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Data Element Detail

Episode of admitted patient care-clinical assessment score
Identifying and Definitional Attributes
QH 040604 v4
Data Element
Data Element
Draft
17-Oct-2019		Current
16-Mar-2021
Standard
Information Management Strategic Governance Committee (IMSGC), Queensland Health
01-Jul-2020
The score achieved by an admitted patient via the application of an appropriate clinical assessment measurement scale or scheme, as represented by a number.
Sub-acute and non-acute admitted patient (SNAP) care.
Clinical assessment score
ADL score (QHAPDC)
Representational Attributes
Integer
Quantitative Value
[N(2)]N
1
3
Permissible Values

Permissible_values

-
Supplementary Values

Supplemenary_values

-
Collection and Usage Attributes
Functional Independence Measure (FIM)
Each item is scored on a 7 point ordinal scale, ranging from a score of 1 to a score of 7. The higher the score, the more independent the patient is in performing the task associated with that item. The total FIM score ranges from 18 to 126.

Score Meaning
1 Total assistance with helper
2 Maximal assistance with helper
3 Moderate assistance with helper
4 Minimal assistance with helper
5 Supervision or setup with helper
6 Modified independence with no helper
7 Complete independence with no helper

Supplementary value:
9 Not stated/inadequately described

Health of the Nation Outcome Scale 65+ (HoNOS65+)
HoNOS65+ is answered on an item-specific anchored 4-point scale with higher scores indicating more problems. Each scale is assigned a value of between 0 and 4.

The sum of the individual scores of each of the scales represents the total HoNOS65+ score. The total HoNOS65+ score ranges from 0 to 48, and represents the overall severity of an individual's psychiatric symptoms.

Score Meaning
0 No problems within the period stated
1 Minor problem requiring no action
2 Mild problem but definitely present
3 Moderately severe problem
4 Severe to very severe problem

Supplementary values:
7 Not stated / Missing
9 Unable to rate because not known or not applicable to the consumer

Resource Utilisation Groups - Activities of Daily Living (RUG-ADL)
Scores are summed for the four ADL variables, i.e. bed mobility, toileting, transfers and eating. A total RUG-ADL score ranges from a minimum score of 4 to a maximum score of 18.

For bed mobility, toileting and transfers:
Score Meaning
1 Independent or supervision only
3 Limited physical assistance
4 Other than two persons physical assist
5 Two or more person physical assist
Note: a score of 2 is not valid.

For eating:
Score Meaning
1 Independent or supervision only
2 Limited assistance
3 Extensive assistance/total dependence/tube fed
Note: a score of 4 or 5 is not valid.

Supplementary value:
9 Not stated/inadequately described

Standardised Mini-Mental State Examination (SMMSE)
The SMMSE consists of 12 items or questions which assess a range of cognitive domains, requiring vocal and physical actions (such as memory recall and drawing) in response to reading and listening to commands.

The final SMMSE score is a sum of the 12 items, and can range from a minimum of 0 to a maximum of 30. The SMMSE can be adjusted for non-cognitive disabilities.

Score Meaning
0 Score of 0
1 Score of 1
2 Score of 2
3 Score of 3
4 Score of 4
5 Score of 5

Supplementary values:
7 Not applicable - item has been omitted
8 Unknown
9 Not stated/inadequately described
Queensland Hospital Admitted Patient Data Collection (QHAPDC):
Must be transmitted as a 3 character string, right adjusted and zero filled from the left.

Mandatory (HBCIS & QHAPDC):
When Clinical assessment tool is FIM and Clinical assessment tool sub-type is BDR, BTH, BWL, CMP, DRL, DRU, EAT, EXP, GRM, LST, LWW, MEM, PRS, SOC, TBC, TBS, TLT or TTL each score must be between 1 and 7 or 999; COG (Cognitive total) must be between 5 and 35 or 999; and MOT (Motor total) must be between 13 and 91 or 999.

When Clinical assessment tool is HON and Clinical assessment tool sub-type is ADL, BEH, CGP, DDU, DPS, HAD, LVC, NAS, OMB, PID, SSR or WLQ each score must be between 0 and 4 or 999; and TOT (Total) must be between 0 and 48 or 999.

When Clinical assessment tool is RUG and Clinical assessment tool sub-type is TOT, the score must be between 4 and 18 or 999.

Optional (HBCIS & QHAPDC):
When Clinical assessment tool is SMMSE and Clinical assessment tool sub-type is:
LAT, ORP or ORT each score must be between 0 and 5 or 999;
ACP, MIM or MSH each score must be between 0 and 3 or 999;
ACD, LAC, LAV, LMP, LMW or LNG each score must be between 0 and 1 or 999; and
TOT must be between 0 and 30 or 999.
The supplementary values for the clinical assessment tools listed in the Guide for Use are excluded from HBCIS and QHAPDC.

Hospital Based Corporate Information System (HBCIS):
For operational purposes SMMSE data is accessed via a separate field 'Other ADL type'.

Queensland Hospital Admitted Patient Data Collection (QHAPDC):
At least one set of ADL scores must be provided for each SNAP episode to enable classification into the AN-SNAP classification.

The ADL score is the actual numerical rating reported for the ADL tool being used to measure the patient's functional ability.

More than one ADL score per SNAP episode can be recorded; however, only one ADL score per day may be recorded. All ADL scores should be supplied to the Statistical Services Branch (SSB).

The HoNOS requires the reporting the 12 subscale scores and the total score.

The FIM requires the reporting of the 18 subscale scores and a total cognition and motor score. Note: For Paediatric Rehabilitation Episodes (age at admission is < 3 years), as a FIM score is not required to derive any of the Paediatric Admitted Rehabilitation AN-SNAP classes, a score of 999 is valid.

The RUG only requires a total score to be reported.

The SMMSE that is optional for GEM patients requires 12 subscale scores and a total score.

For all SNAP episodes:
- Multiple ADL scores are able to be reported. For example, a patient may undergo an assessment during the middle of their stay, in addition to assessments on admission to and discharge of the SNAP episode. In this scenario, the episode would contain 3 sets of ADL Scores.

- ADL Scores can be entered retrospectively. For example, an ADL assessment may be completed on day 2 of the episode, but the scores may not be available for entry into the hospital patient system until day 7. The scores can be retrospectively entered for the appropriate date.

- Clinical guidelines for the timing of ADL assessments should be adhered to wherever possible. For example, the Australasian Rehabilitation Outcomes Centre (AROC) recommends that the FIM should be performed within 72 hours of commencement of a rehabilitation episode.

- An ADL score of 999 is valid when an assessment has not been undertaken.

Scores should be right adjusted and zero filled from the left to three characters.

National Outcomes and Casemix Collection (NOCC):
Scores of 7 (Not stated / Missing) and 9 (Unable to rate because not known or not applicable to the consumer) are part of the NOCC.
Relational Attributes
Related Metadata References

Related Metadata References_IR

  • 1 - 6
ViewRelationshipMetadata Item TypeMetadata Item SubtypeNameIdentifier & VersionApproval Status
SupersedesData ElementData ElementEpisode of admitted patient care-clinical assessment scoreQH 040604 Version 3Superseded
Is used in conjunction withData ElementData ElementEpisode of admitted patient care-clinical assessment tool sub-type usedQH 040603 Version 3Current
Is used in conjunction withData ElementData ElementEpisode of admitted patient care-clinical assessment tool usedQH 040602 Version 3Current
Is used in conjunction withData ElementData ElementEpisode of admitted patient care-date of clinical assessment scoreQH 040605 Version 3Current
Is used in conjunction withData ElementDerived Data ElementEpisode of admitted patient care-date of first clinical assessment scoreQH 042099 Version 2Current
Relates toData ElementData Element ConceptEpisode of admitted patient careQH 041604 Version 1Current
Implementation in Metadata Sets

Implemented

  • 1 - 7
ViewMetadata Item TypeMetadata Item SubtypeNameIdentifer & VersionObligationApproval StatusEffective FromEffective To
Information AssetData CollectionQueensland Hospital Admitted Patient Data Collection (QHAPDC)QH 020001 Version 2ConditionalCurrent01-Jul-2020
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2020-2021QH 020692 Version 1ConditionalSuperseded01-Jul-202030-Jun-2021
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2021-2022QH 020780 Version 1ConditionalSuperseded01-Jul-202130-Jun-2022
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2022-2023QH 0139401 Version 1ConditionalCurrent01-Jul-202230-Jun-2023
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2020-2021QH 020693 Version 1ConditionalSuperseded01-Jul-202030-Jun-2021
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2021-2022QH 020781 Version 1ConditionalSuperseded01-Jul-202130-Jun-2022
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2022-2023QH 0140697 Version 1ConditionalCurrent01-Jul-202230-Jun-2023
Source and Reference Attributes
Australian Institute of Health and Welfare
METeOR data elements:
Person-level of psychiatric symptom severity, Health of the Nation Outcome Scale 65+ score code N, Identifier 748292, Health standard 20/12/2022
https://meteor.aihw.gov.au/content/748292?technical=True
Person-level of functional independence, Functional Independence Measure score code N, Identifier 717982, Health standard 18/12/2019
https://meteor.aihw.gov.au/content/index.phtml/itemId/717982/meteorItemView/long
Person-level of psychiatric symptom severity, Health of the Nation Outcome Scale 65+ score code N, Identifier 717760, Health standard 18/12/2019 https://meteor.aihw.gov.au/content/index.phtml/itemId/717760/meteorItemView/long
Person-level of functional independence, Resource Utilisation Groups - Activities of Daily Living total score code N[N], Identifier 717986, Health standard 18/12/2019 https://meteor.aihw.gov.au/content/index.phtml/itemId/717986/meteorItemView/long
Person-level of cognitive ability, Standardised Mini-Mental State Examination item score, code N, Identifier 681420, Health standard 25/01/2018 https://meteor.aihw.gov.au/content/index.phtml/itemId/681420/meteorItemView/long
ADL; Activity of daily living; SNAP;