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Entering assessment information

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This page contains all information related to entering the assessment information into palCentre. To navigate quickly to a section within this page, please use the menu below:

Assessment level information vs phase level information

The clinical assessments are assessed daily for inpatient or at each community patient contact. They are reported at admission, when the phase changes and at discharge. Thus there are two ways that data can be entered into palCentre – assessment level or phase level.

Assessment level
palCentre allow services to enter all routine assessments as per the service protocol. Some services record daily assessments and some more, some less frequent. The benefits of entering assessment level data are:

  • If data is entered in real time, the reporting function tracks the patient journey with all clinical assessments.  

  • Since all assessments are entered there is no separate data entry protocol to specify what to enter.

  • On average each patient requires approx. 7 minutes to enter.


Phase level
palCentre also allow services to enter data on admission, phase change and discharge. This is referred to as phase level data. The benefits of entering phase level data are:

  • Since only phase change data needs to be entered less time for data entry is required.

  • On average each patient requires approx. 4 minutes to enter.

  • A separate data entry to the assessment protocol is required to specify the entry of phase change only

  • Additional training for the data entry person is required to understand which assessments to enter.

  • Printable reports of the patient journey will only include admission, phase change and discharge assessments. It will be missing any assessments that have occurred in-between.

NB: The legacy system SNAPshot system only allows for phase level data to be collected.



Your service will need to decide if you will be entering assessment level data or phase level data into palCentre before starting data entry. 

Accessing the assessment level screen

The assessment information screen can be access from either the patient screen or the episode screen.

From the patient screen, it can be accessed by clicking on the assessment symbol

Entering Assessment level information

The clinical assessments occur daily for inpatient or at each community patient contact. All assessments will be entered into palCentre. To demonstrate how to enter assessment level data, the following instructions will use this form to show how to enter assessment level information:

The form above has four columns that have been completed by the clinical team, reflecting clinical assessments made each day of the patients episode. To enter assessment level data, all four columns of information need to be entered.

Entering the first assessment

To begin adding assessments click on 'Add assessments'

The Assessment details will pop up and filled with the relevant details.

Enter the following details:

Item to be entered

Additional information

Date

The date the assessment was completed. This is a mandatory item - you cannot submit an assessment without this information.

Time

Optional field. The time of the assessment.

Type

The phase type for the assessment. This is a mandatory item - you cannot submit an assessment without this information.

RUG-ADL

The RUG-ADL consists of four items (bed mobility, toileting, transfer and eating) and measures the patients function.

PCPSS

The PCPSS consists of four items (pain, other symptoms, psychological/spiritual and family/carer) with a score between 0 and 3 and screens the severity of palliative care problems.

AKPS

The AKPS consists of one item with a score between 10 and 100 and measures a patient's ability to perform ordinary tasks.

SAS

The SAS is a patient rated tool with a score between 0 and 10 that measures the patient's distress across seven domains (difficulty sleeping, appetite problems, nausea, bowel problems, fatigue and pain).

There is also a field to capture if the patient or a proxy completed these assessments.

The Assessment details will pop up and can then be filled with the relevant details.

Once the assessment information has been added click 'Submit', it will then appear in the assessment data entry screen below.

Entering the additional assessment

Continue clicking 'Add assessment' or 'Submit and add another' to add in all the Assessments once completed it should look like the below screen. They appear from left to right in chronological order. 

You have now added all the assessments for this episode.

If an item has not been recorded on the form, use the 'Not Assessed' code in the drop down menu. This will ensure you have minimal items appearing on your data quality report.

Assessments can be added in any order into palCentre. Once an assessment is added, palCentre will check the date against all other assessment dates and then order all assessments by date.

If you miss adding an assessment by accident, add the assessment into the data entry section on the right hand side of the screen and palCentre will place it in the correct order.

Entering Phase level information

When entering phase level information, you only need to add assessments into palCentre on admission, where the phase changes and when the patient is discharged. To demonstrate how to enter phase level data, the following instructions will use this form to show how to enter phase level information:

The form above shows four columns have been completed by the clinical team, reflecting clinical assessments made each day of admission. To capture the information for these four columns in when entering phase level assessments, you only need to create/enter records for admission, phase change and discharge. As such, you only need to enter the following 3 records.

  1. A record with:
    The information in the first column i.e. Phase = 2 (unstable) and date of 11/02/2018. 

  2. A record with:
    The information from the third column i.e. Phase= 1 (stable) and date of 13/02/2018.
    NOTE: we have skipped the second column of data as the phase is unchanged (i.e. still 2 - unstable). A new record only needs to be entered when the phase changes

  3. A record with:
    The information from the fourth column i.e. Phase = 1 (stable) and a date of 14/02/2018.
    NOTE: This assessment must be included as it is the discharge assessment regardless of whether the phase has changed or not.

If a patient is discharged from your service, it is important to enter the final assessment into palCentre. This will ensure you have minimal items on your data quality report and ensures that your assessment information is as complete as possible.

If a patient dies with your service, no final assessment is required.

Entering the first assessment

To begin adding assessments click on 'Add assessments'

The Assessment details will pop up and filled with the relevant details.

Enter the following details:

Item to be entered

Additional information

Date

The date the assessment was completed. This is a mandatory item - you cannot submit an assessment without this information.

Time

Optional field. The time of the assessment.

Type

The phase type for the assessment. This is a mandatory item - you cannot submit an assessment without this information.

RUG-ADL

The RUG-ADL consists of four items (bed mobility, toileting, transfer and eating) and measures the patients function.

PCPSS

The PCPSS consists of four items (pain, other symptoms, psychological/spiritual and family/carer) with a score between 0 and 3 and screens the severity of palliative care problems.

AKPS

The AKPS consists of one item with a score between 10 and 100 and measures a patient's ability to perform ordinary tasks.

SAS

The SAS is a patient rated tool with a score between 0 and 10 that measures the patient's distress across seven domains (difficulty sleeping, appetite problems, nausea, bowel problems, fatigue and pain).

There is also a field to capture if the patient or a proxy completed these assessments.

The Assessment details will pop up and can then be filled with the relevant details.

Once the assessment information has been added click 'Submit', it will then appear in the assessment data entry screen below.

Entering the additional assessment

Continue clicking 'Add assessment' or 'Submit and add another' to add in all the Assessments once completed it should look like the below screen. They appear from left to right in chronological order. 

You have now added all the relevant assessments for this episode.

If an item has not been recorded on the form, use the 'Not Assessed' code in the drop down menu. This will ensure you have minimal items appearing on your data quality report.

Assessments can be added in any order into palCentre. Once an assessment is added, palCentre will check the date against all other assessment dates and then order all assessments by date.

If you miss adding an assessment by accident, add the assessment into the data entry section on the right hand side of the screen and palCentre will place it in the correct order.

Modifying an assessment

To modify an assessment that has already been entered, click on the  button below the assessment you wish to change.


Once any modifications have been made to the assessment values, click on the "Submit" button at the bottom of the pop up to save the changes to that assessment.

The assessment has now been modified.


Deleting an assessment

To delete an assessment, click on the button below the assessment you wish to delete.

The following warning will appear, click on "Yes".

The assessment has now been deleted.



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