Information Specification

User Interface Name	Field Identifier	Definition	Data Value Format (code or other value)	Value Sets
Health Board / Trust	Org_Code	This is the organisation code of the health care provider. The provider code identifies the health care provider who is responsible for managing the treatment of the patient.	3 character alpha-numeric or 5 character alpha-numeric Local Health Board/Trust Code with 2 zeros placed in the 4th and 5th character position.	NHS Wales Data Dictionary WRDS (Organisation Code - Code of Provider)
Hospital Site	Site_Code	The organisation code for the site where the patient will be or is treated.	5 character alpha-numeric	NHS Wales Data Dictionary WRDS (Site Code of Treatment)
Admission Method	Adm_Method	This is the method of admission to a hospital provider spell.	2 digit numeric	NHS Wales Data Dictionary
Source of admission	Adm_Source	This is the source of admission to a hospital	2 digit numeric	NHS Wales Data Dictionary
Ward/Department/Team	Ward_Dept_Team	This is the ward location/department of where the patient is currently being treated or the team the patient is under
Consultant / Lead GP	Cons_Code	Nationally agreed form for consultant code or Independent Nurse. It is the General Medical Council (GMC) code for the Consultant or the GP acting as a Consultant or locum Consultant, which is the unique identifier. The nurse's Registration Number will be used to identify the Independent Nurse.	8 character alpha-numeric	NHS Wales Data Dictionary WRDS (Consultant Code)
Date of Admission	Adm_Date	This is the beginning of a hospital provider spell, or the date of admission. The consultant has assumed responsibility for care following the decision to admit the patient. This may be before formal admission procedures have been completed and the patient is transferred to a ward.	8 digit numeric, CCYYMMDD	n/a
Time of Admission	Adm_Time	This is the beginning of a hospital provider spell, or the time of admission. The consultant has assumed responsibility for care following the decision to admit the patient. This may be before formal admission procedures have been completed and the patient is transferred to a ward.	Format: hh:mm:ss	n/a
Date of Transfer	Transfer_Date	This is the date the patient was transferred from the ward	8 digit numeric, CCYYMMDD	n/a
Time of Transfer	Transfer_Time	This is the time the patient was transferred from the ward	Format: hh:mm:ss	n/a
Estimated Date of Discharge	Estimated_Discharge_Date	This is the estimated date of discharge of the patient at the time of the assessment	8 digit numeric, CCYYMMDD	n/a
Date Fit for Discharge	Date_Fit_Discharge	This is the date it is safe for the patient to be discharged or safe to transfer from hospital to home or another setting.	8 digit numeric, CCYYMMDD
Actual Date of Discharge	Actual_Discharge_Date	Date of discharge from the Hospital Provider Spell. The date on which a patient dies or is discharged from a continuous spell of care using the hospital bed(s) within a single hospital provider. Identical to the end date of the last consultant episode of care and ward stay within a hospital provider spell.	8 digit numeric, CCYYMMDD	n/a
NHS number	NHS_Number	It is mandatory to record the NHS Number for each patient registered with a GP practice in England and Wales. The NHS number is allocated to an individual, to enable unique identification for NHS health care purposes.	10 digit numeric	NHS Wales Data Dictionary
Hospital Number	Hosptial_Number	This is the patient's hospital number which is unique to that patient within a hospital or health care provider.	10 character alpha-numeric. Do not leave blank spaces - lead with zeros if necessary	NHS Wales Data Dictionary
Surname	Person_Family_Name	This is a person’s family name	an35	n/a
Forename (s)	Person_Given_Name	This is a person’s given name. The patient is the arbiter of their name.	an35	n/a
Title	Person_Title	A person’s title is the standard form of address used to precede a person’s name.	[TBC]	[TBC]
Preferred name	Person_Preferred_Name	This is the persons preferred name.	an35	n/a
Date of Birth	Person_Birth_Date	Date of birth of patient	8 digit numeric, CCYYMMDD	n/a
Gender	Person_Stated_Gender	The gender of a client (as stated by the client). Gender identity is a person's sense of identification with either the male or female sex, as manifested in appearance, behaviour, and other aspects of a person's life.	an1	F - Female M - Male N – Non-binary Z – Not specified
Sex at birth	Person_Phenotypic_Sex	Sex at birth; determines how the individual would be treated clinically. A classification of the observed sex of a person, relating to the biological, physiological and physical characteristics that differentiate men and women, determined by endocrine influences. Person sex is observed by a care professional, and is not self-stated.	an1	F - Female M - Male U - Indeterminate (unable to be classified as either male or female)
Religion	Religion	The religious or other belief system affiliation of a person, as specified by the person. Where applicable, religious or other belief system affiliation code is aligned with descriptors for religious and other belief system affiliations in SNOMED CT® as follows: the SNOMED CT Subset: ◦ original ID is 10791000000130 and ◦ name is Religious or Other Belief System Affiliation. Note: Where the person has been asked for their religious or other belief system affiliation but they are unsure what it is: Agnostic should be used Where the person has been asked for their religious or other belief system affiliation and it is one that is not listed: Religion (Other Not Listed) should be used * Where the person has not been asked for their religious or other belief system affiliation: Patient Religion Unknown should be used	an3	the SNOMED CT Subset: ◦ original ID is 10791000000130 and ◦ name is Religious or Other Belief System Affiliation. Note: Where the person has been asked for their religious or other belief system affiliation but they are unsure what it is: Agnostic should be used Where the person has been asked for their religious or other belief system affiliation and it is one that is not listed: Religion (Other Not Listed) should be used * Where the person has not been asked for their religious or other belief system affiliation: Patient Religion Unknown should be used
Ethnic Group	Ethnicity	The ethnicity of a person, as specified by the person, as per the Office of National Statistics (ONS) 2011 Census Categories	an1	NHS Wales Data Dictionary
Occupation	Occupation	The current and/or previous relevant occupation(s) of the patient/individual.		SNOMED CT Subset - Occupation SNOMED CT Subset ID 73241000000131
Permanent Address	Person_Perm_Add	This is the usual address nominated by the patient at the time of admission or attendance. If patients usually reside elsewhere are staying in hotels, hostels or other residential establishments for a short term, say a week, they should be recorded as staying at their usual place of residence. However if long term, such as at boarding school, the school address must be recorded. University students may nominate either their home address or the address of their university accommodation. Where patients are not capable of supplying this information, because of age or mental illness, for example, then the person responsible for the patient, such as a parent or guardian, should nominate the usual address. Patients not able to provide an address should be asked for their most recent address. If this cannot be established then you should record the address as `No fixed abode' or `Address unknown'. These patients are regarded as resident in the local geographical district for contracting purposes. For birth episodes this should refer to the mother's usual place of residence.	175 character alpha-numeric. This is based on 5 lines of 35 characters. This relates to the physical layout of the address, not the logical layout and does not require intelligent intervention when splitting the text string into lines.	n/a
Current Address (If different)	Person_Curr_Add	This is the patients current address if different from their permanent address	175 character alpha-numeric. This is based on 5 lines of 35 characters. This relates to the physical layout of the address, not the logical layout and does not require intelligent intervention when splitting the text string into lines.
Tel. No. Home	Home_Contact_Tel	Home telephone contact details of the person. Contact details may come from eMPI, or those recorded on the local PAS. Both the actual contact number and its use (work number, home number, mobile number etc.) should be sent. A UK telephone number is a number, including any exchange or location code, at which a person can be contacted in the UK by telephonic means.	Max an35
Tel. No. Mobile	Mobile_Contact_Tel	Mobile telephone contact details of the person. Contact details may come from eMPI, or those recorded on the local PAS. Both the actual contact number and its use (work number, home number, mobile number etc.) should be sent.	Max an35	n/a
Email Address	Person_Email_Address	A string of characters that identifies an addressee’s post-box on the internet.	Max an255	n/a
Is the patient wearing a patient identification band?	Patient_id_band	This is to confirm whether the patient is wearing a patient identification band	n1	1 Yes 2 No
Demographic details checked and are correct?	Confirm_Demographics	Confirmation that demographics have been checked and verified by the patient	n1	1 Yes 2 No
Do you have any concerns about the patients capacity to engage in this assessment?	Capacity	Assessors concerns regarding the patients capacity to engage with this assessment	n1	1 Yes 2 No
Preferred method of communication	Communication_Method	The preferred method of communication of a person to enable them to participate in the completion of the assessment	n1	1 - Speech 2 - Sign 3 - Other
First Language	First_Language	This is the first language of the person	2 alpha character	(ISO 639-1 Standard)
Preferred Language	Preferred_Language	This is the patients preferred language	2 alpha character	(ISO 639-1 Standard)
Do you want this admission to be carried out in Welsh?	Welsh_Language	Does the patient require a Welsh Speaker?	n1	1 Yes 2 No
Action	Welsh_Language_Action	If the patient requested the admission to be carried out in Welsh what action was taken	Free Text
Is an interpreter required?	Interpreter	Is an interpreter required in order to complete this assessment with the patient in the language of their choice?	n1	1 Yes 2 No
Action	Interpreter_action	This is to detail what action has been taken if the patient requires an interpreter	Free Text
Any Known Allergies/adverse reactions	Allergies_Adverse_Reaction	A flag to identify whether the patient has any known allergies / adverse reactions	n1	1 Yes 2 No 3 Not know
Name of allergen/ Adverse Reaction	Name_allergen_adverse reaction	The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient	Free Text
Type of reaction	Type of Reaction	This is to indicate the type of reaction the patient has to the substance	Free Text
Epi pen	Epi_Pen_Use	This is to identify whether a patient uses an Epi-pen if they have identified allergies or adverse reactions	n1	1 Patient Uses Epi-Pen 2 Patient Does Not Use Epi-Pen
Other	Allergy_other_action	This is to indicate whether any other action is required	n1	1 - Yes other action required 2 - No other action required
Additional notes	Allergy_add_notes	This is to include any further details regarding the patients allergies / adverse reactions	Free Text
Has the patient had any healthcare outside of the UK or in another Health Board / Trust in the last 12 months?	Healthcare_Outside_UK	A flag to identify whether the patient has had any healthcare outside of the UK or in another health board / trust in the last 12 months	n1	1 Yes 2 No 3 Not Known
Does the patient have a history of multi-drug resistant organisms (MDRO) e.g.MRSA, CPO, CPE, VRE?	Multi_Drug_Resistant_Organisms	A flag to identify whether the patient has previously had a history of multi-drug resistant organisms	n1	1 Yes 2 No 3 Not Known
Does the patient have a history of any Alert infection e.g. Clostridium Difficile, Tuberculosis, a Blood borne virus?	Alert_Infection_History	A flag to identify whether the patient has previously had a history of any Alert Infections	n1	1 Yes 2 No 3 Not Known
Are there any current signs of infection e.g. Diarrhoea/Vomiting, influenza like illness, Pyrexia, Covid-19 related symptoms, suspicious rash etc and/or recent travel outside of the UK?	Infection_Signs	A flag to identify whether the patient is showing current signs of infection	n1	1 Yes 2 No 3 Not Known
Does the patient have a recent history of exposure to an infectious disease in and environment and or/ person(s)?		A flag to identify whether the patient has had recent exposure to an infectious disease in an environment or person(s)	n1	1 Yes 2 No 3 Not Known
Any travel outside of the UK in the last 3 months		A flag to identify if the patient has travelled outside of the UK in the last 3 months	n1	1 Yes 2 No 3 Not Known
GP Surgery name (Current)	GP_Code_Curr	A code which uniquely identifies the GP Practice of the GP. Codes as listed for practices in the UK. Codes are supplied by the Organisation Data Service (ODS)	an 6	Welsh Reference Data Service Default Values: V81997 No Registered GP Practice V81998 Practice Not Applicable i.e. MOD or Prison GP V81999 Practice Code is Unknown
GP Surgery Address	GP_Add_Curr	This is the address of the patient's registered General Practitioner (GP) Practice. This allows the practice to be notified about treatment received by the patient. The registered GP Practice may or may not be the same as the referring GP Practice.	TEXT an175 This is based on 5 lines of 35 characters. This relates to the physical layout of the address, not the logical layout and does not require intelligent intervention when splitting the text string into lines.	Welsh Reference Data Service
GP Surgery Telephone Number	GP_Tel_Curr	This is the telephone number of the patients registered GP practice	an35
GP Surgery name (Permanent)	GP_Code_Perm	A code which uniquely identifies the GP Practice of the GP. Codes as listed for practices in the UK. Codes are supplied by the Organisation Data Service (ODS)	an 6	Welsh Reference Data Service Default Values: V81997 No Registered GP Practice V81998 Practice Not Applicable i.e. MOD or Prison GP V81999 Practice Code is Unknown
GP Surgery Address (Permanent)	GP_Add_Perm	This is the address of the patient's registered General Practitioner (GP) Practice. This allows the practice to be notified about treatment received by the patient. The registered GP Practice may or may not be the same as the referring GP Practice.	TEXT an175 This is based on 5 lines of 35 characters. This relates to the physical layout of the address, not the logical layout and does not require intelligent intervention when splitting the text string into lines.	Welsh Reference Data Service / WCCIS
GP Surgery Telephone Number	GP_Tel_Perm	This is the telephone number of the patients registered GP practice	an35
Name	Contact_One_Name	The name of the patients first point of contact of whom to contact for information regarding this attendance	an35	n/a
Relationship	Contact_One_Relationship	The relationship of the receiver to the patient, where the receiver has a personal relationship to the patient
Main Carer	Contact_One_Main_Carer	This is to indicate whether this point of contact is the patients main carer	n1	1 Yes 2 No 3 Not Known
Daytime Tel. No.	Contact_One_Day_Tel	The daytime telephone number for the patients first point of contact	an35
Evening Tel. No.	Contact_One_Eve_Tel	The evening telephone number for the patients first point of contact	an35
Can they be contacted at any time (24hrs/day)?	Contact_One_24hr_Contact	This is to indicate whether this point of contact is contactable at any time 24hrs a day	n1	1 Yes 2 No
Are they aware of this admission?	Contact_One_Aware_Admission	This is to indicate whether this point of contact is aware of the patients admission	n1	1 Yes 2 No
Name	Contact_Two_Name	The name of the patients second point of contact of whom to contact for information regarding this attendance	an35	n/a
Relationship	Contact_Two_Relationship	The relationship of the receiver to the patient, where the receiver has a personal relationship to the patient, for example, carer or parent
Main Carer	Contact_Two_Main_Carer	This is to indicate whether this point of contact is the patients main carer	n1	1 Yes 2 No 3 Not Known
Daytime Tel. No.	Contact_Two_Day_Tel_Num	The daytime telephone number for the patients second point of contact	an35
Evening Tel. No.	Contact_Two_Eve_Tel_Num	The evening telephone number for the patients second point of contact	an35
Can they be contacted at any time (24hrs/day)?	Contact_Two_24hr_Contact	This is to indicate whether this point of contact is contactable at any time 24hrs a day	n1	1 Yes 2 No
Are they aware of this admission?	Contact_Two_Admission_Aware	This is to indicate whether this point of contact is aware of the patients admission	n1	1 Yes 2 No
Name	Contact_Three_Name	The name of the patients third point of contact of whom to contact for information regarding this attendance	an35	n/a
Relationship	Contact_Three_Relationship	The relationship of the receiver to the patient, where the receiver has a personal relationship to the patient, for example, carer or parent
Main Carer	Contact_Three_Main_Carer	This is to indicate whether this point of contact is the patients main carer	n1	1 Yes 2 No 3 Not Known
Daytime Tel. No.	Contact_Three_Day_Tel_Num	The daytime telephone number for the patients third point of contact	an35
Evening Tel. No.	Contact_Three_Eve_Tel_Num	The evening telephone number for the patients third point of contact	an35
Can they be contacted at any time (24hrs/day)?	Contact_Three_24hr_Contact	This is to indicate whether this point of contact is contactable at any time 24hrs a day	n1	1 Yes 2 No
Are they aware of this admission?	Contact_Three_Admission_Aware	This is to indicate whether this point of contact is aware of the patients admission	n1	1 Yes 2 No
Name	Contact_Four_Name	The name of the patients fourth point of contact of whom to contact for information regarding this attendance	an35	n/a
Relationship	Contact_Four_Relationship	The relationship of the receiver to the patient, where the receiver has a personal relationship to the patient, for example, carer or parent
Main Carer	Contact_Four_Main_Carer	This is to indicate whether this point of contact is the patients main carer	n1	1 Yes 2 No 3 Not Known
Daytime Tel. No.	Contact_Four_Day_Tel_Num	The daytime telephone number for the patients fourth point of contact	an35
Evening Tel. No.	Contact_Four_Eve_Tel_Num	The evening telephone number for the patients Fourth point of contact	an35
Can they be contacted at any time (24hrs/day)?	Contact_Two_24hr_Contact	This is to indicate whether this point of contact is contactable at any time 24hrs a day	n1	1 Yes 2 No
Are they aware of this admission?	Contact_Four_Admission_Aware	This is to indicate whether this point of contact is aware of the patients admission	n1	1 Yes 2 No
Contact details not provided	No_contact_details	This is to detail why no contact details have been provided of whom to contact regarding this patients admission	Free text
Do you receive care support?	Care_support	This is to indicate if the patient has care support	n1	1 Yes 2 No
If yes do you receive support from family, friends, paid care, carer, community health, social care agencies, 3^rd sector, care home, Residential home	Support_Received	This is to indicate whether the patient currently receives support from family, friends, paid carer, carer, community health or social care agencies, 3^rd sector, care home, Residential home	Tick box
If Yes, details	Support_Details	This is to detail what support the patient receives and who from	Free text
Do you have carer responsibilities?	Carer_Responsibilities	This is to indicate whether the patient has carer responsibilities	n1	1 Yes 2 No
If Yes, specify	carer_responsibilites_details	This is to specify what carer responsibilities the patient has	Free text
Does your admission / condition directly affect care of children / relatives/ pets / assistance animal / others?	condition_affect_others	This is to indicate whether the patients admission / condition directly affects care of others	n1	1 - Children 2 - Relatives 3 - Pets 4 - Assistance animal 5 - Other 6 - None
If Yes, specify:	specify_how_affects_others	This is to specify who is affected by the patients admission / condition and how they are affected	Free text
Do you have any concerns regarding continuity of care for dependents?	Continuity_of_care_concerns	This is to indicate whether the patient has any concerns regarding continuity of care for dependents	n1	1 Yes 2 No
If Yes, actions taken	continuity_of_care_actions	This is to detail what action has been taken if there is a concern regarding continuity of care for dependents	Free Text
If over 18 does the patient wish to be referred for a carers assessment?	Over_18_carers_assessment_referral	This is to identify whether the patient wishes to be referred for a carers assessment if they are under 18 years old	n1	1 Yes 2 No
If under 18 does the patient wish to be referred for a young carers assessment?	Under_18_youngcarer_assessment	This is to identify whether the patient wishes to be referred for a carers assessment if they are over 18 years old	n1	1 Yes 2 No
Referral details	Referral_details	This is to document details of any referral that has been made	Free text
Is there a concern that there may be an adult / child at risk of abuse or neglect?	Adult_Child_Risk	This is to indicate whether there may be an adult / child at risk due to the patient being admitted into hospital	n1	1 Yes 2 No
If Yes, actions taken	Risk_actions	This is to detail what action has been taken should there be a concern that there may be an adult / child at risk	Free text
Are there any signs of abuse? (consider physical, emotional, sexual, financial and neglect)	Signs_of_abuse	This is to indicate whether there are any signs of abuse	n1	1 Yes 2 No
If Yes, actions taken	Actions_taken_abuse	This is to provide details on actions taken regarding abuse	Free text
Does the patient have any concerns for their safety?	Safety_Concerns	This is to indicate whether the patient has any concerns for their own safety	n1	1 Yes 2 No
If Yes, details:	Safety_details	This is to detail what concerns the patient has for their own safety	Free text
Are there any signs of about domestic abuse?	Domestic_abuse	This is to indicate whether there are concerns about domestic abuse	n1	1 Yes 2 No
If Yes, details	Domestic_abuse_details	This is to provide further details on the domestic abuse	Free text
Do you need to report any concerns to another agency? (Social Service’s or the Police)?	Agency_ concerns	This is to indicate whether there is a need to report any concerns to another agency	n1	1 Yes 2 No
Reason for Admission	Reason_for_admission	This is the presenting complaint with which the patient attended the hospital / The list and description of the health problems and issues experienced by the patient resulting in their attendance	Free text
Relevant Medical / Surgical History	Relevant_Medical_History	A record of the patient’s significant medical and surgical history.	Free text
Relevant Medical / Surgical History	Relevant_Surgical_History	A record of the patient’s significant medical and surgical history.	Free text
Mental Health History	Mental_Health_History	A record of the patient’s significant mental health history.	Free text
Are you receiving or have you received support from a mental health specialist team?	Mental_Health_Support	This is to indicate whether the patient is or has receiving support from a mental health specialist team	n1	1 Yes 2 No 3 Not Known
If yes, details:	MentalHealth_Support_Details	This is to detail what support the patient has received or is currently receiving from a mental health specialist team	Free text
Is the patient detained under the Mental Health Act (MHA)?	Patient_detained	This is to indicate whether the patient is detained under the Mental Health Act (MHA)	n1	1 Yes 2 No
If Yes, which section of the MHA?	MHA_Section	This is to indicate which section of the Mental Health Act the patient is detained under	Free text
Is the patient on s.17 MHA leave to this ward?	s17_MHA_leave	This is to indicate whether the patient is on s.17 MHA leave to this ward?	n1	1 Yes 2 No
Who is the patient's MHA Responsible Clinician?	MHS_Responsible_Clinician	This is to indicate who the patients MHA Responsible Clinician is	Free text
Contact Details	MH_Contact_Details	This is to provide the contact details for the patient's MHA Responsible Clinician	Free text
Do you currently take any medications?	Medications	This is to indicate whether the patient is currently taking any medications	n1	1 Yes 2 No
Do you self-administer medication?	Self_Administer_Meds	This is to indicate whether the patient self administers their medication	n1	1 Yes 2 No
if no, who administers your medication?	Who_administers_meds	This is to detail who administers the patients medication if they don't self administer	Free text
Do you use a pill / medication organiser / dosette box / multi-compartment compliance aid (MCA)?	Meds_box	This is to indicate whether the patient uses a multi compliance aid (MCA)	n1	1 Yes 2 No
Do you have your medication with you?	Meds_with_patient	This is indicate whether the patient has their medication with them	n1	1 Yes 2 No
If yes, can we use them for this admission	Meds_use_on_admission	This is to confirm whether the hospital staff can use the patients own medication for this hospital admission	n1	1 Yes 2 No
Details: (incl disclaimer (where relevant))	Meds_details	This is to provide further details on the patients medication	Free text
Have you considered medication as a risk to falls?	Medication_falls_risk	This is to indicate whether the patient has considered medication as a risk to falls	n1	1 Yes 2 No
Do you have any reason to doubt the patient's mental capacity to make decisions about their care and treatment?	Mental_capacity	This is to indicate whether the assessor has reason to doubt the patients capacity to make decisions about their care and treatment	n1	1 Yes 2 No
If Yes, details of reasons / cognitive impairment	Capacity_reasons	This is to provide further details on the reasons for doubting the patient's mental capacity	Free Text
Is this due to a pre-existing diagnosis? (e.g. learning disability, dementia, stroke, other cognitive impairment) OR	Pre_existing_diagnosis	This is to indicate whether the doubts on the patients capacity is due to a pre-existing condition	n1	1 Yes 2 No
Is it a new presentation? (e.g. delirium, confusion, new head injury, new stroke)	New_presentation	This is to indicate that doubts on the patients mental capacity is due to a new presentation	n1	1 Yes 2 No
Do you think the patient lacks capacity to consent to their hospital stay i.e. could they be deprived of their liberty?	Hospital_stay_consent	This is to indicate whether the assessor thinks the patient lacks capacity to consent to their hospital stay	n1	1 Yes 2 No
Is there / has anyone made you aware that the patient has an Advance or Future Care Plan?	Advance_future_careplan	This is to indicate whether anyone has made the assessor aware that the patient has an Advance or Future Care Plan	n1	1 Yes 2 No
If Yes, is there a copy in the notes?	ACP_In_notes	This is to confirm whether there is a copy of the Advance Care Plan in the patients medical notes	n1	1 Yes 2 No
Is there / has anyone made you aware that the patient has an Advance Decision to Refuse Treament (ADRT)?	Advance_decision_to_refuse_treatment	This is to indicate whether anyone has made the assessor aware that the patient has an Advance Decision to Refuse Treatment	n1	1 Yes 2 No
If Yes, is there a copy of a written ADRT in the notes or has a verbal ADRT been recorded in the notes?	ADRT_in_notes	This is to confirm whether there is a written copy of the ADRT in the patients medical notes or a verbal ADRT has been recorded in the notes	n1	1 Yes 2 No
Does the ADRT refuse life-sustaining treatment? (must be in writing, signed, witnessed and state that the refusal applies even if life is at risk)	Lifesustaining_treatment_refusal	This is to indicate whether the ADRT refuses life-sustaining treatment	n1	1 Yes 2 No
Is there / has anyone made you aware that the patient has a Health and Welfare Lasting Power of Attorney (LPA) or Court Appointed Deputy? (Note: LPA must be registered with the Office of the Public Guardian)	Health_and_welfare_LPA_CAD	This is to indicate that the assessor is aware that the patient has a Health and Welfare Lasting Power of Attorney (LPA) or Court Appointed Deputy	n1	1 Yes 2 No
If yes, is there a copy in the notes?	Health_Welfare_LPA_in_notes	This is to indicate whether there is a copy of the Health and Welfare LPA or CAD in the patients notes	n1	1 Yes 2 No
Has anyone made you aware that the patient has a Property and Finance Lasting Power of Attorney (LPA) or Court Appointed Deputy? (Note: LPA must be registered with the Office of the Public Guardian)	Property_and_finance_LPA_CAD	This is to indicate that the assessor is aware that the patient has a Property and Finance Lasting Power of Attorney (LPA) or Court Appointed Deputy	n1	1 Yes 2 No
If yes, is there a copy in the notes?	Property_and_finance_LPA_in_notes	This is to indicate whether there is a copy of the Property and Finance LPA or CAD in the patients notes	n1	1 Yes 2 No
Does the patient have a learning disability?	Learning_Disability	This is to identify whether the patient has a learning disability as stated by the patient	n1	1 Yes 2 No
Does the patient have a learning disability passport with them?	Learning_Passport	If the patient states that they have learning disabilities confirm whether the patient has a learning disability passport with them	n1	1 Yes 2 No
If Yes, is there a copy in the notes?	Learning_passport_in_notes	This is to indicate whether there is a copy of the patients learning disability passport in the patients notes	n1	1 Yes 2 No
Does the patient have any specialist involvement with regards to Mental capacity or Learning Disability?	Mental_capacity_specialist_involvement	This is to indicate whether the patient has any specialist involvement regarding their capacity	n1	1 Yes 2 No 3 Not Known
If yes, details	Mental_capacity_details	This is to detail the specialist involvement the patient has regarding their capacity	Free Text
Do you have a hearing problem?	Hearing_problem	This is to indicate whether the patient has a hearing problem	n1	1 Yes 2 No
Are you registered as deaf?	Deaf	This is to indicate whether the patient is registered deaf	n1	1 Yes 2 No
If yes, details	Hearing_details	This is to add further details on the patients hearing problems / deafness	Free Text
Do you have a sight problem?	Sight_problem	This is to indicate whether the patient has a sight problem	n1	1 Yes 2 No
Are you registered as blind?	Blind	This is to indicate that the patient is registered blind	n1	1 Yes 2 No
If yes, details	Sight_details	This is to detail what the patients sight deficit is	Free Text
Do you wear hearing aids?	Hearing_aids	This is to indicate whether the patient wears hearing aids	n1	1 Yes 2 No
with patient	Hearing_aids_with_patient	This is to indicate whether the patient has their hearing aids with them	n1	1 Yes 2 No
Do you wear spectacles?	Spectacles	This is to indicate whether the patient wears spectacles	n1	1 Yes 2 No
with patient	Spectacles_with_patient	This is to indicate whether the patient has their spectacles with them	n1	1 Yes 2 No
Do you wear contact lenses?	Contact_lenses	This is to indicate whether the patient wears contact lenses	n1	1 Yes 2 No
with patient	Patient_contact_lenses	This is to indicate whether the patient has their contact lenses with them	n1	1 Yes 2 No
Do you wear other?	Other_comm_aids	This is to indicate whether the patient wears any other form of communication aids	n1	1 Yes 2 No
with patient	Other_comm_aids_patient	This is to indicate whether the patient has their other form of communication aid with them	n1	1 Yes 2 No
If yes, provide details of Other	Other_comm_aids_details	This is to indicate what the other form of communication aids is	Free Text
Do you have difficulty reading?	Reading_difficulties	This is to indicate whether the patient has difficulty reading	n1	1 Yes 2 No
Do you have difficulty writing?	Writing_difficulties	This is to indicate whether the patient has difficulty writing		1 Yes 2 No
If yes, details:	Reading_writing_details	This is to detail what the patients difficulties are with reading and writing	Free Text
Do you need any equipment to help you to hear or understand written information?	Comm_equipment	This is to indicate whether the patient needs any equipment to help them hear or understand written information	n1	1 Yes 2 No
If yes, details	Equipment_details	This is to detail what equipment the patient needs to help them to hear or understand written information	Free Text
Do you feel that you can communicate clearly and make your needs understood?	Communication	This is to identify whether the patient feels that they can communicate clearly and make their needs understood	n1	1 Yes 2 No
If No, details	Comm_details	This is to details the reasons why the patient feels they are unable to communicate clearly nor are they able to make their needs understood	Free Text
Is this normal for you?	Comm_normal	This is to indicate whether the patients communication on admission is normal for them	n1	1 Yes 2 No
Details:	Comm_normal_details	This is to detail the patients normal communication and whether or not they differ from that on admission	Free Text
Do you have any specialist involvement?	Comm_specialist_involvement	This is to indicate whether the patient has any specialist involvement	n1	1 Yes 2 No 3 Not Known
If yes, details	Comms_details	This is to detail the specialist involvement the patient has regarding communication	Free Text
Do you have any difficulties breathing?	breathing_difficulties	This is to indicate whether the patient has any difficulties breathing	n1	1 Yes 2 No
If Yes, details	Patient_breathing_difficulties_details	This is to include what difficulties the patient has breathing	Free Text
Is this normal for you?	breathing_normal	This is to indicate whether it is normal for the patient to have breathing difficulties	n1	1 Yes 2 No
Details	breathing_normal_details	This is to include further details on whether or not this is normal for the patient	Free Text
Are you on home oxygen?	Home_oxygen	This is to indicate whether the patient is on home oxygen	n1	1 Yes 2 No
Details:	Home_oxygen_details	This is to record details of the patients home oxygen	Free Text
Do you have any specialist involvement?	Breathing_specialist_involvement	This is to indicate whether the patient has any specialist involvement regarding their breathing	n1	1 Yes 2 No 3 No Known
Details:	Breathing_spec_inolv_details	This is to detail any specialist involvement the patient has regarding their breathing	Free Text
Do you use any specialist equipment relating to your condition?	Breathing_specialist_equipment	This is to indicate whether the patient uses any specialist equipment relating to their condition	n1	1 Yes 2 No
If Yes, details	Breathing_equipment_details	This is to detail any specialist equipment the patient uses relating to their condition	Free Text
Do you currently smoke?	Smoker	This is to indicate whether patient currently smokes	n1	1 Yes 2 No 3 – no, but ex smoker
Do you currently vape?	Vaper	This is to indicate whether the patient currently vapes	n1	1 Yes 2 No
Do you currently use nicotine replacement?	Nicotine_replacement_use	This is to indicate whether the patient currently uses nicotine replacement	n1	1 Yes 2 No
If yes, do you require a nicotine replacement whilst in hospital?	Nicotine_replacement_required	This is to indicate whether the patient requires a nicotine replacement whilst in hospital	n1	1 Yes 2 No
If yes, do you agree to a referral to Help Me Quit services?	Helpmequit_referral	This is to indicate whether the patient agrees to a referral to the Help Me Quit services	n1	1 Yes 2 No
Has the patient been informed that it is illegal to smoke within a hospital and its grounds?	Hospital_grounds_smoking	This is to indicate whether the patient has been informed that it is illegal to smoke within a hospital and its grounds	n1	1 Yes 2 No
Admission Height	Admission_height	This is the patients height on admission in metres / feet inches	Free text
Is the value for Height: Measured, Reported, Estimated, Unable to measure	Height_value	This is to indicate whether the patients height on admission is measured, reported, estimated or unable to measure	n1	1 - Measure 2 - Reported 3 - Estimated 4 - Unable to measure
Admission Weight	Admission_weight	This is the patients weight on admission in kilograms / stone pounds	Free text
Is the value for Weight: Measured, Reported, Estimated, Unable to measure	Weight_value	This is to indicate whether the patients weight on admission is measured, reported, estimated or unable to measure	n1	1 - Measure 2 - Reported 3 - Estimated 4 - Unable to measure
If unable to measure, details	Unable_to_measure_details	This is to indicate the reason for being unable to measure the patient	Free text
BMI	BMI	This is to indicate the patients body mass index
Do you have any problems eating?	Eating_problems	This is to indicate whether the patient has any problems eating	n1	1 Yes 2 No
Is Yes, details (consider equipment)	Eating_details	This is to detail what problems the patient has eating	Free Text
Is this normal for you?	Eating_norm	This is to indicate whether the patients problems eating is normal for them	n1	1 Yes 2 No
Details	Eating_norm_details	This is to include further details about whether this is normal for the patient	Free Text
Do you have any problems drinking?	Drinking_problems	This is to indicate whether the patient has any problems drinking	n1	1 Yes 2 No
If Yes, details	Drinking_problems_details	This is to detail what problems the patient has drinking	Free Text
Is this normal for you?	Drink_norm	This is to indicate whether the patients problems drinking is normal for them	n1	1 Yes 2 No
Details	Drink_norm_details	This is to include further details about whether this is normal for the patient	Free Text
Do you have any problems swallowing?	Swallowing_problems	This is to indicate whether the patient has any problems swallowing	n1	1 Yes 2 No
Is this normal for you?	Swallowing_norm	This is to indicate whether the patients problems swallowing is normal for them	n1	1 Yes 2 No
Details	Swallowing_details	This is to include further details regarding the patients swallowing problems	Free Text
Do you need help to eat and drink?	Eat_drink_help	This is to indicate whether the patient needs help to eat and drink	n1	1 Yes 2 No
Details	Eat_drink_details	This is to detail what help the patient needs to eat and drink	Free Text
Do you require a specific diet or nutritional supplements?	Diet	This is to indicate whether the patient requires a special diet or nutritional supplements	n1	1 Yes 2 No
Details	Diet_details	This is to details what special diet or nutritional supplements the patient requires	Free Text
Do you have any food allergies or intolerances?	Food_allergies	This is to indicate whether the patient has any food allergies or intolerances	n1	1 Yes 2 No
Details	Food_details	This is to detail what food allergies or food intolerances the patient has	Free Text
Do you have any specialist involvement?	Nutrition_involvement	This is to indicate whether the patient had any specialist involvement with regards to nutrition and hydration	n1	1 Yes 2 No 3 No Known
If yes, Details	Nutrition_involvement_details	This is to detail what specialist involvement the patient has with regards to nutrition and hydration	Free Text
Do you have any difficulties mobilising?	Mobilising_difficulties	This is to indicate whether the patient has difficulties mobilising	n1	1 Yes 2 No
If Yes, details	Mobilising_difficulties_details	This is to detail the difficulties the patient has mobilising	Free Text
Is this normal for you?	norm_mobility	This is to indicate whether the patients difficulties mobilising is normal for them	n1	1 Yes 2 No
Details	mobility_details	This is to include further details regarding the patients difficulties mobilising	Free Text
Do you have any difficulties with your balance?	Balance_difficulties	This is to indicate whether the patient has any difficulties with their balance	n1	1 Yes 2 No
If Yes, details	balance_details	This is to detail the difficulties the patient has with their balance	Free Text
Is this normal for you?	norm_balance	This is to indicate whether the patients difficulties with their balance is normal for them	n1	1 Yes 2 No
Details	norm_balance_details	This is to include further details regarding the patients difficulties with balance	Free Text
Do you normally use a mobility aid?	Mobility_aid_use	This is to indicate whether the patient normally uses a mobility aid	n1	1 Yes 2 No
If yes, details	Mobility_aid_details	This is to detail what mobility aid the patient normally uses	Free Text
Do you have them with you?	Mobility_aids_in_posession	This is to indicate whether the patient has their mobility aid with them	n1	1 Yes 2 No
Do you have any specialist involvement?	Mobility_specialist_involvement	This is to indicate whether the patient has any specialist involvement regarding their mobility	n1	1 Yes 2 No 3 No Known
If Yes, details	Mobility_specialist_involvement_details	This is to detail the specialist involvement the patient has regarding their mobility	Free Text
Have you fallen in the last 12 months?	Falls_in_12months	This is to indicate whether the patient has fallen within the last 12 months	n1	1 Yes 2 No
If Yes, details (to include number of times)	Falls_details_number	This is to detail the patients falls that have occurred within the last 12 months to include the number of times they have fallen	Free Text
Do you have anxiety or fear of falling?	Falls_fear_anxiety	This is to indicate whether the patient has anxiety or fear of falling	n1	1 Yes 2 No
If Yes, details	Falls_fear_anxiety_details	This is to include details regarding the patients anxiety or fear of falling	Free Text
Have you brought appropriate footwear with you?	Footwear	This is to indicate whether the patient has brought appropriate footwear with them	n1	1 Yes 2 No
If yes, details	Footwear_details	This is to detail what appropriate footwear the patient has with them	Free Text
Do you have have any foot or lower limb problems?	Foot_problems	This is to indicate whether the patient has any foot or lower limb problems	n1	1 Yes 2 No
If yes, details	Foot_problem_details	This is to include details of any foot or lower limb problems the patient has	Free Text
What is your normal bowel pattern?	Bowel_pattern	This is to describe the patients normal bowel pattern	Free text
Do you currently have any problems or concerns with your bowels?	Bowel_problems	This is to indicate whether the patient experiences any bowel problems	n1	1 Yes 2 No
If Yes, details:	Bowel_problem_details	This is to detail what bowel problems the patient experiences	Free Text
Is this normal for you?	Bowel_norm	This is to indicate whether the patients bowel problems are normal for them	n1	1 Yes 2 No
If no, details	Bowel_norm_details	This is to provide further details on whether or not this is normal for the patient	Free Text
Do you have, or experience any bladder problems?	Bladder_problems	This is to indicate whether the patient experiences any bladder problems	n1	1 Yes 2 No
If Yes, details:	Bladder_problem_details	This is to detail what bladder problems the patient experiences	Free Text
Is this normal for you?	Bladder_norm	This is to indicate whether the patients bladder problems are normal for them	n1	1 Yes 2 No
If No, details	Bladder_details	This is to provide further details on the patients bladder problems	Free Text
Do you have any of the following: Colostomy Ileostomy Urostomy Catheter	Colostomy_Ileostomy_Catheter	This is to indicate whether the patient has any of the following: Colostomy, Ileostomy, Urostomy, Catheter	n1	1 – Colostomy 2 – Ileostomy 3 – Urostomy 4 – Catheter 5 – No
Details:	Bladder_proc_details	This is to include further details on whether the patient has colostomy, ileostomy, urostomy, catheter	Free Text
Do you have any specialist involvement?	Bladder_bowel_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to bladder and bowel	n1	1 Yes 2 No 3 No Known
If Yes, details	Bladder_bowel_nvolvement_details	This is to detail what specialist involvement the patient has with regards to bladder and bowel	Free Text
Can you normally attend to your own personal hygiene needs?	Personal_hygiene_needs	This is to indicate whether the patient normally attends to their own personal hygiene needs	n1	1 Yes 2 No
If no – in what areas do you require assistance: Washing Showering Bathing Dressing Mouth Care Foot and Nail care Other	Personal_care_assistance	If the patient doesn’t attend to their own personal hygiene needs this indicates what area they require assistance with	n1	1 – Washing 2 – Showering 3 – Bathing 4 – Dressing 5 – Motuh Care 6 – Foot and Nail Care 7 – Other
Details	Personal_care_details	This is to include further detail about the patient requiring assistance with personal hygiene	Free text
Do you use equipment to support personal care?	Personal_care_equipment	This is to indicate whether the patient requires equipment to support their personal care	n1	1 Yes 2 No
If Yes, details:	Personal_care_equipment_details	This is to detail what equipment the patient requires to support their personal care	Free text
Do you have any specialist involvement?	Personal_care_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to their personal care	n1	1 Yes 2 No 3 No Known
If yes, details	Personal_care_specialist_involvement_detail	This is to detail what specialist involvement the patient has with regards to their personal care	Free text
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	n1	1 Yes 2 No
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	n1	1 Yes 2 No 3 No Known
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	n1	1 Yes 2 No
Do you wear dentures?	Dentures	This is to indicate whether the patient wears dentures	n1	1 Yes 2 No
Do you have your dentures with you?	Dentures_with_patient	This is to indicate whether the patient has their dentures with them	n1	1 Yes 2 No
Do you have any specialist involvement?	Mouth_care_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to their mouth care	n1	1 Yes 2 No 3 No Known
If Yes, details:	Mouth_care_involvement_details	This is to detail what specialist involvement the patient has with regards to their mouth care	Free Text
Are you in pain?	Pain	This is to indicate whether the patient is in pain	n1	1 Yes 2 No
If Yes, details:	Pain_details	This is to detail what pain the patient is in	Free Text
Is the pain normal for you?	Pain_normal	This is to indicate whether this pain is normal for the patient	n1	1 Yes 2 No
Details:	Pain_details	This is to include further details on whether the pain is or isn’t normal for the patient	Free Text
Are there things that you usually do to alleviate your pain?	Alleviate_pain	This is to indicate whether the patient usually does anything to alleviate their pain	n1	1 Yes 2 No
If Yes, details:	alleviate_pain_details	This is to detail what the patient usually does to alleviate their pain	Free Text
Does the pain affect any of the following:	Pain_affect	This is to indicate whether the pain affects any of the following: Mobility, Sleep, Breathing, Eating & Drinking, Toileting, Other	n1	1 – Mobility 2 – Sleep 3 – Breathing 4 – Eating and Drinking 5 – Toileting 6 – Other
Details:	pain_affect_details	This is to include details of what the patients pain affects if other
Do you have any specialist involvement?	Pain_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to their pain	n1	1 Yes 2 No 3 No Known
If Yes, details	Pain_specialist_involvement_details	This is to detail what specialist involvement the patient has with regards to their pain	Free Text
Do you have existing wounds/ulcers or other skin problems?	Wound_Ulcers_Skin_Problems	This is to indicate whether the patient has any existing wounds/ulcers or other skin conditions	n1	1 Yes 2 No
Do you have any specialist involvement?	Skin_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to their skin	n1	1 Yes 2 No 3 No Known
If Yes, details	Skin_details	This is to detail what specialist involvement the patient has with regards to their skin	Free Text
Can you describe your normal sleep pattern including anything you do to help you sleep?	Sleep_pattern	This is to describe the patients normal sleep pattern	Free Text
Do you currently have difficulty sleeping?	Sleep_difficulty	This is to indicate whether the patient has difficulty sleeping	n1	1 Yes 2 No
DetailS	Sleep_difficulty_details	This is to detail what difficulties the patient has sleeping	Free Text
Do you have any specialist involvement?	Sleep_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to their sleep	n1	1 Yes 2 No 3 No Known
If Yes, details:	Sleep_involv_details	This is to indicate what specialist involvement the patient has with regards to their sleep	Free Text
Are there any special cultural or spiritual beliefs that we need to consider?	Beliefs	This is to indicate whether the patient has any specific cultural or spiritual beliefs that need to be considered	n1	1 Yes 2 No
Details:	Beliefs_details	This is to detail what specific cultural or spiritual beliefs the patient has that need to be considered	Free Text
Would you like a visit from the chaplain or another faith leader?	Chaplain_visit	This is to indicate whether the patient would like a visit from the chaplain or another faith leader	n1	1 Yes 2 No
If Yes, details:	Chaplain_visit_details	This is to include further details if the patient would like a visit from the chaplain or another faith leader	Free Text
Do you use recreational drugs?	drug_use	This is to indicate whether the patient uses recreational drugs	n1	1 Yes 2 No
If yes, details	Drug_use_details	This is to include further details if the patient uses recreational drugs	Free text
Do you want information or advice on how to stop or take them safely?	Drug_advice	This is to indicate whether the patient would like information or advice on how to stop or take them safely	n1	1 Yes 2 No
If Yes, details	Drug_advice_details	This is to include further details if the patient would like information or advice on how to stop or take them safely	Free text
Do you have any specialist involvement?	Drug_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to the use of recreational drugs	n1	1 Yes 2 No 3 No Known
If yes, details	Drug_specialist_involvement_details	This is detail what specialist involvement the patient has with regards to recreational drugs	Free text
Do you drink alcohol??	Alcohol	This is to indicate whether the patient drinks alcohol	n1	1 Yes 2 No
If Yes, how many units per week?	Alcohol_units	This is to indicate how many units of alcohol the patient consumes per week	Free text
Do you wish to receive information / advice for reducing or stopping?	Alcohol_advice	This is to indicate whether the patient wishes to receive information / advice for reducing or stopping their alcohol consumption	n1	1 Yes 2 No
If Yes, details:	Alcohol_advice_details	This is to include further detail if the patient wishes to receive information / advice for reducing or stopping alcohol consumption	Free text
Do you have any specialist involvement?	Alcohol_specialist_involvement	This is to indicate whether the patient has any specialist involvement with regards to alcohol	n1	1 Yes 2 No 3 No Known
If Yes, details:	Alcohol_specialist_involvement_details	This is to detail what specialist involvement the patient has with regards to alcohol	Free text
Has a property disclaimer been completed?	Property_disclaimer	This is to confirm whether a property disclaimer has been completed	n1	1 Yes 2 No
Comments:	Property_disclaimer_comments	This is to include any comments regarding the property disclaimer	Free Text
What is important to me at the moment?	Important_to_patient	This is to detail what is important to the patient at the moment	Free text
What is preventing me from achieving this?	Prevention	This is to detail what is preventing the patient from achieving what is important to them at the moment	Free text
I would like to achieve the following from this admission:	Achievements	This is to indicate what the patient would like to achieve from this admission	Free text
My carer, advocate, family members could support me in the following ways:	patient_support	This is what the patient feels their carer, advocate, family members could do to support them	Free text