For reference only – Do Not Use For more information contact: [email protected]
Nursing, Midwifery & Allied Health Professions Care Planning Data Standards
December 2008
National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 74A Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB
Tel: 0131 275 7066 Email to: [email protected] Website: www.clinicaldatasets.scot.nhs.uk
Contents Contents...... 2 Overview & Background...... 3 Overview ...... 3 NMAHP Care Planning Data Standards...... 4 Background to NCDDP ...... 4 Generic Data Standards...... 4 National Clinical Data Standards...... 5 Clinical Terminology...... 5 Date Recording ...... 5 Generic and Previously Consulted Data Standards...... 6 Data Standards For Consultation...... 7 1 Nursing Diagnosis ...... 7 2 Outcome...... 7 3 Planned Outcome Achievement...... 8 4 Reason Outcome Not Achieved...... 8 Appendix 1 - Working Group Membership ...... 10 Membership of the NMAHP Care Planning Data Standards Working Group...... 10 Membership of NMAHP Care Planning Reference Group ...... 10 Appendix 2 - Consultation Distribution List ...... 11
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Overview & Background
Overview
Care Planning was identified as an area of development by the Nursing, Midwifery and Allied Health Professions (NMAHP) eHealth Programme Board. Standards have previously been developed for Nursing Assessment and AHP Care Planning so an opportunity was identified for NMAHP Care Planning data standards to be developed. On 14th September 2007 the NCDDP Board authorized the development of NMAHP Care Planning data standards.
An NMAHP Care Planning Clinical Working Group was established in December 2007 to progress this work, supported by the National Clinical Dataset Development Programme (NCDDP) Support Team in Information Services (ISD).
The Care Planning Data Standards will:
Establish a National approach of collecting and recording Care Planning information, ensuring consistency in the way data is recorded regardless of the Clinical system or setting.
Support and facilitate agreed information sharing with other healthcare professionals and key stakeholders
• Improve and standardise health information for patient care, professional practice, and clinical governance.
• Ensure inter-compatibility of national clinical information systems, and support the implementation of electronic integrated health records, and data sharing with other agencies.
There is a potential impact on existing IT systems, as some re-design may be required to comply with the agreed data standards.
It is important to emphasise that these are data standards rather than a dataset. This means that the individual data items included in this document are not required to be recorded together in a single clinical information system. For example it may not be necessary to record every item for every person subject to their maternal assessment. However, where it is considered appropriate to record a particular data item as part of a person’s maternal assessment, the information should be recorded in accordance with the nationally agreed standard.
Some data items may only be appropriate for use by clinicians within certain settings and therefore would not be used by a clinician outwith such a setting.
The data standards contain data items from Generic Data Standards and other Clinical Datasets, which have previously been developed through the NCDDP and are freely available in the Clinical Datasets section of the web-based Health & Social Care Data Dictionary.
We are now seeking feedback from the wider clinical community in order to ensure that these data standards are fit for purpose. 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 any part of the document are welcome.
Some background information on the NCDDP and the Data Standards development can be found below.
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If you have any further queries, please go to our website: http://www.clinicaldatasets.scot.nhs.uk/ or contact [email protected].
NMAHP Care Planning Data Standards
The membership of the NMAHP Care Planning Data Standards Clinical Working Group is shown in Appendix 1. This group agreed the inclusion of individual data items concerning care planning using the following criteria:
Each data item should be measured against the following inclusion criteria: • Is the data item is one, which would reasonably be expected to be collected by the various disciplines actively involved in care planning. • Is the data item is necessary for the on-going health and healthcare of patients? • Is the data item one which is likely to be shared among health care professionals?
Once consultation is complete the Care Planning Data Standards will be submitted to the NCDDP Board for formal approval as a national standard.
Once approved the Care Planning Standards will be freely and widely available through publication in the Health & Social Care Data Dictionary. As far as possible they are UK compatible. It is expected that the Care Planning Data Standards will 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. Following approval, the Care Planning Data Standards will be reviewed every two years to ensure that they remain fit for purpose.
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
The Chief Medical Officer established the programme 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: http://www.clinicaldatasets.scot.nhs.uk/.
Generic Data Standards
Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by other clinical working groups and approved as national data standards for NHS Scotland. Those data items identified by the Care Planning Working Group as appropriate for inclusion in their dataset are listed in this document for information. The full details of these existing standards are published on the web-based Health and Social Care Data Dictionary.
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National Clinical Data Standards
Clinical Terminology
The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that over the next few years, clinical information systems will progress to record clinical data using this international standard. The NCDDP Support Team will commence in the near future, development of recommended SNOMED-CT specifications as part of the data standards and datasets it supports.
Date Recording
It is good record-keeping practice always to 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 Care Planning 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 Government 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.
An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM-DDThh: mmTZD).
It is recommended that a time should always be recorded with the appropriate date and not on its own, however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed.
Automated times recorded by IT systems should include all elements of the time, i.e. hour, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required.
Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used.
Government Data Standards Catalogue All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00. Values of any element less than 10 should be entered with a zero in the first position. All times for UK transactions/ events will be assumed to be GMT. Systems should record whether the time is Coordinated Universal Time or British Summer Time in the “Time zone designator”. This will allow time elapsed to be calculated correctly, for example for A&E waiting times
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Generic and Previously Consulted Data Standards The data items in the table below are existing, nationally approved data standards, which can be found in the Health and Social Care Data Dictionary
Structured Name †Care Plan Type Address (BS766) Patient Involved in Care Plan
UK Telephone Number †Carer Involved in Care Plan CHI number †Care Plan – Reason Patient Not Involved Person Birth Date †Care Plan – Reason Carer Not Involved Associated Professional †Care Plan Agreed Associated Professional Group †Intervention Associated Professional Role Current Assistance Associated Professional Identifier Equipment/Aids Associated Professional Employing Location Code Organisation Name Associated Professional Employing Associated Person Organisation Type
† Changes will be made to these items in accordance with the change control process, based on additional development done for this set of standards.
Data Standards Currently Under Development
The development of the following standards was commenced by the Care Planning Working Group and they will undergo further development by other Working Groups before being consulted on in due course.
Medical Diagnosis Frequency
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Data Standards For Consultation
Common Name: Nursing Issue Identified
Definition: A clinical judgement about individual, family or community responses to actual or potential health needs and issues/life processes that may include identification of specific strengths/abilities.
Format: In the future all diagnosis should be recorded using SNOMED-CT and codes.
Field length: minimum 18
Codes and Values: Code Value Explanatory Notes 00 No diagnosis e.g. for further assessment SCT SCT specific Diagnosis would be detailed here using the appropriate clinical specific term(s) for coding classification tools, such as NANDA, ICMP code(s) agreed or SNOMED-CT. Diagnosis 99 Not Known
Attributes: Status: Actual Potential
Related data item: Associated Professional Details
Further Information: Definition is taken from North American Nursing Diagnosis Association (NANDA) International (2007) Nursing Diagnoses: Definitions & Classification 2007-2008, Philadelphia: NANDA International.
Recording Guidance: Systems should allow for the recording of multiple diagnoses. Attributes should be recorded only if clinically relevant.
2 Outcome
Definition: The desired or actual outcome(s), for the person or people, of the care delivered.
Format: Characters
Field Length: 64
Codes and values: Code Value Explanatory Notes 00 None No outcome planned. SCT SCT specific term(s) for Specific outcome planned in the patient care plan, or specific planned outcome achieved. code(s) 98 Other, specify Outcome planned or achieved that has no SNOMED term 99 Not known
Attributes: Planned/Actual
Related Data Items: Nursing Diagnosis, Problems Identified, Intervention
Recording Guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the applicable value.
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3 Planned Outcome Achievement
Common Name: Objective(s) Achieved
Definition: The level of achievement of planned outcome(s)/objective(s).
Format: Characters
Field Length: 2
Codes and values: Code Value 01 Achieved 02 Partially achieved 03 Not achieved 99 Not known
Sub-data Items: From Perspective of Code Value 01 Clinician 02 Patient 03 Carer
Point of Outcome analysis Code Value 01 End of plan 02 Review point
Related data items: Objective(s), Discharge Reason, Outcome
Recording guidance: Only one option should be recorded.
4 Reason Outcome Not Achieved
Definition: The reason an individual or overall outcome was not achieved or only partially achieved.
Format: Characters
Field Length: 3
Codes and values: Code Value Sub- Sub-Value Explanatory Notes Code 01 Co-morbidity 02 Adverse Reaction 03 Person non-compliance Can be patient or carer 04 Stasis of condition Condition does not respond to intervention 05 Health Condition includes single deteriorated medical condition and psychosocial health 06 Service/Resource Includes unavailable inaccessibility 07 Equipment Issues A Equipment failure Where achievement of B Equipment outcome is dependent unavailable on use of a piece of a equipment
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08 Contraindicated 95 Not applicable 98 Other (specify) 99 Not known
Related data items: Outcome, Objective(s)
Recording guidance: IT systems should allow for recording of multiple options. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the applicable value.
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Appendix 1 - Working Group Membership
Membership of the NMAHP Care Planning Data Standards Working Group
Name Position Organisation Lesley Robertson Development Officer SSA NHS Dumfries & Galloway (Chair) Karen Walker Case Manager - Community Mental NHS Fife (Deputy Chair) Health Team Alison Bonney NHS Lothian Keith Brunton Mental Health Information NHS Lothian Kirsteen Cameron (to Community Care Coordinator Transformational 17/7/08) Technologies Division (Standards) – Scottish Government Alison Campbell District Nurse Team Leader NHS Lanarkshire Kate Cocozza Practice Development Lead NHS Greater Glasgow & Clyde Sean Doherty Team Manager - Patient Safety and NHS Quality Improvement Performance Assessment Unit Scotland Isabel Easson Clinical Governance Manager - NHS Fife Kirkcaldy and Levenmouth CHP Christine Forgan Nurse Practitioner NHS Lothian Catriona Kellock Team Leader, Stirling CHP NHS Forth Valley Ann Laird Acting Clinical Service Manager NHS Borders Shelagh Mason Nurse Practitioner NHS Fife Liz Mitchell Clinical Advisor – Allied Health NCDDP Professionals Linda Oldroyd Nurse Consultant NHS Grampian Anne Simpson Practice Development Facilitator NHS Fife Jacqui Stevens Nurse Manager NHS Lothian Judy Taylor Senior Nurse – Professional Practice NHS Greater Glasgow & Clyde Will Van der Byl Data Development & Terminology NCDDP Officer Tim Varley Information Manager NCDDP Helen Walker Forensic Mental Health NHS The State Hospital Alison Wallis Clinical Advisor – Nursing NCDDP
Membership of NMAHP Care Planning Reference Group
Name Position Organisation Diane Davidson EHR Clinical Coordinator NHS Fife Vivienne Davidson Practice Development Colette Ferguson Practice Education Facilitator NHS National Education Scotland Jim Foulis Practice Education Regional Co- NHS National Education ordinator Scotland David Langton Nurse Consultant - Forensic NHS The State Hospital Network
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Appendix 2 - Consultation Distribution List
Chief Executives Chief Medical Officer Chief Nursing Officer Directors of Nursing Directors of Public Health Medical Directors National Advisory Committees Managed Clinical Networks (MCNs) Scottish Intercollegiate Guidelines Network
Care Planning Specific Stakeholders Allied Health Professions Forum –Scotland British & Irish Orthoptic Society British Association of Occupational Therapists British Association of Prosthetists & Orthotists British Dietetic Association British Psychological Society Chartered Society of Physiotherapy Community & District Nursing Association Community Children’s Nursing Network CPHVA (Scotland) Directors of Nursing Existing NMAHP systems: Tiara, Tynedale, RIS, PACS, Octagon, Dumfries & Galloway, FACE, Generic Clinical System (GCS) Improving Mental Health Programme Learning Disability eSAY Maternal and Child Health Information Strategy Group NHS Education Scotland (NES) NHS Quality Improvement Scotland NMAHP eHealth ambassador groups for acute, community & mental health nursing, midwifery and AHPs NMAHP eHealth programme board Practice & Professional Development Nursing Forum Royal College of Speech & Language Therapists Royal Colleges – RCN; RCM; RCGP (Scotland); RCP(Scotland); RCS(Scotland) Scottish AHP Networks e.g. Scottish Therapy Managers Network, Managers networks, Advisory committees Scottish Practice Nurse Association
NCDDP Stakeholders Clinical Datasets Working Groups Clinical Information Steering Group (through CMO) Directors of Clinical Information Electronic Clinical Communications Implementation (ECCI) programme board Electronic Community Health Information Programme (eCHIP) GP systems Health & Social Care Information Centre, Datasets Development Programme (England) Information Services Division, NSS Information Standards Group Managed Clinical Networks (MCNs) Health Professions Council NMC Amicus/ Unison National Services Division (NSD) NHS Boards (through Clinical IM&T leads) NHS Improvement Support Team NHS24
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NHSIA – Data Development Project & Data Dictionary Project Patient Representatives Primary Care UK computer systems used in Scotland e.g. TOREX, EMIS, Octagon, Continuum, Vision, Exeter, IPS, Isoft, ePEX (Protechnic) etc. Scottish Care Information (SCI) programme board Scottish Clinical Information Management in Practice (SCIMP) Scottish Intercollegiate Guideline Network (SIGN) Social Care Data Standards (SCDS) programme
NCDDP Reference & Working Groups NCDDP Board NCDDP Support Team Current NCDDP Working Group
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