🎯 Hippo Targets Glossary

Code

Name

When to select this

Who is eligible?

What counts as complete

AST007

Annual review for asthma patients

To recall asthma patients aged 6+ who haven’t had a review in the last 12 months

Patients aged 6+ on the asthma register

Asthma review incl. control assessment, medication check, and inhaler technique

AST008

Smoking status for young asthma patients

To recall asthma patients aged 19 or under without a smoking status recorded in 12 months

Asthma patients aged 19 or under

Smoking status recorded in the last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

AF006

Stroke Risk Assessment (AF)

To recall AF patients who haven’t had a CHA₂DS₂-VASc stroke risk assessment in 12m

Patients diagnosed with AF with no stroke risk score in 12 months

CHA₂DS₂-VASc score recorded in the last 12 months

AF008

Anticoagulants for High-Risk AF Patients

To recall high-risk AF patients not currently prescribed anticoagulants

AF patients with CHA₂DS₂-VASc score ≥2 and no anticoagulant

Anticoagulant (DOAC or warfarin) prescription recorded

Code

Name

When to select this

Who is eligible?

What counts as complete

CHD005

Antiplatelets or Anticoagulants (CHD)

To recall CHD patients not on antiplatelet or anticoagulant therapy

Patients on the CHD register with no such meds recorded

Prescription of aspirin, clopidogrel, or anticoagulant

CHD015

Blood Pressure Control (Age ≤79)

To recall CHD patients under 80 with no recent BP or above-target BP

CHD patients aged 79 or under with no BP ≤140/90 in 12 months

BP ≤140/90 mmHg recorded in last 12 months

CHD016

Blood Pressure Control (Age 80+)

To recall CHD patients aged 80+ with no recent BP or above target

CHD patients aged 80+ with no BP ≤150/90 in 12 months

BP ≤150/90 mmHg recorded in last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

HF003

ACE-I or ARB for LVSD

To recall HF patients with LVSD not on ACE-I or ARB

Patients with HF due to LVSD and no ACE-I/ARB prescribed

Prescription of ACE-I or ARB recorded

HF006

Beta-blockers for HF with LVSD

To recall HF patients with LVSD not on a licensed beta-blocker

Patients with HF due to LVSD and no beta-blocker recorded

Prescription of licensed beta-blocker (e.g. bisoprolol, carvedilol)

HF007

Annual Review (HF)

To recall HF patients who haven’t had an annual review

Patients on HF register with no review in the last 12 months

Review covering symptoms, functional status, meds, and self-management advice

Code

Name

When to select this

Who is eligible?

What counts as complete

BP002

BP Check (Age ≥45)

To recall patients aged 45+ without a BP recorded in the last 5 years

Patients aged 45 or over with no BP reading in 5 years

Blood pressure recorded in the last 5 years

HYP008

BP Control (Hypertension, Age ≤79)

To recall hypertensive patients under 80 with no recent or high BP

Patients aged ≤79 on hypertension register, no BP ≤140/90 in 12m

BP ≤140/90 mmHg recorded in the last 12 months

HYP009

BP Control (Hypertension, Age 80+)

To recall hypertensive patients aged 80+ with no recent or high BP

Patients aged 80+ on hypertension register, no BP ≤150/90 in 12m

BP ≤150/90 mmHg recorded in the last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

STIA007

Antiplatelets or Anticoagulants

To recall stroke/TIA patients not on antiplatelet or anticoagulant therapy

Patients with stroke or TIA with no relevant meds recorded

Prescription of aspirin, clopidogrel, or anticoagulant

STIA014

BP Control (Stroke/TIA, Age ≤79)

To recall stroke/TIA patients under 80 with no recent or high BP

Patients ≤79 with stroke/TIA and no BP ≤140/90 in 12 months

BP ≤140/90 mmHg recorded in the last 12 months

STIA015

BP Control (Stroke/TIA, Age 80+)

To recall stroke/TIA patients aged 80+ with no recent or high BP

Patients ≥80 with stroke/TIA and no BP ≤150/90 in 12 months

BP ≤150/90 mmHg recorded in the last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

CS005

Cervical Screening (Ages 25–49)

To recall women aged 25–49 who haven’t had a smear in the last 3 years

Women aged 25–49 with no smear recorded in the last 3 years

Cervical screening recorded within the last 3 years

CS006

Cervical Screening (Ages 50–64)

To recall women aged 50–64 who haven’t had a smear in the last 5 years

Women aged 50–64 with no smear recorded in the last 5 years

Cervical screening recorded within the last 5 years

Code

Name

When to select this

Who is eligible?

What counts as complete

VI001

8-Month Check (DTaP 3 Doses)

To recall babies approaching 8 months old who haven’t completed DTaP course

Babies turning 8 months with fewer than 3 DTaP doses recorded

3 DTaP doses recorded before 8 months

VI002

18-Month Check (MMR 1 Dose)

To recall children nearing 18 months with no MMR1 recorded

Children turning 18 months with no MMR dose recorded

1 MMR dose recorded before 18 months

VI003

5-Year Check (DTaP Booster + 2 MMR)

To recall children turning 5 missing school-entry immunisations

Children aged 5 with <2 MMR doses or no DTaP booster

2 MMR doses + DTaP booster recorded by age 5

Code

Name

When to select this

Who is eligible?

What counts as complete

CHOL003

Statin Prescription for Cholesterol

To recall patients with CVD or diabetes who aren’t on a statin

Patients on cardiovascular or diabetes register with no statin prescribed

Statin (e.g. atorvastatin) prescribed and recorded

CHOL004

Cholesterol Control

To recall patients whose cholesterol hasn’t been tested recently or is above target

Patients with no cholesterol test or with a result above threshold in the last 12m

Cholesterol test recorded with result within target range

Code

Name

When to select this

Who is eligible?

What counts as complete

COPD010

COPD Annual Review

To recall COPD patients who haven’t had a review in the last 12 months

Patients on the COPD register

Review incl. MRC scale, medication check, inhaler technique, and smoking support if needed

COPD014

Pulmonary Rehab Offer

To recall COPD patients (MRC score ≥3) not offered rehab

COPD patients with MRC score ≥3

Offer of referral to pulmonary rehab recorded in patient record

Code

Name

When to select this

Who is eligible?

What counts as complete

COVID_SPRING25_001

Booster – Aged 75+

To recall patients aged 75+ who haven’t had this year’s spring booster

Patients aged 75+ with no booster recorded since 1st April

Spring COVID booster recorded during current campaign period

COVID_SPRING25_002

Booster – Care Home Residents

To recall care home residents who haven’t had the spring booster

Care home patients with no booster since 1st April

Spring COVID booster recorded during current campaign period

COVID_SPRING25_003

Booster – Immunocompromised

To recall immunocompromised patients with no spring booster

Patients coded as severely immunocompromised since 1st April

Spring COVID booster recorded during current campaign period

Code

Name

When to select this

Who is eligible?

What counts as complete

CQCAZA001

Azathioprine blood monitoring

To recall patients on azathioprine who are not up to date with full blood count and liver function checks

Patients on azathioprine that are overdue monitoring

Full blood count and liver function tests recorded as per monitoring schedule

CQCLI001

Lithium monitoring – serum levels

To recall patients on lithium without a recent serum level check

Patients on lithium missing up-to-date serum level test

Serum lithium levels recorded as per monitoring guidance

CQCMETFORMIN001

Monitoring – patients on metformin

To recall patients on metformin missing renal function tests

Patients on metformin without recent kidney function test

Kidney function test recorded as per monitoring guidance

Code

Name

When to select this

Who is eligible?

What counts as complete

CQCACEARB001

Kidney function check – ACEi/ARB patients

To recall patients on ACE inhibitors or ARBs without a recent kidney function test

Patients on ACE inhibitors or ARBs overdue a kidney function check

Kidney function test recorded within monitoring window

CQCALDANT001

Kidney function check – heart failure on aldosterone antagonists

To recall patients with heart failure on an aldosterone antagonist who need a check

Heart failure patients on aldosterone antagonists needing kidney function check

Kidney function test recorded as per guidance

CQCAMIODERONE001

Function checks – patients on amiodarone

To recall patients on amiodarone without recent thyroid, liver and renal function checks

Patients on amiodarone overdue monitoring

Thyroid, liver, and renal function tests recorded

CQCDOAC001

Creatinine clearance – patients on DOAC

To recall DOAC patients without a CrCl recorded

Patients on DOAC without recent creatinine clearance (CrCl) value

CrCl recorded

CQCDOAC002

Annual CrCl – patients on DOAC

To recall DOAC patients who haven’t had a CrCl recorded in the last 12 months

Patients on DOAC without a CrCl recorded in the past 12 months

Annual CrCl recorded

CQCDOAC003

3-month CrCl – CKD4/5 patients on DOAC

To recall CKD4/5 patients on DOAC if CrCl not recorded in last 3 months

CKD stage 4 or 5 patients on DOAC

CrCl recorded within 3 months

CQCDOAC004

6-month CrCl – CKD3 patients on DOAC

To recall CKD3 patients on DOAC if CrCl not recorded in last 6 months

CKD stage 3 patients on DOAC

CrCl recorded within 6 months

CQCDOAC005

Annual haemoglobin – patients on DOAC

To recall patients on DOAC if haemoglobin not recorded in last 12 months

Patients on DOAC without haemoglobin check in last year

Haemoglobin recorded in last 12 months

CQCDOAC006

Review – DOAC patients with low haemoglobin

To recall patients on DOAC with low Hb who haven’t had a follow-up review

Patients on DOAC with low haemoglobin

Review documented following identification of low haemoglobin

Code

Name

When to select this

Who is eligible?

What counts as complete

DEM004

Face-to-Face Review for Dementia

To recall dementia patients with no care plan review in the last 12 months

Patients with dementia diagnosis and no care plan review in 12m

Face-to-face care plan review recorded covering physical, mental, and social needs

Code

Name

When to select this

Who is eligible?

What counts as complete

DM006

ACE-I/ARB for Microalbuminuric Diabetics

To recall diabetics with signs of nephropathy not on ACE-I or ARB

Diabetic patients with microalbuminuria/proteinuria and no ACE-I/ARB prescribed

ACE-I or ARB prescription recorded

DM012

Foot Examination

To recall diabetics who haven’t had a foot check in 12 months

Patients on diabetes register with no foot check in last 12 months

Foot exam with risk classification recorded

DM014

Diabetes Education Referral

To refer newly diagnosed diabetics to education programme

Patients newly diagnosed with diabetes and no referral recorded

Referral to structured education recorded

DM020

HbA1c Control (Non-frail)

To recall non-frail diabetics with high HbA1c

Diabetic patients without frailty and HbA1c >58 mmol/mol

HbA1c ≤58 mmol/mol recorded in the last 12 months

DM021

HbA1c Control (Frail)

To recall frail diabetics needing relaxed glycaemic control

Diabetic patients with frailty and HbA1c >75 mmol/mol

HbA1c ≤75 mmol/mol recorded

DM022

Statins for Diabetics (No CVD, No Frailty)

To recall diabetics aged 40+ with no statin, no CVD, and no frailty

Diabetic patients aged ≥40 with no CVD/frailty and not on statins

Statin prescription recorded

DM023

Statins for Diabetics with CVD

To recall diabetics with cardiovascular disease not currently on statins

Diabetic patients with CVD and no statin prescription

Statin prescription recorded

DM033

BP Control (Non-frail Diabetics)

To support BP control in non-frail diabetics

Non-frail diabetics with BP >140/80 or no recent reading

BP ≤140/80 mmHg recorded in the last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

HIPPODM8CP001a

HbA1c

To recall diabetics missing an HbA1c check

Diabetics with no HbA1c result in last 12 months

HbA1c recorded in last 12 months

HIPPODM8CP001b

Blood Pressure

To recall diabetics without a recent BP reading

Diabetics with no BP recorded in last 12 months

BP recorded in last 12 months

HIPPODM8CP001c

Cholesterol

To recall diabetics overdue a cholesterol test

Diabetics with no serum cholesterol in last 12 months

Cholesterol result recorded

HIPPODM8CP001d

Creatinine (Kidney Function)

To recall diabetics needing a serum creatinine test

Diabetics with no creatinine test in last 12 months

Creatinine result recorded

HIPPODM8CP001e

Urine ACR

To recall diabetics overdue their ACR urine test

Diabetics with no albumin:creatinine ratio in last 12 months

ACR result recorded

HIPPODM8CP001f

Foot Check

To recall diabetics without recent foot check

Diabetics with no foot check or risk score in last 12 months

Foot check and risk score recorded

HIPPODM8CP001g

BMI

To recall diabetics without a recent BMI

Diabetics with no BMI recorded in last 12 months

BMI recorded

HIPPODM8CP001h

Smoking Status

To recall diabetics with no smoking status on file

Diabetics with no smoking status in last 12 months

Smoking status recorded

Code

Name

When to select this

Who is eligible?

What counts as complete

SFVI001

Flu Jab for Patients Aged 65+

To recall patients 65+ who haven’t had a flu jab this season

Patients aged 65+ with no flu vaccine this season (1 Sept onward)

Flu vaccine recorded for the current season

SFVI002

Flu Jab for At-Risk Patients (18–64)

To recall at-risk patients aged 18–64 with no flu jab

Patients aged 18–64 with LTCs (e.g. diabetes, CVD, COPD) and no flu jab this season

Flu vaccine recorded this season

SFVI003

Flu Jab for Children Aged 2–3

To recall 2–3 year olds without a flu jab

Children aged 2 or 3 on 31 Aug, no flu vaccine recorded this season

Flu vaccine recorded (usually nasal spray) for the season

Code

Name

When to select this

Who is eligible?

What counts as complete

HI-01

Annual Health Check (Learning Disabilities)

To recall LD patients who haven’t had an annual health check

Patients on LD register with no health check recorded since 1 April

Health check completed and recorded, including an action plan

Code

Name

When to select this

Who is eligible?

What counts as complete

HLTC_AF_RVW

AF patients receiving annual review

To recall AF patients overdue a review

Patients with atrial fibrillation (AFIB_REG) without a recent review

Annual review completed

HLTC_AST_RVW

Asthma patients receiving annual review

To recall asthma patients overdue a review

Patients with asthma (AST_REG) without a recent review

Annual review completed

HLTC_CARDIO_NO_DM_RVW

CVD patients without diabetes reviewed

To recall CVD patients without diabetes who haven’t had a review

CVD patients not in DM register, overdue a review

Annual review completed

HLTC_CHD_RVW

CHD patients receiving annual review

To recall CHD patients overdue a review

Patients with coronary heart disease (CHD_REG) without a recent review

Annual review completed

HLTC_COPD_RVW

COPD patients receiving annual review

To recall COPD patients overdue a review

Patients with COPD (COPD_REG) without a recent review

Annual review completed

HLTC_DM_RVW

Diabetes patients receiving annual review

To recall diabetic patients overdue a review

Patients with diabetes (DM_REG) without a recent review

Annual review completed

HLTC_HF_RVW

Heart failure patients receiving review

To recall heart failure patients overdue a review

Patients with heart failure (HF_REG) without a recent review

Annual review completed

HLTC_HYP_RVW

Hypertension patients receiving review

To recall hypertension patients overdue a review

Patients with hypertension (HYP_REG) without a recent review

Annual review completed

HLTC_MH_RVW

Mental health patients reviewed

To recall SMI patients overdue a review

Patients with SMI (MH_REG) without a recent review

Annual review completed

HLTC_NDH_RVW

NDH patients reviewed

To recall non-diabetic hyperglycaemia (NDH) patients without a review

Patients on NDH register without recent review

Annual review completed

HLTC_PAD_RVW

PAD patients receiving review

To recall PAD patients overdue a review

Patients with peripheral arterial disease (PAD_REG) without recent review

Annual review completed

HLTC_STIA_RVW

Stroke/TIA patients receiving review

To recall patients with stroke or TIA overdue a review

Patients with stroke or TIA (STIA_REG) without a recent review

Annual review completed

Code

Name

When to select this

Who is eligible?

What counts as complete

MH002

Care Plan Review

To recall SMI patients without care plan review

Patients with psychosis/bipolar and no care plan in 12 months

Care plan review covering physical and mental health needs

MH003

Blood Pressure

To recall SMI patients with no BP recorded

Patients with SMI and no BP in the last 12 months

BP recorded in last 12 months

MH006

BMI

To recall SMI patients with no BMI recorded

Patients with SMI and no BMI in the last 12 months

BMI recorded in last 12 months

MH007

Alcohol

To recall SMI patients with no alcohol use recorded

Patients with SMI and no alcohol use recorded in 12 months

Alcohol use recorded

MH011

Lipids

To recall SMI patients with no cholesterol check

Patients with SMI and no lipid profile in last 12 months

Lipid profile recorded

MH012

HbA1c

To recall SMI patients with no glucose test

Patients with SMI and no HbA1c in last 12 months

HbA1c result recorded

MH021

SMI Annual Health Check (All 6)

To recall SMI patients who haven’t completed all 6 checks

Patients with SMI missing ≥1 of: BP, BMI, alcohol, smoking, lipids, HbA1c

All 6 checks completed and recorded in last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

HIPPONHSHC001

Overall Coverage

To recall eligible patients who haven’t completed an NHS HC in 5 years

Patients aged 40–74 with no NHS Health Check in last 5 years

Full NHS HC recorded incl. risk score, BP, BMI, cholesterol, lifestyle

HIPPONHSHC002

Current Year Invite

To monitor patients invited this year who haven’t yet had a check

Patients eligible this year, no check recorded yet

NHS HC recorded during the current financial year

HIPPONHSHC002a

Blood Pressure (NHS HC)

To recall NHS HC patients missing a BP reading

NHS HC patients this year with no BP recorded

BP reading recorded

HIPPONHSHC002b

BMI (NHS HC)

To recall NHS HC patients with no BMI

NHS HC patients with no BMI recorded

BMI recorded

HIPPONHSHC002c

Cholesterol (NHS HC)

To recall NHS HC patients with no cholesterol result

NHS HC patients with no total cholesterol recorded

Cholesterol result recorded

HIPPONHSHC002d

HbA1c (NHS HC)

To recall NHS HC patients with no glucose result

NHS HC patients with no HbA1c recorded

HbA1c result recorded

HIPPONHSHC002e

All Components Completed

To find patients who haven’t finished all 5 checks

NHS HC patients missing one or more of: BP, BMI, cholesterol, HbA1c, lifestyle

All checks and lifestyle components completed

Code

Name

When to select this

Who is eligible?

What counts as complete

HIPPOPNEU001A/B

Lifetime Pneumo Vaccine (Age 65+)

To recall patients aged 65+ with no pneumococcal vaccine ever recorded

Patients aged 65+ with no PPV23 recorded

Pneumococcal vaccine (PPV23) recorded

HIPPOPNEU002A/B

First Pneumo Vaccine (At-Risk <65s)

To recall under-65 at-risk patients never vaccinated

Patients aged 2–64 with LTCs and no PPV23 recorded

Pneumococcal vaccine recorded

HIPPOPNEU003A/B

5-Year Pneumo Booster (High-Risk Only)

To recall patients needing 5-year booster

High-risk patients (e.g. asplenia) due a booster dose

Pneumococcal booster recorded within past 5 years

Code

Name

When to select this

Who is eligible?

What counts as complete

NDH002

Blood Glucose Monitoring (Pre-diabetes)

To recall NDH patients with no glucose check in the last 12 months

Patients with NDH (pre-diabetes) and no HbA1c or fasting glucose recorded

HbA1c or FPG result recorded in the last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

SMOK002

Smoking Status – At-Risk Patients

To recall LTC patients with no smoking status in 12 months

Patients with asthma, COPD, diabetes, CVD, SMI, etc. and no status recorded

Smoking status recorded in the last 12 months

SMOK004

Cessation Offer – General Smokers

To offer cessation support to all smokers every 2 years

Patients aged 15+ who are current smokers and no offer in 24 months

Smoking cessation advice or referral recorded in last 24m

SMOK005

Cessation Offer – At-Risk Smokers

To recall smokers with LTCs for a 12-monthly quit offer

Smokers with diabetes, CVD, COPD, SMI, etc. and no cessation offer in 12 months

Cessation support offer recorded in last 12 months

Code

Name

When to select this

Who is eligible?

What counts as complete

HIPPOSHING01

Zostavax (Single Dose)

To recall patients aged 70–79 eligible for legacy Zostavax dose

Patients aged 70–79 with no Zostavax recorded

Zostavax dose recorded

HIPPOSHING02

Shingrix Dose 1 (Immunocompetent 65–79)

To recall new cohort patients due for first Shingrix dose

Immunocompetent patients aged 65 or 70–79 with no Shingrix dose 1 recorded

Shingrix dose 1 recorded

HIPPOSHING03

Shingrix Dose 2 (Immunocompetent)

To recall patients who had dose 1 at least 6 months ago and are due dose 2

Immunocompetent patients with Shingrix 1 recorded ≥6 months ago

Shingrix dose 2 recorded

HIPPOSHING04

Shingrix Dose 1 (Immunocompromised Age 50+)

To recall immunocompromised patients aged 50+ not started on Shingrix

Immunocompromised patients aged 50+ with no shingles vaccine recorded

Shingrix dose 1 recorded

HIPPOSHING05

Shingrix Dose 2 (Immunocompromised)

To recall immunocompromised patients due for second dose ≥2 months after dose 1

Immunocompromised patients with dose 1 recorded ≥2 months ago

Shingrix dose 2 recorded