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{"sheet":"Introduction","index":0,"n_rows":17,"n_cols":2,"rows_kept":17,"cut":false,"hidden":false,"merged":[]}
[]
[]
[]
[]
[null,"Mental Health in General Hospitals"]
[null,"Audit Toolkit"]
[]
[null,"Thank you for downloading the toolkit for 'Mental Health in General Hospitals: Treat As One'. We hope you find this useful and if you have any feedback please do contact us at info@ncepod.org.uk (see below for link). Please can you advise your local audit department if you plan to undertake this audit, it is important that they are made aware of it for the benefit of demonstrating Trust activity and also so that they are in a position to support you and endorse the activity for your benefit."]
[]
[null,"info@ncepod.org.uk"]
[]
[null,"Please complete as many questions which are applicable to the care of the patient"]
[]
[null,"For information on the recommendation to which each question assesses please click on the         button"]
[]
[null,"This toolkit can be used in conjunction with the Self Assessment Checklist. This can be found by clicking on the report image or at:"]
[null,"http://www.ncepod.org.uk/2017mhgh.html"]

{"sheet":"Instructions","index":1,"n_rows":36,"n_cols":1,"rows_kept":36,"cut":false,"hidden":false,"merged":[]}
["Instructions for completion"]
[]
["Before you begin, in order to fill this tool in properly you MAY need to enable macros. To do this please click on the options button above this spreadsheet in the top left of the workbook. In the dialogue box which opens click on enable macros, ok. The spreadsheet should now be functional. "]
[]
["This data collection tool is made up of questions which can be used to assess how well your Trust is meeting recommendations made in \"Mental Health in General Hospitals: Treat as One\""]
[]
["Amending the tool to include more or less patients"]
["This tool has been set up to be completed on 10 patients."]
["If the audit is undertaken on less than 10 patients, please delete out the extra rows."]
["If the audit is undertaken on more than 10 patients, please add in additional rows by copying row 9 (before populated with patient data), and inserting the copied cells above row 10."]
["Following these steps will ensure the formulas work correctly."]
[]
["For information on the recommendation to which each question assesses please click on the         button. This will take you to the recommendations page. Please click on the Audit tool tab to return to the questionnaire."]
[]
["For date fields please insert using the dd/mm/yyyy format; please insert times using the 24 hour clock (hh:mm)"]
[]
["Where a question answer is highlighted in red, this indicates this is an area of care where the recommendation (or the question assessing a recommendation) is not being met. The more answers are highlighted in red, the more likely it is a recommendation is not being met. "]
[]
["Summary data is given at the bottom of the tool (audit tool tab)."]
[]
["As the questionnaire is completed a summary of responses is collated on the summary tab."]
["Each question that relates to a recommendation will become highlighted with the following "]
["Green - Recommendation sub criteria was met in 100% of the sample"]
["Amber - Recommendation sub criteria was met in between 50-90% of the sample"]
["Red - Recommendation sub criteria was met in less than 50% of the sample"]
["Blue - Recommendation sub criteria were not answered/not applicable for any of the sample"]
[]
["The sub criteria can be changed for the tool as a whole where necessary (not for individual questions). Where this is required please amend the % criteria values in the RAG system table on the summary sheet."]
[]
["As the questionnaire is completed the radar chart will be populated based on the answers given in the recommendation sub criteria. The percentage is worked out based on the number of cases completed; therefore if data is completed for only 1 patient and the subcriteria questions are all met then a Trust will be meeting 100% of recommendations. This must be considered when analysing the results. "]
[]
["Each number point on the chart relates to a recommendation; the higher the percentage, the more likely a recommenation is being met. The total percentage for each recommendation is also displayed below the sub criteria questions."]
[]
["In order for the formulas to work, an answer must be given for each recommendation subcategory; therefore please ensure NA's are input where prompted and appropriate"]
[]
["NCEPOD does not ask for any of this data back; it is for each Trust to make a judgement as to whether they are meeting recommendations."]

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["Mental Health in General Hospitals: Treat As One"]
[]
[null,"PATIENT DETAILS",null,null,null,null,null,null,null,null,null,null,"ADMISSION TO HOSPITAL",null,null,null,null,null,null,null,null,null,null,"ADMISSION TO THE HOSPITAL WARD",null,null,null,"INITIAL ASSESSMENT",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CAPACITY AND CONSENT",null,null,null,null,"ESCALATION",null,null,null,null,null,"END OF LIFE CARE/DISCHARGE PLANNING"]
["Recommendation"]
["Question number",1,2,"3a","3b",4,"5a","5b","6a","6b",7,8,9,"10a","10b",11,"12a","12b","13a","13b","13c","14a","14b","15a","15b",16,17,18,19,20,"21a","21b","22a","22b","22c","22d","22e","22f","23a","23b",24,null,null,null,null,null,null,25,26,"27a","27b","28a","28b",29,30,"31a","31b","31c","31d",32,33,34]
[null,"Age at time of admission","Gender","Date of hospital admission","Time of hospital admission","Was the patient's alcohol history recorded on admission?","Was alcohol misuse recorded on admission?","If Yes to 5a, had the patient been in contact with the Alcohol Misuse Service (or equivalent) prior to this admission?","What was the tobacco smoking history of this patient?","Was smoking cessation advice given/ referral made?","Was any other substance misuse recorded for this patient on this admission?","Was the patients mental health condition documented on admission to hospital?","How did the patient present to hospital?","Was a GP referral letter included in the case note record?","If Yes to 10a, was the mental health condition recorded in the referral letter?","Were the case notes transferred from the referring hospital?","Were the mental health case notes transferred from the referring hospital?","If YES to 12a, was the mental health condition recorded in the accompanying documentation?","Was the patient's mental health condition noted at this time?","Was a mental health assessment carried out by the ED team?","Was a referral made by the ED team to liaison psychiatry?","Did the patient receive any psychiatric input whilst in the ED?","If No to 14a, in your opinion, should there have been?","What was the date for the first recorded arrival on the ward?","What was the time for the first recorded arrival on the ward?","Was the patient admitted to hospital with a list of medications for their physical health condition?","Was the patient admitted to hospital with a list of medications for their mental health condition?","If Yes to either Q16 or Q17, did medicine reconciliation occur within the first 24 hours of admission?","Were any new medications prescribed for their mental health condition?","Were any mental health risk issues recorded?","Was mental capacity assessed?","If Yes to 21a, was this documented in the case notes?","Following admission to the ward, was a referral made to the liaison psychiatry* service?","If Yes to 22a, what date was the first referral to liaison psychiatry made?","If Yes to 22a, what time was the first referral to liaison psychiatry made?","If Yes to 22a, what date was the first assessment by liaison psychiatry made?","If Yes to 22a, what time was the first assessment by liaison psychiatry made?","In your opinion, was there a delay in the initial assessment by the liaison psychiatry team?","Did the patient have a named liaison psychiatry consultant overseeing their care?","If Yes to 23a, was this documented in the general hospital case notes?","What was included in the assessment/ review by liaison psychiatry and was this documented in the general hospital notes at the time of assessment?",null,null,null,null,null,null,"Did liaison psychiatry note the patient's mental health condition in the general hospital notes?","Was any mental mental capacity legislation deployed at any time during the admission?","Was the patient's capacity assessed during this admission for any reason?","If Yes to 27a, please select reason capacity was assessed?","Did the primary clinical team have concerns about the mental capacity of this patient?","If Yes to 28a, were liaison psychiatry involved to assist in the decicion making?","Did the patient medically deteriorate at any time during the admission?","Were they seen by a CCOT or equivalent?","Was the patient considered for critical care (Level 2 HDU/ Level 3 ICU)?","If Yes to 31a, was the patient accepted for critical care?","Was the liaison psychiatry team involved in critical care decision of step-up?","Was the liaison psychiatry team involved in critical care decision for step-down? ","What was the discharge destination of the patient?","Was liaison psychiatry involved in the discharge planning for this patient?","Was the mental health condition noted on the discharge summary/death certificate?"]
[null,null,null,"dd/mm/yyyy","hh:mm",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"*Please see definitions*",null,null,"dd/mm/yyyy","hh:mm",null,null,null,null,null,null,null,"*Please see definitions*","dd/mm/yyyy","hh:mm","dd/mm/yyyy","hh:mm",null,null,null,"Mental health risk assessment","Mental health risk management plan","Capacity assessment","Diagnosis","Reconciliation of psychotripic medication","Advice regarding contingencies","A clear discharge plan",null,null,null,"Answers can be selected multiple times",null,null,null,"(Please see definitions)"]
["Patient 1",null,null,null,null,null,null,{"$f":"IF(G8=\"Yes\",\"\",IF(G8=\"No\",\"NA\",IF(G8=\"Not applicable\",\"NA\",IF(G8=\"\",\"\"))))","v":""},null,null,null,null,null,{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"\",IF(M8=\"Inter hospital transfer\",\"NA\",IF(M8=\"via the Emergency Department\",\"NA\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(N8=\"Yes\",\"\",IF(N8=\"\",\"\",IF(N8=\"No\",\"NA\",IF(N8=\"Unknown\",\"NA\",IF(N8=\"NA\",\"NA\")))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"\",IF(M8=\"via the Emergency Department\",\"NA\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"\",IF(M8=\"via the Emergency Department\",\"NA\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(Q8=\"Yes\",\"\",IF(Q8=\"No\",\"NA\",IF(Q8=\"Unknown\",\"NA\",IF(Q8=\"\",\"\",IF(Q8=\"NA\",\"NA\")))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"NA\",IF(M8=\"via the Emergency Department\",\"\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"NA\",IF(M8=\"via the Emergency Department\",\"\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"NA\",IF(M8=\"via the Emergency Department\",\"\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(M8=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M8=\"GP referral\",\"NA\",IF(M8=\"Inter hospital transfer\",\"NA\",IF(M8=\"via the Emergency Department\",\"\",IF(M8=\"Unknown\",\"NA\",IF(M8=\"\",\"\"))))))","v":""},{"$f":"IF(V8=\"Yes\",\"NA\",IF(V8=\"No\",\"\",IF(V8=\"Unknown\",\"NA\",IF(V8=\"\",\"\",IF(V8=\"NA\",\"NA\")))))","v":""},null,null,null,null,{"$f":"IF(Z8=\"Yes\",\"\",IF(AA8=\"Yes\",\"\",IF(Z8=\"No\",\"NA\",IF(AA8=\"No\",\"NA\",IF(Z8=\"Unknown\",\"NA\",IF(AA8=\"Unknown\",\"NA\",IF(Z8=\"Not applicable\",\"NA\",IF(AA8=\"Not applicable\",\"NA\",IF(Z8=\"\",\"\",IF(AA8=\"\",\"\"))))))))))","v":""},null,null,null,{"$f":"IF(AE8=\"Yes\",\"\",IF(AE8=\"No\",\"NA\",IF(AE8=\"Unknown\",\"NA\",IF(AE8=\"\",\"\"))))","v":""},null,null,null,null,null,{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AM8=\"Yes\",\"\",IF(AM8=\"No\",\"NA\",IF(AM8=\"Unknown\",\"NA\",IF(AM8=\"\",\"\",IF(AM8=\"NA\",\"NA\")))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG8=\"Yes\",\"\",IF(AG8=\"No\",\"NA\",IF(AG8=\"Unknown\",\"NA\",IF(AG8=\"\",\"\"))))","v":""},{"$f":"IF(AG10=\"Yes\",\"\",IF(AG10=\"No\",\"NA\",IF(AG10=\"Unknown\",\"NA\",IF(AG10=\"\",\"\"))))","v":""},null,null,{"$f":"IF(AX8=\"Yes\",\"\",IF(AX8=\"No\",\"NA\",IF(AX8=\"Not formally but assessing clinician(s) judged patient had capacity\",\"NA\",IF(AX8=\"\",\"\"))))","v":""},null,{"$f":"IF(AZ8=\"Yes\",\"\",IF(AZ8=\"No\",\"NA\",IF(AZ8=\"Unknown\",\"NA\",IF(AZ8=\"\",\"\"))))","v":""},null,null,null,{"$f":"IF(BD8=\"Yes\",\"\",IF(BD8=\"No\",\"NA\",IF(BD8=\"Unknown\",\"NA\",IF(BD8=\"Not applicable\",\"NA\",IF(BD8=\"\",\"\")))))","v":""},null,null,null,{"$f":"IF(BH8=\"Discharged home\",\"\",IF(BH8=\"Transferred to another hospital\",\"\",IF(BH8=\"Transferred to a mental health unit outside the hospital\",\"\",IF(BH8=\"Still an inpatient\",\"NA\",IF(BH8=\"Died\",\"\",IF(BH8=\"\",\"\"))))))","v":""},{"$f":"IF(BH8=\"Discharged home\",\"\",IF(BH8=\"Transferred to another hospital\",\"\",IF(BH8=\"Transferred to a mental health unit outside the hospital\",\"\",IF(BH8=\"Still an inpatient\",\"NA\",IF(BH8=\"Died\",\"\",IF(BH8=\"\",\"\"))))))","v":""}]
["Patient 2",null,null,null,null,null,null,{"$f":"IF(G9=\"Yes\",\"\",IF(G9=\"No\",\"NA\",IF(G9=\"Not applicable\",\"NA\",IF(G9=\"\",\"\"))))","v":""},null,null,null,null,null,"","","","","","","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 3",null,null,null,null,null,null,"",null,null,null,null,null,"","","","","","","",null,"","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 4",null,null,null,null,null,null,"",null,null,null,null,null,"","","","","","","","","",""," ",null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 5",null,null,null,null,null,null,"",null,null,"  ",null,null,{"$f":"IF(M12=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M12=\"GP referral\",\"\",IF(M12=\"Inter hospital transfer\",\"NA\",IF(M12=\"via the Emergency Department\",\"NA\",IF(M12=\"Unknown\",\"NA\",IF(M12=\"\",\"\"))))))","v":""},"","","","","","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","",{"$f":"IF(AG12=\"Yes\",\"\",IF(AG12=\"No\",\"NA\",IF(AG12=\"Unknown\",\"NA\",IF(AG12=\"\",\"\"))))","v":""},"","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 6",null,null,null,null,null,null,"",null,null,null,null,null,"",{"$f":"IF(N13=\"Yes\",\"\",IF(N13=\"\",\"\",IF(N13=\"No\",\"NA\",IF(N13=\"Unknown\",\"NA\",IF(N13=\"NA\",\"NA\")))))","v":""},"","","",{"$f":"IF(M13=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M13=\"GP referral\",\"NA\",IF(M13=\"Inter hospital transfer\",\"NA\",IF(M13=\"via the Emergency Department\",\"\",IF(M13=\"Unknown\",\"NA\",IF(M13=\"\",\"\"))))))","v":""},"","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 7",null,null,null,null,null,null,"",null,null,null,null,null,"","","",{"$f":"IF(M14=\"Following outpatients appointment/ telephone conversation\",\"NA\",IF(M14=\"GP referral\",\"NA\",IF(M14=\"Inter hospital transfer\",\"\",IF(M14=\"via the Emergency Department\",\"NA\",IF(M14=\"Unknown\",\"NA\",IF(M14=\"\",\"\"))))))","v":""},"","","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 8",null,null,null,null,null,null,"",null,null,null,null,null,"","","","",{"$f":"IF(Q15=\"Yes\",\"\",IF(Q15=\"No\",\"NA\",IF(Q15=\"Unknown\",\"NA\",IF(Q15=\"\",\"\",IF(Q15=\"NA\",\"NA\")))))","v":""},"","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 9",null,null,null,null,null,null,"",null,null,null,null,null,"","","","","","","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","","",null,null,"",null,"",null,null,null,"",null,null,null,"",""]
["Patient 10 Add new patient (above this row before populating with data)",null,null,null,null,null,null,"",null,null,null,null,null,"","","","","","","","","","",null,null,null,null,"",null,null,null,"",null,null,null,null,null,"","","","","","","","","","",{"$f":"IF(AG19=\"Yes\",\"\",IF(AG19=\"No\",\"NA\",IF(AG19=\"Unknown\",\"NA\",IF(AG19=\"\",\"\"))))","v":""},null,null,"",null,"",null,null,null,"",null,null,null,"",{"$f":"IF(BH17=\"Discharged home\",\"\",IF(BH17=\"Transferred to another hospital\",\"\",IF(BH17=\"Transferred to a mental health unit outside the hospital\",\"\",IF(BH17=\"Still an inpatient\",\"NA\",IF(BH17=\"Died\",\"\",IF(BH17=\"\",\"\"))))))","v":""}]
[]
["Yes n",null,null,null,null,null,null,null,null,{"$f":"COUNTIF(J8:J17,\"Yes\")","v":0},null,{"$f":"COUNTIF(L8:L17,\"Yes\")","v":0},null,null,{"$f":"COUNTIF(O8:O17,\"Yes\")","v":0},null,null,{"$f":"COUNTIF(R8:R17,\"Yes\")","v":0},{"$f":"COUNTIF(S8:S17,\"Yes\")","v":0},{"$f":"COUNTIF(T8:T17,\"Yes\")","v":0},null,null,null,null,null,null,null,{"$f":"COUNTIF(AB8:AB17,\"Yes\")","v":0},null,null,null,{"$f":"COUNTIF(AF8:AF17,\"Yes\")","v":0},null,null,null,null,null,{"$f":"COUNTIF(AL8:AL17,\"Yes\")","v":0},0,0,{"$f":"COUNTIF(AO8:AO17,\"Assessed and documented\")","v":0},{"$f":"COUNTIF(AP8:AP17,\"Assessed and documented\")","v":0},0,0,0,0,0,0,null,null,null,null,{"$f":"COUNTIF(BA8:BA17,\"Yes\")","v":0},null,null,null,null,{"$f":"COUNTIF(BF8:BF17,\"Yes\")","v":0},{"$f":"COUNTIF(BG8:BG17,\"Yes\")","v":0},null,{"$f":"COUNTIF(BI8:BI17,\"Yes\")","v":0},{"$f":"COUNTIF(BJ8:BJ17,\"Yes\")","v":0}]
["Yes %",null,null,null,null,null,null,null,null,{"$f":"IF(ISERROR(J19/J23),\"%\",J19/J23*100)","v":"%"},null,{"$f":"IF(ISERROR(L19/L23),\"%\",L19/L23*100)","v":"%"},null,null,"%",null,null,"%","%","%",null,null,null,null,null,null,null,"%",null,null,null,"%",null,null,null,null,null,"%","%","%","%","%","%","%","%","%","%","%",null,null,null,null,"%",null,null,null,null,"%","%",null,"%","%"]
["No n",null,null,null,null,null,null,null,null,{"$f":"COUNTIF(J8:J17,\"No\")","v":0},null,{"$f":"COUNTIF(L8:L17,\"No\")","v":0},null,null,{"$f":"COUNTIF(O8:O17,\"No\")","v":0},null,null,0,0,0,null,null,null,null,null,null,null,0,null,null,null,0,null,null,null,null,null,0,0,0,{"$f":"SUMPRODUCT(COUNTIF(AO8:AO17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AP8:AP17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AQ8:AQ17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AR8:AR17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AS8:AS17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AT8:AT17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AU8:AU17,{\"Assessed but not documented\";\"Not assessed\"}))","v":0},0,null,null,null,null,0,null,null,null,null,0,0,null,0,0]
["No %",null,null,null,null,null,null,null,null,{"$f":"IF(ISERROR(J21/J23),\"%\",J21/J23*100)","v":"%"},null,{"$f":"IF(ISERROR(L21/L23),\"%\",L21/L23*100)","v":"%"},null,null,"%",null,null,"%","%","%",null,null,null,null,null,null,null,"%",null,null,null,"%",null,null,null,null,null,"%","%","%","%","%","%","%","%","%","%","%",null,null,null,null,"%",null,null,null,null,"%","%",null,"%","%"]
["Sub total",null,null,null,null,null,null,null,null,{"$f":"SUM(J19+J21)","v":0},null,{"$f":"SUM(L19+L21)","v":0},null,null,0,null,null,0,0,0,null,null,null,null,null,null,null,0,null,null,null,0,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,null,null,null,null,0,null,null,null,null,0,0,null,0,0]
["No data/Not answered",null,null,null,null,null,null,null,null,{"$f":"J29","v":10},null,{"$f":"L29","v":10},null,null,10,null,null,10,10,10,null,null,null,null,null,null,null,10,null,null,null,10,null,null,null,null,null,10,10,10,10,10,10,10,10,10,10,10,null,null,null,null,10,null,null,null,null,10,10,null,10,10]
["Not applicable",null,null,null,null,null,null,null,null,{"$f":"COUNTIF(J8:J17,\"Not applicable\")","v":0},null,{"$f":"COUNTIF(L8:L17,\"Not applicable\")","v":0},null,null,{"$f":"SUMPRODUCT(COUNTIF(O8:O17,{\"Not applicable\";\"NA\"}))","v":0},null,null,{"$f":"SUMPRODUCT(COUNTIF(R8:R17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(S8:S17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(T8:T17,{\"Not applicable\";\"NA\"}))","v":0},null,null,null,null,null,null,null,{"$f":"SUMPRODUCT(COUNTIF(AB8:AB17,{\"Not applicable\";\"NA\"}))","v":0},null,null,null,{"$f":"SUMPRODUCT(COUNTIF(AF8:AF17,{\"Not applicable\";\"NA\"}))","v":0},null,null,null,null,null,{"$f":"SUMPRODUCT(COUNTIF(AL8:AL17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AM8:AM17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AN8:AN17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AO8:AO17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AP8:AP17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AQ8:AQ17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AR8:AR17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AS8:AS17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AT8:AT17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AU8:AU17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(AV8:AV17,{\"Not applicable\";\"NA\"}))","v":0},null,null,null,null,{"$f":"SUMPRODUCT(COUNTIF(BA8:BA17,{\"Not applicable\";\"NA\"}))","v":0},null,null,null,null,{"$f":"COUNTIF(BF8:BF17,\"Not applicable\")","v":0},0,null,{"$f":"SUMPRODUCT(COUNTIF(BI8:BI17,{\"Not applicable\";\"NA\"}))","v":0},{"$f":"SUMPRODUCT(COUNTIF(BJ8:BJ17,{\"Not applicable\";\"NA\"}))","v":0}]
["Number of cases included in audit",null,null,null,null,null,null,null,null,{"$f":"J19+J21+J24+J25","v":10},null,{"$f":"L19+L21+L24+L25","v":10},null,null,10,null,null,10,10,10,null,null,null,null,null,null,null,10,null,null,null,10,null,null,null,null,null,10,10,10,10,10,10,10,10,10,10,10,null,null,null,null,10,null,null,null,null,10,10,null,10,10]
[]
[]
["No data",null,null,null,null,null,null,null,null,{"$f":"COUNTIF(J8:J17,\"\")","v":10},null,{"$f":"COUNTIF(L8:L17,\"\")","v":10},null,null,10,null,null,10,10,10,null,null,null,null,null,null,null,10,null,null,null,10,null,null,null,null,null,10,10,10,10,10,10,10,10,10,10,10,null,null,null,null,10,null,null,null,null,10,10,null,10,10]
["Number of cases",null,null,null,null,null,null,null,null,{"$f":"IF(J24=J26,\"No data\",IF(J25=J26,\"NA\",IF(J24+J25=J26,\"NA\",J20)))","v":"No data"},null,{"$f":"IF(L24=L26,\"No data\",IF(L25=L26,\"NA\",IF(L24+L25=L26,\"NA\",L20)))","v":"No data"},null,null,"No data",null,null,"No data","No data","No data",null,null,null,null,null,null,null,"No data",null,null,null,"No data",null,null,null,null,null,{"$f":"IF(AL24=AL26,\"No data\",IF(AL25=AL26,\"NA\",IF(AL24+AL25=AL26,\"NA\",AL22)))","v":"No data"},"No data","No data","No data","No data","No data","No data","No data","No data","No data","No data",null,null,null,null,"No data",null,null,null,null,"No data","No data",null,"No data","No data"]

{"sheet":"Summary","index":3,"n_rows":22,"n_cols":25,"rows_kept":22,"cut":false,"hidden":false,"merged":[[20,11,20,21],[1,23,5,23],[1,24,5,24],[0,11,0,21],[10,11,10,21]]}
[null,null,null,null,null,null,null,null,null,null,null,"Recommendation - Sub criteria question number (referrence only)"]
[null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10,11,null,"RAG system (NCEPOD recommends these are set at the following limits, however these can be adapted by your Trust where appropriate by amending the thresholds as required)","%"]
[null,null,null,null,null,null,null,null,null,null,null,8,"22f","23a","24.i","6b",18,"21b","28b","31c",33,25]
[null,null,null,null,null,null,null,null,null,null,null,"10b",null,"23b","24.ii",null,null,null,null,"31d",null,34]
[null,null,null,null,null,null,null,null,null,null,null,"12b",null,null,"24.iii"]
[null,null,null,null,null,null,null,null,null,null,null,"13a",null,null,"24.iv"]
[null,null,null,null,null,null,null,null,null,null,null,"13b",null,null,"24.v",null,null,null,null,null,null,null,null,"Green",100]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"24.vi",null,null,null,null,null,null,null,null,"Amber",50]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"24.vii"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"Recommendation - Sub criteria questions (score)"]
[null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10,11]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!L30","v":"No data"},{"$f":"'Audit Tool'!AL30","v":"No data"},{"$f":"'Audit Tool'!AM30","v":"No data"},{"$f":"'Audit Tool'!AO30","v":"No data"},{"$f":"'Audit Tool'!J30","v":"No data"},{"$f":"'Audit Tool'!AB30","v":"No data"},{"$f":"'Audit Tool'!AF30","v":"No data"},{"$f":"'Audit Tool'!BA30","v":"No data"},{"$f":"'Audit Tool'!BF30","v":"No data"},{"$f":"'Audit Tool'!BI30","v":"No data"},{"$f":"'Audit Tool'!AV30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!O30","v":"No data"},null,{"$f":"'Audit Tool'!AN30","v":"No data"},{"$f":"'Audit Tool'!AP30","v":"No data"},null,null,null,null,{"$f":"'Audit Tool'!BG30","v":"No data"},null,{"$f":"'Audit Tool'!BJ30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!R30","v":"No data"},null,null,{"$f":"'Audit Tool'!AQ30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!S30","v":"No data"},null,null,{"$f":"'Audit Tool'!AR30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!T30","v":"No data"},null,null,{"$f":"'Audit Tool'!AS30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!AT30","v":"No data"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Audit Tool'!AU30","v":"No data"}]
[]
[null,null,null,null,null,null,null,null,null,null,null,"Average % of recommendation"]
[null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(L13=\"No data\",\"No data\",IF(L13=\"NA\",\"NA\",IF(L13=\"%\",\"%\",SUM(L13:L17)/COUNT(L13:L17))))","v":"No data"},{"$f":"IF(M13=\"No data\",\"No data\",IF(M13=\"NA\",\"NA\",IF(M13=\"%\",\"%\",SUM(M13)/COUNT(M13))))","v":"No data"},{"$f":"IF(N13=\"No data\",\"No data\",IF(N13=\"NA\",\"NA\",IF(N13=\"%\",\"%\",SUM(N13:N14)/COUNT(N13:N14))))","v":"No data"},{"$f":"IF(O13=\"No data\",\"No data\",IF(O13=\"NA\",\"NA\",IF(O13=\"%\",\"%\",SUM(O13:O19)/COUNT(O13:O19))))","v":"No data"},{"$f":"IF(P13=\"No data\",\"No data\",IF(P13=\"NA\",\"NA\",IF(P13=\"%\",\"%\",SUM(P13)/COUNT(P13))))","v":"No data"},"No data","No data",{"$f":"IF(S13=\"No data\",\"No data\",IF(S13=\"NA\",\"NA\",IF(S13=\"%\",\"%\",SUM(S13)/COUNT(S13))))","v":"No data"},{"$f":"IF(T13=\"No data\",\"No data\",IF(T13=\"NA\",\"NA\",IF(T13=\"%\",\"%\",SUM(T13:T14)/COUNT(T13:T14))))","v":"No data"},"No data",{"$f":"IF(V13=\"No data\",\"No data\",IF(V13=\"NA\",\"NA\",IF(V13=\"%\",\"%\",SUM(V13:V14)/COUNT(V13:V14))))","v":"No data"}]

{"sheet":"Recommendations","index":4,"n_rows":12,"n_cols":2,"rows_kept":12,"cut":false,"hidden":false,"merged":[[0,0,0,1]]}
["RECOMMENDATIONS"]
[1,"Patients who present with known co-existing mental health conditions should have them documented and assessed along with any other clinicial conditions that have brought them to hospital. These should be documented: in referral letters to hospital, in the emergency department assessment, in the documentation on admission to hospital."]
[2,"As recommended by the Psychiatric Liaison Accreditation Network, mental health liaison assessments should be made in an appropriate timeframe, and by a mental health professional of appropriate seniority to meet the needs of the patient"]
[3,"Patients who have been admitted to hospital and have been referred to liaison psychiatry should have a named liaison psychaitry consultant documented in the general hospital case notes and recorded centrally wherever possible"]
[4,"Liaison psychaitry review should provide clear and concise documented plans in the general hospital notes at the time of assessment. As a minimum the review should cover: what the problem is (diagnosis or formulation), the legal status of the patient and their mental capacity for decision making, a clear documentation of the mental health risk assessment - immediate and medium term, whether the patient requires any further risk management e.g. observation level, a management plan including medication or therapeutic intervention, advice regarding contingencies, a clear discharge plan in terms of mental health follow-up"]
[5,"Patients with mental health conditions should be supported in overcoming/managing alcohol and/or substance abuse. Smoking cessation services and brief interventions must be offered to all patients who would benefit"]
[6,"All general hospital pharmacy departments should be able to undertake medicines reconciliation of medications for mental health conditions within the first 24 hours of admission."]
[7,"Mental capacity assessments should be documented in the case notes using the language of the relevant Act"]
[8,"If the primary clinical team has concerns about mental capacity in patients who have a mental health condition, they should involve liaison psychaitry to assist in decision making."]
[9,"Mental healthcare should be routinely included in step-up and step-down documentation to critical care, with appropriate involvement from liaison psychiatry"]
[10,"Discharge planning for patients with mental health conditions should involve multidisplinary input, including liaison psychiatry where appropriate and in all cases where the patient has been under the care of liaison psychiatry. The discharge letter should be copied to all specialties providing an ongoing mental and physical healthcare outside of the general hospital. Sharing of clinical information between care providers using a Summary Care Record or equivalent should be utilised."]
[11,"Diagnostic coding of mental health conditions must be improved. Liaison psychiatrists should enter the diagnosis in the general hospital notes so that they can be coded appropriately and included in the discharge summaries made by general hospital doctors. "]

{"sheet":"Definitions","index":5,"n_rows":5,"n_cols":2,"rows_kept":5,"cut":false,"hidden":false,"merged":[[0,0,0,1]]}
["DEFINITIONS"]
["Liaison psychiatry","A psychiatric liaison team works in general hospitals, for example in the emergency department or in-patient wards. They provide psychiatric assessment and treatment to those patients who may be experiencing distress whilst in hospital and provide a valuable interface between mental and physical health. The lisiaon team can work with any patient in the hospital who requires psychological help to manage their condition, including, but not limited to: older people who suffer from dementia or delirium, individuals who have self-harmed and are being seen in the emergency department, people who have an existing mental health problem and are currently in hospital with a physical illness, those who have been diagnosed with a physical illness and need some emotional support to adjust to this.\n(Definition from the Royal College of Psychologists website)"]
["Critical Care Outreach Team (or equivalent, e.g. MET, RRT etc)","Specialised clinical teams on hand on general/acute wards to deliver emergency or critical care to patients that become acutely unwell"]
["High dependency unit (HDU - Level 2)","Patients requiring more detailed observation or intervention including support for a single failing organ system or post operative care, and those stepping down from higher levels of care (NB: When basic respiratory and basic cardiovascular support are provided at the same time during the same critical care spell and no other organ support is required, the care is considered to be Level 2 care)"]
["Intensive care unit (ICU - Level 3)","Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organs. This levels includes all complex patients requiring support for multi-organ failure. (NB: Basic respiratory and basic cardiovascular do not count as two organs if they occur simultaneously – see above under level 2 care – but will count as level 3 if another organ is supported at the same time)"]

{"sheet":"Sheet7","index":6,"n_rows":20,"n_cols":11,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["Answer1",null,"Answer2",null,"Answer3",null,"Answer4",null,"Answer5",null,"Answer6"]
["Male ",null,"Yes",null,"Yes",null,"Yes",null,"Current smoker at time of admission",null,"Following outpatients appointment/ telephone conversation"]
["Female",null,"No",null,"No",null,"No",null,"Ex smoker ",null,"GP referral"]
[null,null,"Not applicable",null,"Unknown",null,null,null,"Never smoked",null,"Inter hospital transfer"]
[null,null,null,null,null,null,null,null,"Unknown",null,"via the Emergency Department"]
[null,null,null,null,null,null,null,null,null,null,"Unknown"]
[]
[]
["Answer7",null,"Answer8",null,null,"Answer9",null,"Answer10","Answer11",null,"Answer12"]
["Yes",null,"Yes",null,null,"Yes",null,"Assessed and documented","Yes",null,"Wishing to leave against medical advice"]
["No",null,"No",null,null,"No",null,"Assessed but not documented","No",null,"Refusing investigation"]
["Unknown",null,"Unknown",null,null,"Not recorded",null,"Not assessed","Not formally but assessing clinician(s) judged patient had capacity",null,"Refusing treatment"]
["Not applicable",null,"Not applicable/required",null,null,null,null,null,null,null,"Refusing nutrition/ hydration"]
[null,null,null,null,null,null,null,null,null,null,"Other"]
["Answer13",null,null,null,"Answer14"]
["Not available at this hospital",null,null,null,"Discharged home"]
["Not available at this time ",null,null,null,"Transferred to another hospital"]
["Not considered that it was required",null,null,null,"Transferred to a mental health unit outside the hospital"]
[null,null,null,null,"Still an inpatient"]
[null,null,null,null,"Died"]