National Audit of Psychological Therapies (NAPT) Retrospective case record audit data set

Transcription

1 National Audit of Psychological Therapies (NAPT) Retrospective case record audit data set Instructions: Please view this data set in conjunction with the paper version of the retrospective case record audit form (available on the NAPT website) Pages 2-6: main data set Pages 7-8: list of therapy types accepted Page 9: outcomes list Page 10-11: diagnoses and codes Page 12: list of presenting problems and codes If you are looking to map your IT system to this data set and would like help or support please contact the NAPT Team. Please note this mapping exercise has already been undertaken for CORE, IAPTUS and PC-MIS systems these IT providers will support you in exporting your data if you use their systems for managing your service users clinical records. NAPT Retrospective case record dataset Page 1 of 12

2 Question Number Q1 Q2 Question Response type Response option codes Service code (assigned by central NAPT team). Patient code (assigned by service - not NHS number - please keep track locally). numeric - 3 digits, decimal point, 2 digits Response options Mandatory (data not accepted if missing) Related NAPT Standard n/a n/a Y n/a numeric - 8 digits n/a n/a Y n/a Q3 Therapist initials. text - max 4 digits n/a n/a N (if left blank - Q4 Year of birth. YYYY n/a n/a N (if left blank - Q5 Gender Multiple choice - single 0 Not Known or Y answer only Not specified 1 Male Q6 Ethnicity Multiple choice - single answer only 2 Female n/a 1a & 1b 1a & 1b White Y 1a & 1b A B C British Irish Any other White background NAPT Retrospective case record dataset Page 2 of 12

3 Q7 Date referral received, or date on which 'choose and book' appointment made' Mixed D E F G Asian or Asian British H J K L Black or Black British M N P Other Ethnic Groups R S Z White and Black Caribbean White and Black African White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other Black background Chinese Any other ethnic group Not stated DDMMYYYY n/a n/a N (if left blank - Q8 Source of referral Multiple choice - single B1 Self Y n/a 2&3 NAPT Retrospective case record dataset Page 3 of 12

4 Q9 (includes primary and secondary diagnosis) Q9 (includes primary and secondary diagnosis) Q10 Q11 Primary diagnosis Secondary diagnosis Problem for which psychological therapy is being offered. Date of first appointment attended by service user (for this service, for this episode. May have been for assessment only, for assessment & treatment in one session or straight answer only Z Other Multiple choice - single answer only Multiple choice - single answer only Multiple choice - single answer only ZZZ ICD Codes - include: ZZ - 'not known/not recorded', ZZZ - 'other' ICD Codes - include: ZZ - 'not known/not recorded', ZZZ - 'other' ONLY short list of anxiety and depression options - includes: a - 'same as primary diagnosis' and b - same as 'secondary diagnosis' option Not Known Restricted list of ICD categories. See Diagnosis ICD-10 codes tab. Restricted list of ICD categories. See Diagnosis ICD-10 codes tab. See Presenting problem list tab. DDMMYYYY n/a n/a N (if left blank - Y 4&5 Y 4&5 Y 4&5 2&3 NAPT Retrospective case record dataset Page 4 of 12

5 into treatment without assessment by this service) Q12 Q13 Q14 Q15 Q16 Reason for first appointment Date of first treatment appointment attended Date of last treatment appointment attended (not including follow-up appointments) Number of therapy sessions attended Reason therapy ended (or did not start) List 1 Assessment only Y 2&3 2 Treatment only 3 Assessment and Treatment 4 Not known DDMMYYYY n/a n/a N (if left blank - DDMMYYYY n/a n/a N (if left blank - Numeric - max 3 digits n/a n/a N (if left blank - 5 Multiple choice - single 1 Completed Y 5&10 answer only Treatment 2 Deceased 3 Declined Treatment 3 n/a NAPT Retrospective case record dataset Page 5 of 12

6 Q17 Q17a Q17b Q18 Q18a Q18b High intensity therapy offered (please select even if patient did not attend any therapy sessions) Other - High Intensity Individual Other - High Intensity Group Low intensity therapy offered (please select even if patient did not attend any therapy sessions) Other - Low Intensity Individual Other - Low Intensity Group Multiple choice - multiple answers possible 4 Dropped out of Treatment (unscheduled discontinuation) 5 Not Suitable for Service 6 Referral to another Service 99 Not Known See Tab 2 Type of Therapy See Tab 2 N (if left blank - Free text n/a n/a Y - if answered 'other' to Q17 Free text n/a n/a Y - if answered 'other' to Q17 Multiple choice - multiple answers possible Section G Outcome scores Grid - free text box fields See Tab 2 Type of Therapy See Tab 2 N (if left blank - Free text n/a n/a Y - if answered 'other' to Q18 Free text n/a n/a Y - if answered 'other' to Q18 See Tab 3 Outcomes See Tab 3 N (if left blank - 4&5 4&5 4&5 4&5 4&5 4&5 9a, b & c NAPT Retrospective case record dataset Page 6 of 12

7 Type of therapy categories Therapy Intensity Individual/Group Therapy Type NAPT Code High Individual Cognitive-behavioural therapy HI.1 Person-centred (or other humanistic therapy) HI.2 Solution-focused therapy HI.3 Psychodynamic/psychoanalytic therapy HI.4 Behavioural activation HI.5 Interpersonal therapy HI.6 Cognitive analytic therapy HI.7 Systemic/family therapy HI.8 Arts psychotherapies HI.9 Mindfulness-based cognitive therapy HI.10 Dialectical-behavioural therapy HI.11 Counselling HI.12 Eye movement desensitisation & reprocessing therapy HI.13 Problem-solving therapy HI.14 Couples therapy HI.15 Other O.1 Group Cognitive-behavioural therapy HG.1 Person-centred (or other humanistic therapy) HG.2 Solution-focused therapy HG.3 Psychodynamic/psychoanalytic therapy HG.4 Behavioural activation HG.5 Interpersonal therapy HG.6 Cognitive analytic therapy HG.7 NAPT Retrospective case record dataset Page 7 of 12

8 Systemic/family therapy HG.8 Arts psychotherapies HG.9 Mindfulness-based cognitive therapy HG.10 Dialectical-behavioural therapy HG.11 Counselling HG.12 Eye movement desensitisation & reprocessing therapy HG.13 Problem-solving therapy HG.14 Couples therapy HG.15 Other O.2 Low Individual Computerised Cognitive-behavioural therapy - FACILITATED II.1 Guided/facilitated self-help II.2 Psycho-education II.3 Pure self-help (e.g. books on prescription, unfacilitated ccbt via DVD, etc.) II.4 Signposting/referral facilitation schemes II.5 Structured exercise II.6 Support and advice in adherence of antidepressant/gp-prescribed medication II.7 Other O.3 Group Computerised Cognitive-behavioural therapy - FACILITATED IG.1 Guided/facilitated self-help IG.2 Psycho-education IG.3 Pure self-help (e.g. books on prescription, unfacilitated ccbt via DVD, etc.) IG.4 Signposting/referral facilitation schemes IG.5 Structured exercise IG.6 Support and advice in adherence of antidepressant/gp-prescribed medication IG.7 Other O.4 NAPT Retrospective case record dataset Page 8 of 12

9 Outcomes list HADS - Anxiety subscale HADS - Depression subscale PHQ-9 GAD-7 W&SAS CORE-10 CORE-OM CES-D HoNOS BAI BDI-II Other Other First score Last score NAPT Retrospective case record dataset Page 9 of 12

10 Diagnosis codes 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) 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) NAPT Code zz a b c d e f g h i j k l m n o p q r s NAPT Retrospective case record dataset Page 10 of 12

11 Other phobic anxiety disorder diagnosese (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 diagnosese (F43.0, F43.2, F43.8, F43.9) Body dysmorphic disorder (F45.2) Other t u v w x y z aa ab ZZZ NAPT Retrospective case record dataset Page 11 of 12

12 Presenting problem list Same as primary diagnosis Same as secondary diagnosis Depression Mixed anxiety and depression Social phobias Specific (isolated phobias) Panic disorder (with or without agrophobia) Obsessive compulsive disorder Generalized anxiety disorder Post-traumatic stress disorder Body dysmorphic disorder Other anxiety disorders a b c d f g h i j k l m NAPT Retrospective case record dataset Page 12 of 12