Falls Dataset Version 1.1 Falls Dataset Version 1.1 Note that a number of the data items defined below are not currently routinely captured as part of patient care records; the Falls data set may therefore be implemented in phases, the first implementation phase consisting of those data items that are currently collected. Data Item Description Purpose Codes and Classifications PERSON DEMOGRAPHICS 1.1 NHS NUMBER See NHS Data Dictionary 1.2 See NHS Data Dictionary 1.3 LOCAL PATIENT IDENTIFIER ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) CASE NUMBER 1.3a LOCAL AUTHORITY CODE 1.4 1.2a Used to uniquely identify the patient who is the subject of the dataset. Used to uniquely identify the patient within a health care provider See NHS Data Dictionary See NHS Data Dictionary an5 See NHS Data Dictionary The unique number assigned to a person when they are formally recognised as a social service user and have a case opened for them. The identifier of a local authority within the UK Used to uniquely identify the patient who is the subject of the Dataset within a local authority care provider PERSON FAMILY NAME See NHS Data Dictionary See NHS Data Dictionary 1.5 PERSON GIVEN NAME See NHS Data Dictionary Identifies that part of a person's name which is used to describe family, clan, tribal group, or marital association. Identifies the forename or given name of a person. 1.6 PATIENT USUAL ADDRESS See NHS Data Dictionary Identifies the address details for the person at their usual address See NHS Data Dictionary 1.7 POSTCODE OF USUAL ADDRESS PRESENT ADDRESS See NHS Data Dictionary. 1.8 1.9 POSTCODE OF PRESENT ADDRESS Version: 1.1 Issue Date: 07/12/04 This is the ADDRESS nominated by the PATIENT, with ADDRESS ASSOCIATION TYPE of Present address’ The POSTCODE of the ADDRESS nominated by the PATIENT with ADDRESS ASSOCIATION TYPE 'Present Address’. an10 (up to 10 characters) an4 nnaa See NHS Data Dictionary See NHS Data Dictionary Identifies the address details for the person at their present address where this is different from their usual address See NHS Data Dictionary PATIENT USUAL ADDRESS See NHS Data Dictionary POSTCODE Page 1 of 18 Falls Dataset Version 1.1 1.10 PERSON BIRTH DATE See NHS Data Dictionary 1.11 PERSON GENDER CURRENT See NHS Data Dictionary 1.12 ETHNIC CATEGORY See NHS Data Dictionary. 1.13 GP NAME (NAME OF REGISTERED OR REFERRING GMP) GMP (CODE OF REGISTERED OR REFERRING GMP) See NHS Data Dictionary 1.14a ORGANISATION NAME (GP PRACTICE) 1.15 CODE OF GP PRACTICE (REGISTERED GMP) ORGANISATION CODE (PCT OF GP PRACTICE) 1.14 1.16 1.17 1.18 ORGANISATION CODE (CODE OF PROVIDER) ORGANISATION CODE (CODE OF COMMISSIONER) Version: 1.1 Issue Date: 07/12/04 Additional identifier for the person who is the subject of the dataset. Also required for the calculation of age. To enable the provision of case mix indicators. Identifies the phenotypical gender classification that currently applies to the person. Records the ethnicity of a person, as specified by the person. Identifies the name of the person’s general medical practitioner See NHS Data Dictionary See NHS Data Dictionary. Identifies the unique code for the person’s general medical practitioner See NHS Data Dictionary The name of the GP practice for the GMP who has either registered or referred the PATIENT See NHS Data Dictionary Identifies the name for the person’s general medical practitioner Max an255 Identifies the unique practise code for the person’s general medical practitioner Identifies the unique code of the Primary Care Trust responsible for the GP practise at which the person is registered. Identifies the unique code of the ORGANISATION providing the care to the patient. Identifies the unique code of the ORGANISATION commissioning the care for the patient. See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary See NHS Data Dictionary Page 2 of 18 Falls Dataset 2 CASE FINDINGS - FALLS FALL CHECK DATE 3 NUMBER OF FALLS IN PREVIOUS 12 MONTHS 4 FALL DATE (SAP) Version 1.1 The date on which the person was last routinely asked about their fall history over the past year. This data item is not currently routinely captured as part of patient care records. The number of falls that the person has reported having in the 12 month period prior to the fall check date. This data item is not currently routinely captured as part of patient care records. The date when the person fell. Single Assessment Summary data set v0.7. This data item is not currently routinely captured as part of patient care records. To monitor the proactive approach required by NICE to screen older people for falls at least once every year. Business Requirements v1.0, Reference 1.1. n8 (with 2 spaces): ccyy-mm-dd Identifies those persons who have reported a single fall or multiple falls and who should undergo a simple observation for balance and gait deficit and be considered for detailed fall evaluation, as defined by NICE. Business Requirements v1.0, Reference 1.1, 2.1b. Identifies those persons who have fallen. Supports the documentation of falls, when a person presents for medical attention due to a fall and/or when a person falls in an institution. Business Requirements v1.0, Reference 1,2,1.3. n3 n8 (with 2 spaces): ccyy-mm-dd Ensures that Fall History is included as part of the detailed fall evaluation. Business Requirements v0, Reference 3.1. Version: 1.1 Issue Date: 07/12/04 Page 3 of 18 Falls Dataset 5 6 LOCATION (FALL) DIAGNOSIS DATE (FALL) Version: 1.1 Issue Date: 07/12/04 Version 1.1 Identifies the type of the location where the person fell. For example: Home Hospital Residential care home Nursing care home Street Other This data item is not currently routinely captured as part of patient care records Supports the documentation of falls, when a person presents for medical attention due to a fall and/or when person falls in an institution. Business Requirements v1.0, References 1.2 and 1.3. The date on which the person was diagnosed as having an injury as the result of a fall. May or may not be the same as the FALL DATE Supports the documentation of falls, when a person presents for medical attention due to a fall. Business Requirements v10, Reference 1.2. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n2 01 Home 02 Hospital 03 Residential care home 04 Nursing care home 05 Street 06 Other 07 Not specified 08 Not known Note: The following existing data items and classifications are not appropriate to use: Location Type A&E: Incident Location Type n8 (with 2 spaces): ccyy-mm-dd Page 4 of 18 Falls Dataset 7 DIAGNOSIS (FALL) Repeating Data Item Version 1.1 Identifies the diagnosis of the fragility fracture(s) or other injuries sustained by the person as the result of the fall. Note: Current diagnostic coding is insufficiently sensitive to identify a Fall Supports the documentation of falls, when a person presents for medical attention due to a fall. Identifies the reason why the person presented for medical attention as the result of a fall. Business Requirements v1.0, Reference 1.2. Repeat group. READ, ICD10, SNOMED (when available) Fragility Fracture o Hip o Humerus o Pelvis o Vertebrae o Wrist o Other – need to be defined Other o Collapse o Faint o Head Injury o Senility o Soft Tissue Injury Note: Fall is not strictly a diagnosis. There may be the potential to use the A&E: Patient Group data item and to extend the current classification to include Falls, the current classification is shown below: Road Traffic Accident Assault Deliberate Self-Harm Sports Injury Firework Injury Other accident Brought in Dead Other than above Version: 1.1 Issue Date: 07/12/04 Page 5 of 18 Falls Dataset 8 9 FALLS ASSESSMENT DATE (SAP) RECURRENT SYNCOPE Version 1.1 The date on which the person received a detailed falls evaluation. Single Assessment Summary data set v0.7. Identifies whether or not the person has described recurrent syncope to a health care professional. Enables monitoring that a person having reported a fall during the SAP (or other assessment) is followed up by a detailed falls evaluation. To monitor that a detailed fall evaluation is undertaken when a person suffers 2 or more falls, presents for medical attention because of a fall, falls in an institution, describes recurrent syncope or suffers a single fall and exhibits balance and gait deficit. Business Requirements v1.0, References 1.2, 1.3, 1.4, 2.1b, 3.1. Identifies that a person has described recurrent syncope, therefore enables monitoring that a detailed fall evaluation is performed on the person. Business Requirements v1.0, Reference 1.4, 2.1b. n8 (with 2 spaces): ccyy-mm-dd n2 01 Yes 02 No 98 Not specified 99 Not known To monitor that a person with a history of syncope is considered for referral for specialist investigation, for example for carotid sinus studies, as defined by NICE. Business Requirements v1.0, Reference 3.2. Version: 1.1 Issue Date: 07/12/04 Page 6 of 18 Falls Dataset 10 11 INITIAL ASSESSMENT & SCREENING SIMPLE BALANCE & GAIT OBSERVATION DATE SIMPLE BALANCE & GAIT OBSERVATION Version: 1.1 Issue Date: 07/12/04 Version 1.1 The date on which the person had a simple balance and gait observation performed. This data item is not currently routinely captured as part of patient care records. Identifies whether or not the person’s balance and gait was observed as stable or unstable. This data item is not currently routinely captured as part of patient care records. Enables monitoring that a simple balance and gait observation is performed on an older person who has fallen or who is considered at risk of falling, as defined by NICE. Business Requirements v1.0, Reference 2.1a. n8 (with 2 spaces): ccyy-mm-dd Enables monitoring that people identified with balance and gait problems have a detailed falls evaluation performed. Business Requirements v1.0, Reference 2.1. n2 01 02 98 99 Stable Unstable Not specified Not known Page 7 of 18 Falls Dataset 12 12.1 12.2 DETAILED FALL EVALUATION FALL HISTORY & CIRCUMSTANCES FALL HISTORY (FREQUENCY) FALL HISTORY (RECURRENT UNEXPLAINED FALLS) Version 1.1 The frequency with which the person falls. The average period between falls in days. Identifies people who fall frequently. Identifies whether or not the person has suffered 2 or more recurrent, unexplained falls. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n3 Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n2 01 Yes 02 No 98 Not specified 99 Not known Enables monitoring that a person with recurrent unexplained falls is considered for referral for specialist investigation, for example for carotid sinus studies, as defined by NICE. Business Requirements v1.0, Reference 3.2. 12.3 FALL HISTORY (ALCOHOL HISTORY) Version: 1.1 Issue Date: 07/12/04 Identifies whether or not the person was asked about their alcohol consumption history as part of the detailed falls assessment. Enables monitoring that people with recurrent unexplained falls are considered for tailored, multifactoral interventions, as defined by NICE. Business Requirements v1.0, Reference 4.1. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n2 01 Yes 02 No 98 Not specified 99 Not known Page 8 of 18 Falls Dataset 12.4 12.5 12.6 Version 1.1 FALL HISTORY (MEDICATION HISTORY) Identifies whether or not the person was asked about their medication history as part of the detailed falls assessment. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. FALL HISTORY (MULTIPLE MEDICATION) Identifies whether or not the person is currently taking 4 or more prescribed drugs. Derived data item from patient medication record. Identifies whether or not the person is currently taking culprit medications associated with falls. Derived data item from patient medication record. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. FALL HISTORY (CULPRIT MEDICATION) Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n2 01 02 98 99 n2 01 02 98 99 n2 01 02 98 99 Yes No Not specified Not known Yes No Not specified Not known Yes No Not specified Not known Note: The NHSIA will identify a Pharmacist to provide a comprehensive list of Culprit Medications, for example: Anticonvulsants Antidepressants Benzodiazapins Cardiac drugs Diuretics Neuroleptics Opiates Parkinson’s medicines Psychotropics 12.7 12.7.1 FALL HISTORY (FALLS) Repeating Group in Data Set One incidence of the group is recorded per Fall in the Fall History FALL DATE (SAP) Version: 1.1 Issue Date: 07/12/04 This data item group is not currently routinely captured as part of patient care records. See Data Item 4 Page 9 of 18 Falls Dataset 12.7.2 12.7.3 12.7.4 12.7.5 12.7.6 12.7.7 13 Version 1.1 FALL LOCATION FALL HISTORY (FAINTING OR DIZZINESS) See Data Item 5 Identifies whether or not the person experienced any fainting or dizziness associated with the fall. FALL HISTORY (ABILITY TO GET UP) Identifies whether or not the person was able to get up following the fall. A long lie is implied, if the person was not able to get up. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. FALL HISTORY (INJURY) Identifies whether or not the person was injured as the result of the fall. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. FALL HISTORY (WITNESSED) Identifies whether or not one or more third parties witnessed the person’s fall. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. FALL HISTORY (WITNESS ACCOUNT) Identifies whether or not there is a collaborating witness account of the fall. Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. EXAMINATION Repeating Group in Data Set Version: 1.1 Issue Date: 07/12/04 Ensures that Fall History is evaluated as part of the detailed fall evaluation. Business Requirements v1.0, Reference 3.1. n2 01 02 98 99 n2 01 02 98 99 n2 01 02 98 99 n2 01 02 98 99 n2 01 02 98 99 Yes No Not specified Not known Yes No Not specified Not known Yes No Not specified Not known Yes No Not specified Not known Yes No Not specified Not known Provides a Working Group checklist for best practice recommendations. Page 10 of 18 Falls Dataset 13.1 Version 1.1 FALL EXAMINATION TYPE Identifies the type of examination considered as part of the detailed fall evaluation. This data item is not currently routinely captured as part of patient care records. Ensures that detailed fall evaluation Examination is in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. n2 13.2 FALL EXAMINATION TYPE CARRIED OUT Identifies whether or not the person was assessed for the FALL EXAMINATION TYPE specified. 13.3 FALL EXAMINATION DATE Identifies the date that the FALL EXAMINATION was carried out n2 01 Yes 02 No 98 Not specified n10 – ccyy-mm-dd 14 OSTEOPOROTIC RISK Repeating Group in Data Set Ensures that detailed fall evaluation Examination is in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. Ensures that detailed fall evaluation Examination is in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. Provides a Working Group checklist for best practice recommendations. Version: 1.1 Issue Date: 07/12/04 01 Balance and Gait Assessment (see Data Item 9) 03 Transfers Assessment 04 Footwear Assessment 05 Walking Aids Assessment 06 Blood Pressure Lying 07 Blood Pressure Standing 08 Visual Assessment 09 Foot Examination 10 Lower Limb Examination 11 Cognition Assessment 12 Functional History (Activities of Daily Living) 13 Home Environment History 14 Social Support 15 Alarm Raising 16 Anxiety 17 Depression 18 Fear of Falling 19 Restriction of Activities Page 11 of 18 Falls Dataset 14.1 OSTEOPOROTIC RISK TYPE Version 1.1 Identifies the type of osteoporotic risk considered as part of the detailed fall evaluation. This data item is not currently routinely captured as part of patient care records. Ensures that detailed fall evaluation Osteoporotic Risk is assessed in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. To monitor that osteoporosis risk assessment is carried out on a person diagnosed with a fragility fracture. Business Requirements v1.0, Reference 5.2. 14.2 FALL OSTEOPOROTIC RISK TYPE ASSESSED Identifies whether or not the person was assessed for the OSTEOPOROTIC RISK TYPE specified. Ensures that detailed fall evaluation Osteoporotic Risk is assessed in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. n2 01 Body Mass Index (BMI) 02 Previous Fragility Fractures 03 Prolonged Corticosteroid Therapy 04 Hysterectomy, Premature Menopause or History of Amenorrhoea 05 Liver or Thyroid Disease, Malabsorption, Alcoholism, Rheumatoid Arthritis & Male Hypogonadism 06 Family History of Osteoporosis, including Maternal Hip Fracture 07 Alcohol Consumption 08 Exercise Status 09 Nutrition Status 10 Smoking Status n2 01 Yes 02 No 98 Not specified To monitor that osteoporosis risk assessment is carried out on a person diagnosed with a fragility fracture. Business Requirements v1.0, Reference 5.2. Version: 1.1 Issue Date: 07/12/04 Page 12 of 18 Falls Dataset 14.3 FALL OSTEOPOROTIC RISK ASSESSMENT DATE Version 1.1 Identifies the date that the OSTEOPOROTIC RISK was assessed. Ensures that detailed fall evaluation Osteoporotic Risk is assessed in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 3.1. n10 – ccyy-mm-dd To monitor that osteoporosis risk assessment is carried out on a person diagnosed with a fragility fracture. Business Requirements v1.0, Reference 5.2. Version: 1.1 Issue Date: 07/12/04 Page 13 of 18 Falls Dataset 15 15.1 INTERVENTIONS FALL INTERVENTION Repeating Group in Data Set FALL INTERVENTION TYPE Version 1.1 Provides a Working Group checklist for best practice recommendations. Identifies the type of intervention considered as a result of the detailed falls evaluation. Ensures that interventions arising from a detailed falls evaluation are in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 4.1. Ensures that older people with a history of syncope or recurrent unexplained falls are considered for specialist referral. Business Requirements v1.0, Reference 3.2. Version: 1.1 Issue Date: 07/12/04 n2 01 Diagnosis & treatment of underlying Medical Problem 02 Intervention for cardiac syncope Intervention for postural hypotension 03 Full Dose Calcium and Vitamin D 04 Medication Review 05 Balance and Gait Training 06 Strengthening Training 07 Footwear Advice 08 Vision Advice and Follow Up 08 Foot Advice and Follow Up 09 OT Referral 10 Rehabilitation, e.g. OT and/or PT referral 11 Getting Up Strategies 12 Home hazard modification 13 Safety and/or Mobility Equipment 14 Repairs and/or Improvements 15 Social Care Support 16 Psychological Support Page 14 of 18 Falls Dataset 15.2 FALL INTERVENTION CONSIDERED 15.3 FALL INTERVENTION REFERRAL DATE 15.4 FALL INTERVENTION DATE 16 17 MEDICATION START DATE (FOR PSCHOTROPIC DRUGS) MEDICATION REVIEW DATE (FOR PSYCHOTROPIC DRUGS) Version: 1.1 Issue Date: 07/12/04 Version 1.1 Identifies whether or not the person was considered for the FALL INTERVENTION specified, if appropriate, and if so, whether or not the person was referred. This data item is not currently routinely captured as part of patient care records. The date on which the person considered for the FALL INTERVENTION specified was referred to the care professional or service. The actual date on which the FALL INTERVENTION commenced. The date when the person was first prescribed psychotropic drugs. Note: The NHSIA will identify a Pharmacist to provide a comprehensive list of Psychotropic Medications The date on which the person was prescribed psychotropic drugs were last reviewed. Ensures that interventions arising from a detailed falls evaluation are in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 4.1. n2 Ensures that interventions arising from a detailed falls evaluation are in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 4.1. Ensures that interventions arising from a detailed falls evaluation are in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 4.1. n8 (with 2 spaces): ccyy-mm-dd Enables person’s waiting time from referral to start of intervention to be monitored. Ensures that a person prescribed psychotropic medication should undergo a medication review with justification for continuing medication, as defined by NICE. Business Requirements v1.0, Reference 4.2. Ensures that a person prescribed psychotropic medication should undergo a medication review with justification for continuing medication, as defined by NICE. Business Requirements v1.0, Reference 4.2. 01 Yes, considered but not referred 02 Yes, considered and referred 03 Not considered 98 Not specified n8 (with 2 spaces): ccyy-mm-dd n8 (with 2 spaces): ccyy-mm-dd n10 – ccyy-mm-dd Page 15 of 18 Falls Dataset 18 MEDICATION CONTINUED Version: 1.1 Issue Date: 07/12/04 Version 1.1 Identifies whether or not the person was continued on psychotropic drugs with documented justification following a medication review. Ensures that a person prescribed psychotropic medication should undergo a medication review with justification for continuing medication, as defined by NICE. Business Requirements v1.0, Reference 4.2. n2 01 Yes 02 No 98 Not specified 99 Not known Page 16 of 18 Falls Dataset 19 BONE HEALTH PERSON’S RESIDENCE TYPE Version 1.1 Identifies the person’s usual type of residence. Enables monitoring of equity of access to osteoporosis investigation and treatment. Business Requirements v1.0, Reference 5.2. To ensure identification of a person with fragility fractures for referral for osteoporosis assessment, investigation and treatment. Business Requirements v1.0, Reference 5.2. To ensure identification of a person with fragility fractures for referral for osteoporosis assessment, investigation and treatment. Business Requirements v1.0, Reference 5.2. 20 DIAGNOSIS DATE (FRAGILITY FRACTURE) The date on which the person was diagnosed with a fragility fracture. 21 DIAGNOSIS (FRAGILITY FRACTURE) Repeat Data Item Identifies the diagnosis of the fragility fracture(s) sustained by the person which may or may not have been as the result of a fall. 22 CURRENT BONE STRENGTHENING DRUGS Identifies whether or not the person is currently taking any bone strengthening drugs. 23 DEXA DATE The date on which the person received a DEXA bone mineral scan. Version: 1.1 Issue Date: 07/12/04 To ensure identification of a person with fragility fractures for referral for appropriate osteoporosis assessment, investigation and treatment. Business Requirements v1.0, Reference 5.2. To monitor that osteoporosis investigation is carried out on a person diagnosed with a fragility fracture. Business Requirements v1.0, Reference 5.2. n2 01 Own home 02 Residential care home 03 Nursing car home 04 Prison 98 Not specified 99 Not known n10 – ccyy-mm-dd READ, ICD10, SNOMED (when available) Fragility Fracture o Hip o Humerus o Pelvis o Vertebrae o Wrist o Other n2 01 Yes 02 No 98 Not specified 99 Not known n10 – ccyy-mm-dd Page 17 of 18 Falls Dataset 24 24.1 24.2 OSTEOPOROSIS TREATMENT Repeat group in data set BONE STRENGTHENING TREATMENT BONE STRENGTHENING TREATMENT CONSIDERED Version: 1.1 Issue Date: 07/12/04 Version 1.1 Identifies the type of bone strengthening treatment. To monitor whether or not a person with a fragility fracture was treated for osteoporosis. Business Requirements v1.0, Reference 5.2. n2 01 Full Dose Ca and Vitamin D 02 Bisphosphonates 03 Others Identifies whether or not the person was considered for the BONE STRENGTHENING TREATMET specified, if appropriate, and if so, whether or not the person was given treatment. Ensures that interventions arising from a detailed falls evaluation are in accordance with Working Group recommendations for best practice. Business Requirements v1.0, Reference 5.2. n2 01 Yes, considered but not given 02 Yes, considered and given 03 Not considered 98 Not specified Page 18 of 18