Capitulo vii Disposición Final
ENCUESTA APLICADA A LA COLECTIVIDAD Pregunta Nº-
Presentation and process
Code Attribute Subject Acceptable Acceptable with learning
point
Unacceptable
PP1 Legibility and presentation Comprehensible, all words
legible with reasonable grammar and few spelling/typographical errors
Many words illegible, incorrect grammar or several spelling errors throughout but overall report comprehensible
Only legible with great difficulty
PP2 Jargon / medical
abbreviations
Any abbreviations used (other than ones in common use, e.g. “BP”) are explained
Contains medical jargon or abbreviations but report is likely to be comprehensible to Case Manager
Jargon and/or abbreviations used that make the report difficult to understand or could mislead Case Manager PP3 Clarification of contradictions / conflicts in evidence, Conflicts or contradictions between evidence obtained by HP or any documents is fully explained and justified
Minor conflicts of evidence not addressed in report but insufficient to mislead Case Manager or require
clarification
Major conflicts of evidence, not addressed in report such that Case Manager cannot reliably use report to support a decision on entitlement
PP4 Defined procedures Fully compliant with documented
procedures in DWP guidance Minor breach of documented procedures in DWP guidance Documented procedures in DWP guidance not followed
PP5 Directive advice No directive advice regarding award entitlement
Not applicable Contains directive
advice regarding award entitlement
*Consultation
Code Attribute Subject Acceptable Acceptable with learning
point
Unacceptable
C1 Relevant conditions All functionally relevant
conditions addressed
Not applicable Omission of one or
more functionally relevant conditions
C2 History of conditions History concise and
appropriately recorded, comprehensive, information relevant to functional effects and prognosis recorded, minimal irrelevant information included
Contains irrelevant information, or minor omissions of relevant information Omission of significant elements of history
C3 Current medication and
treatment
Comprehensively recorded or referenced as appropriate. Purpose of medication/ therapy explained. Medication list includes relevant dosage, frequency, efficacy and any significant side effects
Some omissions of functionally relevant medications but with no impact on decision making
Omission of relevant medication/therapy information where this is likely to be important to the decision making process
C4 Aids and/or appliances If relevant, evidence recorded
regarding aids and/or appliances
Some omissions but with no impact on decision making Omissions of relevant information that impact on decision making
C5 Social and occupational
history
Appropriately recorded: relevant to functional ability; if relevant occupational history includes impact of disabling condition(s) on work
Some omissions, but with no impact on decision making Omissions of relevant information that impact on decision making
functional areas covered; and includes level of difficulty in carrying out activity, and any assistance required to carry it out including exploration of standard attained, repeatability, safety and timeliness where relevant
but with no impact on decision making
functional areas; or many omissions of detail such that report cannot be reliably used by Case Manager to support a decision on entitlement
C7 Variability Appropriately recorded:
including frequency of
relapses/remissions; and level of functional ability during both relapse and remission
Not applicable Variation or
functional ability related to
relapses/remissions not addressed
C8 General appearance Appropriate, relevant information
sensitively recorded
Record broadly appropriate and sensitive, but contains some inappropriate detail
Relevant information not recorded; or record contains substantial inappropriate detail; or is recorded in a potentially offensive manner
C9 Mental State Assessment
and Examination
Appropriately recorded: all relevant conditions addressed, with details of their severity and functional effects; Appropriate MSE includes relevant
comprehensive documentation of observations +/- cognitive tests
Omission of some details, but with no impact on decision making
Omission or inadequate assessment of mental state such that report cannot reliably be used by decision maker to support a decision on entitlement C10 Physical / Sensory Examination Appropriately detailed
examination of all relevant areas
Minor omissions or
irrelevant findings that have
Omission or inadequate
recorded no impact on decision making
examination of relevant area(s) such that the report cannot be reliably used by the Case Manager to support a decision on entitlement.
C11 Informal observations Appropriately recorded: all
observations relevant to functional ability recorded
Some minor omissions, or with some inappropriate detail Relevant observations not recorded; or record contains significant inappropriate observations Reasoning
Code Attribute Subject Acceptable Acceptable with learning
point
Unacceptable
R1 Further evidence Requested appropriately and
suitably sourced: evidence sought from the most appropriate person/source
Further evidence sought but selected source is not the most appropriate one
Further evidence requested but case can easily be processed without any further evidence; or further evidence is necessary but has not been requested; or further evidence is sourced form a completely
inappropriate source
R2 Evidence considered All evidence is considered and
this is documented
Documentation lacks detail, but clear from the report that further evidence has
No record to show what, if any,
been taken into
consideration in completing report
considered in completing report
R3 *Terminal illness advice Terminal illness advice medically
reasonable and logical
Not applicable Advice not medically
reasonable or logical
R4 * Daily Living descriptor
advice
Daily Living descriptor advice medically reasonable and logical
Descriptor advice
reasonable but evidence better supports an alternative choice
Advice not medically reasonable, logical or fully considered
R5 Qualifying Period and
Prospective Period
Advice regarding QP and PP is medically reasonable and logical
Advice reasonable but evidence better supports an alternative choice
Advice not medically reasonable, logical or fully considered
R6 Mobility descriptor advice Mobility descriptor advice
medically reasonable and logical
Descriptor advice
reasonable but evidence better supports an alternative choice
Advice not medically reasonable, logical or fully considered
R7 Prognosis advice Advice is medically reasonable
and logical
Advice reasonable but evidence better supports an alternative choice
Advice completely out with consensus of medical opinion
R8 Fully justified Justification is reasonable,
logical, comprehensive and supported by evidence
Justification is reasonable and logical but lacks some detail and/or could be better supported by reference to relevant evidence. It should be sufficient for the Case Manager without clarification Justification is not reasonable or logical; or is not supported by evidence; or it lacks detail or has been omitted for any relevant area
R9 Additional support needs Advice on additional support is
reasonable, logical and based on adequate evidence
Advice reasonable but evidence better supports an alternative choice
Advice not
consistent not logical or based on
inappropriate or inadequate evidence
R10 Reliability criteria Confirmation is included in the report that the HP has fully considered the reliability criteria when formulating their advice
Not applicable No confirmation is
included that the HP has fully considered the reliability criteria when formulating their advice
Professional standards
Code Attribute Subject Acceptable Acceptable with learning
point
Unacceptable
PS1 Independent, impartial,
ethical, honest and fair
Standards independent,
impartial, ethical, honest and fair
Not applicable Not compliant in any
one parameter
PS2 Harmful information Appropriate action taken on
harmful information
Not applicable Harmful information
not recognised
PS3 *Unexpected clinical
findings
Appropriate action taken on unexpected clinical findings
Not applicable Unexpected clinical
findings not recognised; or protocol for dealing with them not followed