Institute of Applied Health Sciences. University of Aberdeen DATABASE REVIEW. Grampian University. Hospitals NHS Trust GRAMPIAN DIABETES

Transcription

1 DATABASE REVIEW Grampian University Hospitals NHS Trust GRAMPIAN DIABETES SERVICES DATABASE Page 1

2 Contents Contents 2 Introduction 3 History 3 Overview of Database 3 Database Structure 4 Main Table Summary 5 Demographic - Patient Demographic Data 5 Diabetes Specific Registration 5 Family History - Family History of Diabetes 5 Presenting Symptoms - Symptoms at Diagnosis 6 Drug Therapy 6 Healthcare Professional Contact 6 Overall Review Plan 6 Routine Tests 6 Lab Results - Details of Laboratory Results 7 Life Event - Details of Life Events 7 Cardiovascular - Details of Cardiovascular Events 7 Renal - Details of Renal Events 7 Feet - Details of Foot Examinations 7 Education - Details of Diabetes Training 8 Diabetes Surveillance 8 Lifestyle 8 Doctor / Practice Nurse / Diabetes Specialist Nurse - Contact Information 8 Dietetics - Dietary Advice Details 8 Eyes - Details of Eye Examinations 9 Sexual Dysfunction 9 Contraception 9 Puberty 9 Pregnancy 9 Pre-Pregnancy - Details of Pre-Conceptual Check 10 Problem List - Details of Associated Problems 10 Associated Publications 11 Page 2

3 Introduction History Diabetes care in Grampian is provided on a multidisciplinary level within hospital diabetic clinics, general practice and the community (professions allied to medicine staff). Over the last 20 years, information gathered at the diabetic clinic was held on paper records and transferred to the Patient Record System (PRS), which was a problem oriented medical record computer system with supplementary documents (Back Pack) for each specialty. The PRS system has been replaced with different database systems within each specialty and problem lists, medication and demographic information for approximately 8000 diabetic patients was transferred to a new system PROTUS in PROTUS has been developed to hold all patient data relevant to the provision of a diabetic service for patients aged 14 and over, in line with the Scottish Intercollegiate Guidelines Network (SIGN) recommendations for a minimum dataset for diabetic patients. The system is fully integrated providing information to all professionals involved in the provision of diabetic care within Grampian, including In Patients, Out Patients and General Practice. Overview of Database PROTUS has been developed to hold all patient data relevant to the provision of a diabetic service for patients aged 14 and over, in line with the Scottish Intercollegiate Guidelines Network (SIGN) recommendations for a minimum dataset for diabetic patients. The system is fully integrated providing information to all professionals involved in the provision of diabetic care within Grampian, including In Patients, Out Patients and General Practice. All patients are reviewed regularly and their review details added to the database. Page 3

4 Database Structure DEMOGRAPHIC DIABETES SPECIFIC REGISTRATION PRESENTING SYMPTOMS FAMILY HISTORY DRUG THERAPY ROUTINE TESTS OVERALL REVIEW PLAN LAB RESULTS LIFESTYLE DIABETES SURVEILLANCE PREGNANCY Page 4

5 Main Table Summary Institute of Applied Health Sciences Demographic - Patient Demographic Data CHI Number Hospital PAS Number Hospital Forename / Surname / Title Patient address, postcode and telephone number Patient s sex Marital status Date of birth Ethnic Grouping Date of Death / Cause of Death GP and Practice Diabetes Specific Registration Hospital PAS Number Hospital Hospital Diabetes Clinic Attendance Flag Hospital or GP Care Indicator Diabetic Status and Diagnosis Date Age at Diagnosis GMC Number and Status of Doctor Fasting Plasma Glucose at Diagnosis Tests for Diabetes Previous History of Gestational Diabetes Family History of Diabetes Family History - Family History of Diabetes Relationship for Family History Type of Diabetes in Relative Page 5

6 Presenting Symptoms - Symptoms at Diagnosis Symptoms / Complications at Presentation Thirst Symptoms / Polyuria / Nocturia Weight Loss / Lassitude Genital Symptoms Visual Symptoms Neurological Symptoms Drug Therapy Drug Therapy Date of Therapy Individual Drugs, Doses, Frequency and Start / Finish Dates Dose Time Relative to Meal Times Healthcare Professional Contact Date and Time of Contact Name and Role of Healthcare Professional Source of Referral New / Return Contacts Type of Consultation InPatient / Outpatient Contact Review Details Closure / Referral to Other Healthcare Professional Overall Review Plan Date of Overall Review Plan Review Interval in Primary Care / Hospital Care Suspension of Review and Reason / Comments Routine Tests Date and Time of Routine Tests Height / Weight / BMI Blood Pressure Measurements Urine Test Results Waist / Hip Circumference Page 6

7 Lab Results - Details of Laboratory Results Date and Time of Sample Fasting for Blood Tests Plasma Glucose Results Blood Test Results Urine Test Results Electrocardiogram Results Life Event - Details of Life Events Date of Life Event Event Type and Code Laterality of Event Cardiovascular - Details of Cardiovascular Events Angina History and Year of Onset Ischaemic Heart Disease History and Year of First Confirmed Myocardial Infarction Previous Coronary Revascularisation and Year of First Event Renal - Details of Renal Events Year Renal Replacement Therapy Commenced Year of End Stage Renal Failure Feet - Details of Foot Examinations Date of Foot Examination Pulse / Capilliary Filling Data Sensation Details Claudication Details Neuropathy Details Paraesthesia Details Callus Details Amputation Status Ulcer Status Deformities / Lesions Self Foot Care / Specialist Footwear Orthotist Referral / Podiatry Attendance Page 7

8 Education - Details of Diabetes Training Educational Topic and Date Discussed Review Plan for Topic and Review Date Literature Provided Leaflet Code Diabetes Surveillance Date of Diabetes Surveillance Record Blood / Urine Monitoring Insulin Delivery Injection Site Hypoglycaemia Details Lifestyle Date of Lifestyle Record Smoking Status Details Alcohol Drinking Status Details Current Occupation Driving Licence Details Day Care Current Membership of British Diabetes Association Doctor / Practice Nurse / Diabetes Specialist Nurse - Contact Information Date of Contact with Professional Treatment Changes Dietetics - Dietary Advice Details Case Record Number Role of Person giving Dietary Advice Nutritional Issues Dietary Assessment and Compliance Targets set for Dietary Changes Diet History Page 8

9 Eyes - Details of Eye Examinations Location and Date of Eye Examination Name and Grade of Reporter Visual Acuity Retinal Imaging Retinal Visualisation Cataract Details Diabetic Retinopathy Diabetic Maculopathy Laser Photocoagulation Scars Ophthalmology Clinic Attended Laser Therapy Details and Year of Commencement Vitrectomy Details Year of Permanent Blindness Blind Registration Sexual Dysfunction Date of Sexual Dysfunction Record Erectile Failure Details Erectile Failure Treatment Details Contraception Date of Contraception Record Method of Contraception Used Puberty Date of Puberty Record Pubertal Status for Patients Under 20 Pregnancy Pregnancy Episode Date of Booking for Antenatal Care Date of Last Menstrual Period Expected Date of Delivery by LMP and Ultrasound Scan Planned Pregnancy Page 9

10 Folic Acid Supplements Smoking Status During Pregnancy Delivery / Abortion Date Birth Details / Gestation Birth Defects Maternal Mortality Antenatal Visits Pre-Pregnancy - Details of Pre-Conceptual Check Date of Pre-Conceptual Check Glycaemic Control Target HbA1c Smoking Advice Folic Acid Importance Explanation Antenatal Care and Delivery Explanation Discontinuation of Contraception Rubella Status UTI Screening Thyroid Status Renal Function Urine Microalbumin Medication Review Problem List - Details of Associated Problems Problem / Diagnosis Read Code Problem Details with Dates Page 10

11 Associated Publications None. Page 11