Alcohol Misuse Tower Hamlets Template Guide 2016

Transcription

1 Alcohol Misuse Tower Hamlets Template Guide

2 Template Control Page Alcohol Misuse Tower Hamlets Template Guide Title Alcohol misuse Tower Hamlets Auth CEG Version 2 Descript Suppts Tower Hamlets Alcohol Misuse NIS 2016/17 (vr2) DOCUMENT MANAGEMENT REVISION HISTORY Version Date Summary of Changes April 2013 Additions: AUDIT infmation; AUDIT (38D3) Extended Intervention (9k1B) Contact details f THCAT Hb Estimation (423) MCV (42A) AST (44HB) Alanine Aminotransferase level (44GB) Hyperlinks: Drink Aware, THCAT Removed: FBC (424) Review done (66e0) 3.0 April 2014 Changed recommendation of what it is a positive sce in AUDIT C f women to comply with DES guidance. Replaced referral code to comply with Alcohol DES 1 April 2015 Added to Emis Template Library so version numbering reset. Remove ** from full AUDIT and referral to specialist service 8CAM. Patient advised about alcohol retired as now using brief intervention Link to AUDIT C document temparily removed due to website issues. 2 July 2016 Added hyperlink to document with info about units and AUDIT AUTHORISATION Reviewed by Approved by Date Confirmed Jo Tissier Dr Anna Livingstone March 2013 Ana Gutierrez Dr Anna Livingstone March 2014 Ana Gutierrez Dr Anna Livingstone April 2015 EMIS Web Library Items Lifestyle Intervention CEG 2

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4 Alcohol Misuse Tower Hamlets Template Guide This template can be used as a stand alone template to recd infmation about alcohol use. Community detoxification should always be in partnership with THCAT ** indicates a payment indicat Prompt Code What does this prompt mean? Emis Web Screening Click here f a link to a document on alcohol units, audit C and Audit questions Infmation Screen Hyperlink Browse/BriefAdvice/?parent=4444&child =4898 Q1. How often do you have a drink containing alcohol? 0 pts less 1 pts 2 4 times a month 2 pts 2 to 3 times a week 3 pts 4 me times a week 4 pts Q2. How many units of alcohol do you drink on a typical day when you are drinking? pts pts pts 7 to 9 3 pts 10 me 4 pts Q3. How often have you had 6 me units if female, 8 me if male, on a single occasion in the last year? 0 pts 1 pts 2 pts 3 pts 4 pts ** Audit C sce 38D4 Value Assessment AUDIT C Info 5+ indicates increasing high risk drinking. Total sce of 5 above is AUDIT C positive, please consider full AUDIT Alcohol Consumption 136 Alcohol intake value in units Assessment AUDIT 38D3 Value Assessment Alcohol risk status Intake within recommended sensible limits (136L) Hazardous alcohol use (136S) Harmful alcohol use (136T) Assessment Brief Intervention 9k1A Tick box Additional Text box Alcohol Leaflet given 8CE1 Tick box Additional Intervention and Referrals Extended Intervention 9k1B Tick box Additional 4

5 Referral to specialist alcohol treatment service Text box 8HkG Tick box Additional Info Patients scing 8+ on AUDIT C (high risk) 16+ on full AUDIT: consider a referral to THCAT ( ) to Lifeline Young Person s service f under 24 year olds. Click f link to TH CAT Hyperlink Infmation Info Box Check the boxes below when patients from THCAT are seen f assessment and prescription Under care of community 9NN2 Tick Box Histy alcohol team **Registered community detox initial visits 9k10 Tick Box Tool Tip: This is a payment indicat Resources Useful Agencies Info A.A ( 10am to 10pm) Al. Anon Family Groups F link to alcohol Hyperlink learning centre Click f link to Hyperlink Drinkaware Additional Examinations Systolic BP 2469 Value Examination Diastolic BP 246A Value Examination O/E height 229 Value Examination O/E weight 22A Value Examination Body Mass Index 22K Automatically calculated by EMIS Examination Other Drug user 13c Tick Box. Text line f details. Histy Health ed. Drugs 679A Tick Box. Health education on drugs of addiction. Additional Detox and Vit B Info Box F detox. And consider Vitamin B administration Medication Given 8B311 Tick Box Additional Patient pregnant Patient pregnant 62 Tick Box. Tooltip: If yes refer to substance misuse midwife not f detox. Female Only Histy Review Dates Detox completed 8BA8 Tick Box Additional **Detox Follow Up by 6 weeks 9k12 Tick Box Additional RESULTS PAGE Hb 423 Haemoglobin value Result MCV 42A Result (indicat of alcohol and liver problems) Result Serum Total Bilirubin 44EC Result Result Serum Alkaline Phosphate 44F Result Result 5

6 GGT 44G4 Result Result AST Serum Level 44HB Result Result Serum alanine aminotransferase level 44GB Result Result DEPRESSION/SUICIDE RISK PAGE Depression/Anxiety Screening Depression Screening Info Box Questions During the past month have you been bothered by: 1. Little interest pleasure in doing things. 2. Feeling down, depressed hopeless. 3. Is this something, you would like help with. Depression Screen done 6896 Tick Box Assessment Suicide Risk Suicide risk tool Info Box Risk Assessment Is life not wth living? Have you thought how you might harm yourself? *If NO - Currently LOW risk Active thoughts of self harm? Made plans to end your life? Might you act on these plans? *If NO - MEDIUM risk, assess, consider referral Made plans & proposed to act on them? Voices telling you to self harm? *If YES - HIGH risk, consider urgent referral Suicide risk assessment 38B0 Tick Box Assessment done Suicide risk 1BD4 Low suicide risk (1BD7) Moderate suicide risk (1BD6) High suicide risk (1BD5) Text line f action taken Assessment 6

7 Alcohol Learning Centre Public Health England This is one unit of alcohol and each of these is me one unit AUDIT C Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 me units if female, 8 me if male, on a single occasion in the last year? Scing system less 2-4 times per month 2-3 times per week 4+ times per week Your sce Scing: A total of 5+ indicates increasing higher risk drinking. An overall total sce of 5 above is AUDIT-C positive. SCORE 7

8 Sce from AUDIT- C (other side) SCORE Remaining AUDIT questions Questions you found that you were not able to stop drinking once you had started? you failed to do what was nmally expected from you because of your drinking? you needed an alcoholic drink in the mning to get yourself going after a heavy drinking session? you had a feeling of guilt remse after drinking? you been unable to remember what happened the night befe because you had been drinking? Have you somebody else been injured as a result of your drinking? Has a relative friend, doct other health wker been concerned about your drinking suggested that you cut down? Scing system No No Yes, but not in the last year Yes, but not in the last year Yes, during the last year Yes, during the last year Your sce Scing: 0 7 Lower risk, 8 15 Increasing risk, Higher risk, 20+ Possible dependence TOTAL Sce equals AUDIT C Sce (above) + Sce of remaining questions TOTAL 8