Case-note review: assessment of psychological well-being and substance use

Selection of patients: please make a list of adults (16 or over) who have attended your service for care for ongoing HIV infection during 2016 or 2017, eg from your HARS or Health Protection Scotland surveillance data. Please divide the number of individual patients on the list (not the number of attendances) by 40, round down to the nearest whole number, and call the result N. Then select every Nth patient from the list and complete this case note review questionnaire for each of these.

This is a dynamic questionnaire. Some questions are not currently visible and will only appear depending on answers to previous ones. A briefing document has been prepared which explains the aims of the audit and lists all possible questions that may be asked, to guide you in reviewing patient case notes and gathering together the data. Please click here to read it if you have not yet done so.

In the event of any queries or technical difficulties, please contact BHIVA's clinical audit co-ordinator, Hilary Curtis hilary@regordane.net 07984 239556.

Patient characteristics

Please assign a number for this patient, from 1 to 40, to make it easier to identify the record in case of any query about the data.
Only numbers may be entered in this field.

HelpPlease keep a list of patients entered in the audit for your own records, matching the number you've entered here to the patient's clinic number or bar-code sticker.
Gender:
Choose one of the following answers
Age in years:
Only numbers may be entered in this field.

HelpEnter a whole number, must be at least 16.
HIV exposure:
Choose one of the following answers
Country of birth:

Ethnicity:
Choose one of the following answers
HelpLetters shown are standard ONS/NHS codes.

Assessment

Has anything been recorded about the patient's psychological well-being/mental health, within the past 18 months?
Choose one of the following answers
Is there a record that the patient has been asked about his/her psychological well-being within the past 18 months?
Choose one of the following answers
Is there a record that the patient has been asked about alcohol use within the past 18 months?
Choose one of the following answers
Is there a record that the patient has been asked about recreational drug use within the past 18 months?
Choose one of the following answers
Is there a record that the patient has been asked specifically about chemsex within the past 18 months?
Choose one of the following answers
Help"Chemsex" describes sex that occurs under the influence of drugs, which are taken immediately preceding and/or during a sexual session. The drugs most commonly associated with chemsex are crystal methamphetamine, GHB/GBL, mephedrone and, to a lesser extent, cocaine and ketamine.
Please click on "Submit" to record the data for this patient. After doing so you will be able save the completed form for your own records before following other options, including entering data for another patient.