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					    Diabetes Footcare Dataset                                                                                              Legend




Legend
       Data items that are contained within the Diabetes Continuing Care Reference (DCCR) Dataset.




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         Diabetes Footcare Dataset                                                                                                                                                        PatientHistory



DI no.          Data Item Name                          Description                                   Requirement                           Codes and Classifications          Footnote

         Patient Clinical History
2.01     Diagnosis Date (Diabetes)      The date on which the first diagnosis of      To monitor processes/outcomes related to   Date format                            4
                                        diabetes was made.                            time of diagnosis
2.02.1   Diabetes Type                  Records the type of diabetes experienced by   To monitor processes/outcomes related to   n2
                                        the patient.                                  type of diagnosis                            01 Type 1
                                                                                                                                   02 Type 2
                                                                                                                                   05 Gestational
                                                                                                                                   06 MODY
                                                                                                                                   08 Other
                                                                                                                                   99 Not specified
8.07.1   Registered Blind               The date on which a patient was registered    Impacts on ability to self care            Date format
                                        as blind.
8.07.2   Registered Partially Sighted   The date on which a patient was registered                                               Date format
                                        as partially sighted
9.09.1.1 Lower Limb Major Amputation Amputation of any part of the lower limb at      To monitor outcomes                        Yes / No
                                     ankle level or below.
9.09.1.2 Procedure Date (Minor       Date of the occurrence of MINOR                                                             Date format
         Amputation)                 amputation.
9.09.2.1 Lower Limb Minor Amputation Amputation of any part of the lower limb                                                    Yes / No
                                     above ankle level.
9.09.2.2 Procedure Date (Major       Date of the occurrence of MAJOR                                                             Date format
         Amputation)                 amputation.




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Diabetes Footcare Dataset              PatientHistory




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         Diabetes Footcare Dataset                                                                                                                                                                   Review - Lifestyle



DI no.          Data Item Name                     Description                                Requirement                               Codes and Classifications                                   Footnote

         Social Context
         Permanent Address Type   Identifies the type of accommodation        Impacts on ability to self care and to attend    n2                                            Categories from SAP dataset
                                  occupied by the person.                     for assessment.                                    01 Detached house or bungalow
                                                                                                                                 02 Semi-detached house or bungalow
                                                                                                                                 03 Terraced house or bungalow
                                                                                                                                 04 Purpose-built flat, maisonette or
                                                                                                                                 05 Flat, maisonette or apartment which is
                                                                                                                                 06 Flat, maisonette or apartment in a
                                                                                                                                 07 A caravan or other mobile or temporary
                                                                                                                                 08 Care Home
                                                                                                                                 09 Care Home with nursing on premises
                                                                                                                               Based on ONS 2001 census
         Person lives alone       Identifies if the person lives in the       Impacts on ability to self care. Identifies if   n2                                            Data Dictionary Item
                                  permanent accommodation alone.              external support is required.                      01 Yes
                                                                                                                                 02 No
                                                                                                                                 09 Not known
        Smoking Assessment
14.01   Observation Date          The date on which tobacco smoking status To monitor patient care process.                    Date format
        (Smoking Status)          was assessed .
14.02.1 Smoking Status            Records the current tobacco smoking status. To monitor patient care process & mgt.           n1                                            21
                                                                                                                                 1 Current smoker
                                                                                                                                 2 Ex smoker
                                                                                                                                 3 Non-smoker history unknown
                                                                                                                                 4 Never smoked
                                                                                                                                 9 History unknown
14.02.2 Cigarettes per day        The number of cigarettes smoked by the      To monitor patient care process & mgt.           n3
                                  patient where they are a current or ex-
                                  smoker
         Alcohol Assessment
15.01    Observation Date         The date on which an alcohol intake was     To monitor patient care process.                 Date format
         (Alcohol Assessment)     assessed.
15.02    Alcohol Intake           The number of units of alcohol regularly    To monitor patient care process & mgt.           n3
                                  consumed by the person with in a week.




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         Diabetes Footcare Dataset                                                                                                                                                                                     Foot Review



DI no.          Data Item Name                           Description                                    Requirement                             Codes and Classifications                                  Footnote

         Foot Review
         Foot Care Review Refused        The date the patient specified that they did   Identifies if the patient has made a personal Date format
                                         not wish to undergo foot care review           decision affecting care management
9.01     Observation Date                The date on which the Diabetic Foot            To monitor patient care process.              Date format                                  17
         (Diabetic Foot Examination)     Examination was carried out.
         Classification of Assessor      The healthcare worker carrying out the foot    Identify the grade of the assessor for audit   n2                                          Definition required for neurovascular technician (if not
         (Diabetic Foot Examination)     review examination.                            accountability and resource management.          00 Diabetologist                          available should be excluded from dataset)
                                                                                                                                         01 Specialist Registrar
                                                                                                                                         02 GP
                                                                                                                                         03 Podiatrist (NHS)
                                                                                                                                         04 Podiatrist (Private)
                                                                                                                                         05 Neurovascular technician
                                                                                                                                         06 Diabetes Specialist Nurse
                                                                                                                                         07 GP with Special Interest in Diabetes
                                                                                                                                         08 Practice Nurse
                                                                                                                                         09 Community Nurse
                                                                                                                                         10 Footcare Assistant
                                                                                                                                         11 Healthcare Support Worker
         Under Podiatry Care             Indicates if the patient is currently having   To identify those people having regular        n2
                                         regular specialist podiatry care by Registered footcare review by a podiatrist.                 00 No
                                         Podiatrist                                                                                      01 NHS Podiatrist
                                                                                                                                         02 Private Podiatrist
9.04     Observation Date                The observation date for the Specialist Foot To monitor waiting time following referral.      Date format
         (Specialist Foot Examination)   Examination.
         Foot Examination Outcome
9.06     Foot Examination Outcome        A description of the outcome from the Foot     To monitor patient care process.               n2                                          15, 18,
                                         Examination.                                                                                    01 Low current risk
                                                                                                                                         02 Increased risk
                                                                                                                                         03 High risk
                                                                                                                                         04 Ulcerated foot
         Referral Footcare
9.02     Date Referral (Footcare         The date referred to footcare protection       To monitor appropriate referral.               Date format                                 22
         Protection Programme)           programme.
9.03     Date Referral                   The date referred to multidisciplinary                                                        Date format                                 22
         (Multidisciplinary Footcare     footcare team.                                                                                                                            This would include referral to Foot Ulcer Clinic
         Team)
         Date Referral                   The date referred to vascular surgeon.                                                        Date format
         (Vascular Surgeon)
         Date Referral                   The date referred to orthopaedic surgeon .                                                    Date format
         (Orthopaedic Surgeon)
         Date Referral                   The date referred for immediate admission.                                                    Date format
         (Immediate Admission)




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Diabetes Footcare Dataset                                                                                                                           Foot Review




Referral Investigation
Date Referral                The date a sample was sent for microculture To monitor appropriate referral and to         Date format
(Microculture)               investigation.                               indicate that test or investigation results
Date Referral                The date a sample was sent for blood culture should be available.                          Date format
(Blood culture)              investigation.
Date Referral                The date a sample was sent for full blood                                                  Date format
(Full blood count)           count investigation.
Date Referral                The date a sample was sent for histology                                                   Date format
(Histology)                  investigation.
Date Referral                The date referred for x-ray investigation.                                                 Date format
(x-ray)
Date Referral                The date referred for bone scan                                                            Date format
(Bone scan)                  investigation.
Date Referral                The date referred for CT scan investigation.                                               Date format
(CT scan)
Date Referral                The date referred for MRI scan                                                             Date format
(MRI Scan)                   investigation.
Date Referral                The date referred for angiography                                                          Date format
(Angiography)                investigation.
Date Referral                The date referred for duplex scan                                                          Date format
(Duplex scan)                investigation.
Date Referral                The date referred for C-Reative Protein                                                    Date format
(CRP)                        investigation.
Date Referral                The date referred for Erythrocyte                                                          Date format
(ESR)                        Sedimentation Rate investigation.
Date Referral                The date referred for nerve conduction                                                     Date format
(Nerve conduction studies)   studies.




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         Diabetes Footcare Dataset                                                                                                                                                                   Foot Appearance



DI no.          Data Item Name                        Description                                    Requirement                            Codes and Classifications                           Footnote

         Foot Appearance
9.05.6.1 Right foot deformity        The observed presence of abnormally             To monitor patient care process and mgt.     n1
                                     shaped foot.                                                                                   1 Yes
9.05.6.2 Left foot deformity                                                                                                        2 No

9.05.7.1 Right foot colour           The observed pathological change in foot        To monitor patient care process and mgt.     n1
                                     colour.                                                                                        01 Normal
9.05.7.2 Left foot colour                                                                                                           02 Abnormal

         Right foot skin type        The observed skin type or texture of the foot. To monitor patient care process.              n2
                                                                                    Identification of skin types that carry an      01 Normal
                                                                                    increased risk of foot ulceration.              02 Dry
         Left foot skin type                                                                                                        03 Abnormally moist
                                                                                                                                    04 Fissured

         Right clinical foot skin    The observed subjective clinical assessment Identification of peripheral vascular disease, n2
         temperature                 of skin temperature.                        infection and Charcot neuroarthropathy.          01 Normal
         Left clinical foot skin                                                                                                  02 Increased
         temperature                                                                                                              03 Decreased
         Right foot nail condition   The observed nail condition of the foot.    Identification of nail types that may          n2                                      Acute : Nail problem of less than 2 mths duration which
                                                                                 contribute to risk of diabetic foot disease.     01 Normal                             has required 1 or more courses of antibiotics
         Left foot nail condition                                                                                                 02 Abnormal acute                     Chronic : Any problem that has lasted two months or
                                                                                                                                  03 Abnormal chronic                   more or recurred within 12 months
         Right foot callus / corns   The observed presence of hard skin at the       Identification of areas of high and           n1
                                     site of a pressure point.                       intensified                                     01 Present
         Left foot callus / corns                                                    pressure – increased potential for ulceration   02 Absent
                                                                                     and potential for effective prophylactic
         Right foot swelling         The observed increase in the volume of          treatment.
                                                                                     Identification of a risk factor for diabetic  n2                                   NB: Swelling and oedema including foot (gradient)
                                     tissue (in the context of infection this will   foot disease.                                   01 None                            The dataset pilot project highlighted a training need in
                                     usually be related to inflammatory                                                              02 Toe swelling                    differentiating between swelling & oedema.
         Left foot swelling          infiltrates).                                                                                   03 Foot swelling
                                                                                                                                     04 Ankle swelling
                                                                                                                                     05 Leg swelling
         Right oedema                The observed increase in fluid in the           Identification of a risk and vunerability    n2                                    Oedema is a particular type of swelling that identifies
                                     interstitial space clinically identified by     factor for diabetic foot disease.              01 None                             vunerability. It is expected that all patients with a
                                     pitting.                                                                                       02 Foot oedema                      recording of oedema will also have a recording of
         Left oedema                                                                                                                03 Ankle oedema                     swelling
                                                                                                                                    04 Leg oedema




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         Diabetes Footcare Dataset                                                                                                                                                                          Foot Circulation



DI no.           Data Item Name                           Description                                   Requirement                                Codes and Classifications                          Footnote

         Foot Circulation
9.05.1.1 Right dorsalis pedis pulse       Presence or absence of dorsalis pedis pulse. To monitor patient care process.               n2                                       18
                                                                                       Identification of peripheral vascular disease.   01 Palpable
9.05.1.2 Left dorsalis pedis pulse                                                                                                      02 Not Palpable

9.05.2.1 Right posterior tibialis pulse   Presence or absence of posterior tibialis      To monitor patient care process.               n2                                     18
                                          pulse.                                         Identification of peripheral vascular disease.   01 Palpable
9.05.2.2 Left posterior tibialis pulse                                                                                                    02 Not Palpable

         Right popliteal pulse            Presence or absence of popliteal pulse.        Identification of peripheral vascular disease. n2
                                                                                                                                          01 Palpable
         Left popliteal pulse                                                                                                             02 Not Palpable
                                                                                                                                          03 Not necessary
         Right femoral pulse              Presence or absence of femoral pulse.          Identification of peripheral vascular disease. n2                                     Clinicians would be expected to record femoral pulses if
                                                                                                                                          01 Palpable                          lower pulses are not palpable before referring to
         Left femoral pulse                                                                                                               02 Not Palpable                      vascular surgeon.
                                                                                                                                          03 Not necessary
         R dorsalis pedis doppler         Wave form of dorsalis pedis peripheral         Identification of peripheral vascular disease. n2
         waveform                         pulses assessed by Doppler ultrasound.                                                          01 Monophasic
         L dorsalis pedis doppler                                                                                                         02 Bi-phasic
         waveform                                                                                                                         03 Tri-phasic
         R dorsalis pedis pressure        Compressibility of dorsalis pedis peripheral Identification of peripheral vascular disease. n2
         (compressability)                pulses assessed by Doppler ultrasound.                                                        01 Compressible
         L dorsalis pedis pressure                                                                                                      02 Incompressible                      Incompressible can be defined as "When the foot artery
         (compressability)                                                                                                                                                     being assessed cannot be compresssed at 75mmhg above
         R dorsalis pedis pressure        Pressure of dorsalis pedis peripheral pulses   Identification of peripheral vascular disease. n3 - nnn                               the level of the brachial artery"
         L dorsalis pedis pressure        assessed by Doppler ultrasound (mmHg).
         R posterior tibial doppler       Wave form of posterior tibial peripheral       Identification of peripheral vascular disease. n2
         waveform                         pulses assessed by Doppler ultrasound.                                                          01 Monophasic
         L posterior tibial doppler                                                                                                       02 Bi-phasic
         waveform                                                                                                                         03 Tri-phasic
         R posterior tibial pressure      Compressibility of posterior tibial peripheral Identification of peripheral vascular disease. n2
         (compressability)                pulses assessed by Doppler ultrasound.                                                          01 Compressible
         L posterior tibial pressure                                                                                                      02 Incompressible                    Incompressible can be defined as "When the foot artery
         (compressability)                                                                                                                                                     being assessed cannot be compresssed at 75mmhg above
         R posterior tibial pressure      Pressure of posterior tibial peripheral pulses Identification of peripheral vascular disease. n3 - nnn                               the level of the brachial artery"
         L posterior tibial pressure      assessed by Doppler ultrasound (mmHg).
         R systolic brachial pressure     Pressure of systolic brachial peripheral       Identification of peripheral vascular disease. n3 - nnn
                                          pulses assessed by Doppler ultrasound
         L systolic brachial pressure
                                          (mmHg).




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         Diabetes Footcare Dataset                                                                                                                         Foot Circulation




         R Ankle Brachial Pressure       Ankle brachial Pressure Index (ABPI).        Identification of peripheral vascular disease. n3 - nnn
         Index                           Can be derived from Brachial Pressure /
         L Ankle Brachial Pressure       Ankle pressure.
         Index
         Right toe pressure              Toe blood pressure (mmHg).                   Identification of peripheral vascular disease. n3 - nnn
         Left toe pressure
         R Toe Brachial Pressure Index   Toe brachial Pressure Index (TBPI).         Identification of peripheral vascular disease. n3 - n.nn
                                         Can be derived from Brachial Pressure / Toe
         L Toe Brachial Pressure Index
                                         pressure.
         Right dorsum TCPO2              The transcutaneous pressure of oxygen       Identification of peripheral vascular disease. n3 - nnn
         Left dorsum TCPO2               measured at the dorsum of the foot (kPa).
         Peripheral Vascular Disease
         Diagnosis                       A diagnosis of Intermittent claudication     Identification of peripheral vascular disease. Yes / No
         (Intermittent claudication)                                                  To monitor outcomes.
         Diagnosis Date                  The date of diagnosis of Intermittent                                                       Date format
         (Intermittent claudication)     claudication
         Diagnosis                       A diagnosis of Ischaemic (rest) pain         Identification of peripheral vascular disease. Yes / No
         (Ischaemic (rest) pain)                                                      To monitor outcomes.
         Diagnosis Date                  The date of diagnosis of Ischaemic (rest)                                                   Date format
         (Ischaemic rest pain)           pain
         Diagnosis                       A diagnosis of Varicose veins                Identification of peripheral vascular disease. Yes / No
         (Varicose veins)                                                             To monitor outcomes.
         Diagnosis Date                  The date of diagnosis of Varicose veins                                                     Date format
         (Varicose veins)
         Diagnosis                       A diagnosis of Venus ulceration              Identification of peripheral vascular disease. Yes / No
         (Venus ulceration)                                                           To monitor outcomes.
         Diagnosis Date                  The date of diagnosis of Venus ulceration                                                   Date format
         (Venus ulceration)
         Vascular Intervention
9.07.1   Peripheral Artery Angioplasty   Peripheral Artery Angioplasty                To monitor outcomes.                           Yes / No

9.07.2   Procedure Date                  The date of Peripheral Artery Angioplasty                                                  Date format
         (Peripheral Artery Angioplasty)
9.08.1   Peripheral Artery Bypass        Peripheral Artery Bypass                     To monitor outcomes.                           Yes / No

9.08.2   Procedure Date                  The date of Peripheral Artery Bypass                                                       Date format
         (Peripheral Artery Bypass)      Procedure




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         Diabetes Footcare Dataset                                                                                                                                                                  Foot Neurological



DI no.          Data Item Name                           Description                                 Requirement                              Codes and Classifications                           Footnote

         Foot Neurological
9.05.3.1 R foot sensory loss 10g         The outcome of the clinical test for foot   To monitor patient care process.              n2                                     18
         monofilament                    sensory loss using 10g monofilament.        Identification of neuropathic deficits that     01 Normal
9.05.3.2 L foot sensory loss 10g                                                     signal increased risk of foot ulceration.       02 Abnormal
         monofilament
9.05.4.1 R foot sensory loss vibration   The outcome of the clinical test for foot   To monitor patient care process.              n2                                     18
         test                            sensory loss using vibration testing.       Identification of neuropathic deficits that     01 Normal
9.05.4.2 L foot sensory loss vibration                                               signal increased risk of foot ulceration.       02 Abnormal
         test
         R hallux vibration perception   The vibration perception threshold using    Identification of neuropathic deficits that   n2                                     A recording of greater than 25 volts would denote a risk
         threshold bioesthesiometer      bioesthesiometer (Volts).                   signal increased risk of foot ulceration.
         L hallux vibration perception
         threshold bioesthesiometer
9.05.5.1 R lower limb neuropathic pain   Observation of sensory symptoms of          Identification of neuropathic deficits that   n1
                                         peripheral neuropathy.                      signal increased risk of foot ulceration.       1 Yes
9.05.5.2 L lower limb neuropathic pain                                                                                               2 No

         Diagnosis Charcot               A diagnosis of Charcot Neuroarthropathy     To monitor outcomes.                          Yes / No                               Diagnosis of acute charcot deformity should always be
         Neuroarthropathy                                                            To monitor patient care process.                                                     recorded. In new systems this should be recorded
         Diagnosis Date                  The date of diagnosis of Charcot                                                          Date format                            retrospectively and if necessary the date would be held
         (Charcot Neuroarthropathy)      Neuroarthropathy                                                                                                                 as month and year, or year only.




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Diabetes Footcare Dataset        Foot Neurological




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         Diabetes Footcare Dataset                                                                                                                                                                                     Foot Ulcer



DI no.          Data Item Name                           Description                                  Requirement                               Codes and Classifications                              Footnote

         Foot Ulcer
9.05.8.1 Diagnosis (Foot Ulcer)          A diagnosis of foot ulcer.                    To monitor outcomes.                          Yes / No                                   29
                                                                                       To monitor waiting time following referral.                                              Diagnosis of foot ulcer should always be recorded. In
9.05.8.2 Diagnosis Date (Foot Ulcer)     The date of diagnosis of foot ulcer.                                                        Date format                                new systems this should be recorded retrospectively and
                                                                                                                                                                                if necessary the dateheld as month and/or year only.
         Start recurring group (for each ulcer)
         Start recurring group (ulcer assessment)
         Observation Date (Diabetic       The date of assessment of a new or ongoing To monitor patient care process and mgt.        Date format
         Foot Ulcer Assessment)           foot ulcer.
         Foot Ulcer Status                Assessment of foot ulcer status.           To monitor patient care process and mgt.        n2
                                                                                                                                       01 Active
                                                                                                                                       02 Healed
         Ulcer - Length                  Assessment of maximum length of foot ulcer    To monitor patient care process and mgt.      n3 - nnn
                                         (mm)
         Ulcer - Width                   Assessment of maximum width of foot ulcer     To monitor patient care process and mgt.      n3 - nnn
                                         (mm)
         Foot Ulcer – Cellulitis         Assessment of maximum spread of foot          To monitor patient care process and mgt.      n3 - nnn
                                         ulcer cellulitis in mm
         Foot Ulcer – Clinical           Observation of clinical signs of underlying   To monitor patient care process and mgt.      n2
         Osteomyelitis                   bone infection.                                                                               01 Sausage digit
                                                                                                                                       02 Probe to bone
                                                                                                                                       03 Bone exposed
         Foot Ulcer – Evidence of        Record of evidence of osteomylitis.           To monitor patient care process and mgt.      n2
         Osteomyelitis                                                                                                                 01 Osteomyelitis on XRay
                                                                                                                                       02 Osteomyelitis on MRI
                                                                                                                                       03 Osteomyelitis on Radio-Isotope scan
                                                                                                                                       04 Osteomyelitis on Bone Biopsy
         Foot Ulcer – Necrosis Length    Assessment of maximum length of foot ulcer To monitor patient care process and mgt.         n3 - nnn
                                         necrosis (mm)
         Foot Ulcer – Necrosis Width     Assessment of maximum width of foot ulcer To monitor patient care process and mgt.          n3 - nnn
                                         necrosis (mm)
         End recurring group (ulcer assessment)
         Foot Ulcer - Debridement        Method used for the removal of wound       To monitor patient care process and mgt.         n2
                                         tissue.                                                                                       01 Physical                              Physical would include sharp debridement
                                                                                                                                       02 Chemical                              Chemical would include Enzymatic debridement
                                                                                                                                       03 Larva therapy
         Procedure Date                  The date of foot ulcer debridement                                                          Date format
         (foot ulcer debridement)
         Procedure Date                  The date of foot ulcer dressing               To monitor patient care process and mgt.      Date format
         (foot ulcer dressed)
         End recurring group (for each ulcer)




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         Diabetes Footcare Dataset                                                                                                                                                          Footwear Review



DI no.          Data Item Name                           Description                                 Requirement                          Codes and Classifications                      Footnote

         Footwear Review
9.05.9   Footwear review                 The recorded outcome of a footwer review.    To monitor patient care process.           n2                                              18
                                                                                                                                   01 Appropriate
                                                                                                                                   02 Inappropriate
         Footwear Review Date            The date on which a review of patient      To monitor patient care process.             Date format
                                         footwear took place.
         R footwear requirements         A description of the footwear recommended. To monitor patient care mgt and evaluate     n2
                                                                                    outcomes.                                      01 Appropriate retail footwear
                                                                                                                                   02 Insoles
                                                                                                                                   03 Stock therapeutic footwear
                                                                                                                                   ("off the shelf")
         L footwear requirements                                                                                                   04 Modular therapeutic footwear
                                                                                                                                   (stock ordered with certain specifications)
                                                                                                                                   05 Bespoke footwear
                                                                                                                                   06 Lower limb orthoses
                                                                                                                                   98 Other
         R temporary offloading device   The type of temporary intervention used to   To monitor patient care mgt and evaluate   n2
                                         reduce pressure at ulcer site.               outcomes.                                    01 Temp felt padding
                                                                                                                                   02 Temp insoles
                                                                                                                                   03 Temp offloading shoe
                                                                                                                                   04 Scotchcast
                                                                                                                                   05 Total contact
                                                                                                                                   06 Removable cast
                                                                                                                                   07 Aircast boot
         L temporary offloading device                                                                                             08 Range of Movement Walker
                                                                                                                                   09 Sampson boot
                                                                                                                                   10 Crutches
                                                                                                                                   11 Heel protection
                                                                                                                                   12 Wheel chair
                                                                                                                                   13 Pressure relieving mattress
                                                                                                                                   14 Charcot Restrained Orthotic Walker
                                                                                                                                   98 Other




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         Diabetes Footcare Dataset                                                                                                                                                   Review - Care Plan



DI no.          Data Item Name                           Description                                  Requirement                            Codes and Classifications               Footnote

         Care Plan
16.01    Observation Date (Diabetes      The date on which the Diabetes Care Plan     To monitor patient care process.              Date format
         Care Plan Agreed)               was last agreed and provided to the patient.

         Patient Education
17.01    Observation Date                The date on which a review of the patients To monitor patient care process.                Date format
         (Patient Education Review)      diabetes education requirements took place.

17.02.1 Date Offered                   The date on which a Diabetes Structured        To monitor patient care process & mgt.        Date format                          26
        (Diabetes Structured Education Education Programme was offered to the
        Programme)                     patient.
17.02.2 Date Attended                  The date it was recorded that a patient has    To monitor patient care mgt.                  Date format                          26, 27
        (Diabetes Structured Education completed/attended a patient structured        To monitor waiting time following referral.
        Programme)                     education programme.
        Diabetes Footcare Specific Education
        Verbal basic footcare advice   The date on which footcare advice was          To monitor patient care process and mgt.      Date format
        given                          given verbally.
        Generic Footcare information The date on which a generic footcare advice      To monitor patient care process and mgt.      Date format
        leaflet given                  leaflet was given.
        Foot at risk leaflet given     The date on which a footcare advice leaflet    To monitor patient care process and mgt.      Date format
                                       was given which specifically related to the
                                       current level of foot risk.
         Patient specific written footcare The date on which specific personal written To monitor patient care process and mgt.     Date format
         advice given                      footcare advice was given.




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         Diabetes Footcare Dataset                                                                                                                                                   Review - Medication



DI no.          Data Item Name                        Description                                 Requirement                       Codes and Classifications                          Footnote

        Medication
        Start Medication group                                                                                                                                  25
18.02.1 Insulin Prescribed            Insulin Prescribed                            To monitor patient care managment.   Yes / No                               Detail will be dictated by NPfIT Medication
                                                                                                                                                                Management
18.02.2 Prescription Date (Insulin)   The date Insulin medication was prescribed.                                        Date format

18.03.1 Hypoglycaemic Tablet          Hypoglycaemic Tablets prescribed.             To monitor patient care managment.   Yes / No
        Prescribed
18.03.2 Prescription Date             The date Hypoglycaemic Tablets were                                                Date format
        (Hypoglycaemic Tablet)        prescribed.
18.04.1 Ace Inhibitor Prescribed      Ace Inhibitor Prescribed                      To monitor patient care managment.   Yes / No

18.04.2 Prescription Date             The date Ace Inhibitors were prescribed.                                           Date format
        (Ace Inhibitor)
18.05.1 A2 Antagonist Prescribed      A2 Antagonist Prescribed                      To monitor patient care managment.   Yes / No

18.05.2 Prescription Date             The date A2 Antagonists were prescribed.                                           Date format
         (A2 Antagonist)
         Antibiotic Prescribed        Antibiotic Prescribed                         To monitor patient care managment.   Yes / No

         Prescription Date            The date Antibiotics were prescribed.                                              Date format
         (Antibiotic)
         End Medication Group




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     Diabetes Footcare Dataset                                                                                                                                                            Appendix 1 - footnotes



No. Footnote
4    The date of diagnosis must allow for the recording of month and year, or year only.
15   This data item is a new requirement to support the NSF and will have associated training issues.
17   Evidence has been put forward that children with diabetes should be seen by a podiatrist with knowledge of childhood diabetes¹ ² ³
18   The NICE guideline - CG10 Type 2 diabetes footcare recommends that examination of a patients foot should include:
      - testing of foot sensation using 10g monofilament or vibration recorded as normal or abnormal
      - palpation of foot pulses
      - inspection for any foot deformity
      - inspection of footwear

     Foot risk should be classified as:
                                        0           Low current risk       normal sensation, palpable pulses )
                                        1           Increased risk         (neuropathy or absent pulses or other risk factor )
                                        2           High risk              (risk factor + deformity or skin changes or previous ulcer )
                                        3           Ulcerated foot

21   Categories approved by ISB and in Data Dictionary.

22   Footcare protection programme:                 Referral to a podiatrist based service that offers footchecks, preventive podiatry, offloading and foot health education to reduce the risk of new ulceration

     Multidisciplinary footcare team:               Referral, often urgent, of someone with a 'red flag' (e.g. new ulceration, non resolving ulceration, pain, swelling, redness) to a team comprising podiatrists,
                                                    nurses, doctors, surgeons, orthotists etc for appropriate multidisciplinary management of the incident problem. This category would include initial referral to a
                                                    Foot Ulcer Clinic.
24   First degree relative applies to parent or sibling.

25   For each of the medications specified information will also be required regarding: contraindications, adverse reactions and when a medication has been declined. In addition dosage information will be
     required to support the GMS contract. All these information requirements will be supported by the NPfIT Medication Management and PSIS work programmes. As details relating to the implementation
     of these work areas are not yet available It was felt inappropriate to include in the Diabetes Core Dataset at this stage.
26   A Structure Education Programme must fulfil the following criteria as defined by the DH Education Reference group:
      (i)    A defined curriculum
      (ii)   Trained teachers / educators
      (iii)  A quality assurance programme
      (iv)    Local audit and outcome evaluation

27   It should only be recorded that a patient has attended a Patient Structured Education Programme if the patient attended for the minimum time required to consider the programme completed. The
     required time should be defined locally for any Structured Education Programme.
28   In an electronic care record the anatomical site would be supported by graphics identifying the specific site of individual ulcers. It would be necessary for such systems to map this information to the
     categories specified in Foot Ulcer Site data items.
29   Systems must provide:
       (i) an identifier for each new ulcer identified    (ii) the functionality to record attributes attached to a particular ulcer (including laterality and location )
     In the longer term it is expected that this functionality will be provided using picture format.

     References:
     1 1996 The principles of good practice for the care of young people with diabetes, BDA
     2 2000 International Society of Paediatric and Adolescent Diabetes Consensus Guidelines, ISPAD
     3 2000 Testing Times, The Audit Commission.

				
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Description: Pain Medication Managment Contract document sample