District Nursing Dataset April 2016 · The project has adhered to Information Governance and...
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Community Health Activity Data District Nursing Dataset April 2016 Definitions & Recording Guidance Version: 1.2
Transcript of District Nursing Dataset April 2016 · The project has adhered to Information Governance and...
Community Health Activity Data
District Nursing Dataset
April 2016
Definitions & Recording Guidance
Version: 1.2
Document Control
Document Control
Version 1.2
Date Issued 12/04/2016
Author(s) Community Activity Data Project Team
Other Related Documents ICNP Interventions
Community Nurse Census 2008
Comments to [email protected]
Document History
Version Date Comments Author
V1.0 26/02/2015 Version 1 CHAD
V1.1 16/04/2015 3.5 Location of contact: Code 6, Patient/Client/Home/Residence examples now includes residential care home
CHAD
V1.2 12/04/2016 3.4 Duration of Contact; 3.12 Duration of Patient Related Activity; 3.13 Travel Time- to be recorded in minutes
CHAD
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TABLE OF CONTENTS
INTRODUCTION ............................................................................................. 3
Dataset ............................................................................................................ 3
Scope .............................................................................................................. 6
Submission ...................................................................................................... 6
CHAD DATA SUMMMARY ............................................................................. 7
SECTION 1: PATIENT DEMOGRAPHICS ...................................................... 8
1.1 CHI Number .............................................................................................. 8
1.2 Surname .................................................................................................... 9
1.3 Forename .................................................................................................. 9
1.4 Date of Birth ............................................................................................ 10
1.5 Postcode ................................................................................................. 10
1.6 Gender .................................................................................................... 11
1.7 Ethnicity ................................................................................................... 12
SECTION 2: CURRENT EPISODE OF CARE .............................................. 14
2.1 Date Referral Received ........................................................................... 14
2.2 Source of Referral ................................................................................... 15
2.3 Main Aim of Care ..................................................................................... 16
2.4 – 2.7 Other Aims of Care ......................................................................... 17
2.8 Date Care Began in Current Episode ...................................................... 18
2.9 Date Care Finished in Current Episode ................................................... 18
2.10 Outcome of Episode .............................................................................. 19
SECTION 3: CONTACTS IN CURRENT EPISODE OF CARE ..................... 20
3.1 Date Contact Started ............................................................................... 20
3.2 Time Contact Started .............................................................................. 20
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3.3 Time Contact Ended ................................................................................ 21
3.4 Duration of Contact ................................................................................. 21
3.5 Location of Contact ................................................................................. 22
3.6 Patient contact category .......................................................................... 22
3.7 Planned/Unplanned ................................................................................. 23
3.8 Joint Contact ........................................................................................... 24
3.9 Number of Staff Present in Joint Contact ................................................ 24
3.10 Visit Status ............................................................................................ 25
3.11 Patient Related Activity Type................................................................. 26
3.12 Duration - Patient Related Activity Type ................................................ 27
3.13 Travel Time ........................................................................................... 27
3.14 Staff Pay Band ...................................................................................... 27
3.15 Service Team ........................................................................................ 28
SECTION 4: INTERVENTIONS .................................................................... 29
4.1 Primary Intervention ................................................................................ 29
4.2 – 4.5: Other Interventions ........................................................................ 33
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INTRODUCTION
It is widely recognised that community health data has for some time been
underdeveloped compared to the detailed acute and hospital based health data that
exists for NHS Scotland. The focus on the Integration of Health & Social Care and
Shifting the Balance of Care1 from hospital based to community based services has
further highlighted how weak community health data currently is.
In the last few years the collection of community data has moved on and a lot of work
has been undertaken to establish information systems which accurately supports the
information needs of staff delivering care within the community.
It was agreed the phase one of the project would develop a District Nursing dataset
and this draft dataset was consulted upon between July and August 2014. This dataset
has been reviewed and updated following the consultation and the final dataset was
ratified by the Project Board in September 2014.
The purpose of this document is to set out the nationally agreed core dataset and
definitions along with in-depth recording guidance.
DATASET
One of the main aims of the project was to minimise data collection by using existing
local sources of health data from Health Board systems. It is accepted that not all
Health Boards will collect all data items included within the dataset, therefore the
number of required data items have been kept to a minimum. However, it is anticipated
that Health Boards will in time try to adopt this data collection and accommodate as
many of the data items to achieve the best possible data.
The dataset has been designed to be flexible to act as a basis for future community
datasets. The definitions, codes and values have been aligned with the ISD Data
Dictionary as far as possible and with the Social Care dataset where applicable. This is
to ensure the ease of any future data linkage between Health & Social Care data.
The dataset has been split into four sections.
1 http://www.shiftingthebalance.scot.nhs.uk/
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Section 1 - Patient Demographics
Section 2 – Current Episode of Care
Section 3 – Contacts in Current Episode
Section 4 – Interventions*
The structure of the dataset has been designed to be consistent with the sequence of
events by the Community District Nurse. This sequence is represented in the flowchart
of page 6.
*Following concerns raised by The Royal College of Nursing (RCN) it was agreed
that further development work would be undertaken to review the Intervention
codes within this dataset by the Community Health Activity Data Project Team
with reference to the Scottish Government District Nursing Review and the
Scottish Executive Nurse Directors (SEND).
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Where codes and values held on local systems differ from those within the dataset the
opportunity to map codes will exist. ISD will develop and hold the mapping as a
reference table however it is the responsibility of Health Boards to notify ISD of any
changes in the mapped data.
The project has adhered to Information Governance and Information Security
safeguards.
SCOPE
Data should be returned for all District Nursing contacts made and all open episodes of
care within the quarter specified.
The emphasis of this project is not to develop a data collection system, but a new
Community Health Activity dataset. A dataset defines a standard set of information that
is generated from care records, from any organisation or system that captures the base
data. They are structured lists of individual data items, each with a clear label, definition
and set of permissible values, codes and classifications. From this, secondary uses
information is derived or compiled, which can then be used to monitor and improve
services.
Health Boards are not expected to make any IT changes to their current systems to
accommodate this data request.
SUBMISSION
Full details on the file submission and processing rules can be found in the data
submission document.
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CHAD DATA SUMMMARY
Section 1: Patient Demographics
1.1 CHI Number 1.2 Surname
1.3 Forename 1.4 Date of Birth
1.5 Postcode 1.6 Gender
1.7 Ethnicity
Section 2: Current Episode of Care
2.1 Date Referral Received 2.2 Source of Referral
2.3 Main Aim of Care 2.4 Other Aims of Care
2.5 Other Aims of Care 2.6 Other Aims of Care
2.7 Other Aims of Care 2.8 Date Care Began in Current Episode
2.9 Date Care Finished in Current Episode
2.10 Outcome of Episode
Section 3: Contacts in Current Episode of Care
3.1 Contact Date 3.2 Time Contact Started
3.3 Time Contact Ended 3.4 Duration of Contact
3.5 Location of Contact 3.6 Patient Contact Category
3.7 Planned/Unplanned 3.8 Joint Contact
3.9 Number of Staff Present in Joint Contact
3.10 Visit Status
3.11 Patient Related Staff Activity Type 3.12 Patient Related Staff Activity Type Duration
3.13 Travel Time for this Contact 3.14 Staff Pay Band
3.15 Service Team
Section 4: Interventions
4.1 Primary Interventions 4.2 Other Interventions
4.3 Other Interventions 4.4 Other Interventions
4.5 Other Interventions
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SECTION 1: PATIENT DEMOGRAPHICS
General Guidance for Section 1:
Demographic data should be submitted for all patients who: o Have had a contact with District Nursing services within the quarterly
reporting period; or o Have an open episode of care within the quarterly reporting period.
The CHI number should be returned for all patients. Where CHI is not available surname, forename, date of birth, postcode and gender must be provided to allow CHI seeding to take place.
1.1 CHI NUMBER
Definition: The Community Health Index (CHI) is a population register which is used in
Scotland for health care purposes. The CHI number uniquely identifies a person on the
index.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=C&ID=128&Title=CHI Number
Format: Integer (10)
Recording Guidance:
CHI is a mandatory field.
Supplementary Information:
The CHI number is a unique numeric identifier allocated to each patient on first
registration with the health service.
The CHI number is a 10-character code consisting of the 6-digit date of birth
(DDMMYY), two digits, a 9th digit which is always even for females and odd for males
and an arithmetical check digit.
Non-Scottish patients and other temporary residents can have a CHI number allocated
if required but it is envisaged that future development may allow the identifying number
used in other UK countries to be used in Scotland.
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1.2 SURNAME
Common Names: Second Name; Family Name
Definition: The surname of a person represents that part of the name of a person
which indicates the family group of which the person is part.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=S&ID=487&Title=Surname
Format: Characters - Free Text (35)
Recording Guidance:
This is a mandatory field if CHI is not provided.
Double-barrelled surnames should be entered with a hyphen between the two
parts of the surname.
Example: DURHAM-JONES.
Where a patient requires remaining anonymous, a pseudo-name, such as A N
Other, should be used.
Must be a minimum of 2 characters.
1.3 FORENAME
Common Names: First Name; Given Name.
Definition: The first forename of a person represents that part of the name of a person
which after the surname is the principal identifier of a person.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=F&ID=250&Title=First Forename
Format: Characters - Free Text (35)
Recording Guidance:
This is a mandatory field if CHI is not provided.
Hyphens occurring within a forename should be entered as a separate character
(but not as a first character).
Example: ANNE-MARIE.
Must be a minimum of 2 characters.
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1.4 DATE OF BIRTH
Definition: The date on which a person was born or is officially deemed to have been
born as recorded on their birth certificate.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=186&Title=Date of Birth
Format: Date - DDMMCCYY
Recording Guidance:
Date of Birth is a mandatory field.
Date of birth should be entered thus: 9th February 1942
0 9 0 2 1 9 4 2
1.5 POSTCODE
Common Name: Postal Code
Definition: The postcode is a basic unit for identifying geographic locations. A
postcode is associated with each address in the UK.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=P&ID=399&Title=Postcode
http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=P&ID=400&Title=Postcode Format
Format: Alpha Numeric (8)
Recording Guidance:
This is a mandatory field if CHI is not provided.
The main place of residence at the end of the quarter should be recorded.
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1.6 GENDER
Common Name: Sex
Definition: A statement by the individual about the gender they currently identify
themselves to be.
Source: www.scotland.gov.uk/Resource/Doc/923/0017910.pdf (page 42)
Format: Integer (1)
Codes and Values:
Code Description Example
0 Not known
1 Male
2 Female
9 Not specified If the client/service user is unable or unwilling to specify their current gender or does not have a clear idea of what their current gender is.
Recording Guidance:
Gender is a mandatory field.
If a client/service user is undergoing or has undergone gender
reassignment/transgender they may record “1 Male” or “2 Female” if they wish to
indicate their perceived gender at that time.
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1.7 ETHNICITY
Definition: A statement made by the patient about their current ethnic group.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnicity Code
Format: Alpha Numeric (2)
Codes and Values:
Code Description
WHITE
1A Scottish
1B Other British
1C Irish
1K Gypsy/Traveller
1L Polish
1Z Other White ethnic group
MIXED OR MULTIPLE ETHNIC GROUPS
2A Any mixed or multiple ethnic groups
ASIAN, ASIAN SCOTTISH OR ASIAN BRITISH
3F Pakistani, Pakistani Scottish or Pakistani British
3G Indian, Indian Scottish or Indian British
3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British
3J Chinese, Chinese Scottish or Chinese British
3Z Other Asian, Asian Scottish or Asian British
AFRICAN
4D African, African Scottish or African British
4Y Other African
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Recording Guidance:
Clients with no Ethnicity recorded should be coded as 99 - Not Known.
CARIBBEAN OR BLACK
5C Caribbean, Caribbean Scottish or Caribbean British
5D Black, Black Scottish or Black British
5Y Other Caribbean or Black
OTHER ETNHIC GROUP
6A Arab, Arab Scottish or Arab British
6Z Other ethnic group
REFUSED/NOT PROVIDED BY PATIENT
98 Refused/Not provided by patient
NOT KNOWN
99 Not Known
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SECTION 2: CURRENT EPISODE OF CARE
General Guidance for Section 2:
Data should be submitted for every open episode of care within the reporting
period.
A district nursing episode starts when a patient is added to a District Nurse’s
caseload and ends when that patient is discharged from the caseload.
Episodes of care may vary in length, from short-term to long-term.
There may be numerous contacts within an episode of care.
An episode may extend over one or more quarters.
2.1 DATE REFERRAL RECEIVED
Definition: Date referral received is the date on which a healthcare service receives a
referral.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=R&ID=193&Title=Date Referral
Received&Title2=Referral Received Date
Format: Date - DDMMCCYY
Recording Guidance:
A referral may come formally from a medical professional or directly from a
patient, carer or family member.
‘Date referral received’ could be, before, after or on the same date as data item
(3.1) ‘Date Contact Started’. (See supplementary information below).
If a referral comes from a medical professional the date in which the referral is
received should be recorded.
If a patient, carer or family member requests a visit from a district nurse, the date
the district nurse receives the request should be recorded. There is no need to
record a subsequent formal referral received date from a medical professional.
Supplementary Information:
In most instances a referral date will be received before the first contact is made
with the patient. However, in some circumstances, the first contact may occur
before the referral date has been received. For example:
o An informal discussion with the patient’s family/carer generates a visit
prior to a formal referral being made.
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o A patient contacts a District Nurse during Out of Hours and is seen before
a referral has been made.
2.2 SOURCE OF REFERRAL
Definition: A source of referral category is a broad category of organisation and/or
professionals who may make a referral, e.g. consultant in other provider unit, GP, self.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=R&ID=938&Title=Referral Source
Format: Alpha Numeric (1)
Codes and Values:
Code Description Example
1 GP
2 Consultant at this Health Board/ Health Care Provider
4 Consultant from a Health Board/ Health Care Provider out with this Health Board area
5 Self referral Includes self, relations, friends and carers
6 Prison/Penal Establishments
7 Judicial
8 Local Authority/Voluntary Agency
9 Other Includes Armed Forces
A Accident and Emergency Department
B Optometrist/Optician
C Allied Health Professional (AHP)
D Dental Practitioner
E Community Health Service (excluding Optometrist/Optician and Allied Health Professional (AHP))
N NHS24
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2.3 MAIN AIM OF CARE
Common Names: Reason for Referral; Presenting Complaint, Principle Aim of Care
Definition: A desired achievement of a programme of care e.g. the primary reason for
a referral to a Community Health Care Professional.
Source: Community Nurse Census 2008 and Scottish Government Community
Nursing Core Dataset.
Format: Integer (1)
Codes and Values:
Code Description Example
1 Assessment Investigation
2 Anticipatory Prevention
3 Maintenance to long-term care
Stabilisation
4 Emergency Care Stabilisation
5 Enabling Facilitation
6 Curative short-term treatment
Resolution
7 Maximising Independence Reablement
8 Supportive Adjustment
9 Palliative Relief
Recording Guidance:
The main reason for referral should be recorded.
Other reasons for referral can be recorded under 2.4-2.7 Other Aims of Care.
It is acknowledged that an assessment could be an element of every contact
however Code 1 - assessment/investigation should only be recorded if the need
for assessment and investigation to be carried out was the main reason for
referral and the patient being added to a caseload.
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2.4 – 2.7 OTHER AIMS OF CARE
Common Names: Other Reasons for Referral; Other Presenting Complaint.
Definition: Other desired achievements of a programme of care, but not deemed to be
the primary desired achievement.
Source: Community Nurse Census 2008 and Scottish Government Community
Nursing Core Dataset.
Format: Integer (1)
Codes and Values:
Code Description Example
1 Assessment Investigation
2 Anticipatory Prevention
3 Maintenance to long-term care
Stabilisation
4 Emergency Care Stabilisation
5 Enabling Facilitation
6 Curative short-term treatment
Resolution
7 Maximising Independence Reablement
8 Supportive Adjustment
9 Palliative Relief
Recording Guidance:
The main reason for referral should be recorded in 2.3 Main Aim of Care.
It is acknowledged that an assessment could be an element of every contact
however Code 1 - assessment/investigation should only be recorded if the need
for assessment and investigation to be carried out was a reason for referral and
the patient being added to a caseload.
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2.8 DATE CARE BEGAN IN CURRENT EPISODE
Definition: A record of the date the episode of care between a healthcare professional
and the patient/client began.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=183&Title=Date and Time Contact Started
Format: Date - DDMMCCYY
Recording Guidance:
The date that the patient is added to a district nurse caseload should be
recorded.
2.9 DATE CARE FINISHED IN CURRENT EPISODE
Common Name: Discharge Date
Definition: Discharge date is the date on which a patient is discharged from an
episode of care.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=222&Title=Discharge%20Date
Format: Date - DDMMCCYY
Recording Guidance:
Date care finished in current episode is only required if the patient has been
discharged from an episode of care.
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2.10 OUTCOME OF EPISODE
Common Name: Discharge Reason
Definition: A discharge marks the end of an episode of care.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=221&Title=Discharge
Format: Integer (1)
Codes and Values:
Code Description Example
1 Care Complete
2 Community Nursing Care Suspended/Transferred
A patient is admitted to hospital or respite care.
3 Discharged to Other Professional/Service
Referrals made to GP Practice, Social Work and/or Other Health Professionals or District Nursing Service out with patient’s local area.
4 Patient Died
5 Incomplete - Declined Further Care
The patient/carer no longer wishes the episode of care to continue.
Source of Codes/Values: Consensus from Community District Nurse Workshops and
Community District Nursing Consultation.
Recording Guidance:
Outcome of Episode is only applicable when 2.8 Date Care Finished in Current
Episode is completed.
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SECTION 3: CONTACTS IN CURRENT EPISODE OF CARE
General Guidance for Section 3:
Data should be submitted for every contact that has taken place between a
patient and the District Nursing Service within the reporting period.
Multiple contacts can exist within one episode of care.
Where there is more than one contact between a patient and the District Nursing
Service on one day each contact should be recorded separately.
3.1 CONTACT DATE
Common Names: Date of Visit, Date Visit Started
Definition: A record of the date the contact between a Healthcare Professional and the
patient/client began within an Episode of Care.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=183&Title=Date and Time Contact Started
Format: Date - DDMMCCYY
Recording Guidance: Contact Date is a mandatory data item.
3.2 TIME CONTACT STARTED
Common Names: Time of Visit, Time Visit Started.
Definition: A record of the time the contact between a Healthcare Professional and the
patient/client began.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=183&Title=Date and Time Contact Started
Format: hh:mm (24hr clock)
Recording Guidance:
The time of the day the contact began should be recorded.
The time contact started will begin when the Healthcare Professional enters the
patient’s home or the time the clinic appointment begins. Travel time should not
be included as this is recorded separately.
If 3.2 Time Contact Started and 3.3 Time Contact Ended is provided, there is no
requirement for 3.4 Duration of Contact to be completed.
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All times must be expressed in the 24 hour clock format, e.g. one minute past
midnight is 00:01, and will be assumed to be GMT.
3.3 TIME CONTACT ENDED
Common Name: Time Visit Ended.
Definition: A record of the time the contact between a Healthcare Professional and the
patient/client ended.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=182&Title=Date and Time Contact Ended
Format: hh:mm (24hr clock)
Recording Guidance:
The time of the day the contact ended should be recorded.
The time the contact ended is when the Healthcare Professional leaves the
patient's home or the finish time of the clinic appointment. Travel time should not
be included as this is collected separately.
If 3.2 Time Contact Started and 3.3 Time Contact Ended is provided, there is no
requirement for 3.4 Duration of Contact to be completed.
All times must be expressed in the 24 hour clock format, e.g. one minute past
midnight is 00:01, and will be assumed to be GMT.
3.4 DURATION OF CONTACT
Common Names: Length of Contact, Length of Visit.
Definition: The length of time contact occurred between the healthcare professional
and the patient/client.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=D&ID=234&Title=Duration of Contact
Format: mmm (minutes)
Recording Guidance:
Duration of contact should be completed if 3.2 Time Contact Started and 3.3
Time Contact Ended are not recorded.
Duration should be recorded in minutes e.g. 20 minute contact – 20.
All times for UK transactions/events will be assumed to be GMT.
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3.5 LOCATION OF CONTACT
Definition: This is any building or set of buildings where events pertinent to NHS
Scotland take place. Locations include hospitals, health centres, GP Surgeries, Clinics,
Nursing Homes, schools and the patient/client home.
Format: Integer (1)
Codes and Values:
Code Description Example
1 Hospital including Day Hospitals
2 Health Centre
3 GP Surgery
4 Clinic
5 Nursing Home
6 Patient/ Client home/residence Includes Residential Care Home
7 Day Centre
8 Other Public places, community centre, street.
Source: Community Nurse Census 2008
Recording Guidance:
This field should be completed when 1 - Direct or 2 - Indirect is recorded in 3.6
Patient Contact Category.
3.6 PATIENT CONTACT CATEGORY
Common Name: Patient Contact Mode
Definition: A patient contact may be categorised as direct, indirect or other.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=P&ID=383&Title=Patient Contact: Category
Format: Integer (1)
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Codes and Values:
Code Description Example
1 Direct A face to face contact between a healthcare professional and a patient.
2 Indirect Also known as a 'proxy' contact.
A face to face contact between a healthcare professional and another person on behalf of a patient, e.g. parent, carer ( excluding the patient).
3 Other May refer to telephone contact, telemedicine, teleconference or video-link with the patient/carer.
Recording Guidance:
Where a contact takes place with a patient and another person (e.g. a relative or
carer) simultaneously the contact should be recorded as 1 - Direct.
3.7 PLANNED/UNPLANNED
Definition: A record of whether the contact with the patient / client was planned in
advance or instigated without prior planning and resulted in adjusting the work
schedule after the day’s work had been planned.
Source of Definition: Community Nurse Census 2008
Format: Integer (1)
Codes and Values:
Code Description Example
1 Planned A contact that is arranged more than 24 hours (one day) in advance.
2 Unplanned District Nurse is notified in the morning that a patient requires to be seen that afternoon.
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3.8 JOINT CONTACT
Common Name: Assisted Visit.
Definition: Where 2 or more staff are required, due to specific patient needs, for one
patient contact.
Source: Consensus from Community District Nurse Workshops.
Format: Integer (1)
Codes and Values:
Code Description
0 No
1 Yes
Recording Guidance:
Where a joint contact takes place only one staff member is required to record the
contact. This should be the senior Healthcare Professional present at the
contact.
A contact should only be recorded as a joint contact when 2 or more staff are
required due to specific patient needs and/or staff safety. This excludes student
attendance at a contact unless it is specifically required for patient care.
3.9 NUMBER OF STAFF PRESENT IN JOINT CONTACT
Definition: The number of staff members in attendance during a joint visit.
Format: Integer (1)
Recording Guidance:
This field only requires to be completed by those Health Boards who record the
number of staff present at a joint contact.
Where a joint contact takes place only one staff member is required to record the
contact. This should be the senior Healthcare Professional present at the
contact.
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3.10 VISIT STATUS
Common Name: Attendance Status.
Definition: Indicates whether the patient attended/was seen.
Source: http://www.ndc.scot.nhs.uk/Dictionary-A-
Z/Definitions/index.asp?Search=A&ID=96&Title=Attendance Status
Format: Integer (1)
Codes and Values:
Code Description Example
1 Patient Was Seen
2 Patient Cancelled A patient has received an appointment but has cancelled, not allowing the Healthcare Professional time to reallocate that time slot.
3 Wasted Visit A contact was due to take place and the District Nurse was present at the allocated time but the patient/carer was not present.
4 Staff Cancelled Appointment cancelled due to staff sickness, emergency personal circumstances or unforeseen travel disruptions. Only applies to a Home/Residence contact/visit.
5 Patient Attended but was not seen (CNW: could not wait)
Only applies to non home/residence contacts.
8 Patient DNA
Only applies to contacts which are a non home/residence visit e.g. Clinic appointment, where the patient did not attend.
Recording Guidance:
This field should be completed when 1 - Direct or 2 - Indirect is recorded in 3.6 Patient Contact Category.
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3.11 PATIENT RELATED ACTIVITY TYPE
Definition: All other patient related activities undertaken by the Healthcare
Professional as a result of a contact.
Source: Consensus from Community District Nurse Workshops and Community
District Nursing Consultation.
Format: Integer (1)
Codes and Values:
Code Description Example
1 Admin Letters, reports, writing up patient related notes, preparation of notes for clinics/consultations, clinical documentation/patient held records, filing records, referrals to other services, emails and faxes to MDT/other professionals.
2 Meetings Attendance in critical incident meetings, MDT meetings/case discussions and case conferences, patient handover.
3 Prescribing
4 Equipment ordering
5 Discussion/Liaison with colleagues and partner agencies
6 Admission/Discharge Co-ordination
7 Combination of above activities
Can be used when one or more of the above activities take place.
Supplementary Information:
Patient Related Activity is not a contact but may be related to a contact.
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3.12 DURATION - PATIENT RELATED ACTIVITY TYPE
Definition: The length of time taken by staff to carry out any activities undertaken
which are patient related but non-contact and serve to enhance the delivery of care.
Format: mmm (minutes)
Recording Guidance:
This should be entered in minutes e.g. 20 minute duration – 20.
3.13 TRAVEL TIME
Definition: The time taken to travel by the staff member to the location of contact. This
should include any of the following: driving, walking, waiting and parking time.
Format: mmm (minutes)
Recording Guidance:
This should be entered in minutes e.g. 20 minutes travel time – 20.
When the exact travel time is unknown an approximate time can be entered e.g.
If you travel for 1 hour in one work day and you see 6 patients then time travel
would be approximately 10 minutes per contact.
Travel time should only be recorded if it is contact related.
3.14 STAFF PAY BAND
Definition: The current staff band as featured on staff payslip. This is agreed by
Agenda for Change (AfC). It is the current National Health Service (NHS) grading and
pay system for all NHS staff, with the exception of doctors, dentists and some senior
managers.
Source: http://www.msg.scot.nhs.uk/pay/agenda-for-change
Format: Integer (2)
28
Codes and Values:
Code Description
2 Band 2
3 Band 3
4 Band 4
5 Band 5
6 Band 6
7 Band 7
8 Band 8a
9 Band 8b
10 Student
3.15 SERVICE TEAM
Definition: The team responsible for delivering the service.
Format: Free text (100)
Recording Guidance:
The Service Team relates to Service Type, e.g. District Nursing Team,
Rehabilitation Team, Reablement Team, in which a Healthcare Professional
works. It is not the location of the team e.g. North West Community Team.
29
SECTION 4: INTERVENTIONS
Following concerns raised by The Royal College of Nursing (RCN) it was agreed
that further development work would be undertaken to review the Intervention
codes within this dataset by the Community Health Activity Data Project Team
with reference to the Scottish Government District Nursing Review and the
Scottish Executive Nurse Directors (SEND).
For the purposes of the District Nursing Dataset we have omitted Infant/Child
Development and Pregnancy/Postnatal and have added Palliative Care as
Interventions under Nursing Categories.
The following codes and values will be used until the development work is completed.
4.1 PRIMARY INTERVENTION
Definition: An activity which is undertaken to maintain or potentially improve a
patient/client's state of health and well-being, relieve distress or reduce risk.
Source: Community Nurse Census 2008 and International Classification for Nursing
Practice (ICNP) Interventions ICNP Interventions (from page 9).
Format: Integer (8)
Codes and Values:
Code Value Sub Value
1 Assessment 10030673 - Assessing During Encounter 10030618 - Assessing Health And Social Care Needs 10030687 - Assessing On Admission
2 Bladder/Bowel Care
10030558 - Assessing Bowel Continence 10030781 - Assessing Urinary Continence 10030884 - Catheterising Bladder 10041427 - Managing Defaecation 10031782 - Managing Encopresis 10031805 - Managing Enuresis 10031879 - Managing Urinary Incontinence 10032150 - Nephrostomy Care 10032788 - Stoma Care 10032987 - Teaching About Nephrostomy Care 10033055 - Teaching About Stoma Care 10033135 - Teaching Self Catheterisation 10033277 - Urinary Catheter Care
30
Code Value Sub Value
3 Care Management 10030809 - Assisting Care Provider 10030911 - Checking Patient Identity 10030953 - Collaborating With Legal Service 10005029 - Consulting Care Provider 10031027 - Coordinating Care Plan 10035825 - Crisis Management 10006016 - Discharge Planning 10031252 - Evaluating Care Plan 10031822 - Managing Health Status After Hospitalisation 10031867 - Managing Negative Response To Situation 10032567 - Referring To Care Provider 10032607 - Referring To Services 10041254 - Supporting Dignified Dying 10033296 - Verifying Death
4 Carers 10030562 - Assessing Caregiver 10024570 - Supporting Caregiver
5 Emotional / Psychological Issues
10030589 - Assessing Emotional Support 10030813 -Assisting With Anger Control 10031062 - Counselling Patient 10031711 - Managing Anxiety 10031814 - Managing Grief 10031833 - Managing Negative Behaviour 10031851 - Managing Negative Emotion 10032505 - Promoting Positive Psychological Status 10027051 - Providing Emotional Support 10024493 - Providing Instructional Material 10027067 - Providing Spiritual Support 10040380 - Teaching About Sleep
6 Equipment 10030493 - Arranging Transport Of Device 10033368 - Assessing Needs 10030924 - Checking Device Safety 10031776 - Managing Device 10032902 - Teaching About Device
7 Family Care 10030440 - Advising About Employment 10030602 - Assessing Family Process 10041064 - Domestic Violence Therapy 10032844 - Supporting Family 10032859 - Supporting Family Coping Process 10032994 - Teaching About Effective Parenting
8 Health Promotion 10030429 - Administering Vaccine 10030969 - Collecting Cervical Cells 10031036 - Counselling About Alcohol Use 10031043 - Counselling About Drug Use 10031058 - Counselling About Tobacco Use
31
Code Value Sub Value
10032465 - Promoting Health Seeking Behaviour 10032477 - Promoting Hygiene 10032483 - Promoting Oral Hygiene 10032580 - Referring To Family Planning Service 10032726 - Screening Patient 10041086 - Smoking Cessation Therapy 10033001 - Teaching About Effective Weight 10040125 - Teaching About Exercise 10032925 - Teaching About Family Planning 10032941 - Teaching About Head Lice Infestation 10033017 - Teaching About Rehabilitation 10024687 - Teaching about Safety Measures 10033038 - Teaching About Sexual Behaviour 10033064 - Teaching About Travel Health 10033072 - Teaching About Vaccine
10 Long-Term Condition Management
10030417 - Administering Insulin 10030438 - Administering Vitamin B12 10039284 - Anticoagulation Therapy 10030907 - Checking Inhalation Technique 10031268 - Evaluating Treatment Regime 10031674 - Maintaining Airway 10031912 - Managing Disease 10032034 - Monitoring Blood Glucose 10032052 - Monitoring Blood Pressure 10032099 - Monitoring Laboratory Result 10039369 - Oxygen Therapy 10026347 - Promoting Self Care 10032800 - Supporting Ability To Manage Regime 10033161 - Tracheostomy Care
11 Medication 10025444 - Administering Medication 10023888 - Managing Medication Regime
10015523 - Prescribing Medication
12 Mobility 10030641 - Assessing Mobility Pattern 10033188 - Transferring Patient
13 Nutrition/Fluids 10030660 - Assessing Nutritional Status 10039330 - Fluid Therapy 10031795 - Managing Enteral Feeding 10031908 - Managing Parenteral Feeding 10019462 - Teaching About Dietary Need 10032939 - Teaching About Fluid Intake
14 Personal Care 10030821 - Assisting With Hygiene 10023531 - Assisting With Toileting 10031164 - Dressing Patient
32
Code Value Sub Value
10031275 - Eye Care 10032184 - Oral Care 10032757 - Skin Care
16 Procedures 10030543 - Assessing Arterial Blood Flow Using Ultrasound 10030775 - Assessing Tissue Perfusion 10030656 - Assessing Urinary Retention Using Ultrasound 10002866 - Assisting Surgeon During Operation 10004588 - Collecting Specimen 10031140 - Diagnostic Testing 10031332 - Flushing Earwax 10031724 - Managing Central Line 10032006 - Measuring Body Temperature 10032047 - Monitoring Blood Oxygen Saturation Using Pulse Oximeter 10032113 - Monitoring Vital Signs 10032258 - Physical Examination 10033220 - Treating Injury 10033323 - Weighing Patient
17 Risk Management 10023520 - Assessing Risk For Falls 10030706 - Assessing Risk For Post Partum Depression 10030710 - Assessing Risk For Pressure Ulcer 10030723 - Assessing Risk For Transfer Injury 10031846 - Managing Impaired Coping Process 10031769 - Managing Post Partum Depression 10032075 - Monitoring For Child Abuse 10032068 - Monitoring For Impaired Family Coping
10032960 - Teaching About House Safety
18 Skin/Wound Care 10030472 - Applying Compression Bandage 10030486 - Applying Elastic Stockings 10030747 - Assessing Self Care of Skin 10030799 - Assessing Wound 10035147 - Compression Therapy 10031117 - Diabetic Ulcer Care 10031592 - Invasive Device Site Care 10031690 - Malignant Wound Care 10032420 - Pressure Ulcer Care 10040224 - Pressure Ulcer Prevention 10032630 - Removing Suture 10032648 - Removing Wound Clip 10032863 - Surgical Wound Care 10032871 - Suturing Wound 10033029 - Teaching About Self Care Of Skin 10034961 - Teaching About Wound Care 10034974 - Teaching About Wound Healing
33
Code Value Sub Value
10033208 - Traumatic Wound Care 10033231 - Treating Skin Condition 10033254 - Ulcer Care 10033249 - Wart Treatment
19 Social Circumstances
10030455 - Advising About Housing 10030536 - Assessing Ability To Prepare Food 10030625 - Assessing Housing Condition 10024298 - Assessing Social Support 10032598 - Referring To Housing Service
20 Symptom Management
10011660 - Managing Pain 10031965 - Managing Symptom
21 Teaching 10033086 - Teaching Caregiver 10033126 - Teaching Patient
22 Palliative Care
Recording Guidance:
Where more than one intervention is undertaken then clinical judgment should
be used to determine the primary intervention.
Additional interventions can be recorded under 4.2 – 4.5 Other Interventions.
4.2 – 4.5: OTHER INTERVENTIONS
Definition: Additional activities which are undertaken to maintain or potentially improve
a patient/client's state of health and well-being, relieve distress or reduce risk.
Source: Community Nurse Census 2008 and International Classification for Nursing
Practice (ICNP) Interventions ICNP Interventions (from page 9).
Format: Integer (8)
Codes and Values:
Code Value Sub Value
1 Assessment 10030673 - Assessing During Encounter 10030618 - Assessing Health And Social Care Needs 10030687 - Assessing On Admission
2 Bladder/Bowel Care
10030558 - Assessing Bowel Continence 10030781 - Assessing Urinary Continence 10030884 - Catheterising Bladder 10041427 - Managing Defaecation 10031782 - Managing Encopresis
34
Code Value Sub Value
10031805 - Managing Enuresis 10031879 - Managing Urinary Incontinence 10032150 - Nephrostomy Care 10032788 - Stoma Care 10032987 - Teaching About Nephrostomy Care 10033055 - Teaching About Stoma Care 10033135 - Teaching Self Catheterisation 10033277 - Urinary Catheter Care
3 Care Management 10030809 - Assisting Care Provider 10030911 - Checking Patient Identity 10030953 - Collaborating With Legal Service 10005029 - Consulting Care Provider 10031027 - Coordinating Care Plan 10035825 - Crisis Management 10006016 - Discharge Planning 10031252 - Evaluating Care Plan 10031822 - Managing Health Status After Hospitalisation 10031867 - Managing Negative Response To Situation 10032567 - Referring To Care Provider 10032607 - Referring To Services 10041254 - Supporting Dignified Dying 10033296 - Verifying Death
4 Carers 10030562 - Assessing Caregiver 10024570 - Supporting Caregiver
5 Emotional / Psychological Issues
10030589 - Assessing Emotional Support 10030813 -Assisting With Anger Control 10031062 - Counselling Patient 10031711 - Managing Anxiety 10031814 - Managing Grief 10031833 - Managing Negative Behaviour 10031851 - Managing Negative Emotion 10032505 - Promoting Positive Psychological Status 10027051 - Providing Emotional Support 10024493 - Providing Instructional Material 10027067 - Providing Spiritual Support 10040380 - Teaching About Sleep
6 Equipment 10030493 - Arranging Transport Of Device 10033368 - Assessing Needs 10030924 - Checking Device Safety 10031776 - Managing Device 10032902 - Teaching About Device
7 Family Care 10030440 - Advising About Employment 10030602 - Assessing Family Process 10041064 - Domestic Violence Therapy
35
Code Value Sub Value
10032844 - Supporting Family 10032859 - Supporting Family Coping Process 10032994 - Teaching About Effective Parenting
8 Health Promotion 10030429 - Administering Vaccine 10030969 - Collecting Cervical Cells 10031036 - Counselling About Alcohol Use 10031043 - Counselling About Drug Use 10031058 - Counselling About Tobacco Use 10032465 - Promoting Health Seeking Behaviour 10032477 - Promoting Hygiene 10032483 - Promoting Oral Hygiene 10032580 - Referring To Family Planning Service 10032726 - Screening Patient 10041086 - Smoking Cessation Therapy 10033001 - Teaching About Effective Weight 10040125 - Teaching About Exercise 10032925 - Teaching About Family Planning 10032941 - Teaching About Head Lice Infestation 10033017 - Teaching About Rehabilitation 10024687 - Teaching about Safety Measures 10033038 - Teaching About Sexual Behaviour 10033064 - Teaching About Travel Health 10033072 - Teaching About Vaccine
10 Long-Term Condition Management
10030417 - Administering Insulin 10030438 - Administering Vitamin B12 10039284 - Anticoagulation Therapy 10030907 - Checking Inhalation Technique 10031268 - Evaluating Treatment Regime 10031674 - Maintaining Airway 10031912 - Managing Disease 10032034 - Monitoring Blood Glucose 10032052 - Monitoring Blood Pressure 10032099 - Monitoring Laboratory Result 10039369 - Oxygen Therapy 10026347 - Promoting Self Care 10032800 - Supporting Ability To Manage Regime 10033161 - Tracheostomy Care
11 Medication 10025444 - Administering Medication 10023888 - Managing Medication Regime
10015523 - Prescribing Medication
12 Mobility 10030641 - Assessing Mobility Pattern 10033188 - Transferring Patient
36
Code Value Sub Value
13 Nutrition/Fluids 10030660 - Assessing Nutritional Status 10039330 - Fluid Therapy 10031795 - Managing Enteral Feeding 10031908 - Managing Parenteral Feeding 10019462 - Teaching About Dietary Need 10032939 - Teaching About Fluid Intake
14 Personal Care 10030821 - Assisting With Hygiene 10023531 - Assisting With Toileting 10031164 - Dressing Patient 10031275 - Eye Care 10032184 - Oral Care 10032757 - Skin Care
16 Procedures 10030543 - Assessing Arterial Blood Flow Using Ultrasound 10030775 - Assessing Tissue Perfusion 10030656 - Assessing Urinary Retention Using Ultrasound 10002866 - Assisting Surgeon During Operation 10004588 - Collecting Specimen 10031140 - Diagnostic Testing 10031332 - Flushing Earwax 10031724 - Managing Central Line 10032006 - Measuring Body Temperature 10032047 - Monitoring Blood Oxygen Saturation Using Pulse Oximeter 10032113 - Monitoring Vital Signs 10032258 - Physical Examination 10033220 - Treating Injury 10033323 - Weighing Patient
17 Risk Management 10023520 - Assessing Risk For Falls 10030706 - Assessing Risk For Post Partum Depression 10030710 - Assessing Risk For Pressure Ulcer 10030723 - Assessing Risk For Transfer Injury 10031846 - Managing Impaired Coping Process 10031769 - Managing Post Partum Depression 10032075 - Monitoring For Child Abuse 10032068 - Monitoring For Impaired Family Coping 10032960 - Teaching About House Safety
18 Skin/Wound Care 10030472 - Applying Compression Bandage 10030486 - Applying Elastic Stockings 10030747 - Assessing Self Care of Skin 10030799 - Assessing Wound 10035147 - Compression Therapy 10031117 - Diabetic Ulcer Care 10031592 - Invasive Device Site Care 10031690 - Malignant Wound Care
37
Code Value Sub Value
10032420 - Pressure Ulcer Care 10040224 - Pressure Ulcer Prevention 10032630 - Removing Suture 10032648 - Removing Wound Clip 10032863 - Surgical Wound Care 10032871 - Suturing Wound 10033029 - Teaching About Self Care Of Skin 10034961 - Teaching About Wound Care 10034974 - Teaching About Wound Healing 10033208 - Traumatic Wound Care 10033231 - Treating Skin Condition 10033254 - Ulcer Care 10033249 - Wart Treatment
19 Social Circumstances
10030455 - Advising About Housing 10030536 - Assessing Ability To Prepare Food 10030625 - Assessing Housing Condition 10024298 - Assessing Social Support 10032598 - Referring To Housing Service
20 Symptom Management
10011660 - Managing Pain 10031965 - Managing Symptom
21 Teaching 10033086 - Teaching Caregiver 10033126 - Teaching Patient
22 Palliative Care
Recording Guidance:
Up to 4 additional interventions can be recorded per contact. Clinical judgment
should be used to determine other interventions.
The primary intervention should be recorded under 4.1 Primary Intervention.
