Episode of admitted patient care—clinical assessment score, code NN
Data Element Attributes
Identifying and definitional attributes | |
Metadata item type: | Data Element |
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Short name: | Clinical assessment score |
METEOR identifier: | 477826 |
Registration status: | Independent Hospital Pricing Authority, Superseded 11/10/2012 |
Definition: | The score achieved by an admitted patient via the application of an appropriate clinical assessment measurement scale or scheme, as represented by a number. |
Data Element Concept: | Episode of admitted patient care—clinical assessment score |
Value Domain: | Clinical assessment score NN |
Value domain attributes | ||
Representational attributes | ||
Representation class: | Code | |
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Data type: | String | |
Format: | NN | |
Maximum character length: | 2 |
Data element attributes | |
Collection and usage attributes | |
Guide for use: | This data element is required to be recorded for all sub-acute and non-acute care type episodes when reporting to the Activity based funding: Admitted sub-acute and non-acute DSS. Note sub-acute and non-acute care is defined using care type and includes palliative care, rehabilitation care, psychogeriatric care, geriatric evaluation and management and maintenance care. The FIM cognitive scale (FIMCOG) score and FIM motor scale (FIMMOT) score are required to be recorded for all rehabilitation and geriatric evaluation and management (GEM) care type episodes. The FIM cognitive scale (FIMCOG) score must be a value between 5 and 35. The FIM motor scale (FIMMOT) score must be a value between 13 and 91. The HoNOS overactive/aggressive/disruptive behaviour score (HONBEH), plus either the HoNOS problems with activities of daily living score (HONADL) or total score (HONTOT) are required to be recorded for all psycho geriatric care type episodes. All Health of the Nation Outcomes Scales for elderly people (HoNOS65+) can also be used for this data element. The HoNOS activities of daily living (HONADL) score must be a value between 0 and 4. The HoNOS overactive, aggressive, disruptive behaviour (HONBEH) score must be a value between 0 and 4. The HoNOS total (HONTOT) score must be a value between 0 and 48. The RUG-ADL total score (RUGTOT) is required to be recorded for all palliative care type episodes, at the commencement of the episode of care and the commencement of every subsequent phase thereafter in the same episode. The RUG-ADL total score (RUGTOT) is also required to be recorded for all maintenance care type episodes. The RUG-ADL total (RUGTOT) score must be a value between 4 and 18. |
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Collection methods: | The method of collection and rating of each clinical assessment tool must comply with the guidelines related to each individual assessment tool. For example, the FIM assessment must be completed by the multi disciplinary team within 72 hours of admission. The HoNOS assessment must be completed within 72 hours of the episode commencing. The RUG-ADL assessment must be completed within 24 hours of the episode commencing or a new palliative care phase commencing. The clinical assessment must be collected at the commencement of each subacute or non-acute episode of care. For palliative care type episodes it must be collected at the commencement of the episode of care and the commencement of every subsequent phase thereafter in the same episode. It is optional to record the clinical assessment at the end of the episode. |
Source and reference attributes | |
Submitting organisation: | Independent Hospital Pricing Authority |
Origin: | Fries BE, Schneider DP et al (1994). Refining a casemix measure for nursing homes. Resource Utilisation Groups (RUG-III). Medical Care, 32, 668-685. Copyright in the Health of the Nation Outcome Scales (HoNOS) is owned by the Royal College of Psychiatrists. Health of the Nation Outcome Scales (HoNOS) © Royal College of Psychiatrists 1996. FIM™ is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities Incorporated. Australasian Rehabilitation Outcomes Centre holds the territory license for the use of the FIM™ instrument in Australia.
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Reference documents: | Uniform Data System for Medical Rehabilitation. 2009. The FIM System® Clinical Guide, Version 5.2. Buffalo: UDSMR. What is the FIM™ Instrument? Australasian Rehabilitation Outcomes Centre, University of Wollongong. Viewed 19 September 2012, http://ahsri.uow.edu.au/aroc/whatisfim/index.html The Royal College of Psychiatrists. 1996. HoNOS 65+ (Older Adults). The Royal College of Psychiatrists, London. Viewed 19 September 2012, http://www.rcpsych.ac.uk/training/honos/olderadults.aspx Palliative Care Outcomes Collaboration Assessment Toolkit. Palliative Care Outcomes Collaboration , University of Wollongong, Wollongong. Viewed 19 September 2012, http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow129133.pdf
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Relational attributes | |
Related metadata references: | Has been superseded by Episode of admitted patient care—clinical assessment score, code NN Independent Hospital Pricing Authority, Standard 30/10/2012 |
Implementation in Data Set Specifications: | Admitted sub-acute and non-acute care activity based funding DSS 2012-2013 Independent Hospital Pricing Authority, Superseded 11/10/2012 Implementation start date: 01/07/2012 Implementation end date: 30/06/2013 Conditional obligation: Only required to be reported for episodes of care for patients with a care type of rehabilitation care, palliative care, geriatric evaluation and management, psychogeriatric care or maintenance care. |