[WWW - 2021.12.16]
Identifying and Definitional Attributes
Identifier
QH 040604
Version
4
Metadata Item Type
Data Element
Data Element Type
Data Element
Approval Status
Draft
17-Oct-2019  
Current
16-Mar-2021  
Approval Type
Standard
Approving Authority
Information Management Strategic Governance Committee (IMSGC), Queensland Health
Effective From
01-Jul-2020
Effective To
-
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
-
Representational Attributes
Datatype
Integer
Representation Class
Quantitative Value
Format
[N(2)]N
Minimum Character Length
1
Maximum Character Length
3
Permissible Values
-
Supplementary 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

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
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
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.
Comment
-
Relational Attributes
Related Metadata References
Is used in conjunction with Episode of admitted patient care-clinical assessment tool sub-type used QH 040603 Version 3
Is used in conjunction with Episode of admitted patient care-clinical assessment tool used QH 040602 Version 3
Is used in conjunction with Episode of admitted patient care-date of clinical assessment score QH 040605 Version 3
Is used in conjunction with Episode of admitted patient care-date of first clinical assessment score QH 042099 Version 2
Relates to Episode of admitted patient care QH 041604 Version 1
Supersedes Episode of admitted patient care-clinical assessment score QH 040604 Version 3
Implementation in Metadata Sets

Otherrelational

  • 1 - 3
ViewMetadata Item TypeMetadata Set TypeNameAscendingIdentifier & VersionObligationEffective FromEffective To
Information AssetData CollectionQueensland Hospital Admitted Patient Data Collection (QHAPDC)QH 020001 Version 2Conditional01-Jul-2020
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Private Facility Data Supply Requirement (DSR) 2020-2021QH 020692 Version 1Conditional01-Jul-202030-Jun-2021
Data Supply RequirementHHS Service AgreementQueensland Hospital Admitted Patient Data Collection (QHAPDC) Public Hospital Services Data Supply Requirement (DSR) 2020-2021QH 020693 Version 1Conditional01-Jul-202030-Jun-2021
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 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