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Integrated Care for Drug or Alcohol Users: Principles and Practice Update 2008

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Annex 1

1. Personal Information core data set

Family name and forename

Present address and postcode

Unique identifier

Previously known

Date of birth

Gender

Ethnicity

Referral source

G.P Name

G.P Address

Other professionals/agencies involved

Next of kin

Dependent children at home

Previously known

Previous interventions

Presenting problem

Primary drug profile

Secondary drug profile

Injecting

Signs and symptoms of over sedation and/or withdrawal

Consent to assessment

Signed permission to share information with other agencies

2. Assessed Need core data set

Drug use

Other problem drug profile

Alcohol use

Prescribed drugs/medication

Effects on user (positive and negative)

Problems/concerns

Drug history including alcohol

Living arrangements

Household composition

Status of residency

Accommodation type

Carer/cared for

Other drug user(s) in household

Housing support needs

Benefits

Heating

Physical Health

Past medical history

Permanent or long-standing health condition or disability

Current care provision

Seen by GP in last 18 months

Current medical condition

Current medication

Current treatments

Registered disabled

Disease prevention

Sleep patterns

Diet and food preparation

General physical state

Body Mass Index

Injecting practices/techniques

Wound management

Oral health

Vaccination history

History of cervical or breast screening

Mental health

Past psychiatric history

Current signs and symptoms

Risk assessment

Current medication

Seen by psychiatric services in last 18 months

Current diagnosis

Social functioning

Relationships

Family contacts

Social contacts

Spiritual and religious matters

Cultural and ethnic matters

Leisure/hobbies

Employment, past and current

Learning

Legal situation

Current offending behaviour

Previous convictions

Outcomes

Prison

Other

Service user's perspective

Problems and issues perceived and conveyed by the person

Person's motivation

Advocacy required?

Collateral information

Carer/significant others' perspective

Other service provider

Biological measures

Biochemistry

Virology

Hepatitis B

Hepatitis C

HIV

Pregnancy

Readiness to change

Stage of change

Motivational state

Strengths

Barriers to change

Support system

Self-efficacy

Risk and safety

Needle sharing/exchange/cleaning

Sharing of injecting paraphernalia including filters, water and spoons

Sexual risk

Blood borne virus

Sexually transmitted diseases

Personal safety - risk from self

Personal safety - risk from other

Risk to dependent children

Public safety

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Page updated: Tuesday, May 27, 2008