ALCOHOL and SELF-HARM Audit – Core Data Proforma
Family name: ___________________________
First Name: ________________________
Case note number:
CHI number:
Audit no:
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Alcohol & SELF-HARM
Postcode:
Hospital code:
 
Enter the ED
Referred by:
Date:
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1 = Self
Sex:
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.
.
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1 = Male 2 = Female
Time:
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Age 
Seen in Resus:

Audit no:
:
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.
0 = no 1 = yes
2 = GP 3 = NHS 24 4 = Police 5 = friends/family 6 = voluntary services
7 = school
8 = other specify: _________________________________________________________________________________
Arrived by:

1 = Self 2 = SAS 3 = Police 4 = other specify: _______________________________________________________
ED Assessment

Type of Other Specialty in ED: 
Grade of ED staff:
Method of self-harm:
Type of poisoning:
Type of drugs:
Method of self-injury:

Speech
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1= poisoning 2 = injury
3 = Staff Grade
4 = SHOIII 5 = SHO 6 = ENP
3 = both poisoning and injury
1 = drugs 2 = CO poisoning 3 = alcohol
1 = prescribed
1 = cutting
7 = gun
2 = non-prescribed
4 = other chemical specify:________________________
3 = both
2 = traffic-related 3 = hanging 4 = drowning 5 = high fall 6 = burn/scald
8 = other specify: ________________________________________________________
Have the following been assessed? 0 = no 1 = yes
Appearance
Preliminary Psychosocial Assessment
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Mood
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Orientation
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Physical health
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Answer 0 = no 1 = yes
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Is there a history of the course of events 
Is there recent major stress  Is there known mental illness 
Is there previous contact with Mental Health Services  Are there current drug issues 
Is there a family/social network 
Existing care package
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Is there physical risk of injury
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2 = SpR
1 = Emergency Physician 2 = Medical Physician 3 = Surgical 4 = Ortho 5 = Anaesthetist
6 = Maxillo-facial 7= other specify: _________________________________________________
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Basic Mental State Assessment
Behaviour
1 = Consultant
0 = not recorded 1 = none 2 = GP
6 = Community Mental Health Team
SH1
Is there previous self-harm
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Is there ongoing intention of self-harm
3 = CPN/ALN 4 = Psychiatric OPD 5 = Community-based Addiction Team
7 = Social Work 8 = Voluntary Agency 9 = other specify: ______________________________
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ALCOHOL and SELF-HARM Audit – Core Data Proforma
Comments
Drugs taken
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1 = paracetamol 2 = pure or combination of salicylate 3 = anti-depressant 4 = NSAID 5 = other analgesic
6 = major tranquilliser & anti-psychotic 7 = mild sedative 8 = benzodiazepine
9 = Other : specify ____________________________
ToxBase consulted
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Antidote indicated
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Antidote given
Referred for Specialist Psychosocial Assessment
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Where was the assessment carried out?
Date of assessment:
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0 = no
0 = no 1 = yes 2 = not documented
1 = yes 2 = telephone advice
1 = ED 2 = Ward 3 = refused 4 = irregular discharge
5=discharged with OPD
Use of Alcohol
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Was alcohol a contributory factor in the patient’s presentation? 
Had the patient consumed alcohol in the previous 24 hours?
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Are alcohol-related problems documented in the patient’s PMH? 
Was a screening tool used in the ED?
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Was alcohol used around the time of self-harm?
0 = no 1 = yes 2 = not documented
0 = no 1 = yes 2 = not documented
0 = no 1 = yes 2 = not documented
0 = no 1 = yes 2 = not documented
0 = no 1 = yes __________________________________
Discharge Management from the ED
Referred to Specialty:
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Alcohol Liaison Nurse:
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Leave ED date:
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Disposal from the ED: 
Detained under Mental Health Act:
.
0 = no
.
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Psychiatric Services:
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0 = no 1 = yes 2 = not known
1 = yes
Leave ED time:
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:
1 = Home 2 = SSW 3 = Assessment/CDU
4 = Medical 5 = Surgical
6 = Ortho 7 = GI
11 = Neurosurgery
12 = Irregular discharge 13 = Police 14 = Mortuary 15 = Psychiatric Unit
17 = Community non-NHS counselling service 18 = did not wait
8 = ICU 9 = HDU 10 = Maxillo-facial
16 = Specialist NHS treatment
If irregular discharge, are the following documented?
Mental capacity:
Discharge
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Willingness for further assessment:
Ward discharge date:
  
.
Discharge Care Package (from ED or Ward)
.
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0 = no
Total in-patient days:
Discharge plan:
1 = yes
 Outcome: 
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0 = dead 1 = alive
0 = not recorded 1 = none 2 = GP 3 = CPN/ALN 4 = Psychiatric OPD 5 = Community-based Addiction Team 6 = Community Mental Health Team
7 = Social Work 8 = Voluntary Agency 9 = other specify:
SH1
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