Retrospective case record audit: service users who ended therapy

Transcription

1 Retrospective case record audit: service users who ended therapy How to submit your data to NAPT: Your service lead has agreed with the NAPT Team how your service's audit data will be submitted. Please check with your service lead (or the NAPT team) on what has been agreed for your service before submitting data - this is essential to avoid duplication. The options are: 1. Via an online version of this audit form at or 2. Via data extraction from your IT system or 3. Another method agreed between your service lead and NAPT team (this is only in exceptional circumstances). All data must be submitted to NAPT by 11 January Extensions will not be possible. How to complete this form online: All service users who meet the inclusion criteria (see NAPT website should be included in this audit. Please complete a separate audit form for each service user. You will not be able to save partially completed forms to return to later. Each question relates directly to a NAPT Standard (available on the 'Standards' page of the NAPT website: Leaving questions blank will mean we maybe unable to provide you with analysis for the standard(s) that question relates to. Mandatory questions (where data will not be accepted unless all are completed) are marked *. Exclusion criteria: Service users who were receiving psychological therapy for anything other than anxiety or depression should not be included in this audit. Part A: Unique Identifiers 1. *NAPT Service Code (e.g ): 3 digits, decimal place, 2 digits. This is a unique code assigned to your service by the NAPT team. This code will be used to allocate data to the correct service. Please contact your service lead or the NAPT team if you do not know this code. 2. *Patient Code: 8 digit code. Assigned by the service lead to identify the service user for the resolution of any data issues prior to analysis. A log of assigned numbers should be kept by the service lead. Do not use the service users' NHS number. 3. Therapist Initials: The therapist who provided this service user's psychological therapy. This will not be included in analysis and will only be used for the resolution of any data issues prior to analysis. Page 1 of 9

2 Part B: Patient Information 4 Year of birth (YYYY): If year of birth is not entered it will be assumed that year of birth is not known. This will be reflected in the equity of access standards. 5. *Gender (please choose one): If gender is not known this will be reflected in the equity of access standards. Male Not known / not specified Female 6. *Ethnic Group (please choose one): If ethnicity is not known this will be reflected in the equity of access standards. White British Asian/Asian British Bangladeshi White Irish Any other Asian background Any other White Black/Black British Caribbean Mixed White and Black Caribbean Black/Black British African Mixed White and Black African Any other Black background Mixed White and Asian Chinese Any other mixed background Any other ethnic group Asian/Asian British Indian Not known / not stated Asian/Asian British Pakistani Part C: Referral 7. Date referral received (or date on which 'choose and book' appointment made): Please enter as: DDMMYYYY for current episode of psychological therapy you are auditing. If date is not entered it will be assumed that it is not known. This will result in standards on waiting times not being measureable for this service user. 8. *Referral source (please tick one): Self referral Other referral Not Known Page 2 of 9

3 Part D: Reason for therapy Questions 9 and 10 will be used to measure the NICE adherence standards and to ensure that service users included in the audit fit the sampling criteria. 9. *Diagnosis Only choose one diagnosis for 'Primary Diagnosis' and one for 'Secondary Diagnosis'. Only answer for diagnoses held at the time of the current episode of psychological therapy. The numbers in brackets relate to the associated ICD-10 diagnoses. If diagnosis not known please select 'Diagnosis not known/not recorded'. Primary Secondary Diagnosis Diagnosis Diagnosis not known/not recorded Bipolar affective disorder, current episode depression without psychotic symptoms (F31.3 or F31.4) Bipolar affective disorder, current episode severe depression with psychotic symptoms (F31.5) Bipolar affective disorder, currently in remission (F31.7) Other bipolar affective diagnoses (F31.6, F31.8, F31.9) Mild depressive episode (F32.0) Moderate depressive episode (F32.1) Severe depressive episode without psychotic symptoms (F32.2) Severe depressive episode with psychotic symptoms (F32.3) Other depression episode diagnoses (F32.8, F32.9) Recurrent depressive disorder, current episode mild (F33.0) Recurrent depressive disorder, current episode moderate (F33.1) Recurrent depressive disorder, current episode severe without psychotic symptoms (F33.2) Recurrent depressive disorder, current episode severe with psychotic symptoms (F33.3) Recurrent depressive disorder, currently in remission (F33.4) Other recurrent depressive disorder diagnoses (F33.8, F33.9) Dysthymia (F34.1) Other mood [affective] disorder diagnoses (F34.0, F34.8, F34.9, F38.0, F38.1, F38.8, F39) Social phobias (F40.1) Specific (isolated) phobias (F40.2) Other phobic anxiety disorder diagnoses (F40.8, F40.9) Panic disorder with or without agrophobia (F41.0, F40.0) Generalized anxiety disorder (F41.1) Mixed anxiety and depressive disorder (F41.2) Other anxiety disorder diagnoses (F41.3, F41.8, F41.9) Obsessive compulsive disorder diagnoses (F42.0, F42.1, F42.2, F42.8, F42.9) Post-traumatic stress disorder (F43.1) Other stress reaction diagnoses (F43.0, F43.2, F43.8, F43.9) Body dysmorphic disorder (F45.2) Other (diagnoses not included above) Page 3 of 9

4 10. *Problem for which psychological therapy was offered: Choose one to indicate the problem for which the current episode of psychological therapy you are auditing was offered. Only service users receiving therapy for anxiety and/or depression should be included in this audit. Same as primary diagnosis Obsessive compulsive disorder Same as secondary diagnosis Generalized anxiety disorder Depression Post-traumatic stress disorder Mixed anxiety and depression Body dysmorphic disorder Social phobias Other anxiety disorder Specific (isolated phobias) Panic disorder (with or without agrophobia) Part E: Appointment Dates and Attendance 11. Date of first appointment attended by the service user: Please enter as: DDMMYYYY This is for psychological therapy provided by this service, for this recent treatment period. This may have been for an assessment only, for assessment and treatment in one session or straight into treatment without assessment by this service. If date left blank it will be assumed this is not known. This will result in standards on waiting times not being measureable for this service user. 12. *What was the reason for this first appointment? (Please choose one) Assessment only Treatment only Assessment and treatment Not Known (if 'Not known', standards on waiting times may not be measureable) 13. Date of the first treatment appointment attended by service user: Please enter as: DDMMYYYY This is for psychological therapy provided by this service, for this recent treatment period. If this date is the same date as first appointment attended (Q11) please leave blank. If date left blank and you answered 'Assessment only' or 'Not Known' to Q12 it will be assumed that the date for first treatment session is not known. This will result in standards on waiting times not being measureable for this service user. Page 4 of 9

5 14. Date of the last treatment appointment attended: Please enter as: DDMMYYYY This does not include follow-up appointments. If this date is not completed this service user's data may not be included in the analysis as it cannot be confirmed that they completed therapy within the audit period 1 July October How many therapy sessions did the patient attend? Please complete as numbers not text e.g. 16 not sixteen. If this is not answered it will be assumed that this is not known and the standards on NICE recommended number of sessions will not be measureable. 16. *What was the reason for therapy ending? Please choose one. Completed Treatment Not Suitable for the Service Deceased Referral to another Service Declined Treatment Not Known Dropped out of Treatment (unscheduled discontinuation) Page 5 of 9

6 Part F: Type of Therapy Questions 17 (High Intensity Therapy) and 18 (Low Intensity Therapy) will be used to analyse the NICE recommended therapy standards. 17. *High Intensity therapy provided to service user: Please tick all that are applicable. This is psychological therapy provided by this service, for this recent treatment period. Please answer even if the patient did not attend any therapy sessions. Individual Group Cognitive Behavioural Therapy (CBT) Person-Centred (or other Humanistic Therapy) Solution-Focused Therapy Psychodynamic/Psychoanalytic Therapy Behavioural Activation Interpersonal Therapy Cognitive Analytic Therapy (CAT) Systemic/Family Therapy Arts Psychotherapies Mindfulness-Based Cognitive Therapy Dialectical Behavioural Therapy Counselling Eye Movement Desensitisation & Reprocessing Therapy (EMDR) Problem-Solving Therapy Couples Therapy Other If 'Other' 'Individual', please specify: If 'Other' 'Group', please specify: Page 6 of 9

7 18. *Low Intensity therapy provided to service user? Please tick all that are applicable. This is psychological therapy provided by this service, for this recent treatment period. Please answer even if the patient did not attend any therapy sessions. Individual Group Computerised Cognitive-behavioural therapy - FACILITATED Guided/Facilitated Self-Help Psycho-Education Pure Self-Help (e.g. books on prescriptions, un-facilitated ccbt via DVD, etc) Signposting/Referral Facilitation Schemes Structured Exercise Support and Advice in Adherence of Antidepressant/GP- Prescribed Medication Other If 'Other' 'Individual', please specify: If 'Other' 'Group', please specify: Page 7 of 9

8 Part G: Outcomes Please enter the outcomes scores you have for this service user. Please enter as many measures as applicable. This is for the psychological therapy provided by this service, for this recent treatment period. Please enter scores collected at the beginning of treatment and at the end of treatment (or the last occasion that the scale was rated). At least a first score or last score on at least one measure is needed to measure the standards on outcomes. HADs - Anxiety Subscale - First Score HADs - Anxiety Subscale - Last Score HADs - Depression Subscale - First Score HADs - Depression Subscale - Last Score PHQ-9 - First Score PHQ-9 - Last Score GAD-7 - First Score GAD-7 - Last Score W&SAS - First Score W&SAS - Last Score CORE-10 - First Score CORE-10 Last Score CORE-OM - First Score CORE-OM - Last Score CES-D - First Score CES-D- Last Score HoNOS - First Score HoNOS - Last Score BAI - First Score BAI - Last Score BDI-II First Score BDI-II Last Score Other Standardised Measures: Measure Name: First Score Last Score Measure Name: First Score Last Score Page 8 of 9

9 Thank you for completing this audit form. End of audit form How to submit your data to NAPT Your service lead has agreed with the NAPT Team how your service's data will be submitted. Please check with your service lead before submitting data on what has been agreed for your service - this is essential to avoid duplication. All retrospective case record data must be submitted to NAPT by 11 January How to contact the NAPT Team Please contact us with any queries via napt@cru.rcpsych.ac.uk or / 4974 NAPT website and NAPT Forum More information and support is available on the NAPT website and NAPT Forum accessible via Page 9 of 9