary). Field Length: As Associated Professional(s). Codes and Values: N/A Recording guidance: Systems must allow for recording of multiple Discharge Summary Authors when the care plan is multi-disciplinary. It is expected that the Discharge Summary Author will be automatically generated by the system.


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5. Appointments

Appointments Table Data Item Definition Attendance Record For Consultation Date of Next Appointment† 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.

Time of Next Appointment† The time on which the next planned appointment is scheduled to take place between a patient/ client and individual care professional for the purpose of care.


5.01 Attendance Record Definition: A record of whether or not the appointment has been fulfilled. Format: Characters Field Length: up to 3 Codes and Values:

Further Information:

Code Value Sub Code

Sub Value Explanatory Notes

01 Attended The scheduled appointment was met either by the patient attending a venue or by the AHP visiting the patient.

02 Did not attend A patient may be categorised as did not attend (DNA) when the Health Care Provider is not notified in advance of the patient's unavailability to attend on the offered admission date, for any appointment or planned visit

A Conflict of appointments B Patient unwell C Transport unavailable

03 Could not attend

Z Other CNA

A patient may be categorised as could not attend (CNA) when the Health care Provider is notified in advance of the patient's unavailability to attend on the offered admission date, for any appointment or planned visit. This may necessitate rescheduling of the appointment




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The definitions of Could Not Attend and Did Not Attend are from the Data Dictionary http://www.datadictionary.scot.nhs.uk/ Recording guidance: It is expected that Attendance Record will be automatically generated by the system.

04 Patient could not wait A Awaiting results/tests B Staff unavailability C Building unavailability D Equipment unavailability E Patient too unwell to treat F Treatment no longer

indicated

05 Cancelled by staff

Z Other cancelled by staff

A Appointment no longer required

This may facilitate discharge

B Patient died This will facilitate discharge C Patient’s carer unavailable

06 Cancelled by patient/representative

Z Other cancelled by patient/rep

98 Other 99 Not Known



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6. Ethnic, Cultural and Diversity

Ethnic, Cultural and Diversity Table Data Item Definition First Language This is the language that a person acquires in earliest

childhood. This is usually, but not necessarily, the language spoken at home.

Preferred Language† This data item is defined as the person's language of preference and may differ from first language (as defined as the language spoken at home) and is required for effective communication with the person.

Interpretation Assistance Indicator†

Indication of requirement for assistance to communicate in English.

Preferred Communication Method†

The method of communication preferred by the person to make themselves understood.

Religion† A statement made by the service user about their current religious affiliation / faith community.

Spiritual Care Preferences Spiritual Care is person centred care which, through affirmation, enables a person to make the best use of all their personal and spiritual resources in facing and coping with the doubts, anxieties and questions which arise in a health care setting and often accompany ill health and suffering.

Cultural Diet Preferences Diet preference expressed by a patient/ client, which may be related to religion or other cultural issues. This does not include food intolerances or allergies.

All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary.




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7. Socio-Environmental

Socio-Environmental Table Data Item Definition Person Legal Status† A particular status usually sanctioned by the courts or

by the children's hearing system in relation to the client/patient in order to ensure their protection and/or the protection of others.

Lives With† An indicator to identify the person/ client’s domestic circumstances.

Household Composition† The make-up and structure of the client/patient’s household. A household comprises: • one person living alone • a group of people (not necessarily related) living

at the same address with common housekeeping – that is, sharing part or all of the living accommodation and facilities, and/or at least one meal a day

• two or more groups of people (not necessarily related) living at the same address with common housekeeping.

Office for National Statistics (ONS) 2001 National Census (Scotland, England & Wales) Northern Ireland Department of Enterprise, Trade & Investment (DETINI) Local Government Association (LGA), England & Wales

Accommodation Permanence Status†

The permanency of the person’s current living arrangements/ place of residence.

Accommodation Type† The type of accommodation in which the person is normally resident.

Dwelling Type† Dwelling Type is a description of the physical structure in which someone lives.

Home Support Circumstances† A summary of any support available to the patient or the support the patient provides to others when in their own home.

Mobility Status† The degree to which the patient is mobile and what aids, if any, they require to achieve this level of mobility.

Dependency upon Patient/Client† A record of whether the patient/client has dependant(s) relying upon him/her for essential support on an ongoing basis, such that if this support were removed the dependant(s) would be left in a vulnerable position. This may include animals.

Frequency of Care Provision¥ The frequency of care provided by unpaid carer(s). This includes types of care such as physical assistance, supervision, support, prompting, anticipatory care.

Employment Status † Indicates the person's economic position in the labour market in terms of whether he or she is currently employed in paid work, seeking employment or, either by choice or age or other restriction, not economically active.

Occupation† The current and/ or previous relevant occupation(s) of the patient/ client, as described by them.

Driving Licence Type The type of driving licence currently held by the client/patient.


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†The above data items have already been approved and are available in the Health & Social Care Data Dictionary. ¥This item is currently in development through the Nursing Core Assessment Data Standards programme and is subject to change. If you would like to receive a copy of the consultation document for these standards please contact [email protected] 8. Lifestyle Risk Factors

Lifestyle Risk Factors Table Data Item Definition Current Tobacco and Nicotine Consumption Status

Tobacco consumption at date of contact including smoking, chewing and use of other nicotine substances.

Current Alcohol Drinking Status

Record of the individual’s current alcohol consumption in relation to prevailing guidelines, with reference to any past excessive alcohol consumption.

Current Substance Misuse Status

Misuse of drugs (including illicit substances, prescription drugs, over the counter medications, solvents, etc), which leads a person to experience physical, psychological or social (including legal) problems. (Excludes alcohol or tobacco consumption).

Ancestry-Related Health Risk

A statement made by the individual about the geographic area(s) in which they have their ancestral origin. This information may assist Health Care Professionals in providing health care to an individual where there may be altered health risk associated with ancestral origin.








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9.Basic Health Measurements

Basic Health Measurements Table Data Item Definition Height Height in metres (to the nearest centimetre) - measured without

shoes Weight Weight in kilograms taken without shoes or outdoor clothing Body Mass Index Body Mass Index (BMI) = weight/height² (kg/m²)

The above data items have already been approved and are available in the Health & Social Care Data Dictionary.

10. Risks and Alerts

Risks and Alerts Table Data Item Definition Risk Status¥ A high level summary of the patient/ client’s risk status

identified through a specific risk assessment.

Risk History¥ A history of the patient/ client’s risk to themselves and/or another person.

¥ The above data items are currently being reviewed following consultation and as a result may be subject to change. 11. Medications and Devices Record

Medications and Devices Record Table Data Item Definition Medication or Device Name

The generic name by which a drug, preparation or device is known.

Medication or Device Usage Status

An indication of whether or not a specific drug, preparation or device is currently being taken or used.

Date of Planned Start

The proposed date on which a process or period of validity is planned to commence.

Date of Planned Completion

The proposed date on which a particular treatment is planned to terminate.

Duration

The period of time over which a process or period of validity occurs.

Medication Dosage

A description of the quantity, frequency or preparation of a drug and also when it was given/taken.

Route of Administration

Describes the way in which a drug or preparation is given or used.

Verification

An indicator of whether or not the information has been validated.

Please note: all of the above items are currently being finalised as Generic Medications Data Standards through the NCDDP consultation process. Should you wish to receive a copy of the final standards, please email the NCDDP Support Team.





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12. Medication Concordance

Medication Concordance Table Data Item Definition Concordance Status

An indicator of whether or not a patient is taking/using a prescribed medication and/or following recommendations, guidance, advice or assistance as directed by the health care professional(s) or in accordance with the agreement between the patient and health care professional(s).

Reason(s) For Medication Non-concordance

The reason(s) why a prescribed drug, preparation or device was/is not being taken/used by the patient as directed by the health care professional(s) or in accordance with the agreement between the patient and health care professional(s).

Type of Assistance Required to Facilitate Medication Concordance

The aid(s) or guidance required to ensure the prescribed drug, preparation or device was/is being taken/used by the patient as directed by the health care professional(s) or in accordance with the agreement between the patient and health care professional(s).

Please note: all of the above items are currently being finalised as Generic Medications Data Standards through the NCDDP consultation process. Should you wish to receive a copy of the final standards, please email the NCDDP Support Team.



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Appendix 1 – AHP eHealth Working Group Membership of AHP eHealth Working Group (Alphabetical Order) Name Position Organisation

Ken Andrew Executive Professional Officer British Association of Prosthetists and Orthotists

Brian Brockie Physiotherapy Manager

Roodlands Hospital, NHS Lothian

Jim Cannon Radiographer Victoria Hospital, NHS Fife

Hazel Dykes General Manager AHPs – Acute Services

D & G Royal Infirmary, NHS Dumfries & Galloway

Avril Farquhar Orthoptist Wishaw General Hospital, NHS Lanarkshire

Eilidh Fletcher NCDDP Data Development Officer Information Services, NHS National Services Scotland

Lorna Grant Superintendent Physiotherapist

Stirling Hospital, NHS Forth Valley

Margaret Hastings (Chair)

AHP Information Development Officer

Scottish Executive Health Department Primary Care Division

Clinton Heseltine Radiography Services Manager, NHS Lothian

Duncan MacFarlane AHP Advisor to eCHIP & Podiatrist

NHS Glasgow

Michele Mackintosh Professional Lead Dietetics Lomond & Argyll, NHS Argyll & Clyde

John McConway Podiatry Services Manager

NHS Ayrshire & Arran

Peter McCrossan Head of Podiatry

Cleland Hospital, NHS Lanarkshire

Liz Mitchell NCDDP AHP Advisor Information Services, NHS National Services Scotland

Tricia Mitchell Lead Speech & Language Therapist

Borders General Hospital, NHS Borders

Maria Murray Professional Officer Society & College of Radiographers

Rob Packham Therapy & Rehabilitation Manager

Queen Margaret Hospital, NHS Fife

Mary Parham Prof Leader in Physiotherapy

Royal Northern Infirmary, NHS Highland

Jamie Quin Head of Podiatry

Gartnavel Royal Hospital, NHS Glasgow

Lorna Ramsay NCDDP Clinical Lead

Information Services, NHS National Services Scotland

Philomena Reid Dietetics

Monklands Hospital, NHS Lanarkshire

Fiona Smith Physiotherapy Manager

Gilbert Bain Hospital, NHS Shetland

Maggie Stobie Superintendent Physiotherapist

Borders General Hospital, NHS Borders

Chris Upton Superintendent Physiotherapist

Aberdeen Royal Infirmary, NHS Grampian


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Appendix 2 – Physiotherapy Working Group Membership of AHP eHealth Working Group (Alphabetical Order) Name Position Organisation

Hazel Dykes General Manager AHPs – Acute Services NHS Dumfries & Galloway

Lorna Grant Superintendent Physiotherapist NHS Forth Valley

Mary Parham Professional Lead Physiotherapy NHS Highland

Rob Packham

Therapy & Rehabilitation Manager - Physiotherapy NHS Fife

Carol Duncan Physiotherapist NHS Fife Janice McNee Physiotherapist NHS Tayside Pat Greenlees Physiotherapist NHS Greater Glasgow Ann Gilchrist Physiotherapist NHS Forth Valley Maggie Stobbie Physiotherapist NHS Borders Marie Gardiner Physiotherapist NHS Fife Deanne Quartermaine Physiotherapist NHS Greater Glasgow Virginia Braid Physiotherapist NHS Greater Glasgow Anne Gilbraith Physiotherapist NHS Greater Glasgow Lesley Bruce Physiotherapist NHS Fife


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Appendix 3 - Consultation Distribution List Chief Executives Medical Directors • 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


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• Queen Margaret University College • Robert Gordon University • SCI Programme Board • Scottish Clinical Information Management Practice (SCIMP) • 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

Physiotherapy DRAFT Extension Dataset

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