Fields that are important for your SMR: Diagnosis, Physiology, Hospital outcome, GCS, Treatment goals, Chronic conditions. Please ensure these fields are accurately collected. Diagnosis and Chronic fields need clinical insight. Non-Mandatory variables DOB SEX INDIGENOUS Male Intersex/Indeterminate Yes Female Unknown No HOSPITAL ADMISSION DETAILS Admission Date Admission Time Admission Source Home Hospital ICU* Hospital ED* Other Acute Hospital (not ICU/ED)* Unknown – – Inborn Rehabilitation Mental Health Nursing Home/Chronic Pain/Palliative Care *Transferred from Height Weight (kg) Smoking Status Current Ex-Smoker Never HOSPITAL DISCHARGE DETAILS Discharge Date Discharge Time Destination on Discharge Died Hospital in the Home Other Hospital ICU* Other Acute Hospital* – Home Rehabilitation Nursing Home/Chronic Pain/Palliative Care Mental Health Unknown *Transferred to CHRONIC CONDITIONS DIABETES FRAILTY SCORE (Refer to Definitions) (Refer to Definitions) Evidence of insufficiency or immunocompromised state Present at Hospital Admission PRIOR to Hospital Admission. Immune Disease Immunosuppressed Diabetes Type 1 1 Very Fit – AIDS Leukaemia/Myeloma Diabetes Type 2 2 Well – Metastases Lymphoma Gestational Diabetes 3 Managing Well – Hepatic Failure Cirrhosis (biopsy proven) (Secondary diabetes, previous 4 Vulnerable – Chronic Respiratory Chronic Cardiovascular gestational diabetes, impaired Based on the patient’s 5 Mildly Frail – level of physical function Chronic Renal Failure No Chronic Conditions fasting glucose/glucose 6 Moderately Frail – in the 2 months PRIOR intolerance). 7 Severely Frail – to their first ICU Not Diagnosed with diabetes 8 Extremely – Admission during this hospital stay. ICU ADMISSION DETAILS Admission Date Admission Time Care Unit Admitted to Admission Source Elective Surgery* Coronary Care ICU Other Hospital Other HDU Yes No – Direct Admission ICU Same Hospital hospital* *only applicable if Source is OT or Other hospital – (from home)
Fields that are important for your SMR: Diagnosis, Physiology, Hospital outcome, GCS, Treatment goals, Chronic conditions. Please ensure these fields are accurately collected. Diagnosis and Chronic fields need clinical insight. Non-Mandatory variables DOB SEX INDIGENOUS Male Intersex/Indeterminate Yes No Female Unknown HOSPITAL ADMISSION DETAILS Admission Date Admission Time Admission Source Home Hospital – ICU* Hospital – ED* Other Acute Hospital (not ICU/ED)* Unknown Inborn Rehabilitation Mental Health Nursing Home/Chronic Pain/Palliative Care *Transferred from Height Weight (kg) Smoking Status Current Ex-Smoker Never HOSPITAL DISCHARGE DETAILS Discharge Date Discharge Time Destination on Discharge Died Hospital in the Home Other Hospital – ICU* Other Acute Hospital* Home Rehabilitation Nursing Home/Chronic Pain/Palliative Care Mental Health Unknown *Transferred to CHRONIC CONDITIONS (Refer to Definitions) DIABETES FRAILTY SCORE (Refer to Definitions) Evidence of insufficiency or immunocompromised state PRIOR to Hospital Admission. Present at Hospital Admission Immune Disease Immunosuppressed Diabetes Type 1 1 – Very Fit AIDS Leukaemia/Myeloma Diabetes Type 2 2 – Well Metastases Lymphoma Gestational Diabetes 3 – Managing Well Hepatic Failure Cirrhosis (biopsy proven) (Secondary diabetes, previous gestational diabetes, impaired fasting glucose/glucose intolerance). 4 – Vulnerable Chronic Respiratory Chronic Cardiovascular Based on the patient’s level of physical function in the 2 months PRIOR to their first ICU Admission during this hospital stay. 5 – Mildly Frail Chronic Renal Failure No Chronic Conditions 6 – Moderately Frail 7 – Severely Frail Not Diagnosed with diabetes 8 – Extremely ICU ADMISSION DETAILS Admission Date Admission Time Care Unit Admitted to Admission Source Elective Surgery* Coronary Care ICU – Other Hospital Other HDU Yes No Direct Admission (from home) ICU – Same Hospital hospital* *only applicable if Source is OT or Other hospital
APD-Data-Collection-Form.docx