Once an episode has been created, you can enter the assessment information for that episode. To access the episode and assessment screen, click on the * icon next to the patient name.
The following 'episode and assessments' screen will appear.
The episode information is on the left hand side of the screen and the patient's details can be found above the episode information. This includes the patient name, patient identifier and date of birth.
The assessment information is on the right hand side of the screen. The assessment information that appears on the right hand side of the screen relate to the episode that is highlighted on the left hand side. To look at the assessments for different episodes, highlight the episode that you are interested in.
In the top right hand corner of the screen is a 'View Report' button. This button will create a report for the current episode including all the patient, episode and phase information.
Assessment level information can only been entered if an episode has been created for the patient. Assessment dates must be between on or after episode start date and on or before the episode end date.
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. Please follow the appropriate instructions below for data entry.
The clinical assessments are assessed 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.
In the episode and assessment screen, make sure you have selected the correct episode on the left hand side of the screen. On the right hand side of the screen 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 assessement. 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 information for the first assessment is entered as below. Once all the information has been added, click on the purple 'Add' button.
Once the assessment information has beend added, it will appear on the left hand side of the assessment data entry screen as below.
Entering the additional assessment
Next we add the second assessment on the form and click on 'Add'. The assessment will appear on the left hand side of the data entry screen.
Continue to add the assessments on the form until all the assessments have been added into palCentre
(UPDATE - remove the red circle!!!)
You have now added all the assessment 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 left hand side of the screen and palCentre will place it in the correct order.
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. 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 assessment level data, the following instructions will use this form to show how to enter assessment level information:
The form above shows four columns have been completed by the clinical team, reflecting clinical assessments made each day of admission. However, to capture the information for these four columns, you only need to create/enter records for admission, phase change and discharge. As a result, you only need to enter the following 3 records.
- A record with:
The information in the first column i.e. Phase = 2 (unstable) and date of 11/02/2018. - 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 - 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.