Definitions and Data Recording Manual
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Balance of Care / Continuing Care Census Definitions and data recording manual Updated March 2014 CONTENTS 1 Introduction 1.1 Purpose of this Paper 3 3 1.2 Background 3 3 1.3 Coverage and context of census 3 2 Data Requirements 2.1 Census Data 4 4 2.2 Census Date 4 4 2.3 Data Quality 4 4 2.4 Guidance for Data Input 4 5 2.4.1 Example of Excel Spreadsheet 5 3 NHS Continuing Care Census Data Items 3.1 Location Code 6 6 3.2 Location Name 6 3.3 Ward 6 6 3.4 CHI (Community Health Index) 6 3.5 Patient Identifier 6 7 3.6 Patient Name 6 8 3.7 Gender 7 8 3.8 Date of Birth 7 8 3.9 Date of Admission 7 9 3.10 Ethnicity 8 10 3.11 Specialty 9 11 3.12 Patient’s Postcode of Home Address 11 3.13 Patient’s town/city of Home Address (only required if postcode is unavailable) 11 3.14 Patient’s area of town/city of Home Address (only required if the postcode is unavailable and Glasgow or Edinburgh) 11 3.15 Delayed Discharge check 11 4 Submissions of Data 4.1 Census Data Collection 12 15 4.2 Date of Submission 12 15 4.3 Method of Submission 12 15 5 Contacts 5.1 NHS National Services Scotland – Information Services Division 13 Appendix 1 What is NHS Continuing Healthcare? 14 Appendix 2 Location codes reported at March 2013 census 15 Version 3.5, March 2014 2 1 Introduction 1.1 Purpose of this Paper This paper provides guidance to NHS Boards on definitions, procedures and information concerning the Balance of Care / Continuing Care Census. 1.2 Background Until 2008, there was no method for identifying all patients who were receiving NHS care that is on-going non-acute care, delivered as an inpatient, and often over an extended period, in whatever setting (including hospice or care home). This made it difficult to assess the balance of care for people with longer term needs. In February 2008, the Scottish Government revised the formal guidance on NHS continuing health care (see also Appendix 1): http://www.sehd.scot.nhs.uk/mels/CEL2008_06.pdf. This replaced previous guidance contained in MEL (1996) 22. http://www.sehd.scot.nhs.uk/mels/1996_22.pdf Information Services Division (ISD) were asked to develop a census approach as a means of gathering information from the NHS that will support the need for information about the balance of long term care and will inform on the application of the NHS Continuing Health care guidance. 1.3 Coverage and context of census The patients who should be included in the census are: Category A Patients who are receiving NHS Continuing Health Care as a result of a decision made under the terms of the guidance referred to above. Note that although NHS Continuing Health Care may be provided in a hospital ward it may also be provided on a contractual basis in a hospice or care home. Category B Patients who do not specifically meet the criteria for NHS Continuing Care (as outlined under the terms of the guidance referred to above) but who have been in hospital for over one year and for whom no estimated date of discharge has been set. This also includes patients in NHS contracted beds in care homes. The census should not include anyone for whom a jointly funded package of care is in place with the local authority or anyone who partly or wholly funds their own care. The census should not include anyone under the age of 18 years. The NHS Continuing Care Census information will be gathered by ISD electronically. Paper submissions will not be accepted. Version 3.5, March 2014 3 2. Data requirements 2.1 Census Data The following information will be required for all relevant patients: location, patient name, patient ID, CHI, ethnicity, date of birth, gender, date of admission, specialty, postcode of residence, city/town of residence and area if large and whether patient is a delayed discharge. 2.2. Census Date The census date is undertaken annually on the 31st March. If there is local benefit however in undertaking the national census on a date other than the 31st March NHS Boards can select a date up to 3 calendar days prior to the census date. Under no circumstances can NHS Boards undertake the census outwith these timescales. 2.3 Data Quality For the purposes of comparison it is essential that there is a uniform and consistent interpretation and application of the definitions and data recording rules set out in this paper. Any further revisions or points of clarification will need to be agreed by ISD. 2.4 Guidance for Data Input The following mandatory fields should be recorded in an Excel spreadsheet, one patient record per row and one data item per column. If a particular data item is unavailable please leave it blank in the spreadsheet; do not exclude patients from the census because of incomplete data. National Dataset: Location Code Location Name Ward CHI Number Patient Identifier (If CHI is unavailable) Patient Name Gender Date of Birth Date of Admission Ethnicity Specialty Patient’s postcode of residence Patient’s town/city of residence (if postcode unavailable) Patient’s area of town/city (only if Glasgow or Edinburgh and postcode is unavailable) Delayed Discharge (Yes/No) Patients who meet the definition in Category A should be recorded on the first sheet entitled Cat A – Continuing Care Patients. Patients who meet the definition of Category B should be recorded on the second sheet entitled Cat B – Continuing Care Patients. Version 3.5, March 2014 4 2.4.1 Example of Excel Spreadsheet For Gender, Ethnicity and Speciality codes see Section 3 NHS Continuing Care Census Data Items. Location Code Location Name Ward CHI Patient Identifier Patient Name Gender Date of Birth T105H Ashludie Hospital Ward 1 2502702132 JOHN MCKENZIE 1 - Male 25/02/1970 L330V Carrickstone House Eastfield 0105085555 Rachel Bell 2 - Female 01/05/1908 L330V Carrickstone House Eastfield 1506893333 Michael Hardcastle 1 - Male 15/09/1989 L330V Carrickstone House Eastfield 1802526666 Lizzie Mellors 2 - Female 18/02/1952 City/Town if Area of City if Delayed Date of Postcode of Patient's Postcode Glasgow or Discharge (Yes or Admission Ethnicity Speciality home address unavailable Edinburgh No) 05/09/2008 D - African G4 Psychiatry of Old Age EH42F6Q Glasgow Partick No 01/03/2001 A - White AB Geriatric Medicine (see note 1) G671JH No 06/09/2007 A - White AB Geriatric Medicine (see note 1) G671PZ Yes 03/04/2005 A - White AB Geriatric Medicine (see note 1) G672BJ No Version 3.5, March 2014 5 3 NHS Continuing Care Census Data Items (Definitions provided in ISD Scotland Data Dictionary) 3.1. Location Code This is the reference number of the location where the patient is undergoing NHS health care. Each location in Scotland, at which events pertinent to the Scottish Health Service take place, is allocated a location code. Although NHS health care is likely to be provided in a hospital ward it may also be provided in a hospice or care home. Every effort should be made to ensure patients from all of these settings are included in the census. The location code should be entered with no spaces between the characters e.g. A101H. For reference, Appendix 2 contains a list of location codes reported within the previous census. If a particular location is not included within the list, please contact the Continuing Care Team at ISD ([email protected]). 3.2 Location Name This is the full name of the building or set of buildings the patient is undergoing NHS health care e.g. Falkirk Royal Infirmary. A location is any building or set of buildings where events pertinent to the NHSScotland take place and include hospitals, hospices and care homes. 3.3 Ward A ward is a group of beds with associated treatment facilities which is managed by a senior nurse. It may comprise a number of rooms or one room may be divided into a number of wards. 3.4 CHI (Community Health Index) 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. It should be recorded on every record and advice should be sought from your Medical Records Manager if no CHI is available. Each CHI has a unique 10-digit number (CHI number) that consists of the date of birth and four other numbers. The entry should be left justified with no spaces between characters. It is essential that the CHI is completed as accurately and as consistently as possible as this data item may be used as an identifier. 3.5 Patient Identifier (to be provided if CHI is not available) A patient identifier is a code (set of characters) used to uniquely identify a patient within a health register or a health records system if the CHI is not available. Patient's identifiers include: Hospital patient identifier, Departmental patient identifier, NHS Number, Hospital Patient Identifier (HPI). The entry should be left justified with no spaces between characters. For those CHI numbers starting with a ‘0’, please record as ‘010112111. 3.6 Patient Name The full name of the patient. This is additional identification for quality assurance purposes if the CHI number is not available and should be entered left justified. Version 3.5, March 2014 6 3.7 Gender A statement by the individual about the gender they currently identify themselves to be.