ALCOHOL and SELF-HARM Audit – Core Data Proforma
Family name: ______First Name: ______
Case note number: CHI number: Audit no:
.
Alcohol & SELF-HARM Hospital code: Audit no: .Postcode: Sex:1 = Male 2 = Female Age:
Enter the ED Date: .. Time: . Seen in Resus: 0 = no 1 = yes
Referred by: 1 = Self 2 = GP 3 = NHS 24 4 = Police 5 = friends/family 6 = voluntary services 7 = school
8 = other specify: ______
Arrived by: 1 = Self 2 = SAS 3 = Police 4 = other specify: ______
ED Assessment
Grade of ED staff: 1 = Consultant 2 = SpR 3 = Staff Grade 4 = SHOIII 5 = SHO 6 = ENP
Type of Other Specialty in ED: 1 = Emergency Physician 2 = Medical Physician 3 = Surgical 4 = Ortho 5 = Anaesthetist
6 = Maxillo-facial 7= other specify: ______
Method of self-harm: 1= poisoning 2 = injury 3 = both poisoning and injury
Type of poisoning: 1 = drugs 2 = CO poisoning 3 = alcohol 4 = other chemical specify:______
Type of drugs: 1 = prescribed 2 = non-prescribed 3 = both
Method of self-injury: 1 = cutting 2 = traffic-related 3 = hanging 4 = drowning 5 = high fall 6 = burn/scald
7 = gun 8 = other specify: ______
Basic Mental State Assessment Have the following been assessed?0 = no 1 = yes
Behaviour Speech Appearance Mood Orientation Physical health
Preliminary Psychosocial Assessment Answer 0 = no 1 = yes
Is there physical risk of injury Is there previous self-harm Is there ongoing intention of self-harm
Is there a history of the course of events Is there recent major stress Is there known mental illness
Is there previous contact with Mental Health Services Are there current drug issues
Is there a family/social network
Existing care package
0 = not recorded 1 = none 2 = GP 3 = CPN/ALN 4 = Psychiatric OPD 5 = Community-based Addiction Team
6 = Community Mental Health Team 7 = Social Work 8 = Voluntary Agency 9 = other specify: ______
Comments
Drugs taken
1 = paracetamol 2 = pure or combination of salicylate 3 = anti-depressant 4 = NSAID 5 = other analgesic
6 = major tranquilliser & anti-psychotic 7 = mild sedative 8 = benzodiazepine 9 = Other : specify ______
ToxBase consulted Antidote indicated Antidote given 0 = no 1 = yes 2 = not documented
Referred for Specialist Psychosocial Assessment 0 = no 1 = yes 2 = telephone advice
Where was the assessment carried out? 1 = ED 2 = Ward 3 = refused 4 = irregular discharge 5=discharged with OPD
Date of assessment: ..
Use of Alcohol
Was alcohol used around the time of self-harm? 0 = no 1 = yes 2 = not documented
Was alcohol a contributory factor in the patient’s presentation? 0 = no 1 = yes 2 = not documented
Had the patient consumed alcohol in the previous 24 hours? 0 = no 1 = yes 2 = not documented
Are alcohol-related problems documented in the patient’s PMH? 0 = no 1 = yes 2 = not documented
Was a screening tool used in the ED? 0 = no 1 = yes ______
Discharge Management from the ED
Referred to Specialty: Alcohol Liaison Nurse: Psychiatric Services: 0 = no 1 = yes 2 = not known
Detained under Mental Health Act: 0 = no 1 = yes
Leave ED date: .. Leave ED time: :
Disposal from the ED:
1 = Home 2 = SSW 3 = Assessment/CDU 4 = Medical 5 = Surgical 6 = Ortho 7 = GI 8 = ICU 9 = HDU 10 = Maxillo-facial
11 = Neurosurgery 12 = Irregular discharge 13 = Police 14 = Mortuary 15 = Psychiatric Unit 16 = Specialist NHS treatment
17 = Community non-NHS counselling service 18 = did not wait
If irregular discharge, are the following documented?
Mental capacity: Willingness for further assessment: 0 = no 1 = yes
Discharge Ward discharge date:.. Total in-patient days: Outcome: 0 = dead 1 = alive
Discharge Care Package (from ED or Ward) Discharge plan:
0 = not recorded 1 = none 2 = GP 3 = CPN/ALN 4 = Psychiatric OPD 5 = Community-based Addiction Team 6 = Community Mental Health Team 7 = Social Work 8 = Voluntary Agency 9 = other specify: ______
1
SH1