Template for CVA/TIA: Sunderland Dataset In Use: Updated 7/06
Code+ means list of lower codes Codes in the first column in blue (and not in bold) are picking list title codes and are only GMS Codes used in EMIS. They are not for entry into the reocrd themselves and as such it is acceptable for their meaning given to be different from the true Read code rubric Code Rubric > Picking List 6662 f/u neurological assessment Picking list Exclusions 9h0 9h21 Patient excluded: unsuitable 9h22 Paient excluded: informed dissent f/note
Reason why unsuitable as per allowed criteria-in free text e.g. Terminally ill or extreme frailty @ New code accepted to mean patient refuses monitoring discussed and signed. @
History (For patient care..not GMS points) 13CA Housebound free text 'family care etc?' Lower level codes no paralysis/ paresis-weakness/ hemiplegia etc. Free text: 'side and severity' 283 O/E Paralysis 2831-z 13C Mobility 13C1 Fully Mobile 13C2 Mobile Outside with aid Free text: details (e.g. type of aid) 13C3 Mobile in home 13C4 Needs walking aid in home 13C5 Chairbound 13C6 Bedbound 1B9 Speech Problem 1B91-z Lower level codes: No speech problem, diff with speech etc. Free text detail: 138 Exercise grading 1381 Exercise physically impossible 1383 No aerobic exercise 1384 Enjoys light exercise (long walks eg.) 1388+Value Enjoys moderate exercise times and type per week 8CA5 Advise exercise 6896 2Q depression screen 0-2 Q positive in free text Not required for QOF 2006/7 Smoking (Lines 32-45 can be set up as a subtemplate and used as part of IHD/Asthma/Gen Health/Diabetic templates) 137 Tobacco consumption 1371 Never smoked tobacco ) 137P +V cigarette smoker (include rolled) ) 137H +V pipe smoker )--------------------------> pipe/cigar?' free text 'Ex: 137J +V cigar smoker )
137S +V 137d 137c 137b 137T date stopped/restarted 137T 137e (388B) Pack years (yrs@20cig/d) 6791 Health education smoking 8HTK Refer Smoking Cess Clinic 137G Motivation' 2469+V 246A+V 242 8BL0 F/U 662V 229+V 22A+V 22K+V 8CA4 44OE+V 8BL1
Ex smoker Not interested in stopping Thinking of stopping Ready/Planning to stop Date ceased smoking restarted smoking
) Content Smoker Concerned Smoker Planning to stop free test 'how long stopped?' &
local/ specialist
Diastolic BP Systolic BP Pulse rate free text 'regular?' On Maximum tolerated Rx for hypertension Max dose 4 agents or mutliple intolerance Blood pressure monitoring Diary entry O/E Height O/E weight BMI (calculated) Advised re Diet 8CA41-z Lower level codes for type of diet. First item is weight loss diet. Total Cholesterol Max Tol Rx for lipids From lablinks On maximum tolerated dose lipid Rx Statins c/i Perm statin C/I Statin declined Diary entry
@
8BL1 8I27 U60CA 8I3C
lasts1 year lasts1 year lasts1 year
@ @
F/U 44OE F/U choleterol due 567 CAT scan
569 MRI scan
5672 CAT scan normal 5673 CAT scan abnormal 5675 CAT scan brain 567C CAT brain abnormal 56FO CAT scan declined 8HQ3 Refer CAT 5692 MRI normal 5693 MRI abnormal 5694 MRI brain abnormal
sig if in 12m after diagnosis
585Q
Carotid Doppler scan
5695 8HQ4 5C10 5C01 585Q
MRI declined Refer MRI Carotid doppler abnormal Carotid doppler normal Carortid doppler (result unclear)
sig if in 12m after diagnosis Free text side/% obstructed Free text side/% obstructed
TREATMENT+CONTRAINDICATIONS: 8B6 Drug Prophylaxis 8B63 8B3T 67I8 8124 U6051 8I38 8B6C Antiplatelet Rx (other) (free text clopid,warf. Etc.) 8I2K c/I clopidogrel 8I25 U6048 8I3R 8I25 C/I Warfarin 8I25 8I3E U6042 TJC44 C/I Dipridamole TJC44 8I2b 8I3n 65E Fluvaccine 65E 90X5 68NE 8I2F 6572 68NX 8I2E
Salicylate Prophylaxis OTC aspirin Aspirin advised Aspirin Contraindicated (+text) @ C/I Aspirin permanent (AR) Aspirin refused GMS will pick up from medication as well Clopidogrel c/I (this year) C/I Clopidogrel: permanent Clopidogrel declined Warfarin C/I Warfarin declined C/I Warfarin permanent (AR) Dipyridamole C/I permanent Dipyridamole C/I this year. Dipyridamole declined Flu Vaccine given Flu vaccine declined No consent Flu-vaccine (declined) Flu vaccine c/i Pneumovac given No consent pn/vac Pneumovac c/i Diary entry @
enter yearly: free text why?
@
@
To exclude from aspirin target group patient needs to have c/I to aspirin/ Clopdiogrel AND Warfarin
@ @
6572 Pneumovac
F/U 6662 F/U neuro/CVA review
@ means enter yearly. All c/I and exclusions should have reason in free text
Blood results may require different codes from hospital other than Sunderland
Stroke Diagnostic codes copied from Sunderland Notebusters list. All new strokes should have been seen at hospital and they should have done a CT scan which would clarify which of these codes to use Old/ unclassified CVAs where no scan
Intracerebral haemorhage Cerebrial Arterial Occlusion Transient Cerebral Ischaemia (TIA) Stroke / CVA Unspecified
G61.. G64.. G65 G66..
means blockage or infarct
ed CVAs where no scan