Data Element Detail

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Identifying and Definitional Attributes
Representational Attributes
Collection and Usage Attributes
Relational Attributes
Source and Reference Attributes

Episode of admitted patient care-clinical assessment score

Identifying and Definitional Attributes

Identifier & Version

QH 040604 v3

Metadata Item Type

Data Element

Data Element Type

Data Element

Approval Status

Draft
14-Mar-2016

Current
15-Aug-2016

Superseded
15-Mar-2021

Approval Type

Standard

Approving Authority

Information Management Strategic Governance Committee (IMSGC), Queensland Health

Effective From

01-Jul-2016

Effective To

30-Jun-2020

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.

Context

Sub-acute and non-acute admitted patient (SNAP) care.

Short Name

Clinical assessment score

Name in Other Contexts

ADL score

Representational Attributes

Datatype

Integer

Representation Class

Quantitative Value

Format

[N(2)]N

Minimum Character Length

Maximum Character Length

Permissible Values

Permissible_values

Supplementary Values

Supplemenary_values

Collection and Usage Attributes

Guide for Use

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

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.

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 Not known/not specified

New

Verification Rules

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.

Collection Methods

Hospital Based Corporate Information System (HBCIS):
For operational purposes SMMSE data is accessed via a separate field 'Other ADL type'. Scores 7 (Not stated / Missing) and 9 (Unable to rate because not known or not applicable to the consumer) are excluded from HBCIS.

Queensland Hospital Admitted Patient Data Collection (QHAPDC):
At least one set of mandatory scores must be provided for each SNAP episode. Collection of SMMSE subtype scores is optional.

Do not provide more than one set of scores on the same date for the same clinical assessment tool (ADL type) and clinical assessment tool subtype (ADL subtype).

Report actual clinical assessment scores (ADL scores) for each SNAP episode. Report a score of 999 if it is unknown or cannot be determined.

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

Scores 7 (Not stated / Missing) and 9 (Unable to rate because not known or not applicable to the consumer) are excluded from QHAPDC.

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.

Comments

Relational Attributes

Related Metadata References

Related Metadata References_IR

1 - 7

Relationship	Metadata Item Type	Metadata Item Subtype	Name	Identifier & Version	Approval Status
Supersedes	Data Element	Data Element	Episode of admitted patient care-clinical assessment score	QH 040604 Version 2	Superseded
Has been superseded by	Data Element	Data Element	Episode of admitted patient care-clinical assessment score	QH 040604 Version 4	Current
Is used in conjunction with	Data Element	Data Element	Episode of admitted patient care-clinical assessment tool sub-type used	QH 040603 Version 3	Current
Is used in conjunction with	Data Element	Data Element	Episode of admitted patient care-clinical assessment tool used	QH 040602 Version 3	Current
Is used in conjunction with	Data Element	Data Element	Episode of admitted patient care-date of clinical assessment score	QH 040605 Version 3	Current
Is used in conjunction with	Data Element	Derived Data Element	Episode of admitted patient care-date of first clinical assessment score	QH 042099 Version 2	Current
Relates to	Data Element	Data Element Concept	Episode of admitted patient care	QH 041604 Version 1	Current

Implementation in Metadata Sets

Implemented

1 - 10

Metadata Item Type	Metadata Item Subtype	Name	Identifer & Version	Obligation	Approval Status	Effective From	Effective To
Information Asset	Data Collection	Queensland Hospital Admitted Patient Data Collection (QHAPDC)	QH 020001 Version 2	Conditional	Current	01-Jul-2019	30-Jun-2020
Information Asset	Data Collection	Queensland Hospital Admitted Patient Data Collection (QHAPDC)	QH 020001 Version 1	Conditional	Superseded	01-Jul-2016	30-Jun-2020
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2016-2017	QH 020315 Version 1	Conditional	Superseded	01-Jul-2016	30-Jun-2017
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2017-2018	QH 020501 Version 1	Conditional	Superseded	01-Jul-2017	30-Jun-2018
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2018-2019	QH 020503 Version 1	Conditional	Superseded	01-Jul-2018	30-Jun-2019
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2019-2020	QH 020581 Version 1	Conditional	Superseded	01-Jul-2019	30-Jun-2020
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2016-2017	QH 020314 Version 1	Conditional	Superseded	01-Jul-2016	30-Jun-2017
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2017-2018	QH 020329 Version 1	Conditional	Superseded	01-Jul-2017	30-Jun-2018
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2018-2019	QH 020504 Version 1	Conditional	Superseded	01-Jul-2018	30-Jun-2019
Data Supply Requirement	HHS Service Agreement	Queensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2019-2020	QH 020582 Version 1	Conditional	Superseded	01-Jul-2019	30-Jun-2020

Data Quality Declaration

Source and Reference Attributes

Source Organisation

Australian Institute of Health and Welfare

Source Document

METeOR data elements:
Person-level of functional independence, Functional Independence Measure score code N, Identifier 449150, Health standard 11/04/2014 https://meteor.aihw.gov.au/content/index.phtml/itemId/449150/meteorItemView/long
Person-level of psychiatric symptom severity, Health of the Nation Outcome Scale 65+ score code N, Identifier 449363, Health standard 11/04/2014 https://meteor.aihw.gov.au/content/index.phtml/itemId/449363/meteorItemView/long
Person-level of functional independence, Resource Utilisation Groups - Activities of Daily Living total score code N[N], Identifier 588361, Health standard 13/11/2014 https://meteor.aihw.gov.au/content/index.phtml/itemId/588361/meteorItemView/long
Person-level of cognitive ability, Standardised Mini-Mental State Examination item score, code N, Identifier 617812, Health standard 19/11/2015 https://meteor.aihw.gov.au/content/index.phtml/itemId/617812/meteorItemView/long
Person-level of cognitive ability, Standardised Mini-Mental State Examination item score, code N, Identifier 647335, Health standard 03/11/2016 https://meteor.aihw.gov.au/content/index.phtml/itemId/647335/meteorItemView/long

Keywords

ADL; Activity of daily living; SNAP;