User Interface Name

Field Identifier

Definition

Data Display Format

Data Value Format (code or other value)

Value Sets

Date and Time of Assessment

Assessment_Date_Time

This is the date and time the assessment took place

Date and Time Picker

8 digit numeric, YYYY-MM-DD

4 digit numeric, hh:mm

Part 1: Mouth Care Assessment
(If assessment declined must reassess at another time during the same day or the next day)

Are you able to eat and drink unaided?

Eat_drink_unaided

This is to indicate whether the patient is able to eat and drink unaided

Radio Button (No Yes)

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1 No
2 Yes

Would you describe your mouth as comfortable (e.g. no pain, not dry, no soreness)

Comfortable_mouth

This is to indicate whether the patient describes their mouth as feeling comfortable

Radio Button (Multiple Options - single select)

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1 No
2 Yes
3 Not Applicable

Are you able to clean your teeth and mouth without assistance?

Mouth_care_assistance

This is to indicate whether the patient is able to clean their teeth and mouth without assistance

Radio Button (No Yes)

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1 No
2 Yes

At this time a full Mouth Care Assessment is not routinely required - Please select if you would like to start a full Assessment - Start Assessment button

Please select the highest risk to inform the mouth care plan

Mouth_care_start

This will enable a user start a full assessment when it's not routinely required

Radio Button (Multiple Options - single select)

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1 - Not required
2 - Continue with Full Mouthcare Assessment

Part 2 - Level of Support
Determine the level of support needed for mouth care - Please select the highest risk to inform the mouth care plan

Level of support needed for mouth care

Mouthcare_support

This is to indicate the level of support needed for the patients mouth care

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - No help required for mouth care. Advice given / leaflet
2 - (M) Medium Risk - Needs some help with mouth care / additional mouth care throughout the day
3 - (H) High Risk - Fully dependent on others for mouth care, advanced dementia, end of life care

Part 3 - Oral Hygiene and Prevention
Please complete the following mouth care assessment and link to the care plan
STAFF MUST LOOK IN THE MOUTH TO DO THIS PART OF THE ASSESSMENT
(i) Please record the highest risk to inform the care plan

Have you undertaken a full mouth care assessment?

Mouth_care_ass_undertaken

This is to indicate whether a full mouth care assessment has been undertaken

Radio Button (No Yes)

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1 No
2 Yes

Please enter reason why a full mouth care assessment has not been undertaken

No_mouth_ass_details

This is to provide further details on why a full mouth care assessment has not been undertaken

Text Box

nvarchar(500)

Oral Hygiene and Prevention
Record the highest risk (L, M or H) to inform the mouth care plan

Daily Diet

Daily_diet

This indicates whether the patient is at risk of tooth decay

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - Balanced diet
3 - (H) Has a high sugar diet or prescribed nutritional supplements
4-Nil by Mouth (NBM)

Risk of choking

Choking_risk

This indicates whether the patient has a swallowing problem and is at risk of choking

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - Low choking risk
2 - (M) Medium Risk - Some swallow problems or uses thickeners
3 - (H) High Risk - High choking risk or PEG / tube fed

Saliva

Saliva

This indicates if the patient is at risk from a dry mouth

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - Mouth moist, no problems
3 - (H) High Risk - Dry Mouth

Mouth Cleanliness

Mouth_cleanliness

This indicates if the patient requires additional support to keep their mouth clean

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - Teeth and mouth clean
2 - (M) Medium Risk - Some areas of the mouth not clean
3 - (H) High Risk - Teeth and mouth not clean

Gum Health

Gum_health

This indicates if the patient is at risk of gum disease

Radio Button (Multiple Options - single select)

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1 - (L) Low Risk - Gums do not bleed on brushing
2 - (M) Medium Risk - Gums sometimes bleed on brushing
3 - (H) High Risk - Gums bleed all the time on brushing

Part 4: Dental need

Record the highest risk (L, M or H) to inform the mouth care plan

Please tick all that applies:

Dentures

Dentures

This is to indicate whether the patient wears dentures

Radio Button (Multiple Options - multi select)

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1 - Upper
2 - Lower
3 - Obturator
4 - Removable Partial Denture
5 - No dentures

Dentures

Denture_risk

This indicates whether the patient requires further advice from the dental team regarding their dentures

Radio Button (Multiple Options - multi select)

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1 - (L) Low Risk - Dentures clean
2 - (M) Medium Risk - Dentures not clean or patient complains of loose dentures
3 - (H) High Risk - Denture broken, painful or recently lost

Please tick all that applies:

Natural Teeth

Natural_teeth

This is to indicate whether the patient has natural teeth

Radio Button (Multiple Options - multi select)

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1 - Upper
2 - Lower
3 - No natural teeth

Natural Teeth

Natural_teeth_risk

This indicates whether the patient requires further advice from the dental team regarding their natural teeth

Radio Button (Multiple Options - multi select)

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1 - (L) Low Risk - No problems, All appear healthy
2 - (M) Medium Risk - Broken or decayed teeth but no pain
3 - (H) High Risk - Behaviour indicates dental pain, Very loose teeth

Lips, Tongue & Soft Tissues

Lips_tongue_softtissues

This indicates whether the patient is at risk of a dry coated tongue due to insufficient fluids / mouth care.
If the patient has a very sore mouth or reports painless white or red patches / ulcers they will need referral to the dental team

Radio Button (Multiple Options - multi select)

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1 - (L) Low Risk - All appear healthy
2 - (M) Medium Risk - Lips dry, tongue 'coated'
3 - (H) High Risk - Very sore mouth - White or red patches, multiple ulcers, swelling or thrush

Mouth Care Products

Does the patient have mouth care products with them?

Mouthcare_products

This is to indicate whether the patient has mouth care products with them

Radio Button (No Yes)

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1 No
2 Yes

Has a relative/carer been asked to supply within 24 hours?

Products_supply

This is to indicate that for those patients with no mouth care products, a relative or carer has been asked to supply them within 24 hours

Radio Button (Multiple Options – single select)

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1 No
2 Yes
3 Not Applicable

Part 5: Overall Risk

Overall risk
(Please record the highest risk overall to inform the mouth care plan)

Mouthcare_risk

This is to indicate the patients overall risk with regards to mouth care

Radio Button (Multiple Options)

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1 - Low
2 - Medium
3 - High

Review Period

Mouthcare_Review

This is to indicate how often the patients mouth care assessment should be reviewed

Radio Button (Multiple Options)

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1 - Assess Daily
2 - Assess Weekly
3 - Monthly for long stay patients

Displayable text - Or sooner if condition changes