AHP Episode

(ISD)

An AHP episode is the care provided to a patient over a period of time by AHP personnel of a specific profession at a specific hospital or other location.

The care may take place in the AHP department, or elsewhere in the hospital. It may also take place in the patient's home or in community premises.

The episode comprises one or a series of contacts, which are initiated by an AHP referral or re-referral and ended by an AHP discharge.

Note

1. For information purposes an AHP patient is classified at each contact in the episode as an AHP inpatient, an AHP outpatient, AHP day patient, AHP direct access patient or AHP community patient.

For example, a physiotherapy episode may begin while the patient is an inpatient and continue at the same location when the patient goes home.

Thus at some contacts the patient is a physiotherapy inpatient and at others a physiotherapy outpatient. This change does NOT constitute a new physiotherapy episode.

From the local management and administration point of view, it is important to know of such changes. This can be achieved in local information systems by recording the patient type at each contact.

If the patient continues to receive services from a specific profession but the location changes and hence the group of staff providing the care changes, then the patient starts a new episode.

This situation usually arises when a patient moves from hospital to community care or from one hospital to another.

2. AHP patients are classified on a second dimension according to the specific AHP (e.g. physiotherapy patient, occupational therapy patient) and each type associated with a type of AHP episode.

3. A patient may be in more than one episode at a time. For example, an inpatient receiving

Physiotherapy treatment is involved in an inpatient episode and a physiotherapy episode.

4. A patient may be in more than one AHP episode at any time. For example, a patient may be involved in both physiotherapy and occupational therapy episodes.

5. An episode is not defined for radiography (diagnostic), as it is not normally identifiable in practice.

AHP Summary Programmes

(eCHIP)

The Programmes of Care approach will provide a summary dataset for AHPs that identify the summary reason that a patient / client / group has been on their active clinical caseload.

Care Pathway

(ISB)

A model or template which provides a set of inter-related types of activity for a given Health Issue. It identifies the types of action to do / not to do appropriate to the health issue it is for. It is likely to include types of action recommended by one (or more) protocol, and should include those to be performed by all the staff disciplines involved. It contains types of goal and the sequence of actions specific to the health issue. It will be used to record the care provided for that issue and their outcomes for individual patients. A care pathway may also indicate any constraints on the staff discipline that may perform a specific activity (and may name the individual who should perform it). A model care pathway is a living structure that evolves, subject to version control, according to the outcomes of its use and advances in clinical practice and technology.

Care Plan

(ISB)

All the activities that are planned to happen / should not happen for the patient for all health issues for which the patient is currently receiving care. It will involve intended interventions of every assigned CP that the patient is using, plus any other interventions that relate to health issues not included within the model Care Plan

Casemix

(ISD)

Casemix is a combination of patient diagnoses and treatments linked together and forming a

single item for the purpose of resource analysis. A casemix may include complex high-resource

treatments together with routine low-resource treatments.

Clinical Caseload

The number of cases for which an AHP is responsible for at any one times.

These cases will require a mixture of face to face contacts and case management and may involve advice and support tp parents / carers in the management of the clinical condition.

Clinical Guideline

(ISB)

Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.

Clinical Protocol

(ISB)

Agreed statements with explicit steps based on clinical guidelines and/or organisational consensus. The agreement is binding for a specified community; which may be a team or larger organisation. The clinical protocol may say what kind of care professional can perform an action, or even name a specific individual as an action’s performer.

Clinical Records

(NHSQIS)

Patient’s notes which includes all documentation of  identification and assessment of health and social care needs, formulation and delivery of plands and strategies for meeting these needs and critical evalutaion of the impact of interventions and actions delivered by the Allied Health Professional.

Community Health Index Number. CHI

(ISD)

Reliable and consistent authentication of patient information is vital when assembling different ‘fragments’ into the same record.   The keystone of our strategy for this is to use the patient’s Community Health Index Number.

Decision support

(ISD)

Improvement to the quality of clinical care should be supported by online access to clinical decision support systems and, where appropriate, the use of evidence based algorithms.

eHealth

(ISD)

encompasses much more than the deployment of computer technology. It conveys the message of electronics in support of health and stimulates thought and discussion about the broad range of issues and opportunities that technology offers in the health care setting to both healthcare professionals and patients.

Generic Data Set

(ISD)

The administrative, social and health care minimum information fields required in all health care records and recorded using information standards.

Health Care Framework

(ISB)

Healthcare Frameworks are tools designed for displaying aggregated data on people, patients, their treatment and its outcome. They plot Health Benefit Groups (groupings of people with similar health conditions and expected outcomes given similar interventions) against Healthcare Resource Groups (groupings of interventions that are similar in resource use and clinical meaning). Healthcare Frameworks reflect the natural history of disease and healthcare processes. They are designed to enable the total healthcare process to be described, regardless of setting.

Health Care Goal

(eCHIP)

A measurable desired outcome, e.g. to weigh <12 stone, within 2 months, to be able to walk to ward toilet and back unaided, to stop smoking by January 1^st. A goal in a care pathway should always be attached to an intervention or group of intervention(s) on that pathway.

Health Care Objective

(eCHIP)

The desired ultimate achievement of the specified action or effort of the health care professional to address the health issues / problems identified by the patient / client / population group.

Health Issue

(eCHIP)

The healthcare problem as identified by the patient / client and recognised and defined by the health care practitioner.

Integrated Care Pathway

(ISB)

An Integrated Care Pathway determines locally-agreed, multi-disciplinary practice based on guidelines and evidence, where available, for a specific client group. It forms all or part of the clinical record, documents care given and facilitates the evaluation of outcomes for continuous quality improvement.
Integrated care pathways (ICPs) use the current best evidence gained from systematic reviews, as well as input from multidisciplinary teams, to outline the optimal course of care for all clients who have a specific condition or who are undergoing a specific procedure. Other common names for these tools include clinical pathways, clinical care pathways, and Care Maps.
ICPs plot out for a particular presenting problem or procedure the optimal sequence and timing of interventions by physicians, nurses, and other professionals. Because pathways prescribe treatment and care across different care settings and even between different localities, they help ensure that a co-ordinated, quality service is provided over the full continuum of care

Intervention

(ISB)

An action intended to observe, change, support or maintain the state of the patient. It excludes: - context actions (e.g. GP consultations, inpatient spells, clinic appointments, telephone contacts, i.e., those actions during which interventions occur), - subject responsibility actions (where responsibility for a patient or a health issue is sought and / or assigned).

Local Integrated Care Record:

(ISD)

NHS board-wide information system holding test results, clinical letters and summaries of care contributions.   These may be assembled through speciality electronic records to give a clinician a “view” across all the specialty systems which have current information about the patient to be archived in the SCI Store repository.

Outcome Indicators

(ISB)

Measurements of the success of clinical treatment/intervention in terms of the impact on the health of the individual.

Patient Care Pathway

(ISB)

A Care Pathway which has been tailored to meet the specific needs of a particular Service User / Patient. It is linked to the Care Pathway from which it was derived and contains the set of planned activities.

Problem

(ISB)

Unknown underlying cause of one or more Incidents.

Progammes of Care

(eCHIP & CEN)

Description of planned and duly personalised service interventions, informed by one or more protocols, addressing one or more health issues and encompassing all health care activities by one or more health care parties.

SNOMED-CT

(ISB)

SNOMED-Clinical Terms (SNOMED-CT) is a computerised clinical language designed by clinicans to provide a single unified terminology for use in acute and primary care. It will be an underpinning feature of the development of Electronic Patient Records and Electronic Health Records in Scotland by facilitating integration of computerised clinical information.

Specified referral indicators for Intervention Data sets

(eCHIP)

To ensure the appropriate involvement of the right AHP it is essential that accurate information about the health problem / issue is provided by the referrer or person direct. This information will allow the AHP to make a clinical decision to see the patient or not or to refer to another professional.

Standard Assessment Tools

(eCHIP)

The use of Validated Assessment tools is recognised for many diseases / conditions and these should be encouraged and standards for their application should be agreed throughout Scotland.

Standard Disease Specific Outcome Measures

(eCHIP)

Agreed methods of measuring the success of clinical treatment/interventions in terms of the impact on the health of the individual for individual disease processes.

Standard Disease Specific Record Fields

(ISD)

For Benchmarking, Clinical Effectiveness and Electronic Integrated Care Records it is essential that agreement is reached by professional groups on the minimum data fields to record the required standard of clinical information for each specific disease. Work has already started in Podiatry and Dietetics for Diabetes and a Musculoskeletal data set is being reviewed. Working groups will be established for Stroke, CHD, Children, Cancer and Older People as ISD has the resources to start the work.

Waiting Times Data Set

(ISD)

The specified fields required to deliver the waiting times information.