EXPLANATION OF FIELD NAMES
No.
FIELD NAME
LONGER DESCRIPTION
v1.9 13/06/05
DEFINITION / COMMENTS
FIXED = only takes data in a set format or choice/s from a dropdown list
FREE = any text or numbers accepted
Italic with grey highlight = local use only, need not be completed
1.01
Hospital
FIXED to identify your programme to CCAD – built in to programme
1.02
Hospital number
your own hospital / PCT case or unit
numbering scheme
FREE variables in italics and highlighted in grey, they can be used as a handy storage
space for anything you like and for any purpose you wish.
1.03
NHS Number
patients unique NHS number
FIXED must be valid NHS number, i.e. have 10 digits no spaces
1.04
Surname
FREE
1.05
Forename
FREE
1.06
DOB
1.07
Gender
1.08
Address
patient’s address
FREE
1.09
Postcode
patient’s postcode
FIXED collected to compare deprivation scores and use GIS to map provision
1.10
Telephone
contact telephone number / s
FREE. space for a series of different numbers, bleeps, extensions etc.
1.11
Next of kin
FREE
1.12
Contact Notes
FREE for example, ‘works nights, only contact in the afternoon’
1.13
Ethnic Group
1.14
Consultants Name
FREE any of the following variables can be used locally in any way desired
1.15
Consultant Phone No.
FREE
date of birth
FIXED in dd/mm/yyyy format i.e. 21/05/1951
FIXED
patient completed questionnaire
07/03/2016
FIXED same as used for the national census to allow for comparison with that data.
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EXPLANATION OF FIELD NAMES
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1.16
GP Name
FREE
1.17
Health Centre/Practice name
FREE
1.18
Facilitator/Key Worker Name(s)
FREE
1.19
Facilitator Contact Details
FREE
1.20
Marital Status
FIXED
1.21
Rehab Initiating Event
reason for referral for rehabilitation
FIXED The reason why the patient was referred or recruited. Choose the most recent, e.g. if
patient had an MI , closely followed by angioplasty choose angioplasty.
1.22
Attended Rehab
whether the patient attended
FIXED yes / no
FIXED you can only choose one reason. If given choose the patients reason. On
occasions there may be more than one, in which case choose which you think the
most important.
1.23
Reason for not taking part
If ‘no’ to 1.21. Multiple choice list.
1.24
Date Initiating Event
date of the event that is the main cause of FIXED e.g. if ‘reason for rehab’ (1.20 above) is angioplasty, even if an MI triggered the
the current referral to your programme,
angioplasty, the date of the angioplasty should be used. If a review of a cardiac
this may include a search of a CHD
register for people with heart failure or angina was the initiating event for being
register.
invited to a programme then the date of the search. If surgery the date of the
surgery should be given. What we are trying to capture is how long people are
having to wait and the extent of the wait at each part of the ‘patient journey’.
1.25
Other Previous Events
previous acute cardiac events sustained
by this patient.
FIXED preferably collected from case notes – if this is not possible through patient
completed questionnaire
1.26
Referred By
role of person referring the patient
FIXED
1.27
Name of Referrer
contact name / organisation of referring
FREE
1.28
Date Referred to Rehab
date patient was referred to the rehab
programme.
FIXED Date on referral letter to you, or when you first became aware of the patient, e.g.
contact from ward asking you to see the patient, or you identified their name from a
surgery list or by searching a CHD register. This date may often be the same as
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that at 1.24. For example, if a patient is admitted with AMI and is referred to rehab
on the same day. This is to identify the wait time between the event and being
referred to the programme.
1.29
Date Invited for Rehab
date invited to join programme.
FIXED The date on which the patient was invited to come to the rehab programme and
given a definite start date. Or, the date such a letter was sent to the patient. This is
not the same as the date they were told that there is a programme that they could
attend at some time in the future. It is to identify how long it takes, from the event to
the patient receiving a definite start date.
1.30
Date Rehab Started
date patient first ‘did something’ other
than read about rehabilitation.
FIXED If it is group based programme it is the date of the first attendance at the group or, if
home based or individualised it is the date on which the patient undertook their first
‘homework’. Although the patient may have been seen on the ward or in a clinic, or
a home visit and given general advice and things to read, however important this is,
it is not what we mean here as the first day of the programme unless that advice
meant them doing something observable, i.e. a structured home exercise plan.
1.31
Date Rehab Programme
Completed
date patient completed the formal /
supervised part of the programme
FIXED Date of last day of your programme, i.e. usually 6-12 weeks . We realise that a few
programmes extend for much longer than this and that a menu based programme
may (should) involve triage to other interventions (psychology, dietetics, phase 4,
patient support group etc.), these benefits will be measured at 12 months.
1.32
First follow-up due
1.33
First follow-up done
simple yes / no choice
FIXED it is to help administration, the database user can search for forthcoming
1.34
Reason 1st follow-up not done
if no above a space to write a note
FREE re-assessment dates and check which have not been done easily, plus keep a
1.35
12 month follow-up due
date started rehab + 12 months
FIXED note if there are any special reasons – eg. ‘running 7 marathons back in 2 months’
1.36
12 month follow-up done
yes / no
FIXED
1.37
Reason 12 month fu not done
note as to why not done
FREE
FIXED this is calculated and appears automatically – it is day started rehab + 12 weeks
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COMORBIDITY this is being collected to compare programmes fairly according to different case mix.
1.38
Angina
FIXED Ideally the following information would be taken from case notes, if this is not
possible it can be collected using the (provided) patient completed questionnaire
1.39
Arthritis (osteoarthritis)
FIXED
1.40
Cancer
FIXED
1.41
Diabetes
FIXED
1.42
Rheumatism
FIXED
1.43
1.44
Stroke
Osteoporosis
FIXED
FIXED
1.45
1.46
Chronic bronchitis
Emphysema
FIXED
FIXED
1.47
1.48
Asthma
AIDS
FIXED
FIXED
1.49
1.50
Claudication
Chronic back problems
FIXED
FIXED
1.51
1.52
Other comorbid complaint
Other comorbid complaint –
describe
space to record other chronic conditions
that might limit the patient
FIXED
FREE Free text.
1.53
Risk assessment
low, Moderate, High
07/03/2016
FIXED BACR recommendations (Note 1. page 9)
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CARDIAC REHABILITATION ASSESSMENTS
The demographic details above are completed only once although fields can be edited, if for example the patient moves or changes doctor.
Everything below this point is filled in at each assessment point. A new record is created each time a new assessment is done. Any number of new assessment records can be
created but for benchmarking we require 3, before the programme – (Assessment no. = 1) At 12 weeks (Assessment = 2) and at twelve months (Assessment = 3). Other
assessments should be given different numbers even if they came between these points. Extensive individual notes can be added to each assessment record.
The record can be printed out to share and discuss with the patient and if you use a menu based system to agree on the treatment choices. Following each assessment the
records can be printed out and compared and the patient can see what has been achieved and what remains to be achieved. These records can also be sent to the GP,
consultant, primary care nurse, etc. as a record of what has been achieved in the programme and what should be achieved in the future. There is a large free text area at the
end of the report to allow you to write recommendations and notes for the patient and other clinicians.
We realise that some of these variables, (eg. cholesterol assay) may be hard to collect due to resource limitations. Also it may not be possible to recall patients to a clinic at 12
months and that postal questionnaires must be sent making an accurate BMI or BP hard to get at this point. If you cannot collect these then they will have to be left blank. If you
can involve practice nurses in collecting this data through the annual NSF secondary prevention clinics this may solve the problem and help to make the service seamless.
2.01
2.02
Assessment date
Assessment Number
FIXED date assessment carried out with patient
FIXED Assessment 1 = before the programme. Occasion 2 = 12 weeks later. Occasion
3 = 12 months later. Other can be completed depending on your resources.
2.03
Rehab phase
2.04
Rehabilitation Type – home
based
FIXED e.g. Heart Manual, Papworth Programme, or other programme in which patient
mainly works at home whether supervised from primary or secondary care.
Some programmes use home for 6 weeks then hospital (2.05), in this case
answer YES to both 2.04 and 2.05 but only if the patient actually took part in
both, only one if they attended only one of them. This does not include a home
exercise programme set as ‘homework’ between hospital attendances.
2.05
Rehabilitation Type – hospital
based
FIXED programme in which patient is expected to attend a hospital on a regular
succession of dates for the major part of their rehabilitation programme – even
if they also do ‘homework’ during the week or have a home visit.
2.06
2.07
Rehabilitation Type – community
based
Rehabilitation Type – other
FIXED programme based in a community setting, leisure centre, health centre,
voluntary setting, etc. regardless of where the staff are employed.
FIXED if your programme does not fit any of the above answer YES.
2.08
Menu / Sessions Attended
the BACR phase
FIXED asked for by some reviewers, not collected
all of the most common elements of a CR FIXED only endorse if at least 50% of the intended treatment was completed by the
programme are listed
patient. This is important because we will be comparing ‘processes’ and if
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2.09
Onward Referral
referrals to other professionals /agencies
dropouts are shown as having attended it may make that intervention seem
ineffectual. As many as desired may be ticked.
FIXED e.g. smoking cessation, GP, Phase 4 leisure centre, etc.
2.10
Details onward referral
space to record other referrals made
FREE
CBMI & MEDICATION USE
2.11 Height
height in meters or feet & inches
FIXED without shoes, preferably using special height rule
2.12
Weight
weight in kg or stones and pounds
FIXED light clothing
2.13
2.14
BMI
Aspirin or Other Antiplatelet
calculated by programme
yes, no, contraindicated
FIXED
FIXED
2.15
2.16
ACE Inhibitor
Beta Blocker
FIXED
FIXED
2.17
2.18
Statin
Medication Notes
FIXED
FREE space to jot down any information about medications for this patient
COMPLIANCE / COMPLETERS
2.19
Rehab Programme Completed
did patient complete programme?
2.20
Percentage Completed
amount of programme completed.
2.21
Reason for Non-Completion
if patient did not complete reason why.
FIXED YES = did whole programme as intended. NO = did none of the programme,
PARTIALLY = completed some, see below
FIXED Percentage in quartiles of the estimated number of sessions/appointments
completed by patient. If YES above = 100%, if NO = ‘zero’
FIXED Choose one main reason from list presented.
MAIN BIOLOGICAL RISK MARKERS
2.22
2.23
Blood Pressure - Systolic
Blood Pressure - Diastolic
FIXED method as currently practiced in your centre
FIXED
2.24
2.25
Cholesterol - Total
Cholesterol - HDL
FIXED method as currently practiced in your centre
FIXED
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EXPLANATION OF FIELD NAMES
2.26
Cholesterol - LDL
FIXED
2.27
2.28
Cholesterol - Ratio
Triglycerides
FIXED
2.29
Smoking in Last 4 Weeks
FIXED Patient self report questionnaire
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PSYCHOLOGICAL ADJUSTMENT
2.30 Psychological – Anxiety
anxiety subscale from HAD Scale
FIXED Hospital Anxiety and Depression Scale
2.31
Psychological – Depression
depression subscale score from HAD
FIXED
2.32
anxiety normal
2.33
anxiety borderline
2.34
anxiety treatment indicated
FIXED The database programme automatically calculates and displays the three
FIXED ranges – ‘normal’- ‘borderline’ – ‘treatment indicated’ from the HAD scores you
enter
FIXED
2.35
2.36
depression normal
depression borderline
FIXED
FIXED
2.37
depression treat indicated
FIXED
PHYSICAL ACTIVITY
2.38 Physical Activity - Vigorous
number of times per week doing vigorous FIXED Patient completed questionnaire. Based on one developed by Godin & Shepard
activity
2.39
2.40
Physical Activity – Moderate
Physical activity – Mild
as above Moderate
as above Mild
FIXED
FIXED
2.41
Physical activity – Total
computer generated from 2.37-2.39
FIXED Total estimated exercise per week in METs
2.42
Physical Activity - Frequency
2.43
Physical Activity – 30 min
duration 5 times a week
HEALTH RELATED QUALITY OF LIFE
2.44 HRQOL - Physical fitness
FIXED From modified Godin questionnaire
this is the NSF audit question
FIXED Patient completed questionnaire.
Health Related Quality of Life
FIXED Patient completed questionnaire. Dartmouth COOP Scales
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EXPLANATION OF FIELD NAMES
2.45
HRQOL - Feelings
FIXED
2.46
2.47
HRQOL - Daily Activities
HRQOL - Social Activities
FIXED
FIXED
2.48
2.49
HRQOL - Pain
HRQOL - Change in Health
FIXED
FIXED
2.50
2.51
HRQOL - Overall health
HRQOL - Social Support
FIXED
FIXED
2.52
HRQOL - Quality of Life
Employment status
FIXED
2.53
2.54
Notes and comments
any case notes
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v1.9 13/06/05
FIXED Patient completed questionnaire using national census format
If you open an assessment page for a patient and go to print it will print a two
page report of all of the data from that assessment. These notes will print out
so you can use them for making further recommendations to the patient or his or
her doctor and send them a copy.
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EXPLANATION OF FIELD NAMES
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Note: 1
STRATIFICATION OF RISK FOR DISEASE PROGRESSION
LOWEST RISK
MODERATE RISK
HIGHEST RISK

No significant LV dysfunction (EF >
50%)

Moderately impaired left ventricular
function (EF = 40-49%)

Decreased LV function (EF <40%)



Survivor of cardiac arrest or sudden death
No resting or exercise-induced
complex dysrhythmias


Complex ventricular dysrhythmias at rest or
with exercise
Uncomplicated MI; CABG; angioplasty;
atherectomy; or stent
Signs/symptoms including angina at
moderate levels of exercise (5-6.9
METs) or in recovery

MI or cardiac surgery complicated by
cardiogenic shock. CHF, and/or
signs/symptoms of post-procedure ischemia

Abnormal hemodynamics with exercise
(especially flat or decreasing systolic blood
pressure or choronotropic incompetence with
increasing workload)

Signs/symptoms including angina pectoris at
low levels of exercise (< 5.0 METS) or in
recovery

Functional capacity < 5.0 METS*

Clinically significant depression
-
absence of CHF or sings/symptoms
indicating post-event ischemia

Normal hemodynamics with exercise of
recovery

Asymptomatic including absence or
angina with exertion or recovery

Functional capacity  7.0 METs*

Absence of clinical depression
Moderate risk is assumed for patients
who do not meet the classification of
either highest risk or lowest risk
Lowest risk classification is assumed
when each of the risk factors in the
category is present
Highest risk classification is assumed with the
presence of any one of the risk factors included
in this category
* NOTE: If measured functional capacity is not available, this variable is not considered in the risk-stratification process.
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