NHS Connecting for Health
NHS Data Model and Dictionary Service
| Reference: | Change Request 1205 |
| Version No: | 1.0 |
| Subject: | Dictionary Extract Patch |
| Effective Date: | Immediate |
| Reason for Change: | Patch |
| Publication Date: | 7 December 2010 |
Background:
The NHS Data Model and Dictionary Service is producing an extract tool which will allow the user to create a text file listing the values reported for data elements reporting using National Codes.
During this process the following issues have been raised:
- it has been found that some data element and attribute definitions have not been formatted consistently with respect to retired National Codes
- some data element definitions also include lists of National Codes and will need to be formatted so that the extract tool can recognise these.
This patch applies corrections to the formatting in these attribute and data element definitions in order to allow for the extract tool to recognise these codes correctly.
Summary of changes:
| Date: | 7 December 2010 |
| Sponsor: | Richard Kavanagh, NHS Connecting for Health |
Note: New text is shown with a blue background. Deleted text is crossed out. Retired text is shown in grey. Within the Diagrams deleted classes and relationships are red, changed items are blue and new items are green.
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Change to Supporting Information: Changed Description
- A broad classification of types of investigation which may be requested to assist with diagnosis as a result of Accident And Emergency Attendance.
- Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.
- It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
- ACCIDENT AND EMERGENCY INVESTIGATION is a six character code, comprising:
Investigation n2 (see Table below) Local sub-Analysis up to an4 Accident And Emergency Investigation Table
Investigation Code X-ray plain film 01 Electrocardiogram 02 Haematology 03 Cross match blood/group and save serum for later cross match 04 Biochemistry 05 Urinalysis 06 Bacteriology 07 Histology 08 Computerised Tomography - Retired 2006-04-0109Computerised Tomography - Retired 2006-04-01 09 Ultrasound 10 Magnetic Resonance Imaging 11 Computerised Tomography (excludes genitourinary contrast examination/tomography) 12 Genitourinary contrast examination/tomography 13 Clotting studies 14 Immunology 15 Cardiac enzymes 16 Arterial/capillary blood gas 17 Toxicology 18 Blood culture 19 Serology 20 Pregnancy test 21 Dental investigation 22 Refraction, orthoptic tests and computerised visual fields 23 None 24 Other 99 Items expected to be sub-analysed at discretion of individual Accident And Emergency Departments.
Change to Supporting Information: Changed Description
- A broad classification of types of treatment or guidance which may be provided to a PATIENT as a result of Accident And Emergency Attendance.
- Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.
- It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
- ACCIDENT AND EMERGENCY TREATMENT is a six character code, comprising:
Condition n2 (see Treatment Table below) Sub-Analysis n1 (see Sub-analysis Table below) Local use up to an3 Accident and Emergency Treatment - Treatment
Treatment Code Dressing* 01 Bandage/support 02 Sutures* 03 Wound closure (excluding sutures)* 04 Plaster of Paris* 05 Splint 06 Prescription - Retired 2006-04-0107Prescription - Retired 2006-04-01 07 Removal foreign body 08 Physiotherapy* 09 Manipulation* 10 Incision & drainage 11 Intravenous cannula 12 Central line 13 Lavage/emesis/charcoal/eye irrigation 14 Intubation & Endotracheal tubes/laryngeal mask airways/rapid sequence induction 15 Chest drain 16 Urinary catheter/suprapubic 17 Defibrillation/pacing* 18 Resuscitation/cardiopulmonary resuscitation 19 Minor surgery 20 Observation/electrocardiogram, pulse oximetry/head injury/trends 21 Guidance/advice only* 22 Anaesthesia* 23 Tetanus* 24 Nebuliser/spacer 25 Parenteral thrombolysis* 28 Other Parenteral drugs* 29 Recording vital signs 30 Burns review 31 Recall/x-ray review 32 Fracture review 33 Wound cleaning 34 Dressing/wound review 35 Sling/collar cuff/broad arm sling 36 Epistaxis control 37 Nasal airway 38 Oral airway 39 Supplemental oxygen 40 Continuous positive airways pressure/nasal intermittent positive pressure ventilation/bag valve mask 41 Arterial line 42 Infusion fluids 43 Blood product transfusion 44 Pericardiocentesis 45 Lumbar puncture 46 Joint aspiration 47 Minor plastic procedure/split skin graft 48 Active rewarming of the hypothermic patient 49 Cooling - control body temperature 50 Medication administered* 51 Occupational Therapy* 52 Loan of walking aid (crutches) 53 Social work intervention 54 Eye* 55 Dental treatment 56 Prescription/medicines prepared to take away 57 Other (consider alternatives) 27 None (consider guidance/advice option) 99 Items sub-analysed in Table below
Accident and Emergency Treatment - Sub-analysis
Sub-analysis Treatment Code Dressing - dressing minor wound/burn/eye
- dressing major wound/burn1
2Sutures - primary sutures
- secondary/complex suture
- removal of sutures/clips1
2
3Wound closure (excluding sutures) - steristrips
- wound glue
- other (e.g. clips)1
2
3Plaster of Paris - application Plaster of Paris
- removal Plaster of Paris1
2Physiotherapy - strapping, ultra sound treatment, short wave diathermy, manipulation
- gait re-education, falls prevention1
2Manipulation - manipulation of upper limb fracture
- manipulation of lower limb fracture
- manipulation of dislocation1
2
3Defibrillation/pacing - defibrillation
- external pacing1
2Guidance/advice only - written
- verbal1
2Anaesthesia - general anaesthetic
- local anaesthetic
- regional block
- entonox
- sedation
- other1
2
3
4
5
6Tetanus - immune
- tetanus toxoid course
- tetanus toxoid booster
- human immunoglobulin
- combined tetanus/diphtheria course
- combined tetanus/diphtheria booster1
2
3
4
5
6Parenteral thrombolysis - streptokinase parenteral thrombolysis
- recombinant - plasminogen activator1
2Other Parenteral drugs - intravenous drug, e.g. stat/bolus
- intravenous infusion1
2Medication administered - oral
- intra-muscular
- subcutaneous
- per rectum
- sublingual
- intra-nasal
- eye drops
- ear drops
- topical skin cream1
2
3
4
5
6
7
8
9Occupational Therapy - OT functional assessment
- OT activities of daily living equipment provision1
2Eye - orthoptic exercises
- laser of retina/iris or posterior capsule
- retrobulbar injection
- epilation of lashes
- subconjunctival injection1
2
3
4
5
Change to Supporting Information: Changed Description
Accident and Emergency CDS Type List:
ACCIDENT AND EMERGENCY ATTENDANCE
Admitted Patient Care CDS Type List:
GENERAL EPISODE
DELIVERY EPISODE
BIRTH EPISODE
DETAINED AND - OR LONG TERM PSYCHIATRIC CENSUS
OTHER BIRTH EVENT
OTHER DELIVERY
CDS Interchange and Message Controls:
CDS INTERCHANGE HEADER
CDS MESSAGE HEADER
CDS MESSAGE TRAILER
CDS INTERCHANGE TRAILER
CDS Transaction Header Group:
CDS TRANSACTION HEADER GROUP NET CHANGE
CDS TRANSACTION HEADER GROUP BULK UPDATE
Elective Admission List CDS Type
ELECTIVE ADMISSION LIST CDS TYPE 030 - END OF PERIOD CENSUS (STANDARD)
ELECTIVE ADMISSION LIST CDS TYPE 040 - END OF PERIOD CENSUS (OLD)
ELECTIVE ADMISSION LIST CDS TYPE 050 - END OF PERIOD CENSUS (NEW)
ELECTIVE ADMISSION LIST CDS TYPE 060 - EVENT DURING PERIOD (ADD)
ELECTIVE ADMISSION LIST CDS TYPE 070 - EVENT DURING PERIOD (REMOVE)
ELECTIVE ADMISSION LIST CDS TYPE 080 - EVENT DURING PERIOD (OFFER)
ELECTIVE ADMISSION LIST CDS TYPE 090 - EVENT DURING PERIOD (AVAILABLE/UNAVAILABLE)
ELECTIVE ADMISSION LIST CDS TYPE 100 - EVENT DURING PERIOD (OLD SERVICE AGREEMENT)
ELECTIVE ADMISSION LIST CDS TYPE 110 - EVENT DURING PERIOD (NEW SERVICE AGREEMENT)
Out-patient Attendance CDS Type List:
OUT-PATIENT ATTENDANCE
Ward Attendance CDS Type List (Retired 31st March 2005):WARD ATTENDANCEWARD ATTENDANCE
Change to Supporting Information: Changed Description
The following tables set out the authorised versions of the Commissioning Data Set.
Commissioning Data Set Version 6The Commissioning Data Set Version 6 derivatives consists of several components identified in the CDS Version CDS006 Type List.
| CDS Version | Available From | Mandated From | Usable To | Message Format | Message Version |
| CDS006 | 01/04/2008 | 01/04/2009 | - | XML Schema | CDS-XML-Message-Schema-V6-1-2008-04-01 |
| CDS006 | 14/01/2008 | 14/01/2008 | - | XML Schema | CDS-XML-Message-Schema-V6-0-2008-01-14 |
| CDS006 | 31/12/2007 | 01/04/2008 | Superceded before live use | XML Schema | Message Schema V6.0-2007-10-26 |
| CDS006 | 31/12/2007 | 01/04/2008 | Superceded before live use | XML Schema | Message Schema v6.0-2007-03-01 and CDS XML Message Documentation V6-0-2007-03-01 |
Commissioning Data Set Version 5Commissioning Data Set Version 5The Commissioning Data Set Version NHS005 consists of several components identified in the CDS Version NHS005 Type List.The Commissioning Data Set Version NHS005 consists of several components identified in the CDS Version NHS005 Type List.
| CDS Version | Available From | Mandated From | Usable To | Message Format | Message Version |
| NHS005 | 01/10/2007 | 01/10/2007 | 31/03/2009 | XML Schema | Message Schema v5-0-2007-06-01 and Message Documentation v5-0-2007-06-01 |
| NHS005 | 01/09/2006 | 06/11/2006 | 01/10/2007 | XML Schema | Message Schema v5-0-2006-08-04 and Message Documentation v5-0-2006-08-04 |
| NHS005 | 01/04/2006 | 01/09/2006 | Superceded before live use | XML Schema | V-5-0 schema and documentation |
Commissioning Data Set Version 5-0-2007-06-01 is backward compatible with CDS Version 5-0-2006-08-04.Commissioning Data Set Version 5-0-2007-06-01 is backward compatible with CDS Version 5-0-2006-08-04. Any data conforming with Commissioning Data Set Version 5-0-2006-08-04 conforms with Commissioning Data Set Version 5-0-2007-06-01. Commissioning Data Set Version 5-0-2006-08-04 includes all standards updates to DSCN 14/2005. In addition
value 8 has been included in the enumeration forADMISSION OFFER OUTCOMEto correct an error in Commissioning Data Set Version 5-0-2006-08-04value 3 has been included in the enumeration forPRIORITY TYPE- DSCN 13/2006values 304, 371, 401, 812 and 840 have been included in the enumeration forTREATMENT FUNCTION CODE- DSCN 02/2007values 12, 13,14,15,16, 17 and 97 have been included in the enumeration forSOURCE OF REFERRAL FOR OUT-PATIENTS- DSCN 16/2007. Code 8 'Other', which is retired in DSCN 16/2007, has been retained in Commissioning Data Set Version 5-0-2007-06-01 for backward compatibility.- value 8 has been included in the enumeration for ADMISSION OFFER OUTCOME to correct an error in Commissioning Data Set Version 5-0-2006-08-04
- value 3 has been included in the enumeration for PRIORITY TYPE - DSCN 13/2006
- values 304, 371, 401, 812 and 840 have been included in the enumeration for TREATMENT FUNCTION CODE - DSCN 02/2007
- values 12, 13,14,15,16, 17 and 97 have been included in the enumeration for SOURCE OF REFERRAL FOR OUT-PATIENTS - DSCN 16/2007. Code 8 'Other', which is retired in DSCN 16/2007, has been retained in Commissioning Data Set Version 5-0-2007-06-01 for backward compatibility.
V-5-0-2006-08-04 corrects an error in V-5-0 in the definition of the data type supporting CRITICAL CARE UNIT FUNCTION and restricts the length of CRITICAL CARE LOCAL IDENTIFIER to 8 characters.V-5-0-2006-08-04 corrects an error in V-5-0 in the definition of the data type supporting CRITICAL CARE UNIT FUNCTION and restricts the length of CRITICAL CARE LOCAL IDENTIFIER to 8 characters.
| CDS Version | Available From | Mandated From | Usable To | Message Format | Message Version |
| NHS004 | 01/10/2005 | Only for NWCS-SUS migration | XML Schema | V-4-2-a | |
This Commissioning Data Set version was released to support the initial implementation of the CDS-XML processes submitting data to the Secondary Uses Service and must be used only for migration.This Commissioning Data Set version was released to support the initial implementation of the CDS-XML processes submitting data to the Secondary Uses Service and must be used only for migration.
| CDS Version | Available From | Mandated From | Usable To | Message Format | Message Version |
| NHS003 | 2001 | 2001 | 31 March 2007 | UN/EDIFACT | CDSM - MIG V4 |
Change to Supporting Information: Changed Description
A Local Health Board (Wales) (formerly known as Welsh Local Health Board) is an ORGANISATION.
Local Health Boards (Wales) are bodies corporate established by the Welsh Ministers under s.11 of the National Health Service (Wales) Act 2006.
A Local Health Board (Wales) will be responsible for:
- Those functions undertaken by the twenty-two Welsh Local Health Boards up to 30 September 2009 (including securing the provision of health care services for the PERSONS resident within their respective areas);
- The provision of health care services within their areas;
- The planning and provision of specialised and tertiary services that were commissioned by Health Commission Wales up to 30 September 2009. The planning of some of those specialised and tertiary services may be executed via joint committees such as that envisaged for the Welsh Health Specialised Services Committee (WHSSC).
This model will ensure the emphasis remains on co-operation and engagement with local partners, particularly in relation to the Health, Social Care and Well-being Strategies and Children and Young People’s Plans.
WELSH LOCAL HEALTH BOARD DESCRIPTION REPLACED 1 OCTOBER 2009
A Welsh Local Health Board is an ORGANISATION.A Welsh Local Health Board is an ORGANISATION.
A Welsh Local Health Board is a body corporate established by the Welsh Ministers under s.A Welsh Local Health Board is a body corporate established by the Welsh Ministers under s.11 of the National Health Service (Wales) Act 2006; whose areas are coterminous with local authority boundaries. Welsh Local Health Boards are responsible for PATIENTS who are “usually resident in their area”. Welsh Local Health Boards are responsible for PATIENTS who are “usually resident in their area”.
The overall function of a Welsh Local Health Board is to improve the health of the responsible population, develop primary health services, and commission community and secondary care services.The overall function of a Welsh Local Health Board is to improve the health of the responsible population, develop primary health services, and commission community and secondary care services. A Welsh Local Health Board will, if it so wishes and is capable of doing so, be able to provide directly a range of community health services, creating new opportunities to integrate primary and community health services as well as health and social care provision.
Welsh Local Health Boards will be the leading NHS ORGANISATION for partnership with Local Authorities and other partners; including NHS Trusts and other Welsh Local Health Boards, and local communities to improve health and deliver wider objectives for social and economic regeneration.Welsh Local Health Boards will be the leading NHS ORGANISATION for partnership with Local Authorities and other partners; including NHS Trusts and other Welsh Local Health Boards, and local communities to improve health and deliver wider objectives for social and economic regeneration.
Save for certain specialised services commissioned by Health Commission Wales, Welsh Local Health Boards commission services themselves, although they may by agreement with other Welsh Local Health Boards, work together to commission certain services, e.g. on a Regional basis. In this case a lead Welsh Local Health Board will be identified for the group.Save for certain specialised services commissioned by Health Commission Wales, Welsh Local Health Boards commission services themselves, although they may by agreement with other Welsh Local Health Boards, work together to commission certain services, e.g. on a Regional basis. In this case a lead Welsh Local Health Board will be identified for the group.
Change to Attribute: Changed Description
One of the business definitions listed in the ACTIVITY GROUP class as a type of this class.
Consultant Episode (Hospital Provider) has four 'sub types' (General, Birth, Delivery and Detained and Long Term Psychiatric Patient Census) which form four individual ACTIVITY GROUP TYPE values.
National Codes:
Note: The list is not in alphabetical order.
Change to Attribute: Changed Description
The acute myocardial infarction diagnosis at discharge.
National codes:National Codes:
| 01 | Myocardial infarction (ST elevation) |
| 02 | Myocardial infarction (non ST elevation) |
| 03 | Threatened Myocardial Infarction |
| 04 | Acute coronary syndrome (troponin positive) |
| 05 | Acute coronary syndrome (troponin negative) |
| 10 | Acute coronary syndrome (troponin unspecified) |
| 06 | Chest pain of uncertain cause |
| 07 | Myocardial infarction (unconfirmed) |
| 08 | Other diagnosis |
Note: The classification has been listed in logical sequence rather than alphanumeric order.
References:
Acute Myocardial Infarction Core Dataset
Change to Attribute: Changed Description
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
This is the type of feeding a baby is receiving.
National Codes:
| 01 | Exclusively maternal breast milk feeding |
| 02 | Partially maternal breast milk feeding |
| 03 | Exclusively formula milk feeding |
Change to Attribute: Changed Description
This is the morphology of a Basal Cell Carcinoma as determined by a clinician on the basis of the worst clinical area.
National codes:National Codes:
| A | Nodular or cystic |
| B | Superficial |
| C | Morphoeic |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
CLINICAL TRIAL INDICATOR is used to record whether an individual episode of care within a Cancer Care Spell is being delivered to a PATIENT as part of a CLINICAL TRIAL.
National codes:National Codes:
| 01 | PATIENT is taking part in a CLINICAL TRIAL |
| 02 | PATIENT is not taking part in a CLINICAL TRIAL |
Change to Attribute: Changed Description
The reason that a colonoscopy was incomplete.
National codes:National Codes:
| 1 | Obstructing tumour |
| 2 | Poor bowel presentation |
| 3 | Patient intolerance/technical reasons |
| 4 | Other |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
This will be recorded for PATIENTS attending a Sexual and Reproductive Health Clinic or receiving a domiciliary visit from a family planning advisor, for the purposes of CONTRACEPTION.
The CONTRACEPTION METHOD POST COITAL should be recorded for each contact involving emergency post coital contraception.
Classification: (used in KT31)
| a | hormonal |
| b | Intrauterine Device (IUD) |
Introduced For the Sexual and Reproductive Health Activity Data Set:
National Codes (introduced for the Sexual and Reproductive Health Activity Data Set)National Codes:
| 1 | Emergency Oral |
| 2 | Emergency Intrauterine Device (IUD) |
Change to Attribute: Changed Description
An indication of evidence of Chronic Obstructive Pulmonary Disease in a PATIENT with a Lung Cancer Care Spell.
National codes:National Codes:
| Y | Yes |
| N | No |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
Indicates if the PATIENT was discharged from hospital on a particular AMI DRUG TYPE.
National codes:National Codes:
| 0 | No |
| 1 | Yes |
| 2 | Contraindicated |
| 8 | Not indicated |
References:
Acute Myocardial Infarction Core Dataset Version 3.0
Change to Attribute: Changed Description
The method of delivery of Drug Treatment.
National codes:National Codes:
| 01 | Intra-vesicular |
| 02 | Oral |
| 03 | Topical |
| 04 | Intravenous |
| 05 | Subcutaneous |
| 97 | Other |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The type of Endocrine Therapy given to the PATIENT during a Cancer Care Spell.
National codes:National Codes:
| R | Radiotherapy ablation (e.g. radiation induced menopause) |
| S | Surgical ablation (e.g. oophrectomy, orchidectomy) |
| M | Medical ablation (e.g. LHRH analogues) |
| A | Adjuvant endocrine therapy (e.g. Tamoxifen + surgery) |
| D | Definitive endocrine therapy (e.g. Tamoxifen alone) |
| O | Other |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
The type of genetically determined skin cancer syndrome of the PATIENT.
National codes:National Codes:
| G | Gorlin syndrome |
| P | Melanoma-prone syndromes |
| X | Xeroderma pigmentosa |
| M | Muir Torre syndrome |
| O | Other |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
A classification of a Genitourinary Care Contact.
National codes:National Codes:
| 01 | Genitourinary medicine |
| 02 | Contraceptive/reproductive health |
| 03 | Psychosexual |
| 04 | Chronic problems |
| 05 | Sexual assault |
| 06 | Human immunodeficiency virus (HIV) |
Change to Attribute: Changed Description
The grade of the operating surgeon.
National codes:National Codes:
| 1 | Consultant |
| 2 | Associate Specialist |
| 3 | Staff grade/clinical assistant |
| 4 | Specialist Registrar (SPR) |
| 5 | Senior House Officer (SHO) |
| 6 | House Officer (HO) |
| 7 | Other Medical |
| 8 | Non medically qualified practitioner |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
An indicator of accreditation in Gynaecological Oncology for the CARE PROFESSIONAL.
National codes:National Codes:
| Y | Yes |
| N | No |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
Identifies if a home is a Care Home or a Children's Home.
National codes:National Codes:
| 01 | Care Home |
| 02 | Children's Home |
Change to Attribute: Changed Description
A flag which identifies if a clinic is conducted jointly between two CONSULTANTS.
When a CONSULTANT conducts an Out-Patient Clinic jointly with another CONSULTANT (or by a doctor representing the CONSULTANT), the second consultant is a Shared Care Consultant.
A clinic should not be recorded as a shared clinic when two or more CONSULTANTS hold clinics at the same LOCATION and time specifically in order to allow PATIENTS to go from one consultant to another, even if they share a single list of PATIENTS. These are separate Consultant Clinics.
National codes:National Codes:
| 01 | Yes, clinic conducted jointly |
| 02 | No, clinic not conducted jointly |
Change to Attribute: Changed Description
An indicator of the presence or absence of metastases in a marker lymph node that is of therapeutic and prognostic importance relating to a Cancer Care Spell.
For breast cancer, the marker lymph node will be the sentinal node.
For colorectal cancer, the marker lymph node will be the apical node.
National codes:National Codes:
| N | Marker lymph node 1 negative |
| Y | Marker lymph node 1 positive present |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
A classification of the type of care professional staff dealing with the PATIENT during an Out-Patient Attendance Consultant or Nurse or Midwife Contact.
National Codes:
| 01 | Consultant (Retired 2005-04-01) |
| 02 | Member of Consultant firm (Retired 2005-04-01) |
| 03 | Lead Care Professional (Effective 2005-04-01) |
| 04 | Member of Care Professional team (Effective 2005-04-01) |
Change to Attribute: Changed Description
The PATIENT's menstrual status at the start of the Breast Cancer Care Spell.
National codes:National Codes:
| 1 | Premenopausal |
| 2 | Perimenopausal |
| 3 | Postmenopausal |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
The primary reason for the detention of PATIENTS under the Mental Health Act 1983, as amended by the Mental Health Act 2007.
MENTAL HEALTH ACT 2007 MENTAL CATEGORY should be used for PATIENTS detained from 3rd November 2008 when the relevant section of the Mental Health Act 2007 comes into force, and replaces MENTAL CATEGORY which is applicable until then.
A PATIENT should be included under only one MENTAL HEALTH ACT 2007 MENTAL CATEGORY.
National Codes:
| A | Mental disorder (Learning Disability not present or not primary reason for using Act) |
| B | Mental disorder (Learning Disability primary reason for using Act) |
Change to Attribute: Changed Description
A classification of Legal Status. The classification 'informal' is used for those PATIENTS who are not formally detained or not receiving supervised aftercare.
National Codes:
| 01 | Informal |
| 02 | Formally detained under Mental Health Act Section 2 |
| 03 | Formally detained under Mental Health Act Section 3 |
| 04 | Formally detained under Mental Health Act Section 4 |
| 05 | Formally detained under Mental Health Act Section 5(2) |
| 06 | Formally detained under Mental Health Act Section 5(4) |
| 07 | Formally detained under Mental Health Act Section 35 |
| 08 | Formally detained under Mental Health Act Section 36 |
| 09 | Formally detained under Mental Health Act Section 37 with section 41 restrictions |
| 10 | Formally detained under Mental Health Act Section 37 |
| 12 | Formally detained under Mental Health Act Section 38 |
| 13 | Formally detained under Mental Health Act Section 44 |
| 14 | Formally detained under Mental Health Act Section 46 |
| 15 | Formally detained under Mental Health Act Section 47 with section 49 restrictions |
| 16 | Formally detained under Mental Health Act Section 47 |
| 17 | Formally detained under Mental Health Act Section 48 with section 49 restrictions |
| 18 | Formally detained under Mental Health Act Section 48 |
| 19 | Formally detained under Mental Health Act Section 135 |
| 20 | Formally detained under Mental Health Act Section 136 |
| 31 | Formally detained under Criminal Procedure(Insanity) Act 1964 as amended by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991 |
| 32 | Formally detained under other acts |
| 33 | Supervised Discharge (Mental Health (Patients in the Community) Act 1995) (Retired 03 November 2008 - but may apply to some patients until 3 May 2009) |
| 34 | Formally detained under Mental Health Act Section 45A |
| 35 | Subject to guardianship under Mental Health Act Section 7 |
| 36 | Subject to guardianship under Mental Health Act Section 37 |
Change to Attribute: Changed Description
An indication of whether or not the CLINICAL INTERVENTION is an OPERATIVE PROCEDURE.
National codes:National Codes:
| N | No |
| Y | Yes |
Change to Attribute: Changed Description
A type of specimen to be examined in the Pathology Laboratory Investigation.
National codes:National Codes:
| EX | Excision |
| BXI | Incisional (diagnostic) biopsy |
| BXP | Punch biopsy |
| BXS | Shave biopsy |
| BXC | Curettings |
| 9 | Uncertain/other |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
An indication of whether the PATIENT is on any form of immunosuppressive therapy recorded as a risk factor as part of a Cancer Care Plan.
National codes:National Codes:
| Y | Yes |
| N | No |
| 9 | Unknown |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The result of a procedure such as a colonoscopy.
National codes:National Codes:
| 1 | Normal |
| 2 | Abnormal |
| 3 | Inadequate |
| 4 | Not done |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
An indication of whether there is any perineural invasion of skin cancer.
National codes:National Codes:
| N | No, perineural invasion not present |
| Y | Yes, perineural invasion present |
| U | Uncertain whether perineural invasion is present or not |
| 9 | Not known |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
An indicator to identify the legal marital status of a PERSON.
National Codes:
| S | Single |
| M | Married/Civil Partner |
| D | Divorced/Person whose Civil Partnership has been dissolved |
| W | Widowed/Surviving Civil Partner |
| P | Separated |
| N | Not disclosed |
Previous specification, now obsolete and not for use:Previous specification, now obsolete and not for use:
| 1 | Single (Retired 2006-10-01) |
| 2 | Married/separated (Retired 2006-10-01) |
| 3 | Divorced (Retired 2006-10-01) |
| 4 | Widowed (Retired 2006-10-01) |
Change to Attribute: Changed Description
An indicator of whether the PATIENT has had previous treatment for head and neck cancer elsewhere, as another Head And Neck Cancer Care Spell.
National codes:National Codes:
| Y | Yes |
| N | No |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
The code identifying the version of the READ CLASSIFICATION used.
Classification:
| a. | Read Code 4Byte Version (retired 1 October 2009) |
| b. | Read Code Version 2 |
| c. | Read Code Clinical Terms Version 3 (CTV3) |
Change to Attribute: Changed Description
Identifies the originating source of a REFERRAL REQUEST.
National Codes:
| 01 | GP referral request |
| 02 | Consultant referral request |
| 03 | Other - Retired April 2006 |
| 04 | Patient self-referral request |
| 97 | Other |
Change to Attribute: Changed Description
The relationship of the second PERSON to the first PERSON. Note that this is a limited list.
National codes:National Codes:
| A | Aunt |
| B | Brother |
| C | Child unspecified |
| D | Daughter |
| F | Father |
| G | Grandparent |
| H | Husband |
| K | Cousin |
| M | Mother |
| N | Nephew/niece |
| P | Parent unspecified |
| S | Sister |
| U | Uncle |
| W | Wife |
| X | Grandchild unspecified |
| Z | Son |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
An indicator of whether the second PERSON in the PERSON RELATIONSHIP has had cancer.
National codes:National Codes:
| Y | Yes |
| N | No |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Attribute: Changed Description
The RELIGIOUS OR OTHER BELIEF SYSTEM AFFILIATION GROUP of a PERSON, as specified by a PERSON.
Note: This is the Religious Affiliation of a PERSON, not their Religion.
National codes:National Codes:
| A | Baha'i |
| B | Buddhist |
| C | Christian |
| D | Hindu |
| E | Jain |
| F | Jewish |
| G | Muslim |
| H | Pagan |
| I | Sikh |
| J | Zoroastrian |
| K | Other |
| L | None |
| M | Declines to Disclose |
| N | Patient Religion Unknown |
Change to Attribute: Changed Description
An indicator of whether a TRANSPORT REQUEST has been resolved by telephone advice only. This is only applicable for TRANSPORT REQUESTS with a RESPONSE CATEGORY of 'Category C: other emergency calls which are not immediately life threatening or serious' and the most appropriate response is through clinical advice to be provided over the phone (with no Emergency Ambulance response required), and calls are dealt with by a CARE PROFESSIONAL accountable to the NHS Trust or passed to another ORGANISATION working with the NHS Trust through an agreed contract or SERVICE PROVIDED UNDER AGREEMENT.
A successfully completed call is one where advice has been given with any appropriate action being agreed with the PATIENT and where no further response is required from the Ambulance Service.
National Codes:National Codes:
| 01 | Telephone advice successfully completed |
| 02 | Telephone advice not appropriate or not completed |
Change to Attribute: Changed Description
On the pathway to a diagnosis of sarcoma, the PATIENT may have undergone a number of procedures. This is the condition of the tumour as first seen by a sarcoma specialist.
National codes:National Codes:
| UT | Untouched |
| NB | Needle Biopsy |
| OB | Open Biopsy |
| EX | Excision |
| LR | Local recurrence |
| NR | Not referred |
| 9 | Not known |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
A classification for the condition (either inherited or other physical condition) from which the PATIENT suffers or is related to the PATIENT, which might indicate a tendency to sarcoma.
National codes:National Codes:
| LF | Li-Fraumeni Family |
| NF | NF 1 |
| FP | Familial Adenomatous Polyposis |
| PA | Paget's |
| OD | Ollier's Disease |
| MS | Maffucci's Syndrome |
| EX | Exostosis |
| CH | Chondrodysplasia |
| PR | Previous Radiotherapy to site |
| OT | Other |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
This is whether the soft tissue tumour is superficial or deep to the fascia. Any spread through the fascia should be defined as deep.
National codes:National Codes:
| A | Superficial |
| B | Deep |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The overall type of the surgical procedure carried out for the treatment of sarcoma.
National codes:National Codes:
| A | Amputation |
| E | Simple Excision |
| R | Excision and reconstruct |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
This indicates care activity provided and carried out by the Sexual and Reproductive Health Service.
National codes:National Codes:
| 01 | Sexual Health Advice (e.g. covers all other advice that is not an inherent part of an activity listed under Sexual and Reproductive Health Service Activities) |
| 02 | Pregnancy Test (record all instances where pregnancy testing is part of the clinic's activity) |
| 03 | Pregnancy Advice and/or Options (where the patient is confirmed as pregnant and requires advice and detailed discussion or options available) |
| 04 | Abortion Assessment (includes assessment of gestation, medical history and social circumstances, a detailed discussion of the options available, their appropriateness and usually obtaining consent for any chosen procedure) |
| 05 | Pre Abortion Counselling (includes counselling given by a trained counsellor) |
| 06 | Abortion Medical Procedure |
| 07 | Abortion Surgical Procedure |
| 08 | Abortion Aftercare |
| 09 | Abortion Referral (with advice) |
| 10 | Post Abortion Counselling (includes counselling given by a trained counsellor) |
| 11 | Cervical Screening (includes smear tests and cytology) |
| 12 | Psychosexual Therapy (where psychosexual therapy is provided by a trained counsellor) |
| 13 | Psychosexual Referral (with advice) |
| 14 | Sterilisation/Vasectomy Assessment |
| 15 | Sterilisation/Vasectomy Treatment (including procedure) |
| 16 | Sterilisation/Vasectomy Aftercare |
| 17 | Sterilisation/Vasectomy Referral (with advice) |
| 18 | Premenstrual Syndrome (PMS) Treatment (includes consultation, clinical care and all therapies) |
| 19 | Implant Removal |
| 20 | Intrauterine System (IUS) Removal |
| 21 | Intrauterine Device (IUD) Removal |
| 22 | Intrauterine System (IUS) Insertion (non contraception) |
| 23 | Intrauterine System (IUS) Check (non contraception) |
| 24 | Menopause Management and Treatment (excluding IUS insertion/check) |
| 25 | Colposcopy Treatment |
| 26 | Colposcopy Referral (with advice) |
| 27 | Ultra Sound Scan |
| 28 | Sub Fertility Treatment and Care (including consultation, blood test for sub fertility purposes and semen analysis) |
| 29 | Other Gynaecology Treatment and Care (includes all gynaecology treatment not covered under cervical screening, colposcopy and sub fertility care. Includes gynaecology consultation, investigation (vaginal or pelvic examination) and treatment) |
| 30 | Alcohol Brief Intervention (see Alcohol Learning Centre) |
| 31 | Safeguarding Children Referral (see Every Child Matters) |
| 32 | Common Assessment Framework (CAF) Referral (see Every Child Matters) |
| 33 | Other Referrals (include referrals to Genitourinary Medicine clinics, Primary Care, Gynaecology Departments and other Outpatient Services) |
Change to Attribute: Changed Description
The medical condition or reason for a Sexual Health And HIV Episode.
National codes:National Codes:
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| Diagnosis and/or treatment of infection or disease | ||
| Code | Description | Definition/Guidance |
| A1 | Primary syphilis | This refers to primary infectious syphilis. Laboratory confirmation is required. |
| A2 | Secondary syphilis | This refers to secondary infectious syphilis. Laboratory confirmation is required. |
| A3 | Early latent syphilis | This refers to patients who acquired syphilis in the preceding 2 years who have no signs of primary or secondary syphilis. Proof of negative serology within the preceding 2 years is required. |
| A4 | Cardiovascular syphilis | This refers to cardiovascular syphilis. For codes A4-A5, the patient is only coded once in each of these categories in the United Kingdom, i.e. the patient is not given this code again unless there is a new complication. For example, a diagnosis of cardiovascular syphilis after having been diagnosed as a case of late latent syphilis. Therefore patients attending for routine follow up of say, latent syphilis, are not re-coded in this category; and if they attend another clinic elsewhere in the country they are not coded as A4, A5, A6. |
| A5 | Neurosyphilis | This refers to syphilis of the nervous system. For codes A4-A5, the patient is only coded once in each of these categories in the United Kingdom, i.e. the patient is not given this code again unless there is a new complication. For example, a diagnosis of cardiovascular syphilis after having been diagnosed as a case of late latent syphilis. Therefore patients attending for routine follow up of say, latent syphilis, are not re-coded in this category; and if they attend another clinic elsewhere in the country they are not coded as A4, A5, A6. |
| A6 | All other late and latent syphilis | This refers to latent syphilis after the first two years of infection and all other latent syphilis. For codes A4-A5, the patient is only coded once in each of these categories in the United Kingdom, i.e. the patient is not given this code again unless there is a new complication. For example, a diagnosis of cardiovascular syphilis after having been diagnosed as a case of late latent syphilis. Therefore patients attending for routine follow up of say, latent syphilis, are not re-coded in this category; and if they attend another clinic elsewhere in the country they are not coded as A4, A5, A6. |
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| A7 | Congenital syphilis, aged under 2 years (Retired 01 January 2011) | |
| A8 | Congenital syphilis, aged 2 years or over (Retired 01 January 2011) | |
| A9 | Epidemiological treatment of suspected syphilis (Retired 01 January 2011) | This should include all cases where syphilis has not been confirmed, but epidemiological treatment is prescribed because the index patient (the partner) was found to be syphilis positive. |
| A7A | Congenital syphilis | Serological evidence of syphilis in an infant or child and clinical signs consistent with congenital syphilis, for example: Early (<2 years): snuffles, skin and mucous membrane lesions, lymphadenopathy, hepatosplenomegaly. Late (>2 years): gummatous ulcers, interstitial keratitis, optic atrophy, sensorineural deafness, Hutchinson’s incisors. |
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| B1 | Uncomplicated post-pubertal gonorrhoea (Retired 01 January 2011) | This includes all cases of uncomplicated gonorrhoea of the lower genitourinary tract, anorectum, mouth, throat, and adult conjunctivitis. Persistent/recurrent gonorrhoea:Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
| B2 | Uncomplicated Pre-pubertal gonorrhoea (Retired 01 January 2011) | This includes all cases of uncomplicated gonorrhoea of the lower genitourinary tract, anorectum, mouth, throat, and adult conjunctivitis. Persistent/recurrent gonorrhoea:Treatment failures should not be given a new diagnosis, Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
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| B3 | Gonococcal ophthalmia neonatorum (Retired 01 January 2011) | |
| B4 | Epidemiological treatment of suspected gonorrhoea (Retired 01 January 2011) | This should include all cases where gonorrhoea has not been confirmed, but where epidemiological treatment has been prescribed because the index patient (the partner) was found to be infected with gonorrhoea. |
| B5 | Complicated gonococcal infection - including pelvic inflammatory disease and epididymitis Retired 01 January 2011) | This includes all cases of complicated gonorrhoea e.g. upper genitourinary tract complications (such as pelvic inflammatory disease and epididymitis), and systemic complications. Where a patient has complications that are associated with both gonococcal and chlamydial infections, the patient should be included as B5 and as C4B. |
| B | Gonorrhoea | This includes all cases of complicated and uncomplicated gonorrhoea (pre- and post-pubertal) involving any site. Persistent/recurrent gonorrhoea: Treatment failures should not be given a new diagnosis. Treatment failures include those in whom first line antibiotics have failed (for example, symptoms not resolved, antibiotics not taken correctly) and those who have had sexual intercourse with an untreated partner (not a new partner) within 6 weeks. Patients who are thought to be newly infected after a previous episode of gonorrhoea should be regarded as a new GUM episode and be investigated, treated and diagnosed/coded accordingly. |
| C1 | Chancroid | Laboratory confirmation is essential for this condition. |
| C2 | Lymphogranuloma venereum | Laboratory confirmation is essential for this condition. |
| C3 | Donovanosis | Laboratory confirmation is essential for this condition. |
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| C4A | Uncomplicated chlamydial infection of the lower genital tract (Retired 01 January 2011) | This includes all cases of uncomplicated chlamydial infections (diagnosed by culture or antigen detection) involving the lower genitourinary tract. Persistent/recurrent chlamydia:Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
| C4B | Complicated chlamydial infection - including pelvic inflammatory disease and epididymitis (Retired 01 January 2011) | This includes all cases of complicated chlamydial infections e.g. upper genitourinary tract complications (such as pelvic inflammatory disease and epididymitis), perihepatitis and arthritis. Diagnosis may be based on culture, antigen detection or high micro-immunoflourescence titre. Where a patient has complications that are associated with both gonococcal and chlamydial infections, the patient should be included as B5 and as C4B. |
| C4C | Uncomplicated chlamydial infection, other sites (Retired 01 January 2011) | This includes all cases of uncomplicated chlamydial infections (diagnosed by culture or antigen detection) involving all other sites and including adult conjunctivitis. Persistent/recurrent chlamydia:Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly.This includes all cases of complicated chlamydial infections e.g. upper genitourinary tract complications (such as pelvic inflammatory disease and epididymitis), perihepatitis and arthritis. Diagnosis may be based on culture, antigen detection or high micro-immunoflourescence titre. Where a patient has complications that are associated with both gonococcal and chlamydial infections, the patient should be included as B5 and as C4B. |
| C4D | Chlamydial ophthalmia neonatorum (Retired 01 January 2011) | |
| C4E | Epidemiological treatment of suspected chlamydia (Retired 01 January 2011) | This should include all cases where chlamydia has not been confirmed, but where epidemiological treatment has been prescribed because the index patient (the partner) was found to be chlamydia positive. If a male partner presents as a contact of C4A and has non-specific urethritis, he should be coded as C4H only and not C4E. |
| C4H | Uncomplicated non-gonococcal/non-specific urethritis in males, or treatment of mucopurulent cervicitis in females (Retired 01 January 2011) | In males, this is diagnosed in the absence of gonorrhoea and laboratory confirmed chlamydia and the presence of polymorphonuclear leucocytes at >5 per high power field. Also, if a male partner presents as a contact of C4A and has non-specific urethritis, he should be coded as C4H only and not C4E. Females being treated for non-specific mucopurulent cervicitis are also to be coded C4H.Persistent/recurrent urethritis:Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
| C4I | Epidemiological treatment of non-specific genital infection (Retired 01 January 2011) | This diagnosis is used for either males or females; e.g. the female would be diagnosed as C4I if she tested negative for gonorrhoea and chlamydia and is treated because her partner had been diagnosed with uncomplicated or complicated non-specific infection (C4H or C5). Similarly, the male partner is diagnosed as C4I if he tested negative for gonorrhoea and chlamydia and is treated because the female partner has been diagnosed as C4H or C5. |
| C4 | Chlamydial infection | This includes all cases of complicated and uncomplicated Chlamydia trachomatis infections (diagnosed by culture or antigen detection) involving any site. Persistent/recurrent chlamydia: Treatment failures should not be given a new diagnosis. Treatment failures include those in whom first line antibiotics have failed (for example, symptoms not resolved, antibiotics not taken correctly) and those who have had sexual intercourse with an untreated partner (not a new partner) within 6 weeks. Patients who are thought to be newly infected after a previous episode of chlamydia should be regarded as a new GUM episode and be investigated, treated and diagnosed/coded accordingly. |
| C4N | Non-specific genital infection | This includes all cases of complicated and uncomplicated NSGI. In males, this is diagnosed in the absence of gonorrhoea and laboratory confirmed chlamydia and the presence of polymorphonuclear leucocytes at >5 per high power field. Females being treated for non-specific mucopurulent cervicitis are also to be coded C4N. Persistent/recurrent urethritis: Treatment failures should not be given a new diagnosis. Treatment failures include those in whom first line antibiotics have failed (for example, symptoms not resolved, antibiotics not taken correctly) and those who have had sexual intercourse with an untreated partner (not a new partner) within 6 weeks. Patients who are thought to be newly infected after a previous episode of non-specific infection should be regarded as a new GUM episode and be investigated, treated and diagnosed/coded accordingly. |
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| C5 | Complicated infection (non-chlamydial/non-gonococcal) - including pelvic inflammatory disease and epididymitis (Retired 01 January 2011) | This includes all cases of complicated non-specific infections requiring treatment and negative tests for gonorrhoea and chlamydia e.g. upper genitourinary tract complications (such as pelvic inflammatory disease and epididymitis), prostatitis and arthritis. |
| C5A | Pelvic inflammatory disease and epididymitis | This includes all cases of pelvic inflammatory disease and all cases of epididymitis associated with chlamydial, gonococcal or non-specific infections. Can be used with the relevant infection code, where appropriate. Other complications should be coded D2B. |
| C5B | Ophthalmia neonatorum | This includes all cases of ophthalmia neonatorum. Can be used with the relevant infection code. |
| C6A | Trichomoniasis | If associated with bacterial vaginosis then code C6A only should be used. |
| C6B | Anaerobic/Bacterial vaginosis and anaerobic balanitis | Diagnosis of bacterial vaginosis is generally based on microscopy, pH vaginal fluid and the amine test. This diagnosis is very rarely appropriate in males and used only if the patient has confirmed anaerobic balanitis. Other and non-confirmed anaerobic balanitis should be coded as C6C. Asymptomatic patients who do not require treatment should not be coded C6B. |
| C6C | Other vaginosis/vaginitis/ balanitis | |
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| C7A | Anogenital candidosis (Retired 01 January 2011) | This is diagnosed only when there is microscopic or culture evidence of Candida infection. Asymptomatic patients who do not require treatment should not be coded C7A. |
| C7B | Epidemiological treatment of C6 and C7 (Retired 01 January 2011) | This should include all cases where C6 and C7 have not been confirmed, but where epidemiological treatment has been prescribed. |
| C7 | Anogenital candidosis | This is diagnosed only when there is microscopic or culture evidence of Candida infection. If no microbiological evidence then case should be coded as C6C. Asymptomatic patients who do not require treatment should be coded D3. |
| C8 | Scabies | This includes cases treated on either a clinical or epidemiological basis. Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
| C9 | Pediculosis pubis | This includes cases treated on either a clinical or epidemiological basis. Treatment failures should not be given a new diagnosis. Patients who are thought to be re-infected should be regarded as new cases, and investigated, treated and diagnosed/coded accordingly. |
| C10A | Anogenital Herpes simplex: first episode | An episode should be recorded here only if the patient has never (as far as can be ascertained) previously had a confirmed diagnosis with anogenital herpes at any Genitourinary Medicine clinic. Laboratory confirmation is essential. |
| C10B | Anogenital Herpes simplex: recurrence | This should include all other episodes of anogenital herpes. If there has been previous confirmation, then clinical judgement is enough for this diagnosis. |
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| C11A | Anogenital warts infection: first episode | An episode should be recorded here only if the patient has never (as far as can be ascertained) been previously treated for anogenital warts at any Genitourinary Medicine clinic. C11A diagnosis refers to macroscopic warts, not acetowhite patches or abnormalities revealed by acetowhite staining, nor is the cytological finding of wart virus change sufficient to use this code. |
| C11B | Anogenital warts infection: recurrence (Retired 01 January 2011) | This should include patients in whom warts reappeared after a wart-free interval of at least 3 months. C11B diagnosis refers to macroscopic warts, not acetowhite patches or abnormalities revealed by acetowhite staining, nor is the cytological finding of wart virus change sufficient to use this code. |
| C11C | Anogenital warts: Re-registered cases (Retired 01 January 2011) | This is to be used for a patient previously diagnosed as C11A or C11B in whom warts persist and treatment continues for longer than three months, or which recur within 3 months of apparent eradication. This code is not to be re-entered for the same patient more than once every 3 months.C11C diagnosis refers to macroscopic warts, not acetowhite patches or abnormalities revealed by acetowhite staining, nor is the cytological finding of wart virus change sufficient to use this code. |
| C11D | Anogenital warts infection: recurrence | This should include all other episodes of anogenital warts and should only be used once per episode. C11D diagnosis refers to macroscopic warts, not acetowhite patches or abnormalities revealed by acetowhite staining, nor is the cytological finding of wart virus change sufficient to use this code. |
| C12 | Molluscum contagiosum | |
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| C13A | Viral hepatitis B: Hepatitis B surface antigen (HbsAg) positive: First diagnosis (Retired 01 January 2011) | C13A records a first diagnosis of antigen positive hepatitis B. |
| C13B | Viral hepatitis B: Hepatitis B surface antigen (HbsAg) positive: Acute viral hepatitis B at first diagnosis (Retired 01 January 2011) | C13B is a subset of C13A, so that a patient coded C13B must also be coded C13A. C13B records the number of first diagnoses of hepatitis B infections that were acute, where this is known. The definition of acute hepatitis B is newly identified HBsAg positive with Hepatitis B core antigen (anti-HBc) Immunoglobulin M (IgM) positive (>200 iu/l) or discrete onset of jaundice or anicteric illness accompanied by deranged Liver function tests (LFTs) (Aspartate aminotransferase (AST) / Alanine aminotransferase (ALT) >2x normal range) accompanied by HBsAg and Hepatitis B core antigen (anti-HBc) Immunoglobulin M (IgM) positive. |
| C13C | Viral hepatitis B: subsequent presentation (Retired 01 January 2011) | All subsequent presentations of hepatitis B that require management, or known carriers of hepatitis B who present at a clinic for the first time, should be coded as C13C. Subsequent attendances by carriers that are unrelated to hepatitis B management should not be coded as C13C. |
| C13 | Viral hepatitis B (HbsAg positive): First diagnosis | C13 records a first diagnosis of antigen positive hepatitis B. Known carriers of hepatitis B who present at a clinic for the first time should also be coded as C13. All subsequent presentations of hepatitis B that require management should be coded as D2B. Subsequent attendances by carriers that are unrelated to hepatitis B management should not be coded. |
| C14 | Viral hepatitis C: first diagnosis | This code records the first diagnosis of hepatitis C, defined as anti-HCV positive or Hepatitis C virus (HCV) Ribonucleic acid (RNA) positive. All other hepatitis diagnoses should be coded as D2B/D3. |
| C15 | Viral hepatitis A: acute infection | This code records a diagnosis of acute hepatitis A, defined as detection of hepatitis A virus specific IgM antibodies. |
| D2A | Urinary Tract Infection | Includes all patients with a positive culture, otherwise patients should be coded D2B. |
| D2B | Other conditions requiring treatment at GUM clinic | |
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| E1A | New Human Immunodeficiency Virus (HIV) diagnosis: asymptomatic (Retired 01 January 2011) | This is a new HIV diagnosis in a patient without symptoms who is not known to have been diagnosed previously at any Genitourinary Medicine clinic. It includes patients with seroconversion illness. A patient can receive this code only once and it is mutually exclusive of E2A and E3A1. |
| E2A | New Human Immunodeficiency Virus (HIV) diagnosis: symptomatic (not AIDS) (Retired 01 January 2011) | This is a new HIV diagnosis in a patient with symptoms who is not known to have been diagnosed previously at any Genitourinary Medicine clinic. It excludes patients with seroconversion illness (see code E1A). A patient can receive E2A only once and it is mutually exclusive of E1A and E3A1. |
| E1B | Subsequent asymptomatic Human Immunodeficiency Virus (HIV) presentation (not AIDS) (Retired 01 January 2011) | Includes all subsequent presentations by an asymptomatic patient who has been diagnosed with HIV previously (and therefore excludes those with AIDS). The patient should be given this code only once during any quarterly period. |
| E2B | Subsequent symptomatic Human Immunodeficiency Virus (HIV) presentation (not AIDS) (Retired 01 January 2011) | Includes all subsequent presentations by a symptomatic patient who has been diagnosed with HIV previously, but excludes those with AIDS. The patient should be given this code only once during any quarterly period. |
| E3A1 | AIDS: first presentation - new Human Immunodeficiency Virus (HIV) diagnosis (Retired 01 January 2011) | An AIDS diagnosis is used for HIV infected patients with one or more AIDS indicator diseases. It is necessary to discriminate between first AIDS presentations that are also the first HIV diagnosis and those for which HIV was diagnosed previously. E3A1 is a first presentation of AIDS where HIV has not been diagnosed previously. The patient (as far as can be ascertained) should not have been given an HIV or AIDS diagnosis at any clinic in the United Kingdom. This patient cannot be coded E1 or E2 ever again. E3A1 is mutually exclusive of E3A2. |
| E3A2 | AIDS: first presentation - Human Immunodeficiency Virus (HIV) diagnosed previously (Retired 01 January 2011) | E3A2 is a first presentation of AIDS where HIV has been diagnosed previously. The patient (as far as can be ascertained) should not have been given an AIDS diagnoses at any clinic in the United Kingdom. This patient cannot be coded E1 or E2 ever again. E3A2 is mutually exclusive of E3A1. |
| E3B | AIDS: subsequent presentation (Retired 01 January 2011) | The patient who has had an AIDS diagnosis at any time in the past should be given this code only once during any quarterly period and cannot be coded E1, E2 or E3A ever again. |
| H | HIV positive | This code is to be use for first attendances in patients who are known to have previously been diagnosed with HIV infection in any clinical setting but who are not attending specifically for HIV-related care. Codes H, H1, H1A, H1B and H2 are all mutually exclusive. |
| H1 | New HIV diagnosis | This includes all new HIV diagnoses. Codes H, H1, H1A, H1B and H2 are all mutually exclusive. |
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| H1A | New HIV diagnosis: Acute | This includes all new HIV diagnoses which have evidence of one or more of the following in the last 6 months: a) a documented negative HIV test b) laboratory evidence (e.g. RITA assay, RNA, neutralisable p24 antigen and antibody negative), or c) evidence of seroconversion illness. Codes H, H1, H1A, H1B and H2 are all mutually exclusive. |
| H1B | New HIV diagnosis: Late | This includes all new HIV diagnoses which have a clinical AIDS diagnosis within three months of their HIV diagnosis. Codes H, H1, H1A, H1B and H2 are all mutually exclusive. |
| H2 | Attendance for HIV-related care | This includes all attendances relating to HIV care. Codes H, H1, H1A, H1B and H2 are all mutually exclusive. |
| P4A | Cervical cytology: minor abnormality | Includes smears showing lower grades (i.e. borderline or mild) of dyskaryosis on cytological examination. |
| P4B | Cervical cytology: major abnormality | Includes smears showing moderate or worse (i.e. moderate or severe) dyskaryosis on cytological examination. |
| Services Provided The services provided codes are used to code patients receiving services or undergoing tests. | ||
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| S1 | Sexual health screen (no Human Immunodeficiency Virus (HIV) antibody test) (Retired 01 January 2011) | S1 should only be used where a full sexual health screen is given (i.e. including gonorrhoea and chlamydia testing) and should not be used to record tests for recurrent candidosis/ bacterial vaginosis etc. It will be used to count all patients who are given a sexual health screen excluding an HIV test. (This may be because the patient refuses or is not offered an HIV test. However, if the patient is known to be HIV antibody positive, he/she can be coded S1 and one of E1B/E2B/E3A2/E3B). S1 is mutually exclusive of S2 and P1A. |
| S2 | Human Immunodeficiency Virus (HIV) antibody test and sexual health screen (Retired 01 January 2011) | S2 is used to count all patients who are given a sexual health screen including an HIV test. It should only be used where a full sexual health screen is given (i.e. including gonorrhoea and chlamydia testing) and should not be used to record tests for recurrent candidosis/ bacterial vaginosis etc. If the patient tests positive for HIV antibody then they would be coded S2, E1A. S2 is mutually exclusive of S1, P1A and P1B. |
| T1 | Chlamydia test | T1 should be used for patients tested for chlamydia but who are not tested for gonorrhoea or syphilis. T1 is mutually exclusive of T2, T3 and T4 but may be used with P1A, P1B and P1C. |
| T2 | Chlamydia and gonorrhoea tests | T2 should be used to code a sexual health screen which includes gonorrhoea and chlamydia testing but excludes syphilis testing. T2 is mutually exclusive of T1, T3 and T4 but may be used with P1A, P1B and P1C. |
| T3 | Chlamydia, gonorrhoea and syphilis tests | T3 should only be used to code a sexual health screen which includes gonorrhoea, chlamydia and syphilis testing but excludes HIV testing. T3 is mutually exclusive of T1, T2, T4 and P1A but may be used with P1B and P1C. |
| T4 | Full sexual health screen including HIV antibody test | T4 is used to code a full sexual health screen including gonorrhoea, chlamydia, syphilis and HIV testing. T4 is mutually exclusive of T1, T2, T3, P1A, P1B and P1C. |
| P1A | Human Immunodeficiency Virus (HIV) antibody test (no sexual health screen) | This code is to be used for any HIV antibody testing done which is not part of a full sexual health screen as described by code T4. P1A is mutually exclusive of T3, T4, P1B and P1C but may be used with T1 and T2. |
| P1B | Human Immunodeficiency Virus (HIV) antibody test offered and refused | This code refers to all patients offered an HIV test who decline the test even though the clinician believes there is some possible HIV risk that could be screened by testing on that day. The code is used regardless of whether a pre-test discussion or counselling was given, or whether the patient intends to test in the future. P1B is mutually exclusive of T4, P1A and P1C. |
| P1C | HIV test inappropriate | This code is used to describe a patient attendance where an HIV test was not offered because it was not appropriate or was offered but after discussion it was deemed not appropriate e.g. where the patient has been recently tested, is in the ‘window’ period, is already known to be HIV positive etc. |
| ||
| P2 | Hepatitis B vaccination (1st dose only) (Retired 01 January 2011) | Only the 1st dose of any new Hepatitis B vaccination course should be included. This would include those patients who may have been vaccinated some time in the past but are now receiving the first dose of a new course of vaccination. Subsequent doses and boosters should be coded as D2B. |
| P2A | Hepatitis B vaccination: 1st dose | Only the 1st dose of any new Hepatitis B vaccination course should be included. This would include those patients who may have been vaccinated some time in the past but are now receiving the first dose of a new course of vaccination. Subsequent doses should be coded P2B/P2C and boosters should be coded as D2B. |
| P2B | Hepatitis B vaccination: 2nd dose | Includes only the second dose of a Hepatitis B vaccination course, including those who are known to have received a first dose at another clinic. |
| P2C | Hepatitis B vaccination: 3rd dose | Includes only the third dose of a Hepatitis B vaccination course, including those who are known to have received a first and/or second dose at another clinic. |
| P2I | Hepatitis B immune | Includes patients who are ineligible for hepatitis B vaccination because they are already immune. This should only be recorded once, the first time a patient attends a particular clinic, or when first known to be immune. |
| P3 | Contraception (excluding condom provision) | This code will be used to record contraception (females only), including prescribing and sexual and reproductive health advice, and excluding condom provision. |
| P4 | Cervical cytology done | Includes all patients who had cervical cytology done, regardless of outcome. |
| W1 | HPV vaccination: 1st dose | Only the 1st dose of any new human papillomavirus vaccination course should be included. This would include those patients who may have been vaccinated some time in the past but are now receiving the first dose of a new course of vaccination. Subsequent doses should be coded W1/2. |
| W2 | HPV vaccination: 2nd dose | Includes only the second dose of a HPV vaccination course, including those who are known to have received a first dose at another clinic. |
| W3 | HPV vaccination: 3rd dose | Includes only the third dose of a HPV vaccination course, including those who are known to have received a first and/or second dose at another clinic. |
| PN | Partner notification initiated | Level 2 & Level 1 services only: Partner notification has been initiated for this patient by this clinic. |
| PNC | Partner notification: Chlamydia | This should be used for those presenting as a partner of an index case diagnosed with chlamydia (at this or any setting). If the partner is found to be infected with chlamydia he/she should also be coded C4. |
| PNG | Partner notification: Gonorrhoea | This should be used for those presenting as a partner of an index case diagnosed with gonorrhoea (at this or any setting). If the partner is found to be infected with gonorrhoea he/she should also be coded B. |
| PNS | Partner notification: Syphilis | This should be used for those presenting as a partner of an index case diagnosed with syphilis (at this or any setting). If the partner is found to be infected with syphilis he/she should also be coded A1, A2 or A3. |
| PNH | Partner notification: HIV | This should be used for those presenting as a partner of an index case diagnosed with HIV (at this or any setting). If the partner is found to be infected with HIV he/she should also be coded H1, H1A or H1B. |
| PEPS | Post exposure prophylaxis after sexual exposure (PEPSE) | Used for patients given HIV prophylaxis following sexual exposure |
| ||
| ||
| D3 | Other episodes not requiring treatment | D3 is used to code any new patient episode where no treatment is given, whether or not a sexual health screen and/or an HIV test are/is performed. D3 can therefore be used to record an episode where a patient tests negative for all tests done, or where testing the patient is not indicated and otherwise no treatment is given. D3 may also be used to record any other contact with a patient for clinical purposes but which does not result in treatment. Patients who do not attend appointments may be coded D3 if a) they have already been triaged, or b) they have had contact with a health advisor. Otherwise patients who do not attend should not be coded D3. D3 can be used only once per patient episode. |
| Special Patient Groups It is useful to record additional information on certain patient groups receiving services or undergoing tests. Codes to be reported separately at each First Attendance. | ||
| Z | Prisoner | The ‘Z’ code is used to code the provision of a service to a patient known to be a current prisoner. |
| SW | Sex Worker | The ‘SW’ code is used to code the provision of a service to a patient known to be a current sex worker. |
| ||
| Suffixes to Codes For a number of conditions it is useful to record additional information about the patient’s presentation or service given. This information may be collected through the use of suffixes which can be applied to some Sexual Health and HIV Activity Property codes. Where appropriate, multiple suffixes can be used on the same Sexual Health and HIV Activity Property code. The suffixes and the codes with which they can be used are given below. These codes are appended to the Sexual Health and HIV Activity Property Code. | ||
| ||
| ||
| ||
| ||
| ||
| R | Rectal infection | The ‘R’ suffix is added where a diagnosis includes infection of the anorectum. Where the patient is infected at multiple sites including the anorectum the patient need only be coded once using the Sexual Health and HIV code and the ‘R’ suffix. Suffix code may be used with B, C4, C2, C4N |
| O | Pharyngeal infection | The ‘O’ suffix is added where a diagnosis includes a pharyngeal infection but excludes anorectal and genital infections. Suffix code may be used with B, C4, C2 |
| X | Diagnosed previously elsewhere | For use in GUM only: The ‘X’ suffix is added where a patient is known to have been diagnosed with their presenting condition at another non-GUM clinic health setting in the UK before this attendance. Suffix code may be used with B, C4, H1, H1A, H1B |
| M | Medication given | For use in Level 2 & level 1 services only: The patient was given/prescribed treatment at this setting for the presenting condition. The M suffix should be used whether or not the patient is then referred for further management. Suffix code may used with B, C4, C10A, C10B, C11A, C11D. |
| Q | Quadrivalent HPV vaccine | The ‘Q’ suffix is added where a patient being immunised against HPV receives the quadrivalent vaccine. Suffix code may be used with W1, W2, W3 |
| Permissible Code Permutations Using Suffixes | ||
| B - Gonorrhoea | ||
| BR | Rectal infection | |
| BO | Pharayngeal infection | |
| BX | Diagnosed previously elsewhere | |
| BM | Medication given | |
| BRX | Rectal infection, Diagnosed previously elsewhere | |
| BRM | Rectal infection, Medication given | |
| BOX | Pharayngeal infection, Diagnosed previously elsewhere | |
| BOM | Pharayngeal infection, Medication given | |
| C4 - Chlamydia | ||
| C4R | Rectal infection | |
| C4O | Pharayngeal infection | |
| C4X | Diagnosed previously elsewhere | |
| C4M | Medication given | |
| C4RX | Rectal infection, Diagnosed previously elsewhere | |
| C4RM | Rectal infection, Medication given | |
| C4OX | Rectal infection, Diagnosed previously elsewhere | |
| C4OM | Rectal infection, Medication given | |
| C2 - LGV | ||
| C2R | Rectal infection | |
| C2O | Pharayngeal infection | |
| C4N - NSGI | ||
| C4NR | Proctitis | |
| H1 - HIV | ||
| H1X | Diagnosed previously elsewhere | |
| H1A - HIV | ||
| H1AX | Diagnosed previously elsewhere | |
| H1B - HIV | ||
| H1BX | Diagnosed previously elsewhere | |
| C10A - HSV | ||
| C10AM | Medication given | |
| C10B - HSV | ||
| C10BM | Medication given | |
| C11A - Warts | ||
| C11AM | Medication given | |
| C11D - Warts | ||
| C11DM | Medication given | |
| W1 - HPV Vaccine | ||
| W1Q | Quadrivalent Vaccine | |
| W2 - HPV Vaccine | ||
| W2Q | Quadrivalent Vaccine | |
| W3 - HPV Vaccine | ||
| W3Q | Quadrivalent Vaccine | |
| |||
The National Code mapping list to KC60 has been retired from the NHS Data Model and Dictionary as at 01 April 2010 due to the retirement of KC60 which has been replaced by the Genitourinary Medicine Clinic Activity Data Set.
The last live version of KC60 is available in the May 2010 release of the NHS Data Model and Dictionary.
Access to this version can be obtained by emailing datastandards@nhs.net with "NHS Data Model and Dictionary - Archive Request" in the email subject line.
Change to Attribute: Changed Description
The SEXUAL ORIENTATION of a PATIENT.
National codes:National Codes:
| 1 | Heterosexual |
| 2 | Homosexual |
| 3 | Bi-sexual |
| 4 | PERSON asked and does not know or is not sure * |
| Z | Not Stated (PERSON asked but declined to provide a response) * |
Note:
* Code not to be used for the Genitourinary Medicine Clinic Activity Data Set.
These codes have not yet been assured by the Information Standards Board for Health and Social Care.
Change to Attribute: Changed Description
An indicator of whether this lesion is a recurrence of a previous diagnosed lesion.
National codes:National Codes:
| N | New lesion |
| R | Recurrence |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The clinical variant of a T-cell lymphoma which may not be able to be distinguished pathologically.
The coding system used is ICD-O (International Classification of Diseases for Oncology) Morphology coding, with an additional letter to make the code unique.
National codes:National Codes:
| M97003A | Mycosis fungoides |
| M97013A | Sezary syndrome |
| M97003B | Localised MF variants - pagetoid reticulosis (Woringer Kolopp disease) |
| M97003C | Other MF variants - follicular mucinosis |
| M97003D | Other MF variants - granulomatous slack skin |
| M97183A | CD30+ primary cutaneous lymphoproliferative disorders - lymphomatoid papulosis |
| M97183B | CD30+ primary cutaneous lymphoproliferative disorders - primary large cell anaplastic lymphoma |
| M97083A | Subcutaneous panniculitis-like T-cell lymphoma |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The surface area of a T-cell lymphoma classified as T1 or T2.
National codes:National Codes:
| T1 | less than or equal to 10% |
| T2 | greater than 10% |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
The status of a skin cancer tumour at the Cancer Clinical Status Assessment.
National codes:National Codes:
| 1 | Local cutaneous metastases |
| 2 | 'In transit' metastases |
| 3 | Distant cutaneous metastases |
References:
National Cancer Dataset Version 2.1_ISB October 2002
Change to Attribute: Changed Description
National Codes:
| L1 | Employers in large organisations |
| L2 | Higher managerial occupations |
| L3 | Higher professional occupations |
| L4 | Lower professional and higher technical occupations |
| L5 | Lower managerial occupations |
| L6 | Higher supervisory occupations |
| L7 | Intermediate Occupations |
| L8 | Employers in small organisations |
| L9 | Own account workers |
| L10 | Lower supervisory occupations |
| L11 | Lower technical occupations |
| L12 | Semi-routine occupations |
| L13 | Routine occupations |
| L14 | Never worked and long-term unemployed |
| L15 | Full time student |
| L16 | Occupations not stated or inadequately described |
| L17 | Not classifiable for other reasons such as home carer (i.e. looking after children, family or home), sick or disabled and unable to work |
| 090 | Non-employed |
Further guidance on coding can be found at the Office for National Statistics - The National Statistics Socio-economic Classification (NS-SEC).
Change to Attribute: Changed Description
The surgical urgency relating to an operative procedure. A classification based on the National Confidential Enquiry into Perioperative Deaths (NCEPOD) classification of operation urgency. Used for local surgical and anaesthesia audits.
National codes:National Codes:
| 01 | Elective - operation pre-planned at a time to suit both patient and surgeon |
| 02 | Scheduled - an early operation usually within 3 weeks. Often applicable to cancer surgery |
| 03 | Urgent - operation as soon as possible and usually within 24hrs |
| 04 | Immediate - requires immediate surgery without time for preparation or resuscitation |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The time band for the number of hours wait for those PATIENTS where the A AND E ATTENDANCE DISPOSAL is National Code 01 - Admitted to hospital bed/became a LODGED PATIENT of the same Health Care Provider.
This is the number of hours between the A and E ATTENDANCE CONCLUSION TIME to A and E DEPARTURE TIME. This is expressed as below:-
Permitted National Codes:
| 1 | less than 2 hours |
| 2 | 2 to less than 4 hours |
| 3 | 4 or more hours |
| 99 | Time spent not recorded |
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The time band for the number of hours wait between the ARRIVAL TIME and A and E DEPARTURE TIME.
Permitted National Codes:
| 1 | less than 1 hour |
| 2 | 1 to less than 2 hours |
| 3 | 2 to less than 3 hours |
| 4 | 3 to less than 4 hours |
| 5 | 4 hours or more |
| 99 | Time spent not recorded |
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
A code to determine the format of the associated PATIENT USUAL ADDRESS data.
This is necessary whenever an address is included in a CDS message to allow correct interpretation by the recipient. The following values have been used in many CDS message implementations and are recommended to be used: The following values have been used in many CDS message implementations and are recommended to be used.
Permitted National Codes:
| 1 or S | To denote a "Label format" address, i.e. an address consisting of up to five address lines of 35 characters where each line is left justified as a specific data element |
| 2 or U | To denote an unstructured address, i.e. an address consisting of up to five contiguous data elements of 35 characters representing a 175 character string |
Change to Data Element: Changed Description
| Format/length: | n4 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is the code value list of OPCS-4 codes used to:
- monitor specific targets (0001 and 0002), i.e. the "Patients waiting longer than three months (13 weeks) for revascularisation" target and
- monitor waiting times (0003 and 0004) for other cardiovascular related procedures that are not specifically included in the target above.
The groupings are based upon specified OPCS-4 codes as recorded by the CLINICAL CLASSIFICATION CODE of the CLINICAL CLASSIFICATION which is an OPERATIVE PROCEDURE for the PLANNED ACTIVITY of an ELECTIVE ADMISSION LIST ENTRY for a PATIENT being admitted electively.
When the OPCS-4 code of the OPERATIVE PROCEDURE is within the range of the specified ADMISSION INTENDED PROCEDURE for the sub group within the data set, the PATIENT should be included in the count providing all the other criteria of the count are also met.
An Intended Patient Procedure is a PLANNED ACTIVITY where PLANNED ACTIVITY TYPE is National Code 04 'Intended Patient Procedure'.
One of the following values can be set:Permitted National Codes:
| OPCS-4 codes | |
| 0001 | CABG - Coronary Artery Bypass Graft Code Range: K40.- Saphenous vein graft replacement of coronary artery K41.- Other autograft replacement of coronary artery K42.- Allograft replacement of coronary artery K43.- Prosthetic replacement of coronary artery K44.- Other replacement of coronary artery K45.- Connection of thoracic artery to coronary artery K46.- Other bypass of coronary artery |
| 0002 | PTCA - Percutaneous Transluminal Coronary Angioplasty Coding Range: K49.- Transluminal balloon angioplasty of coronary artery Excludes: Percutaneous transluminal balloon angioplasty and insertion of stent into coronary artery (K75) K50.1 Percutaneous transluminal laser coronary angioplasty K75.- Percutaneous transluminal balloon angioplasty and insertion of stent into coronary artery Excludes: Transluminal balloon angioplasty of coronary artery (K49) |
| 0003 | Valves Coding Range Open K25.- Plastic repair of mitral valve K26.- Plastic repair of aortic valve K27.- Plastic repair of tricuspid valve K28.- Plastic repair of pulmonary valve K29.- Plastic repair of unspecified valve of heart K30.- Revision of plastic repair of valve of heart K31.- Open incision of valve of heart K34.- Other open operations on valve of heart Closed K32.- Closed incision of valve of heart Therapeutic transluminal K35.- Therapeutic transluminal operations on valve of heart |
| 0004 | Angiography Coding Range K63.- Contrast radiology of heart K65.- Catheterisation of heart |
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of advanced cardiovascular support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 04 'Advanced Cardiovascular Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of advanced respiratory support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and theACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 02 'Advanced Respiratory Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: | 99 - Not known i.e. date of birth not known |
Notes:
This is derived as the number of completed years between the PERSON BIRTH DATE of the PERSON and the SMOKING QUIT DATE of the PERSON STOP SMOKING EPISODE.
The following values are to be used:Permitted National Codes:
| 01 | Under 18 years of age |
| 02 | 18 to 34 years of age |
| 03 | 35 - 44 years of age |
| 04 | 45 - 59 years of age |
| 05 | 60 and over years of age |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component AGE GROUPS INTENDED is required to be separately recorded.
The following values for the attribute AGE GROUP INTENDED, with the addition of Home Leave, are to be used:Based on the classifications of attribute AGE GROUP INTENDED, with the addition of Home Leave:
Permitted National Codes:
| 1 | Neonates |
| 2 | Children and /or adolescents |
| 3 | Elderly |
| 8 | Any age |
| 9 | Home Leave |
AGE GROUP INTENDED will be replaced with INTENDED AGE GROUP, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | See AMI ADMISSION WARD TYPE |
| Default Codes: | 9 - Unknown |
Notes:
Refers to the unit to which the PATIENT is admitted either from A&E or directly by ambulance service and where PATIENT will spend majority of first 24 hours in hospital. If PATIENT admitted direct to the catheter lab, enter facility to which PATIENT admitted on leaving lab.
Central Cardiac Audit Database (CCAD) item name:
Admission Ward
Change to Data Element: Changed Description
| Format/length: | max 75 characters |
| HES item: | |
| National codes: | See AREA OF WORK NAME |
| Default codes: |
Notes:This is the same as attribute AREA OF WORK NAME.AREA OF WORK NAME is the same as attribute AREA OF WORK NAME.
The area, function or specialty where work activity takes place.
Change to Data Element: Changed Description
| Format/length: | a1 |
| HES item: | |
| National codes | See ASSIGNMENT GROUP CODE |
| Default codes |
Notes:This is the same as attribute ASSIGNMENT GROUP CODE.ASSIGNMENT GROUP CODE is the same as attribute ASSIGNMENT GROUP CODE.
A classification for Non-Medical workforce to identify EMPLOYEES who are GP Practice staff or NHS Direct staff for Non-Medical Workforce Census purposes.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See ASSIGNMENT JOB SHARE INDICATOR |
| Default Codes: | 97 - Not recorded |
| 98 - Not applicable | |
| 99 - Not known |
Notes:This is the same as attribute ASSIGNMENT JOB SHARE INDICATOR.ASSIGNMENT JOB SHARE INDICATOR is the same as attribute ASSIGNMENT JOB SHARE INDICATOR.
An indicator of whether or not an ASSIGNMENT is subject to a Job Share agreement
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes: | See ASSIGNMENT STATUS CODE |
| Default codes: |
Notes:This is the same as attribute ASSIGNMENT STATUS CODE.ASSIGNMENT STATUS CODE is the same as attribute ASSIGNMENT STATUS CODE.
The classification of the status of an ASSIGNMENT, in terms of the nature of the POSITION and the EMPLOYEE appointed to it.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes: | See ASSIGNMENT TYPE CODE |
| Default codes: |
Notes:This is the same as attribute ASSIGNMENT TYPE CODE.ASSIGNMENT TYPE CODE is the same as attribute ASSIGNMENT TYPE CODE.
A classification which indicates whether an EMPLOYEE has a full-time or part-time EMPLOYMENT CONTRACT for the ASSIGNMENT.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of basic cardiovascular support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 03 'Basic Cardiovascular Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of basic respiratory support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 01 'Basic Respiratory Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/Length: | an2 |
| HES Item: | |
| National Codes: | |
| Default Codes: | 99 - unknown |
Notes:
CANCER CARE SETTING (TREATMENT) is the type of care setting where the cancer care relating to the TREATMENT START DATE (CANCER) took place.
Where the care is delivered during a Hospital Provider Spell, distinction is made between care delivered as part of an ordinary admission (where the PATIENT CLASSIFICATION is National Code 1 - Ordinary Admission) and a day case admission (where PATIENT CLASSIFICATION is National Code 2 - Day case admission).
National Codes:Permitted National Codes:
| 01 | Cancer treatment delivered as part of a Hospital Provider Spell (where PATIENT CLASSIFICATION is National code 1 - Ordinary admission) |
| 02 | Cancer treatment delivered as part of a Hospital Provider Spell (where PATIENT CLASSIFICATION is National Code 2 - Day case admission) |
| 03 | Cancer treatment delivered in an Out-patient setting |
| 04 | Cancer treatment delivered in another care setting |
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
This indicates whether the Interchange is a production or test Interchange.
Permitted National Codes:
| 1 | The whole Interchange contains Test data |
| 0 (zero) | The whole Interchange contains Production data |
| Other Blank Null | The whole Interchange contains Production data |
Usage:
This optional test facility enables interchanges submitted to be marked and therefore processed as Test or Production data.Whilst the data element is optional it is highly recommended that correct values be completed in the data.
On receipt of a Test Interchange, the processes are as follows:
a) All normal validation processes will be carried out
b) The Interchange data will not be entered into the Secondary Uses Service database
CDS-XML Interchanges:
All CDS-XML interchanges submitted may contain a CDS INTERCHANGE TEST INDICATOR.Change to Data Element: Changed Description
| Format/length: | an6 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
This is a recommended data element and should be used to indicate the type of message within an Interchange.
Recommended values are:Permitted National Codes:
| NHSCDS | CDS Message |
Usage:
Interchanges should only contain multiple message of the same CDS MESSAGE TYPE.
Change to Data Element: Changed Description
| Format/length: | an6 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
This is a mandatory data element and reflects the version number of the message in use. Message version numbers are updated as required during the on-going message development processes.
Permitted values are:Permitted National Codes:
| NHS003 | The 2000 / 2001 Specification | ||
| NHS004 | The 2004 / 2005 CDS-XML Specification | ||
| NHS005 | The 2005 / 2006 CDS-XML Specification | For implementation of XML messaging in the Secondary Uses Service | |
| CDS006 | The 2007 CDS-XML Specification | Note the change to the prefix CDS |
Usage:
Interchanges must only contain CDS Messages of the same CDS MESSAGE VERSION NUMBER and each and every CDS TYPE must contain a CDS MESSAGE VERSION NUMBER.
Change to Data Element: Changed Description
| Format/length: | an3 or an5 |
| HES item: | |
| National Codes: | See ORGANISATION CODE |
| ODS Default Codes: | Q99 - Primary Care Trust of residence not known (Note: this code must not be used in the Commissioning Data Set (CDS) header. It is not a default Commissioner code.) |
| TDH00 - Overseas Visitor exempt from charges | |
| X98 - Primary Care Trust code not applicable (e.g. Overseas Visitors, Wales, Scotland or Northern Ireland). (Note: this code must not be used in the Commissioning Data Set (CDS) header. It is not a default Commissioner code.) |
Notes:
CDS PRIME RECIPIENT IDENTITY is the mandatory NHS ORGANISATION CODE (or valid Organisation Data Service Default Code) representing the ORGANISATION determined to be the Commissioning Data Set Prime Recipient of the Commissioning Data Set Message as indicated in the Commissioning Data Set Addressing Grid.
Usage:
The CDS PRIME RECIPIENT IDENTITY must be allocated on the first creation and submission of a CDS TYPE for a PATIENT and must not change even if the ADDRESS or Primary Care Trust of the PATIENT changes during the lifetime of the Commissioning Data Set record otherwise duplicate Commissioning Data Set data may be lodged in the Secondary Uses Service database.
In other specific circumstances, Organisation Data Service Default Codes are recommended as defined in the Commissioning Data Set Addressing Grid. This is a mandatory data item crucial for the correct indexing of the database and must not be changed during the life of the associated Commissioning Data Set. It does not identify the first or most important recipient of data, i.e. there is no inference of primacy of one recipient over another.
Change to Data Element: Changed Description
| Format/length: | n3 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
A code to identify the Commissioning Data Set Submission Protocol associated with the transaction.
Permitted values are:Permitted National Codes:
| 010 | Net Change Update Mechanism (This is the recommended Protocol for Commissioning Data Set submissions) |
| 020 | Bulk Replacement Update Mechanism |
Usage:
This is a mandatory data item for the processing of Commissioning Data Set data.See the supporting information in the Commissioning Data Set Submission Protocol for more details.
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This function is not supported by the Secondary Uses Service and must not be used.
Permitted values are:Permitted values are:
| CODE | CLASSIFICATION |
| T | The CDS Message contains Test CDS data |
| Other | The CDS Message contains production CDS data |
Usage:
a) Delivery of the test record to the receiver as addressed;a) Delivery of the test record to the receiver as addressed;
b) The test-marked record will not be entered into the database;
c) Delivery of all other records to the receiver as addressed;
d) All non-test marked records will be entered into the database.
Production Commissioning Data Set submissions must not be marked as a Test.Production Commissioning Data Set submissions must not be marked as a Test.
It is strongly recommended that Test and Production Commissioning Data Set data are not mixed in the same interchange. A further test facility exists where the whole CDS Interchange is marked as Test by setting the CDS INTERCHANGE TEST INDICATOR in the CDS Interchange Header.It is strongly recommended that Test and Production Commissioning Data Set data are not mixed in the same interchange. A further test facility exists where the whole CDS Interchange is marked as Test by setting the CDS INTERCHANGE TEST INDICATOR in the CDS Interchange Header.
Change to Data Element: Changed Description
| Format/length: | n3 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
A code to identify the specific type of Commissioning Data Set data.
Permitted values are:Permitted National Codes:
| 010 | Accident and Emergency Attendance |
| 020 | Outpatient (Known in the Schema as Care Activity from CDS v6) May also be used to submit a Referral To Treatment Clock Stop Administrative Event |
| 021 | Future Outpatient (Introduced in CDS Version 6 - known in the Schema as Future Care Activity) |
| 030 | Elective Admission List End of Period Census (Standard) |
| 040 | Elective Admission List End of Period Census (Old) |
| 050 | Elective Admission List End of Period Census (New) |
| 060 | Elective Admission List Event During Period (Add) |
| 070 | Elective Admission List Event During Period (Remove) |
| 080 | Elective Admission List Event During Period (Offer) |
| 090 | Elective Admission List Event During Period (Available/Unavailable) |
| 100 | Elective Admission List Event During Period (Old Service Agreement) |
| 110 | Elective Admission List Event During Period (New Service Agreement) |
| 120 | Finished Birth Episode |
| 130 | Finished General Episode |
| 140 | Finished Delivery Episode |
| 150 | Other Birth |
| 160 | Other Delivery |
| 170 | Detained and/or Long-Term Psychiatric Census |
| 180 | Unfinished Birth Episode |
| 190 | Unfinished General Episode |
| 200 | Unfinished Delivery Episode |
Usage:
This is a mandatory data element for the processing of Commissioning Data Set data.
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
A code to indicate the required database update process for the submitted CDS Message.
Permitted values are:Permitted National Codes:
| 1 | To indicate a CDS Deletion or Cancellation |
| 9 | To indicate a CDS Original or Replacement |
Usage:
This is a mandatory data item when using the Net Change Update Mechanism. It is not required when using the Bulk Replacement Update Mechanism.
Change to Data Element: Changed Description
| Format/length: | an6 |
| HES item: | |
| National Codes: | See ORGANISATION CODE |
| ODS Default Codes: | V81997 - No Registered GP Practice |
| V81998 - GP Practice Code not applicable | |
| V81999 - GP Practice Code not known |
Notes:
This is the ORGANISATION CODE of the GP Practice from which the referral is made.
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
This is derived from the presence of COLORECTAL OR STOMA NURSE SEEN DATE.
National codes:Permitted National Codes:
| Y | Yes |
| N | No |
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This indicates whether a Central Information Requirement Data Set and the data it contains is a submission from the ORGANISATION in the role of commissioner of care or provider of care.
One of the following values can be used:Permitted National Codes:
| 01 | Commissioner submission |
| 02 | Provider submission |
Change to Data Element: Changed Description
| Format/length: | an6 |
| HES item: | |
| National Codes: | |
| Default Codes: | 99 - Not known |
Notes:
This is PATIENT DIAGNOSIS with a PATIENT DIAGNOSIS CODING SIGNIFICANCE of not 'Primary'.
This is primarily to record whether the patient has Pancreatitis in the Cancer Care Spell.
See DIAGNOSTIC CODING for details on coding.
Cancer Care Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 05 'Cancer Care Spell'.
Change to Data Element: Changed Description
| Format/length: | an175 (5 lines each an35) |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is the correspondence ADDRESS (ADDRESS STRUCTURED) nominated by a PERSON, with ADDRESS ASSOCIATION TYPE of 'correspondence'. CORRESPONDENCE ADDRESS will consist of BUILDING NAME, BUILDING NUMBER, STREET OR ROAD NAME, POST TOWN, POSTAL COUNTY.
For a REFERRAL REQUEST, a contact address is specifically for that referral. This allows any correspondence about the referral to be directed appropriately. The CORRESPONDENCE ADDRESS need not be the initiator's practice address.
Change to Data Element: Changed Description
| Format/length: | See COUNTRY CODE |
| HES item: | |
| National Codes: | |
| Default Codes: | 97 - Not recorded 99 - Not known |
Notes:
COUNTRY CODE (AT ASSIGNMENT) is the same as attribute COUNTRY CODE.
The nationality of the EMPLOYEE as declared by the individual on appointment for an ASSIGNMENT to a POSITION or as advised by the individual in the course of employment (should they change their nationality).
This is the COUNTRY CODE of the COUNTRY where the NATIONALITY INDICATOR of NATIONALITY OR RESIDENCY is National Code 01 'National of the respective country at birth and still a national' or 03 'National of respective country subsequent to birth and still a national'.
For Electronic Staff Record and National Workforce Data Set usage only one nationality can be identified so in the case of dual nationality, the EMPLOYEE should choose the preferred COUNTRY for recording their nationality.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more level 2 days |
| 999 - level 2 days occurred but day count not known |
Notes:
The total number of days a PATIENT received level 2 care during a CRITICAL CARE PERIOD. From 000 to 997 days can be recorded; if 998 or more days have occurred the default code should be used.
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the CRITICAL CARE LEVEL is National Code 02 'Level 2' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more level 3 days |
| 999 - level 3 days occurred but day count not known |
Notes:
The total number of days a PATIENT received level 3 care during a CRITICAL CARE PERIOD. From 000 to 997 days can be recorded; if 998 or more days have occurred the default code should be used.
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the CRITICAL CARE LEVEL is National Code 03 'Level 3' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/Length: | an3 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The identifier for the three Maternity and Children's Data Sets which support the National Service Framework for Children Young People and Maternity Services.
National Codes:Permitted National Codes:
| MAT | Maternity Services Secondary Uses Data Set |
| CAM | Child and Adolescent Mental Health Services Secondary Uses Data Set |
| CYP | Children and Young People's Health Services Secondary Uses Data Set |
Change to Data Element: Changed Description
| Format/Length: | an3 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
This is the identifier of the type of row of data carried in a data submission file for one of the three Maternity and Children's Data Sets which support the National Service Framework for Children Young People and Maternity Services (Maternity Services Secondary Uses Data Set, Children and Young People's Health Services Secondary Uses Data Set or Child and Adolescent Mental Health Services Secondary Uses Data Set).
See Maternity and Childrens Data Sets Submission Requirements for usage requirements.
National Codes:Permitted National Codes:
| HDR | Data Set File Header Row |
| TRL | Data Set File Footer Row |
Change to Data Element: Changed Description
| Format/Length: | an6 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The segment identifier for the Child and Adolescent Mental Health Services Secondary Uses Data Set, which is one of the three Maternity and Children's Data Sets which support the National Service Framework for Children Young People and Maternity Services.
National Codes:Permitted National Codes:
| CAM010 |
Change to Data Element: Changed Description
| Format/Length: | an6 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The segment identifier for the National Children's and Young People's Health Services Secondary Uses Data Set, which is one of the three Maternity and Children's Data Sets which support the National Service Framework for Children Young People and Maternity Services.
National Codes:Permitted National Codes:
| CYP010 |
Change to Data Element: Changed Description
| Format/Length: | an6 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The segment identifier for the Maternity Services Secondary Uses Data Set, which is one of the three Maternity and Children's Data Sets which support the National Service Framework for Children Young People and Maternity Services.
National Codes:Permitted National Codes:
| MAT010 |
Change to Data Element: Changed Description
| Format/Length: | an19 YYYY-MM-DDThh:mm:ss |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care
Notes:
The combined date and time of an event.
This is the e-Government Interoperability Framework (e-GIF) standard for Date and Time, but not including the Time Zone Designator. As an example this is presented as 2009-12-02T14:20:20.
References:
The e-GIF version approved for use in NHS England is:
Government Data Standards Catalogue: (GDSC), Version 1.0, Agreed 23 November 2004.
GDSC: http://www.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards.aspx.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Permitted National Codes:
| 1 | Date supplied |
| 8 | Date not applicable |
| 9 | Date not known |
Change to Data Element: Changed Description
| Format/length: | n |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
DAY CARE ATTENDANCE MH NON-NHS SITE INDICATOR is an indicator of whether or not:
| a. | one or more Day Care Attendance at Day Care Session within the Adult Mental Health Care Spell has occurred during the REPORTING PERIOD | |
| and | ||
| b. | where the ATTENDED OR DID NOT ATTEND is National Code 5 'Attended on time or, if late, before the relevant health care professional was ready to see the patient' or 6 'Arrived late, after the relevant health care professional was ready to see the patient, but was seen' | |
| and | ||
| c. | where the DAY CARE FUNCTION classification is e. 'Mental illness' | |
| and | ||
| d. | where the FACILITY TYPE of the Day Care Facility is c. 'Facilities financed, planned and run solely by non-NHS organisations. Staffing is solely by non-NHS employees'. | |
Permitted National Codes:
| 0 | no attendance at a Non-NHS Day Care Facility occurred during the REPORTING PERIOD | |
| 1 | one or more attendances at a Non-NHS Day Care Facility occurred during the REPORTING PERIOD | |
Day Care Attendance is a CARE CONTACT where CARE CONTACT TYPE is National Code 12 'Day Care Attendance'.
Day Care Session is a SESSION where CLINIC OR FACILITY FREQUENCY is National Code 02 'Day Care Session'.
Adult Mental Health Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 23 'Adult Mental Health Care Spell'.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of dermatological support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 08 'Dermatological Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is used in the Clinical Information Group of the Commissioning Data Set to denote the code scheme basis of the Diagnosis.
Permitted values are:Permitted National Codes:
| 01 | Accident & Emergency Diagnosis |
| 02 | ICD-10 |
| 03 | Read Code 4Byte Version (retired 1 October 2009) |
| 04 | Read Code Version 2 |
| 05 | Read Code Clinical Terms Version 3 (CTV3) |
Read Code Clinical Terms Version 3 (CTV3) with qualifiers (previously known as 3.1) is not supported in the Commissioning Data Sets.
CDS-XML Message:
The codes specified above must be used in Commissioning Data Set - XML messages.
Change to Data Element: Changed Description
| Format/length: | an7 for The Read Codes |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Records the DIAGNOSTIC CODING identified in the following relevant conditions and complication associated with the diabetic condition:
Read Codes (diagnosis)
| DKA (Hyperglycaemic emergencies) 4Byte Version (retired 1 October 2009) | |
| C2.. | Diabetes mellitus (retired 1 October 2009) Ketoacidosis - diabetic (synonym) (retired 1 October 2009) |
| C24. | Diabetes mellitus + ketoacidosis - no coma (retired 1 October 2009) |
| C25. | Diabetes with coma (retired 1 October 2009) |
| Version 2 | |
| C101. | Diabetes mellitus with ketoacidosis |
| C1010 | Diabetes mellitus, juvenile type, with ketoacidosis |
| C1011 | Diabetes mellitus, adult onset, with ketoacidosis |
| C101y | Other specified diabetes mellitus with ketoacidosis |
| C101z | Diabetes mellitus NOS with ketoacidosis |
| ANGINA 4Byte Version (retired 1 October 2009) | |
| G44. | Angina pectoris (retired 1 October 2009) |
| G440 | Unstable angina (retired 1 October 2009) |
| G444 | Stable angina (retired 1 October 2009) |
| Version 2 | |
| G3111 | Unstable angina |
| G33.. | Angina pectoris |
| G33z. | Angina pectoris NOS |
| G33z7 | Stable angina |
| MI (Myocardial Infarction) 4Byte Version (retired 1 October 2009) | |
| G6A. | Heart failure (preferred term) (retired 1 October 2009) Cardiac failure (synonym) (retired 1 October 2009) |
| G6A1 | Congestive cardiac failure (retired 1 October 2009) |
| Version 2 | |
| G58.. | Heart failure (preferred term) Cardiac failure (synonym) |
| G580. | Congestive cardiac failure |
| CVA (Stroke/Cerebro-Vascular Accident) 4Byte Version (retired 1 October 2009) | |
| G7.. | Cerebrovascular disease (retired 1 October 2009) |
| G712 | Intracerebral haemorrhage (retired 1 October 2009) |
| G73. | Cerebral arterial occlusion (retired 1 October 2009) |
| G75. | Stroke/CVA undefined (retired 1 October 2009) |
| Version 2 | |
| G6... | Cerebrovascular disease |
| G61.. | Intracerebral haemorrhage |
| G64.. | Cerebral arterial occlusion |
| G66.. | Stroke/CVA unspecified |
| RRT (End stage renal failure requiring renal replacement therapy) 4Byte Version (retired 1 October 2009) | |
| J16. | Chronic renal failure (preferred term) (retired 1 October 2009) End stage renal failure (synonym) (retired 1 October 2009) |
| Version 2 | |
| K050. | End stage renal failure |
Change to Data Element: Changed Description
| Format/length: | character 6 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The time band for reporting on Diagnostics Waiting Times and Activity Data Set and Diagnostics Waiting Times Census Data Set.
For monthly reporting of diagnostic waiting times and activity, this is expressed as below:For monthly reporting of diagnostic waiting times and activity:
Permitted National Codes:
| 00-<01 | less than 1 week |
| 01-<02 | 1 to less than 2 weeks |
| 02-<03 | 2 weeks to less than 3 weeks |
| 03-<04 | 3 weeks to less than 4 weeks |
| 04-<05 | 4 weeks to less than 5 weeks |
| 05-<06 | 5 weeks to less than 6 weeks |
| 06-<07 | 6 weeks to less than 7 weeks |
| 07-<08 | 7 weeks to less than 8 weeks |
| 08-<09 | 8 weeks to less than 9 weeks |
| 09-<10 | 9 weeks to less than 10 weeks |
| 10-<11 | 10 weeks to less than 11 weeks |
| 11-<12 | 11 weeks to less than 12 weeks |
| 12-<13 | 12 weeks to less than 13 weeks |
| 13+ | 13 weeks or more |
For the diagnostic waiting times census, this is expressed as below:For the diagnostic waiting times census:
Permitted National Codes:
| 06-<13 | 6 weeks to less than 13 weeks |
| 13+ | 13 weeks or more |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from CLINICAL INTERVENTION whether an echocardiography was performed during the Hospital Provider Spell within the Acute Myocardial Infarction Care Spell or is planned after admission and recorded as Therapy After Discharge with DISCHARGE THERAPY TYPE 'echocardiology'.
Permitted National Codes:
| 0 | No |
| 1 | Yes |
| 2 | Planned after admission |
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Acute Myocardial Infarction Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National code 02 'Acute Myocardial Infarction Care Spell'.
Therapy After Discharge is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 31 'Therapy After Discharge'.
The derived values are:
Central Cardiac Audit Database (CCAD) item name:
Echocardiography
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: | 99 - Not known: a validation error |
Notes:
This data item is derived and indicates whether a PATIENT is available for treatment or suspended from the ELECTIVE ADMISSION LIST for medical or social reasons.
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 01 | Patient is available for treatment |
| 02 | Patient is not available for treatment (e.g. suspended for medical or social reasons) |
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | EMPLOYEE DISABILITY STATUS CODE |
| Default Codes: | 97 - Not recorded |
| 98 - Not applicable | |
| 99 - Not known |
Notes:
This is the same as attribute EMPLOYEE DISABILITY STATUS CODE.
An indicator to denote whether or not an EMPLOYEE considers that they are disabled.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See EMPLOYMENT CONTRACT SESSION TYPE CODE |
| Default Codes: | 97 - Not recorded |
| 99 - Not known |
Notes:
This is the same as attribute EMPLOYMENT CONTRACT SESSION TYPE CODE.
A description of the type of session specified in an EMPLOYMENT CONTRACT.
Change to Data Element: Changed Description
| Format/length: | an4 |
| HES item: | |
| National codes: | |
| Default codes: |
Notes:
This is the same as attribute EMPLOYMENT CONTRACT WORKING HOURS. EMPLOYMENT CONTRACT WORKING HOURS is reported as a real number, including decimal point and 2 decimal places.
The number of hours an EMPLOYEE is contracted to work for an ORGANISATION in an ASSIGNMENT.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes | See EMPLOYMENT HISTORY EXIT INTERVIEW INDICATOR |
| Default codes | 97 - Not recorded |
| 99 - Not known |
Notes:
This is the same as attribute EMPLOYMENT HISTORY EXIT INTERVIEW INDICATOR.
An indicator to denote whether or not an Exit Interview has taken place prior to an EMPLOYEE leaving employment with an NHS ORGANISATION.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes | See EMPLOYMENT HISTORY EXIT QUESTIONNAIRE INDICATOR |
| Default codes | 97 - Not recorded |
| 99 - Not known |
Notes:
This is the same as attribute EMPLOYMENT HISTORY EXIT QUESTIONNAIRE INDICATOR.
An indicator to denote whether or not an EMPLOYEE has completed an Exit Questionnaire prior to leaving employment with an NHS ORGANISATION.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See EMPLOYMENT HISTORY RECRUITMENT SOURCE CODE |
| Default Codes: |
Notes:This is the same as attribute EMPLOYMENT HISTORY RECRUITMENT SOURCE CODE.EMPLOYMENT HISTORY RECRUITMENT SOURCE CODE is the same as attribute EMPLOYMENT HISTORY RECRUITMENT SOURCE CODE.
The classification of the source of recruitment of an EMPLOYEE immediately prior to joining an employing ORGANISATION.
If the EMPLOYEE has been employed, the type of employer, or 'Self Employed', is recorded.
Where the EMPLOYEE has come from abroad, whether employed or not, the source or recruitment indicates whether the respective country is within the EU or outside the EU.
Where the EMPLOYEE was not employed, the source of recruitment indicates whether the EMPLOYEE is Newly Qualified, has undertaken some other form of Education/Training, is Returning to Practice, or was otherwise not employed.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Not given |
Notes:
ETHNIC GROUP is the old classification of ethnicity replaced by ETHNIC CATEGORY CODE.
New ethnic categories defined in the 2001 census have become the national mandatory standard for the collection of ethnicity. These new ethnic categories have replaced the existing categories of ethnic data as classified by ETHNIC GROUP but there will be a period where both may need to co-exist at the same time.
Note: ETHNIC CATEGORY CODE should be used when classifying people from 01/04/2001 and in the Commissioning Data Sets.
ETHNIC GROUP classifies the ethnicity of a PERSON, as specified by the PERSON. The classification was used in the 1991 census, and will exist in parallel with ETHNIC CATEGORY CODE for some time.
Permitted National Codes:
| 0 | White |
| 1 | Black - Caribbean |
| 2 | Black - African |
| 3 | Black - Other |
| 4 | Indian |
| 5 | Pakistani |
| 6 | Bangladeshi |
| 7 | Chinese |
| 8 | Any other ethnic group |
When recording Ethnic Group in a 2-digit field, the national code should be entered as the left digit. In order to avoid coding errors, providers collecting ethnic group to the national standard with no further detail are advised to add 0 (zero) after the national code.
Code 8 does not carry the standard default meaning of Not applicable.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from whether an exercise test was performed during the Hospital Provider Spell within the Acute Myocardial Infarction Care Spell or is planned after admission and recorded as Therapy After Discharge where DISCHARGE THERAPY TYPE of CLINICAL INTERVENTION is National Code 02 'Exercise Test'.
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Acute Myocardial Infarction Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 02 'Acute Myocardial Infarction Care Spell'.
Therapy After Discharge is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 31 'Therapy After Discharge'.
The derived values are:Permitted National Codes:
| 0 | - No |
| 1 | - Yes |
| 2 | - Planned after admission |
Central Cardiac Audit Database (CCAD) item name:
Exercise Test
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
A typing for use when ordering and classifying reporting information on the Legal Status i.e. the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE, at the point of admission to a Hospital Provider Spell of PATIENTS detained under the Mental Health Act or other acts.
Each set value represents a row on a central return data set, for example the Patients Detained In Hospital Or On Supervised Community Treatment Data Set (KP90), and should be used to populate a recorded number or total for a entry on the row.
The set values are:Permitted National Codes:
| 01 | LEGAL STATUS CLASSIFICATION CODE 02 Section 2 |
| 02 | LEGAL STATUS CLASSIFICATION CODE 03 Section 3 |
| 03 | LEGAL STATUS CLASSIFICATION CODE 03 Section 3 and admitted whilst a Supervised Discharge Episode not ended at date of admission note this will no longer apply after 2nd November 2008 |
| 04 | LEGAL STATUS CLASSIFICATION CODE 04 Section 4 |
| 05 | LEGAL STATUS CLASSIFICATION CODE 07 Section 35 |
| 06 | LEGAL STATUS CLASSIFICATION CODE 08 Section 36 |
| 07 | LEGAL STATUS CLASSIFICATION CODE 09 Section 37 with Section 41 restrictions |
| 08 | LEGAL STATUS CLASSIFICATION CODE 10 Section 37 |
| 09 | LEGAL STATUS CLASSIFICATION CODE 34 Section 45A |
| 10 | LEGAL STATUS CLASSIFICATION CODE 15 Section 47 with Section 49 restrictions |
| 11 | LEGAL STATUS CLASSIFICATION CODE 16 Section 47 |
| 12 | LEGAL STATUS CLASSIFICATION CODE 17 Section 48 with Section 49 restrictions |
| 13 | LEGAL STATUS CLASSIFICATION CODE 18 Section 48 |
| 14 | LEGAL STATUS CLASSIFICATION CODE 19 Section 135 only include those patients for whom the place of safety was the hospital |
| 15 | LEGAL STATUS CLASSIFICATION CODE 20 Section 136 only include those patients for whom the place of safety was the hospital |
| 16 | LEGAL STATUS CLASSIFICATION CODES 12, 13 and 14 Sections 38, 44 and 46 |
| 17 | LEGAL STATUS CLASSIFICATION CODES 31 and 32 formally detained under other acts |
Hospital Provider Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of gastro-intestinal support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 07 'Gastrointestinal Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
HOME HELP VISIT INDICATOR is an indicator of whether or not one or more Home Help Visit within the Adult Mental Health Care Spell has occurred during the REPORTING PERIOD.
Home Help Visit is a CARE CONTACT where CARE CONTACT TYPE is National Code 35 'Home Help Visit'.
Adult Mental Health Care Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 23 'Adult Mental Health Care Spell'.
Recorded as:Permitted National Codes:
| 0 | no Home Help Visit occurred during the REPORTING PERIOD |
| 1 | one or more Home Help Visit occurred during the REPORTING PERIOD |
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | See AGE GROUP INTENDED |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component AGE GROUPS INTENDED is required to be separately recorded.
The following values for the attribute AGE GROUP INTENDED, with the addition of Home Leave, are to be used:Based on the classifications of attribute AGE GROUP INTENDED, with the addition of Home Leave:
Permitted National Codes:
| 1 | Neonates |
| 2 | Children and /or adolescents |
| 3 | Elderly |
| 8 | Any age |
| 9 | Home Leave |
INTENDED AGE GROUP replaces AGE GROUP INTENDED and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See CLINICAL CARE INTENSITY |
| Default Codes: |
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component INTENDED CLINICAL CARE INTENSITY is required to be separately recorded.
INTENDED CLINICAL CARE INTENSITY is the same as attribute CLINICAL CARE INTENSITY and the values recorded within the Commissioning Data Set messages are the National Codes contained within the definition of CLINICAL CARE INTENSITY, but with the addition of:INTENDED CLINICAL CARE INTENSITY is the same as attribute CLINICAL CARE INTENSITY, and the values recorded within the Commissioning Data Set messages are the National Codes contained within the definition of CLINICAL CARE INTENSITY, including additions:
| For patients with mental illness | |
| 51 | for intensive care: specially designated ward for patients needing containment and more intensive management. This is not to be confused with intensive nursing where a patients may require one to one nursing while on a standard ward |
| 52 | for short stay: patients intended to stay less than a year |
| 53 | for long stay: patients intended to stay a year or more |
| For patients with learning disabilities | |
| 61 | designated or interim secure unit |
| 62 | patients intending to stay less than a year |
| 63 | patients intending to stay a year or more |
| For maternity patients | |
| 41 | only for patients looked after by consultants |
| 43 | only for patients looked after by General Medical Practitioners |
| 42 | for joint use by consultants & General Medical Practitioners |
| For neonates | |
| 33 | maternity: associated with the maternity ward in that cots are in the maternity ward nursery or in the ward itself |
| 32 | non-maternity: not associated with the maternity ward and without designated cots for intensive care |
| 31 | not associated with the maternity ward and in which there are some designated cots for intensive care |
| For the younger physically disabled | |
| 21 | spinal units, only those units which are nationally recognised |
| 22 | other units |
| For terminally ill/palliative care | |
| 81 | terminally ill/palliative care |
| For general patients | |
| 11 | for intensive therapy, including high dependency care |
| 12 | for normal therapy: where resources permit the admission of patients who might need all but intensive or high dependency therapy |
| 13 | for limited therapy: where nursing care rather than continuous medical care is provided. Such wards can be used only for patients carefully selected and restricted to a narrow range in terms of the extent and nature of disease |
| additional codes | |
| 71 | Home Leave, non-psychiatric |
| 72 | Home Leave, psychiatric |
INTENDED CLINICAL CARE INTENSITY will be replaced with INTENDED CLINICAL CARE INTENSITY CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an2 |
| HES Item: | |
| National Codes: | See CLINICAL CARE INTENSITY |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component INTENDED CLINICAL CARE INTENSITY CODE is required to be separately recorded.
INTENDED CLINICAL CARE INTENSITY CODE is the same as attribute CLINICAL CARE INTENSITY and the values recorded are the National Codes contained within the definition of CLINICAL CARE INTENSITY, but with the addition of:INTENDED CLINICAL CARE INTENSITY CODE is the same as attribute CLINICAL CARE INTENSITY and the values recorded are the National Codes contained within the definition of CLINICAL CARE INTENSITY, including additions:
| For patients with mental illness | |
| 51 | for intensive care: specially designated ward for patients needing containment and more intensive management. This is not to be confused with intensive nursing where a patients may require one to one nursing while on a standard ward |
| 52 | for short stay: patients intended to stay less than a year |
| 53 | for long stay: patients intended to stay a year or more |
| For patients with learning disabilities | |
| 61 | designated or interim secure unit |
| 62 | patients intending to stay less than a year |
| 63 | patients intending to stay a year or more |
| For maternity patients | |
| 41 | only for patients looked after by consultants |
| 43 | only for patients looked after by General Medical Practitioners |
| 42 | for joint use by consultants & General Medical Practitioners |
| For neonates | |
| 33 | maternity: associated with the maternity ward in that cots are in the maternity ward nursery or in the ward itself |
| 32 | non-maternity: not associated with the maternity ward and without designated cots for intensive care |
| 31 | not associated with the maternity ward and in which there are some designated cots for intensive care |
| For the younger physically disabled | |
| 21 | spinal units, only those units which are nationally recognised |
| 22 | other units |
| For terminally ill/palliative care | |
| 81 | terminally ill/palliative care |
| For general patients | |
| 11 | for intensive therapy, including high dependency care |
| 12 | for normal therapy: where resources permit the admission of patients who might need all but intensive or high dependency therapy |
| 13 | for limited therapy: where nursing care rather than continuous medical care is provided. Such wards can be used only for patients carefully selected and restricted to a narrow range in terms of the extent and nature of disease |
| additional codes | |
| 71 | Home Leave, non-psychiatric |
| 72 | Home Leave, psychiatric |
INTENDED CLINICAL CARE INTENSITY CODE replaces INTENDED CLINICAL CARE INTENSITY and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an2 |
| HES Item: | |
| National Codes: | See CLINICAL CARE INTENSITY |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) is the same as attribute CLINICAL CARE INTENSITY but the only allowable values from the list of National Codes are:INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) is the same as attribute CLINICAL CARE INTENSITY, but the only permitted values from the list of National Codes are:
For PATIENTS with Mental Illness:
| For PATIENTS with Mental Illness: | |
| 51 | For Intensive Care - specially designated ward for PATIENTS needing containment and more intensive management (eg Psychiatric Intensive Care Unit (PICU)). This is not to be confused with intensive nursing where a PATIENT may require one-to-one nursing while on a standard WARD |
| 52 | For Short Stay - PATIENTS intended to stay for less than a year |
| 53 | For Long Stay - PATIENTS intended to stay for a year or more |
For PATIENTS with Learning Disabilities:
| For PATIENTS with Learning Disabilities: | |
| 61 | Designated or interim secure unit |
| 62 | PATIENTS intending to stay less than a year |
| 63 | PATIENTS intending to stay a year or more |
In addition to this, the following value which is not part of the National Codes is also permitted for the Child and Adolescent Mental Health Services Data Set and the Mental Health Minimum Data Set (see INTENDED CLINICAL CARE INTENSITY CODE):
| The following value is also permitted for the Child and Adolescent Mental Health Services Data Set and the Mental Health Minimum Data Set (see INTENDED CLINICAL CARE INTENSITY CODE): | |
| 72 | Home Leave, psychiatric |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:The following values are to be used:
Permitted National Codes:
| 1 | Operative procedure intended |
| 8 | Not applicable: no operative procedure intended |
| 9 | Not known |
INTENDED PROCEDURE STATUS will be replaced with INTENDED PROCEDURE STATUS CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:The following values are to be used:Permitted National Codes:
| 1 | Operative procedure intended |
| 8 | Not applicable: no operative procedure intended |
| 9 | Not known |
INTENDED PROCEDURE STATUS CODE replaces INTENDED PROCEDURE STATUS and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | Minimum length an5, maximum length an9 |
| HES Item: | |
| National Codes: | See ORGANISATION SITE CODE |
| Default Codes: | 89999 - Non-NHS UK Provider where no ORGANISATION SITE CODE has been issued |
| 89997 - Non-UK Provider where no ORGANISATION SITE CODE has been issued |
Notes:
See SITE CODE (OF TREATMENT) for details on coding.
This is the ORGANISATION SITE CODE for the ORGANISATION SITE where it is intended to treat the PATIENT. This enables those ORGANISATIONS to be recorded which have been sub-commissioned to provide treatment.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
This is used in the Clinical Activity Group of the Commissioning Data Set to denote the scheme basis of an investigation.
Permitted values are:Permitted National Codes:
| 01 | Accident & Emergency Investigation |
CDS-XML Message:
The codes as specified above must be used for CDS-XML messages.Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | SPELEND |
| National Codes: | |
| Default Codes: | 9 - Not known |
Notes:
This derived data element identifies whether the consultant episode is the final episode in the Hospital Provider Spell.
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 1 | This episode is the last episode in the hospital provider spell |
| 2 | The episode is not the last episode in the hospital provider spell |
LAST EPISODE IN SPELL INDICATOR will be replaced with LAST EPISODE IN SPELL INDICATOR CODE, which should be used for all new and developing data sets and for XML messages.
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | SPELEND |
| National Codes: | |
| Default Codes: | 9 - Not known |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
This derived data element identifies whether the consultant episode is the final episode in the Hospital Provider Spell.
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 1 | This episode is the last episode in the Hospital Provider Spell |
| 2 | The episode is not the last episode in the Hospital Provider Spell |
LAST EPISODE IN SPELL INDICATOR CODE replaces LAST EPISODE IN SPELL INDICATOR and should be used for all new and developing data sets and for XML messages.
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See LEAVE OF ABSENCE END REASON |
| Default Codes: | 99 - Not known |
Notes:
This is the LEAVE OF ABSENCE END REASON for the last Mental Health Leave Of Absence of the PATIENT, involving an overnight stay, that ended within the REPORTING PERIOD.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
A typing for use when ordering and classifying reporting information on changes of the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE, during a Hospital Provider Spell for PATIENTS detained under the Mental Health Act or other acts.
Each set value represents a row on a central return data set, for example the Patients Detained In Hospital Or On Supervised Community Treatment Data Set (KP90), and should be used to populate a recorded number or total for a entry on the row.
The set values are:Permitted National Codes:
| 01 | LEGAL STATUS CLASSIFICATION CODE 01 Informal to 06 Section 5(4) |
| 02 | LEGAL STATUS CLASSIFICATION CODE 01 Informal to 05 Section 5(2) |
| 03 | LEGAL STATUS CLASSIFICATION CODE 06 Section 5(4) to 05 Section 5(2) |
| 04 | LEGAL STATUS CLASSIFICATION CODE 01 Informal to 02 Section 2 |
| 05 | LEGAL STATUS CLASSIFICATION CODE 04 Section 4 to 02 Section 2 |
| 06 | LEGAL STATUS CLASSIFICATION CODE 20 Section 136 to 02 Section 2 |
| 07 | LEGAL STATUS CLASSIFICATION CODE 06 Section 5(4) to 02 Section 2 |
| 08 | LEGAL STATUS CLASSIFICATION CODE 05 Section 5(2) to 02 Section 2 |
| 09 | LEGAL STATUS CLASSIFICATION CODE 01 Informal to 03 Section 3 |
| 10 | LEGAL STATUS CLASSIFICATION CODE 06 Section 5(4) to 03 Section 3 |
| 11 | LEGAL STATUS CLASSIFICATION CODE 05 Section 5(2) to 03 Section 3 |
| 12 | LEGAL STATUS CLASSIFICATION CODE 04 Section 4 to 03 Section 3 |
| 13 | LEGAL STATUS CLASSIFICATION CODE 20 Section 136 to 03 Section 3 |
| 14 | LEGAL STATUS CLASSIFICATION CODE 02 Section 2 to 03 Section 3 |
| 15 | LEGAL STATUS CLASSIFICATION CODE 05 Section 5(2) to 01 Informal |
| 16 | LEGAL STATUS CLASSIFICATION CODE 06 Section 5(4) to 01 Informal |
| 17 | LEGAL STATUS CLASSIFICATION CODE 04 Section 4 to 01 Informal |
| 18 | LEGAL STATUS CLASSIFICATION CODE 20 Section 136 to 01 Informal |
| 19 | LEGAL STATUS CLASSIFICATION CODE 02 Section 2 to 01 Informal |
| 20 | LEGAL STATUS CLASSIFICATION CODE 03 Section 3 to 01 Informal |
| 21 | LEGAL STATUS CLASSIFICATION CODE 07 Section 35 to 01 Informal |
| 22 | LEGAL STATUS CLASSIFICATION CODE 10 Section 37 to 01 Informal |
| 23 | LEGAL STATUS CLASSIFICATION CODE 07 Section 35 to 10 Section 37 |
| 24 | LEGAL STATUS CLASSIFICATION CODE 01 Informal to 33 Supervised Discharge (will not occur after 2 November 2008) |
| 25 | LEGAL STATUS CLASSIFICATION CODE 03 Section 3 to 33 Supervised Discharge (will not occur after 2 November 2008) |
| 26 | LEGAL STATUS CLASSIFICATION CODE 10 Section 37 to 33 Supervised Discharge (will not occur after 2 November 2008) |
| 27 | LEGAL STATUS CLASSIFICATION CODE All other changes not specified |
Hospital Provider Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
A typing for use when ordering and classifying reporting information on when the MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE was 'suspended' to enable a period of Supervised Community Treatment to start for PATIENTS detained under the Mental Health Act or other acts.
Each set value represents a row on a central return data set, for example the Patients Detained In Hospital Or On Supervised Community Treatment Data Set (KP90), and should be used to populate a recorded number or total for a entry on the row.
The set values are:Permitted National Codes:
| 01 | LEGAL STATUS CLASSIFICATION CODE 03 Section 3 to Supervised Community Treatment |
| 02 | LEGAL STATUS CLASSIFICATION CODE 10 Section 37 to Supervised Community Treatment |
| 03 | LEGAL STATUS CLASSIFICATION CODE 16 Section 47 to Supervised Community Treatment |
| 04 | LEGAL STATUS CLASSIFICATION CODE 18 Section 48 to Supervised Community Treatment |
| 05 | LEGAL STATUS CLASSIFICATION CODE All other not specified |
Supervised Community Treatment is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 47 'Supervised Community Treatment'.
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of liver support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 09 'Liver Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
A classification for use within Commissioning Data Set messages of the physical location within which the recorded patient event occurs.
Permitted National Codes:
| 01 | Health Site (General Occurrence) |
| 02 | Home |
| 03 | Delivery Place |
| 04 | Health site at the start of Health Care Activity |
| 05 | Health site at the end of Health Care Activity |
CDS-XML Message:
The codes as specified above must be used in CDS-XML messages.Change to Data Element: Changed Description
| Format/length: | n3 |
| HES item: | |
| National Codes: | |
| Default Codes: | 096 - Other |
Notes:
The LOCATION TYPE where the Human Papillomavirus vaccine was administered.
The codes to be used are as follows:Permitted National Codes:
| 003 | GP Practice Premises other than Health Centre |
| 070 | Health Clinic/Community Clinic. This is derived from Location Type Code 002 'Health Centre', 019 'Health Clinic managed by the NHS' and 020 'Health Clinic managed by Voluntary or Private Agents' |
| 080 | Educational Establishment Premises. This is derived from Location Type Code 029 'Educational Establishment Premises managed by Local Authority or Grant Maintained' and 030 'Educational Establishment Premises managed by Voluntary or Private Agents' |
| 096 | Other |
Note: If a GP Practice is also based at a Health Centre, those vaccinations administered by the GP Practice should be recorded under 003 'GP Practice Premises other than Health Centre'.
Change to Data Element: Changed Description
| Format/length: | n3 |
| HES item: | |
| National Codes: | See MAIN SPECIALTY CODE |
| Default Codes: |
Notes:
This is the MAIN SPECIALTY CODE of the Mental Health Responsible Clinician for the PATIENT within the REPORTING PERIOD. If there is more than one during the REPORTING PERIOD, this will be the last or final one of REPORTING PERIOD.
If the Mental Health Responsible Clinician is the PATIENT's GENERAL MEDICAL PRACTITIONER, the code will be 600. If the Mental Health Responsible Clinician is a CONSULTANT, it will typically be one of the adult or elderly mental health MAIN SPECIALTIES, although it may be either a learning disability or child and adolescent psychiatry in certain circumstances. When the Mental Health Responsible Clinician is not a CONSULTANT, this should be the appropriate pseudo-specialty code or left blank.
The allowable values are listed below:Permitted National Codes:
National Codes:
| 600 | General Medical Practice |
| 700 | Learning Disability |
| 710 | Adult Mental Illness |
| 711 | Child and Adolescent Psychiatry |
| 712 | Forensic Psychiatry |
| 713 | Psychotherapy |
| 715 | Old Age Psychiatry |
| 950 | Nursing Episode |
| 960 | Allied Health Professional Episode |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | MARSTAT |
| National Codes: | see PERSON MARITAL STATUS CODE |
| Default Codes: | 8 - Not applicable, i.e. not a psychiatric episode |
| 9 - Not known |
Notes:
This is the same as PERSON MARITAL STATUS CODE.
PERSON MARITAL STATUS should be used for all new and developing systems and for XML messages. PERSON MARITAL STATUS CODE carries codes for use in all new and developing systems and XML messages.
Commissioning Data Set Messages
Following the recommendation of the Data Protection Registrar, Marital Status should not be recorded by providers in the Commissioning Data Set except in respect of the psychiatric specialties in the Admitted Patient Care Commissioning Data Set. The data item remains in the data standards since it will be needed by the provider.
Mental Health Minimum Data Set Messages
For the Mental Health Minimum Data Set, MARITAL STATUS must be recorded and kept up to date for all psychiatric PATIENTS.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | See MEDICAL STAFF TYPE SEEING PATIENT |
| Default Codes: | 08 - Not applicable |
| 09 - Not known |
Notes:
A classification of the type of medical staff seeing the PATIENT during an Out-Patient Attendance Consultant.
Use in the Future Outpatient CDS:
If the MEDICAL STAFF TYPE SEEING PATIENT is not yet known, use default value 08 - Not applicable
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Definition:
This indicates whether the Mental Health Minimum Data Set is a production or test file.
Permitted National Codes:
| 0 (zero) | The whole Interchange contains live (production) data and will be stored in the Secondary Uses Service database |
| 1 | The whole Interchange contains test data and will not be stored in the Secondary Uses Service database. |
Usage:
This test facility enables interchanges submitted to be marked and therefore processed correctly.
The data is mandatory and must be completed.
CDS-XML Interchanges:
All XML interchanges submitted must contain a MHMDS TEST INDICATOR.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Not known: a validation error |
Notes:
This is used in the CDS to identify the format of a PATIENT NAME, with the classification values indicating whether it is a PERSON NAME STRUCTURED or PERSON NAME UNSTRUCTURED.
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 1 | Structured - two element name, forename followed by surname, each element an35 |
| 2 | Unstructured - an70 |
Change to Data Element: Changed Description
| Format/length: | n3 |
| National Codes: | |
| Default Codes: | 998 - 998 or more days of neurological support |
| 999 - occurred but day count not known |
Notes:
This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 06 'Neurological Support' within the CRITICAL CARE PERIOD.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR will be replaced with NHS NUMBER STATUS INDICATOR CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | See NHS NUMBER STATUS INDICATOR |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The NHS NUMBER STATUS INDICATOR of the NHS NUMBER (BABY) within the Commissioning Data Set Delivery Episode and Commissioning Data Set Home Delivery.
The values to be used are as for NHS NUMBER STATUS INDICATOR.Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR (BABY) will be replaced with NHS NUMBER STATUS INDICATOR CODE (BABY), which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | See NHS NUMBER STATUS INDICATOR |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The NHS NUMBER STATUS INDICATOR of the NHS NUMBER (MOTHER) within the Commissioning Data Set Birth Episode and Commissioning Data Set Home Birth.
The values to be used are as for NHS NUMBER STATUS INDICATOR.Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR (MOTHER) will be replaced with NHS NUMBER STATUS INDICATOR CODE (MOTHER), which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an2 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:The following values can be used:
Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR CODE replaces NHS NUMBER STATUS INDICATOR and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | See NHS NUMBER STATUS INDICATOR CODE |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The NHS NUMBER STATUS INDICATOR CODE of the NHS NUMBER (BABY).
The values to be used are as for NHS NUMBER STATUS INDICATOR CODE.Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR CODE (BABY) replaces NHS NUMBER STATUS INDICATOR (BABY), and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | See NHS NUMBER STATUS INDICATOR CODE |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The NHS NUMBER STATUS INDICATOR CODE of the NHS NUMBER (MOTHER).
The values to be used are as for NHS NUMBER STATUS INDICATOR CODE.Permitted National Codes:
| 01 | Number present and verified |
| 02 | Number present but not traced |
| 03 | Trace required |
| 04 | Trace attempted - No match or multiple match found |
| 05 | Trace needs to be resolved - (NHS Number or patient detail conflict) |
| 06 | Trace in progress |
| 07 | Number not present and trace not required |
| 08 | Trace postponed (baby under six weeks old) |
NHS NUMBER STATUS INDICATOR CODE (MOTHER) replaces NHS NUMBER STATUS INDICATOR (MOTHER) and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | NUMBBABY |
| National Codes: | |
| Default Codes: | 9 - Not known: a validation error |
Notes:
This derived data item records the number of REGISTERABLE BIRTHS (live or still born at a particular delivery).
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 1 | One |
| 2 | Two |
| 3 | Three |
| 4 | Four |
| 5 | Five |
| 6 | Six or more |
NUMBER OF BABIES will be replaced with NUMBER OF BABIES INDICATOR, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | NUMBBABY |
| National Codes: | |
| Default Codes: | 9 - Not known: a validation error |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
This derived data item records the number of REGISTERABLE BIRTHS (live or still born at a particular delivery).
The following values with the addition of the Default Code, can be used:Permitted National Codes:
| 1 | One |
| 2 | Two |
| 3 | Three |
| 4 | Four |
| 5 | Five |
| 6 | Six or more |
NUMBER OF BABIES INDICATOR replaces NUMBER OF BABIES and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
Notes:
NUTRITIONAL SUPPORT PROVIDED (CANCER) is derived from the presence of NUTRITIONAL SUPPORT PROVIDED TYPE.
National Codes:Permitted National Codes:
| N | No |
| Y | Yes |
References:
National Cancer Dataset Version 1.3_ISB October 2002
Change to Data Element: Changed Description
| Format/length: | an3 |
| HES item: | |
| National codes | See OCCUPATION CODE |
| Default codes |
Notes:This is the same as attribute OCCUPATION CODE.OCCUPATION CODE is the same as attribute OCCUPATION CODE.
The standard national NHS Occupation Code for an EMPLOYEE filling a POSITION through an ASSIGNMENT.
The NHS Occupation Codes are maintained by The NHS Information Centre for health and social care, on behalf of the Department of Health and can be viewed at NHS Occupation Code Manual.
Change to Data Element: Changed Description
| Format/length: | max 255 characters |
| HES item: | |
| National codes | See OCCUPATION CODE DESCRIPTION |
| Default codes |
Notes:This is the same as attribute OCCUPATION CODE DESCRIPTION.OCCUPATION CODE DESCRIPTION is the same as attribute OCCUPATION CODE DESCRIPTION.
A description or name corresponding to a specific NHS OCCUPATION CODE.
The NHS Occupation Codes are maintained by The NHS Information Centre for health and social care, on behalf of the Department of Health and can be viewed at NHS Occupation Code Manual.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | OPERSTAT |
| National Codes: | |
| Default Codes: |
Notes:
OPERATION STATUSES should be used once for each record to record states of knowledge regarding the operative procedure.
Permitted National Codes:
| 1 | One or more operative procedure carried out |
| 8 | Not applicable i.e. no operative procedures performed or intended |
| 9 | Not known i.e. finished episode/out-patient attendance but no data entered or the episode is unfinished and no data needs to be present. This would be a validation error only for a finished episode |
Use in the Future Outpatient CDS:
If it is not intended to perform a procedure at the future attendance, use value 8. Otherwise this data element should be omitted.
OPERATION STATUS will be replaced with OPERATION STATUS CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | OPERSTAT |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
OPERATION STATUS CODES should be used once for each record to record states of knowledge regarding the operative procedure.
Permitted National Codes:
| 1 | One or more operative procedure carried out |
| 8 | Not applicable i.e. no operative procedures performed or intended |
| 9 | Not known i.e. finished episode/out-patient attendance but no data entered or the episode is unfinished and no data needs to be present. This would be a validation error only for a finished episode |
Use in the Future Outpatient CDS:
If it is not intended to perform a procedure at the future attendance, use value 8. Otherwise this data element should be omitted.
OPERATION STATUS CODE replaces OPERATION STATUS and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The follow-up status of the PATIENT at the time of the CLINICAL STATUS ASSESSMENT DATE (CANCER).
National Codes:Permitted National Codes:
| 1 | Under follow-up - where the Consultant Out-Patient Episode is open with Out-Patient Attendance Consultant |
| 2 | Lost to follow-up - an Out-Patient Appointment, where ATTENDED OR DID NOT ATTEND code is 2. 'Appointment cancelled by patient' or 3. 'Did not attend, no advance warning given' and no further appointments have been made |
| 3 | Discharged - where the Consultant Out-Patient Episode is closed and there are no Out-Patient Appointments, where the ATTENDED OR DID NOT ATTEND code is 2. 'Appointment cancelled by patient' or 3. 'Did not attend, no advance warning given' |
| 4 | Transferred to another unit - where episodes are closed and new episodes opened under a new Health Care Provider |
Consultant Out-Patient Episode is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 15 'Consultant Out-Patient Episode'.
Out-Patient Attendance Consultant is a CARE CONTACT where CARE CONTACT TYPE is National Code 27 'Out-Patient Attendance Consultant'.
Change to Data Element: Changed Description
| Format/length: | an7 |
| HES item: | |
| National codes | See PAYSCALE CODE |
| Default codes |
Notes:This is the same as attribute PAYSCALE CODE.PAYSCALE CODE is the same as attribute PAYSCALE CODE.
A unique identifier of PAYSCALE.
The format for national codes is "NHSaannn", where 'NHS' is a literal text string, and 'aannn' is a 2-character and 3-digit string corresponding to nationally-recognised codes maintained by the Department of Health. Local codes have the format "nnnaaaaa", where 'nnn' is a 3-digit code (maintained by the Electronic Staff Record system) corresponding to the relevant ORGANISATION CODE, and 'aaaaa' refers to the appropriate local PAYSCALE code.
Note that local PAYSCALE CODES will be phased-out, as the Agenda for Change programme implements consistent national PAYSCALES across the entire NHS.
Change to Data Element: Changed Description
| Format/length: | To be decided |
| HES item: | |
| National codes | See PAYSCALE SPINE POINT CODE |
| Default codes |
Notes:This is the same as attribute PAYSCALE SPINE POINT CODE.PAYSCALE SPINE POINT CODE is the same as attribute PAYSCALE SPINE POINT CODE.
The point within a PAYSCALE that has been reached by an EMPLOYEE for an ASSIGNMENT.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See PAYSCALE TYPE |
| Default Codes: | 97 - Not recorded |
| 99 - Not known |
Notes:This is the same as attribute PAYSCALE TYPE.PAYSCALE TYPE is the same as attribute PAYSCALE TYPE.
A classification which indicates whether a PAYSCALE is associated with a national or local negotiating body.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from Patient Procedure history.
Indicates whether the patient has had a coronary artery bypass graft at any time prior to this admission.Indicates whether the PATIENT has had a coronary artery bypass graft at any time prior to this admission.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.
CCAD item name:
Previous CABG
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from Patient Procedure history.
Indicates if the patient underwent a percutaneous coronary intervention at any time prior to this admission.Indicates if the PATIENT underwent a percutaneous coronary intervention at any time prior to this admission.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.
CCAD item name:
Previous PCI
Change to Data Element: Changed Description
| Format/length: | an1 |
| HES item: | |
| National Codes: | see PERSON MARITAL STATUS CODE |
| Default Codes: | 8 - Not applicable, i.e. not a psychiatric episode |
| 9 - Not known |
Notes:
PERSON MARITAL STATUS is the same as PERSON MARITAL STATUS CODE.
PERSON MARITAL STATUS should be used for all new and developing systems and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from PATIENT DIAGNOSIS history for the PATIENT.
Any form of obstructive airways disease.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Asthma or COPD
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from PATIENT DIAGNOSIS history for the PATIENT.
A history of symptoms of cerebrovascular ischaemia. To include transient cerebral ischaemic episodes and events with deficit lasting >24 hrs.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Cerebrovascular disease
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from MEASURED PERSON OBSERVATION history for the PATIENT. Identify where Creatinine chronically >200 micromol/l.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Chronic renal failure
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from PATIENT DIAGNOSIS and Drug Treatment history for the PATIENT.
Identifies the type of management, if any, for diabetes.
The derived values are: Permitted National Codes:
| 0 | Not Diabetic |
| 1 | Diabetes (dietary control) |
| 2 | Diabetes (oral medicine) |
| 3 | Diabetes (insulin) |
| 4 | Newly diagnosed diabetes |
Drug Treatment is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 09 'Drug Treatment'.
Central Cardiac Audit Database (CCAD) item name:
Diabetes
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from MEASURED OBSERVATION VALUE in class MEASURED PERSON OBSERVATION.
A previously validated diagnosis of heart failure on any therapeutic regime.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Heart failure
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from MEASURED PERSON OBSERVATION and Drug Treatment history for the PATIENT.
Identifies if PATIENT has elevation of serum cholesterol requiring dietary or drug treatment.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Drug Treatment is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 09 'Drug Treatment'.
Central Cardiac Audit Database (CCAD) item name:
Hypercholesterolaemia
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from Blood Pressure history for the PATIENT.
Identifies if the PATIENT has hypertension.
A patient is defined as having hypertension if they are receiving treatment or dietary advice or if blood pressure has been recorded at greater than 140/90 on at least two occasions prior to admission.A PATIENT is defined as having hypertension if they are receiving treatment or dietary advice or if blood pressure has been recorded at greater than 140/90 on at least two occasions prior to admission.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Hypertension
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from PATIENT DIAGNOSIS history for the PATIENT.
Indicates if the PATIENT has a history of peripheral vascular disease.
The presence of peripheral vascular disease, either presently symptomatic or previously treated by intervention or surgery. Include known renovascular disease and aortic aneurysm.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Peripheral vascular disease
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from PATIENT DIAGNOSIS history for the PATIENT.
Any previously validated episode of acute myocardial infarction.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Previous AMI
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from MEASURED OBSERVATION VALUE in class MEASURED PERSON OBSERVATION.
Symptoms thought to be indicative of ischaemic cardiac pain either at rest or on exertion existing at least two weeks prior to this admission.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
Central Cardiac Audit Database (CCAD) item name:
Previous Angina
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes | |
| Default codes | 99 - Unknown |
Notes:
PLANNED CANCER TREATMENT TYPE (FIRST DEFINITIVE) is the same as attribute PLANNED CANCER TREATMENT TYPE.
This is the PLANNED CANCER TREATMENT TYPE of the Planned Cancer Treatment with FIRST DEFINITIVE TREATMENT PLANNED classification of a. 'yes'.
Use of Default Code 99 'Unknown' should be carefully monitored as it is highly unlikely that a treatment plan would be drawn up where the modality of treatment is unknown.
From 01 January 2009, this data element is no longer used in the National Cancer Waiting Times Monitoring Data Set. It may still be used in other data sets or collected locally if required.
Planned Cancer Treatment is a PLANNED ACTIVITY where PLANNED ACTIVITY TYPE is National Code 02 'Cancer Treatment'.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See POSITION INTERNATIONAL RECRUITMENT INDICATOR |
| Default Codes: | 97 - Not recorded |
| 98 - Not applicable | |
| 99 - Not known |
Notes:This is the same as attribute POSITION INTERNATIONAL RECRUITMENT INDICATOR.POSITION INTERNATIONAL RECRUITMENT INDICATOR is the same as attribute POSITION INTERNATIONAL RECRUITMENT INDICATOR.
An indicator to denote whether or not a POSITION is suitable for International Recruitment.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See POSITION ROTA PATTERN CODE |
| Default Codes: |
Notes:This is the same as attribute POSITION ROTA PATTERN CODE.POSITION ROTA PATTERN CODE is the same as attribute POSITION ROTA PATTERN CODE.
A classification of the type shift rota pattern for a POSITION.
The classification is only applicable to POSITIONS for Medical and Dental Staff.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See POSITION SHIFT TYPE CODE |
| Default Codes: |
Notes:This is the same as attribute POSITION SHIFT TYPE CODE.POSITION SHIFT TYPE CODE is the same as attribute POSITION SHIFT TYPE CODE.
A classification of the type of shift for a POSITION.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See POSITION STATUS CODE |
| Default Codes: |
Notes:This is the same as attribute POSITION STATUS CODE.POSITION STATUS CODE is the same as attribute POSITION STATUS CODE.
A classification of the status of a POSITION.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See POSITION VACANCY STATUS CODE |
| Default Codes: |
Notes:This is the same as attribute POSITION VACANCY STATUS CODE.POSITION VACANCY STATUS CODE is the same as attribute POSITION VACANCY STATUS CODE.
Change to Data Element: Changed Description
| Format/length: | annn for OPCS-4, an7 for Clinical Terms (The Read Codes) |
| HES item: | OPERTN |
| National Codes: | |
| Default Codes: | X998 - Out-patient procedure carried out but no appropriate OPCS-4 code available (Retired 01-10-2010) |
| X999 - No out-patient procedure carried out (Retired 01-10-2010) |
Notes:
This is a CLINICAL CLASSIFICATION CODE.PROCEDURE CODING is a CLINICAL CLASSIFICATION CODE.
See OPCS Classification of Interventions and Procedures for Classification of Surgical Operations and Procedures (OPCS-4) and Read Coded Clinical Terms.
Record any operative procedures carried out, such as an endoscopy or electro-convulsive therapy (ECT), as part of the current consultant episode.
Clinical Terms (The Read Codes) (an7) may be used as an optional addition to OPCS-4.
Where a procedure is carried out and required for reporting using the OPCS-4 classification every effort must be made to report the appropriate OPCS-4 code in the Out-Patient Attendance Commissioning Data Set.
Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.
The default codes 'X998' and 'X999' and their descriptions have been retired as at 1st October 2010. Although these bespoke Data Set default codes do not currently exist in the OPCS Classification of Interventions and Procedures, it has been agreed that these codes will never be assigned within the OPCS Classification so as to avoid any confusion in the future.
Change to Data Element: Changed Description
| Format/length: | an7 for the Read Codes |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Records the PROCEDURE CODING identified in the following relevant procedures associated with the diabetic condition.
Read Codes
| LASER (Ocular retinal photocoagulation) 4Byte Version (retired 1 October 2009) | |
| 8633 | Retinal photocoag. therapy (retired 1 October 2009) |
| Version 2 | |
| No equivalent term | |
| AMPUTATION 4Byte Version (retired 1 October 2009) | |
| 7EU. | Amputation - lower limb (retired 1 October 2009 ) |
| 7EU1 | Amputation of toes (retired 1 October 2009) |
| 7EU2 | Amputation foot: tarsal-metatar (retired 1 October 2009) |
| 7EU3 | Amputation foot: mid-tarsal (retired 1 October 2009) |
| 7EU5 | Supramalleolar ankle amptat (retired 1 October 2009) |
| 7EU6 | Below knee amputation (retired 1 October 2009) |
| 7EU7 | Above knee amputation (retired 1 October 2009) |
| Version 2 | |
| 7L06. | Amputation of leg |
| 7L07. | Amputation of foot |
| 7L08. | Amputation of toe |
| RRT (End stage renal failure requiring renal replacement therapy) 4Byte Version (retired 1 October 2009 - CP1016) | |
| 8874 | Haemodialysis (preferred term) (retired 1 October 2009) Dialysis - renal (synonym) (retired 1 October 2009) |
| 7A4 | Kidney Transplant (retired 1 October 2009) |
| Version 2 | |
| 7L1A. | Compensation for renal failure |
| 7B00. | Kidney Transplant |
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is used in the Clinical Activity Group of the Commissioning Data Set to denote the scheme basis of an Intervention, Operation or A&E Treatment.
Permitted National Codes:
| 01 | Accident & Emergency Treatment |
| 02 | OPCS-4 |
| 03 | Read Code 4Byte Version (retired 1 October 2009) |
| 04 | Read Code Version 2 |
| 05 | Read Code Clinical Terms Version 3 (CTV3) |
Read Code Clinical Terms Version 3 (CTV3) with qualifiers (previously known as 3.1) is not supported in the Commissioning Data Sets.
CDS-XML Message:
The codes as specified above must be used in Commissioning Data Set - XML messages.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The status of a PROFESSIONAL REGISTRATION of a PERSON.
It is derived from comparing the PROFESSIONAL REGISTRATION EXPIRY DATE of the PROFESSIONAL REGISTRATION with the REPORTING PERIOD END DATE.
If the PROFESSIONAL REGISTRATION EXPIRY DATE is on or after the REPORTING PERIOD END DATE then the PROFESSIONAL REGISTRATION it is classified as valid otherwise it is classified as expired.
The derived values are:Permitted National Codes:
| 01 | Valid |
| 02 | Expired |
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See PROFESSIONAL REGISTRATION TYPE CODE |
| Default Codes: |
Notes:This is the same as attribute PROFESSIONAL REGISTRATION TYPE CODE.PROFESSIONAL REGISTRATION TYPE CODE is the same as attribute PROFESSIONAL REGISTRATION TYPE CODE.
The classification of the type of PROFESSIONAL REGISTRATION TYPE.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | ADMISTAT |
| National Codes: | |
| Default Codes: |
Notes:
Where a PATIENT has a history of admissions to several Hospital Provider, then priority between National Codes 1 and 2 should be given to the current Hospital Provider, and National Code 1 selected, irrespective of whether or not the last admission was to the same Hospital Provider.
This data item applies only to PATIENTS admitted or transferred to a CONSULTANT in one of the psychiatric specialties within a Hospital Provider Spell. Record this against the first consultant episode under a CONSULTANT in one of the psychiatric specialties but not for subsequent psychiatric consultant episodes or for any non-psychiatric episodes. This information is used to indicate the turnover period within the service and identify, where possible, all first time psychiatric admissions and re-admissions.
National Codes:Permitted National Codes:
| 0 | No known previous Hospital Provider Spells with a Consultant Episode (Hospital Provider) within a psychiatric speciality within any Health Care Provider. | |
| 1 | One or more previous Hospital Provider Spells involving a Consultant Episode (Hospital Provider) within a psychiatric specialty with this Health Care Provider. | |
| 2 | One or more previous Hospital Provider Spells involving a Consultant Episode (Hospital Provider) within a psychiatric specialty with another Health Care Provider, but none with this Health Care Provider. | |
| 8 | Not applicable: the PATIENT is not receiving admitted patient care under a CONSULTANT in a psychiatric specialty. | |
| 9 | Not known: the PATIENT is receiving admitted patient care under a CONSULTANT in a psychiatric specialty, but the information is not available. This constitutes a validation error | |
PSYCHIATRIC PATIENT STATUS will be replaced with PSYCHIATRIC PATIENT STATUS CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | ADMISTAT |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
Where a PATIENT has a history of admissions to several Hospital Provider, then priority between National Codes 1 and 2 should be given to the current Hospital Provider, and National Code 1 selected, irrespective of whether or not the last admission was to the same Hospital Provider.
This data item applies only to PATIENTS admitted or transferred to a CONSULTANT in one of the psychiatric specialties within a Hospital Provider Spell. Record this against the first consultant episode under a CONSULTANT in one of the psychiatric specialties but not for subsequent psychiatric consultant episodes or for any non-psychiatric episodes. This information is used to indicate the turnover period within the service and identify, where possible, all first time psychiatric admissions and re-admissions.
National Codes:Permitted National Codes:
| 0 | No known previous Hospital Provider Spells with a Consultant Episode (Hospital Provider) within a psychiatric speciality within any Health Care Provider. | |
| 1 | One or more previous Hospital Provider Spells involving a Consultant Episode (Hospital Provider) within a psychiatric specialty with this Health Care Provider. | |
| 2 | One or more previous Hospital Provider Spells involving a Consultant Episode (Hospital Provider) within a psychiatric specialty with another Health Care Provider, but none with this Health Care Provider. | |
| 8 | Not applicable: the PATIENT is not receiving admitted patient care under a CONSULTANT in a psychiatric specialty. | |
| 9 | Not known: the PATIENT is receiving admitted patient care under a CONSULTANT in a psychiatric specialty, but the information is not available. This constitutes a validation error | |
PSYCHIATRIC PATIENT STATUS CODE replaces PSYCHIATRIC PATIENT STATUS and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See QUALIFICATION SUBJECT AREA CODE |
| Default Codes: |
Notes:This is the same as attribute QUALIFICATION SUBJECT AREA CODE.QUALIFICATION SUBJECT AREA CODE is the same as attribute QUALIFICATION SUBJECT AREA CODE.
A classification of the broad category of an QUALIFICATION.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: | 9 - Unknown |
Notes:
Derive from CLINICAL INTERVENTION whether a radionuclide study was performed during the Hospital Provider Spell within the Acute Myocardial Infarction Care Spell or is planned after admission and recorded as Therapy After Discharge with DISCHARGE THERAPY TYPE classification of 'radionuclide study'.
The derived values are: Permitted National Codes:
| 0 | No |
| 1 | Yes |
| 2 | Planned after admission |
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Acute Myocardial Infarction Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 02 'Acute Myocardial Infarction Care Spell'.
Therapy After Discharge is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 31 'Therapy After Discharge'.
Central Cardiac Audit Database (CCAD) item name:
Radionuclide Study
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | RECTYPE |
| National Codes: | |
| Default Codes: |
Notes:
This indicates whether consultant/ midwife/ nursing episode is finished or unfinished and what type of record it relates to, please note this is a Hospital Episode Statistics item only.
Permitted National Codes:
| 11 | Annual census/unfinished episode - general patient |
| 13 | Finished episode - general patient |
| 21 | Annual census/unfinished episode - delivery |
| 23 | Finished episode - delivery |
| 31 | Annual census/unfinished episode - birth |
| 33 | Finished episode - birth |
| 41 | Annual census record - psychiatric |
| 53 | Finished episode - other maternity event, delivery |
| 63 | Finished episode - other maternity event, birth |
| 70 | Integrity record |
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See below |
| Default Codes: |
Notes:
The reason for referral of the PATIENT as part of an inter-provider transfer.
This is the same as SERVICE REQUEST RAISED REASON, but has a restricted national code list.
For inter-provider transfers, use one of the followingFor inter-provider transfers, use one of the following:
Permitted National Codes:
| 01 | Transfer of Clinical Responsibility |
| 02 | Opinion Only |
| 03 | Diagnostic Test |
| 98 | Not Applicable |
| 99 | Not Known |
Change to Data Element: Changed Description
| Format/length: | an7 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The time band for the Referral to Treatment Summary Patient Tracking List Data Set in weeks. These are the time bands of the number of weeks until the REFERRAL TO TREATMENT PERIOD BREACH DATE.
Permitted values are as below:Permitted National Codes:
| unknown | Patients with an unknown REFERRAL TO TREATMENT PERIOD START DATE |
| >6-8 | Patients who will breach in more than 6 and up to and including 8 weeks |
| >4-6 | Patients who will breach in more than 4 and up to and including 6 weeks |
| >2-4 | Patients who will breach in more than 2 and up to and including 4 weeks |
| >1-2 | Patients who will breach in more than 1 and up to and including 2 weeks |
| 0-1 | Patients who will breach in 0 and up to and including 1 week |
Guidance for calculating days until breach:
The REFERRAL REQUEST RECEIVED DATE is day zero in the REFERRAL TO TREATMENT PERIOD. Therefore:
Patients who are reported in the more than 6 and up to and including 8 weeks time band are those who have 43 to 56 days until breach at the REPORTING PERIOD END DATE
Patients who are reported in the more than 4 and up to and including 6 weeks time band are those who have 29 to 42 days until breach at the REPORTING PERIOD END DATE
Patients who are reported in the more than 2 and up to and including 4 weeks time band are those who have 15 to 28 days until breach at the REPORTING PERIOD END DATE
Patients who are reported in the more than 1 and up to and including 2 weeks time band are those who have 8 to 14 days until breach at the REPORTING PERIOD END DATE
Patients who are reported in the 0 and up to and including 1 week time band are those who have 0 to 7 days until breach at the REPORTING PERIOD END DATE
Change to Data Element: Changed Description
| Format/length: | an7 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
These are the time bands of the number of weeks until a PATIENT's wait for treatment would exceed 18 weeks.
This is expressed as below:Permitted National Codes:
| unknown | Patients with unknown REFERRAL TO TREATMENT PERIOD START DATE |
| >6-8 | Patients whose wait for treatment will exceed 18 weeks in more than 6 and up to and including 8 weeks |
| >4-6 | Patients whose wait for treatment will exceed 18 weeks in more than 4 and up to and including 6 weeks |
| >2-4 | Patients whose wait for treatment will exceed 18 weeks in more than 2 and up to and including 4 weeks |
| >1-2 | Patients whose wait for treatment will exceed 18 weeks in more than 1 and up to and including 2 weeks |
| 0-1 | Patients whose wait for treatment will exceed 18 weeks in 0 and up to and including 1 week |
Guidance for calculating days until 18 weeks wait for treatment is exceeded:
The REFERRAL REQUEST RECEIVED DATE is day zero in the REFERRAL TO TREATMENT PERIOD. Therefore:
PATIENTS who are reported in the >6-8 weeks time band are those who have 43 to 56 days until 18 weeks wait for treatment is exceeded at the REPORTING PERIOD END DATE
PATIENTS who are reported in the >4-6 weeks time band are those who have 29 to 42 days until 18 weeks wait for treatment is exceeded at the REPORTING PERIOD END DATE
PATIENTS who are reported in the >2-4 weeks time band are those who have 15 to 28 days until 18 weeks wait for treatment is exceeded at the REPORTING PERIOD END DATE
PATIENTS who are reported in the >1-2 weeks time band are those who have 8 to 14 days until 18 weeks wait for treatment is exceeded at the REPORTING PERIOD END DATE
PATIENTS who are reported in the 0-1 weeks time band are those who have 1 to 7 days until 18 weeks wait for treatment is exceeded at the REPORTING PERIOD END DATE
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is the same as attribute REFERRAL TO TREATMENT PERIOD STATUS.
For inter-provider transfers, a restricted list of REFERRAL TO TREATMENT PERIOD STATUSES are used. Allowable values are
Permitted National Codes:
| For first and subsequent activity | |
| 12 | consultant referral - the first activity at the start of a new REFERRAL TO TREATMENT PERIOD following a decision to refer directly to the CONSULTANT for a separate condition |
| 20 | subsequent ACTIVITY during a REFERRAL TO TREATMENT PERIOD - further ACTIVITIES anticipated |
| For activity not part of a Referral to Treatment Period | |
| 90 | after treatment - first treatment occurred previously (e.g. admitted as an emergency from A&E or the ACTIVITY is after the start of treatment) |
| 98 | not applicable - ACTIVITY not applicable to REFERRAL TO TREATMENT PERIODS |
Change to Data Element: Changed Description
| Format/length: | n |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
RESIDENTIAL MH NON-NHS COMMUNITY CARE INDICATOR is an indicator of whether or not:
| a. | one or more Care Home Stay (Nursing Care) and/or Care Home Stay (Residential) within the Adult Mental Health Care Spell has occurred during the REPORTING PERIOD | |
| and | ||
| b. | where the BROAD PATIENT GROUP CODE is National Code 5 'Patients with mental illness' | |
| and | ||
| c. | where the Care Home is operated and managed by a Non-NHS ORGANISATION as classified by ORGANISATION TYPE. | |
Recorded as:Permitted National Codes:
| 0 | no stays in a Non-NHS care home occurred during the REPORTING PERIOD | ||
| 1 | one or more stays in a Non-NHS care home occurred during the REPORTING PERIOD | ||
Care Home Stay (Nursing Care) is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 08 'Care Home Stay (Nursing Care)'.
Care Home Stay (Residential) is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 09 'Care Home Stay (Residential)'.
Adult Mental Health Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 23 'Adult Mental Health Care Spell'.
Change to Data Element: Changed Description
| Format/length: | an8 |
| HES item: | See Hospital Episode Statistics Cross Reference Tables |
| National Codes: | |
| ODS Default Codes: | C9999998 - CONSULTANT, GENERAL MEDICAL COUNCIL REFERENCE NUMBER not known |
| CD999998 - Dental Consultant: GENERAL MEDICAL COUNCIL REFERENCE NUMBER or GENERAL DENTAL COUNCIL REGISTRATION NUMBER not known | |
| D9999998 - Dentist, Dental Practice Board (DPB) number not known | |
| G9999998 - GENERAL MEDICAL PRACTITIONER PPD CODE not known | |
| H9999998 - Other CARE PROFESSIONAL | |
| M9999998 - MIDWIFE | |
| N9999998 - NURSE |
Notes:
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) is the GENERAL MEDICAL COUNCIL REFERENCE NUMBER, Dental Practice Board or other professional registration code for the CARE PROFESSIONAL undertaking the OPCS-4 classified operative Patient Procedure. This will usually, but not exclusively, be the lead CARE PROFESSIONAL or a junior member of the same team.
Where the actual PROFESSIONAL REGISTRATION code is unknown or the professional is not a doctor or a dentist, the appropriate Organisation Data Service Default Code should be used.
Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | BIRRESUS |
| National Codes: | |
| Default Codes: | 8 - Not applicable (e.g. stillborn, where no method of resuscitation was attempted) |
| 9 - Not known: a validation error |
Notes:
This data item is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGS
It records the means by which regular respiration of the baby was attempted. This is not recorded for stillbirths. For local purposes, the actual drugs administered should be specified.
The following values with the addition of the Default Codes, can be used:Permitted National Codes:
| 1 | Positive pressure nil, drugs nil |
| 2 | Positive pressure nil, drugs administered |
| 3 | Positive pressure by mask, drugs nil |
| 4 | Positive pressure by mask, drugs administered |
| 5 | Positive pressure by endotracheal tube, drugs nil |
| 6 | Positive pressure by endotracheal tube, drugs administered |
RESUSCITATION METHOD will be replaced with RESUSCITATION METHOD CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | BIRRESUS |
| National Codes: | |
| Default Codes: | 8 - Not applicable (e.g. stillborn, where no method of resuscitation was attempted) |
| 9 - Not known: a validation error |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
This data item is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGS
It records the means by which regular respiration of the baby was attempted. This is not recorded for stillbirths. For local purposes, the actual drugs administered should be specified.
The following values with the addition of the Default Codes, can be used:Permitted National Codes:
| 1 | Positive pressure nil, drugs nil |
| 2 | Positive pressure nil, drugs administered |
| 3 | Positive pressure by mask, drugs nil |
| 4 | Positive pressure by mask, drugs administered |
| 5 | Positive pressure by endotracheal tube, drugs nil |
| 6 | Positive pressure by endotracheal tube, drugs administered |
RESUSCITATION METHOD CODE replaces RESUSCITATION METHOD and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
SARCOMA PREDISPOSING CONDITION (FAMILY) is the same as the attribute SARCOMA PREDISPOSING CONDITION CODE.
Any inherited or family SARCOMA PREDISPOSING CONDITION.
Allowable codes are as follows:Permitted National Codes:
| LF | Li-Fraumeni Family |
| NF | NF 1 |
| FP | Familial Adenomatous Polyposis |
| PA | Paget's |
| OD | Ollier's Disease |
| MS | Maffucci's Syndrome |
| EX | Exostosis |
| CH | Chondrodysplasia |
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
SARCOMA PREDISPOSING CONDITION (OTHER PHYSICAL) is the same as the attribute SARCOMA PREDISPOSING CONDITION CODE.
Any physical SARCOMA PREDISPOSING CONDITION other than family or inherited conditions.
Allowable codes are as follows:Permitted National Codes:
| PR | Previous Radiotherapy to site |
| OT | Other |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component SEX OF PATIENTS is required to be separately recorded. The classifications for SEX OF PATIENTS are not the same as the National Codes contained within the definition of PERSON GENDER.
The following values for the classifications of attribute SEX OF PATIENTS, with the addition of Home Leave, can be used:Based on the classifications of attribute SEX OF PATIENTS, with the addition of Home Leave:
Permitted National Codes:
| 1 | Male |
| 2 | Female |
| 8 | Not specified |
| 9 | Home Leave |
SEX OF PATIENTS will be replaced with SEX OF PATIENTS CODE, which should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component SEX OF PATIENTS CODE is required to be separately recorded. The classifications for SEX OF PATIENTS CODE are not the same as the National Codes contained within the definition of PERSON GENDER.
The following values for the classifications of attribute SEX OF PATIENTS CODE, with the addition of Home Leave, can be used:Based on the classifications of attribute SEX OF PATIENTS, with the addition of Home Leave:
Permitted National Codes:
| 1 | Male |
| 2 | Female |
| 8 | Not specified |
| 9 | Home Leave |
SEX OF PATIENTS CODE replaced SEX OF PATIENTS and should be used for all new and developing data sets and for XML messages.
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
SHELTERED WORK ATTENDANCE INDICATOR is an indicator of whether or not one or more Sheltered Work Attendance at Sheltered Work Sessions within the Adult Mental Health Care Spell has occurred during the REPORTING PERIOD.
Recorded as:Permitted National Codes:
| 0 | no attendance at a Sheltered Work Facility occurred during the REPORTING PERIOD | ||
| 1 | one or more attendances at a Sheltered Work Facility occurred during the REPORTING PERIOD | ||
Sheltered Work Attendance is a CARE CONTACT where the CARE CONTACT TYPE is National Code 29 'Sheltered Work Attendance'.
Sheltered Work Session is a SESSION where the SESSION TYPE is National Code 07 'Sheltered Work Session'.
Adult Mental Health Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 23 'Adult Mental Health Care Spell'.
Change to Data Element: Changed Description
| Format/length: | an2 |
| HES item: | |
| National Codes: | SOCIO-ECONOMIC CLASSIFICATION CODE |
| Default Codes: | 99 - Unknown |
Notes:
The SOCIO-ECONOMIC CLASSIFICATION CODE for the Stop Smoking Service based on a simplified version of the Office for National Statistics socio-economic classification. These are derived as:
National Codes:Permitted National Codes:
| 01 | Full time student (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L15) |
| 02 | Never worked or unemployed for over one year. If unemployed for less than one year, last known occupation should be used for classification.(The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L14) |
| 03 | Retired (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE Non-employed) |
| 04 | Home carer i.e. looking after children, family or home (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L17) |
| 05 | Sick or disabled and unable to work (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L17) |
| 06 | Managerial/professional. Examples include: accountant, artist, civil/mechanical engineer, medical practitioner, musician, nurse, police officer (sergeant or above), physiotherapist, scientist, social worker, software engineer, solicitor, teacher, welfare officer. Those usually responsible for planning, organising and co-ordinating work for finance. (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L1-L6) |
| 07 | Intermediate. Examples include: call centre agent, clerical worker, nursery auxiliary, office clerk, secretary. (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L7-L9) |
| 08 | Routine and manual (self employed should not be included in this category). Examples include: electrician, fitter, gardener, inspector, plumber, printer, train driver, tool maker, bar staff, caretaker, catering assistant, cleaner, farm worker, HGV driver, labourer, machine operative, messenger, packer, porter, postal worker, receptionist, sales assistant, security guard, sewing machinist, van driver, waiter/waitress. (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L10-L13) |
| 96 | Unable to code (The National Statistics SOCIO-ECONOMIC CLASSIFICATION CODE L16 - Occupations not stated or inadequately described) |
Further guidance on coding can be found at NHS Stop Smoking Services, Services and monitoring guidance - 2007/08 and the Office for National Statistics - The National Statistics Socio-economic Classification (NS-SEC).
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | CENSAT |
| National Codes: | |
| Default Codes: |
Notes:
The information about the current detained status is derived from LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE) and the length of stay in hospital derived from details held about the current Hospital Provider Spell
See Mental Health Act Table for details of how this data item relates to Parts and Sections of the Act.
The following values can be used:Permitted National Codes:
| 1 | Detained patient |
| 2 | Long term patient |
| 3 | Detained and long term patient |
STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS will be replaced with STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS CODE, which should be used for all new and developing data sets and for XML messages.
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/Length: | an1 |
| HES Item: | CENSAT |
| National Codes: | |
| Default Codes: |
This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.
Notes:
The information about the current detained status is derived from MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE) and the length of stay in hospital derived from details held about the current Hospital Provider Spell
See Mental Health Act Table for details of how this data item relates to Parts and Sections of the Act.
The following values can be used:Permitted National Codes:
| 1 | Detained patient |
| 2 | Long term patient |
| 3 | Detained and long term patient |
STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS CODE replaces STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS, and should be used for all new and developing data sets and for XML messages.
Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.
Change to Data Element: Changed Description
| Format/length: | 8 characters HH:MM:SS |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The TIME (using a 24 hour clock) at which an event, or the action in an event, takes place.
This is the e-Government Interoperability Framework (e-GIF) standard that should be used for all new and developing systems and for XML messages.
Concatenated date time elements are in use and are derived from the e-GIF standards for DATE and TIME, these should continue to be used unless further notified.
References:
The e-GIF version approved for use in NHS England is:
Government Data Standards Catalogue: (GDSC), Version 2.0, Agreed 1 January 2002.
GDSC: http://www.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards.aspx.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See TRAINING ACTIVITY ASSESSOR TYPE CODE |
| Default Codes: |
Notes:This is the same as attribute TRAINING ACTIVITY ASSESSOR TYPE CODE.TRAINING ACTIVITY ASSESSOR TYPE CODE is the same as attribute TRAINING ACTIVITY ASSESSOR TYPE CODE.
A classification of the type of Assessor for a TRAINING ACTIVITY undertaken by an EMPLOYEE.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National codes | See TRAINING ACTIVITY DELIVERY METHOD TYPE CODE |
| Default codes |
Notes:This is the same as attribute TRAINING ACTIVITY DELIVERY METHOD TYPE CODE.TRAINING ACTIVITY DELIVERY METHOD TYPE CODE is the same as attribute TRAINING ACTIVITY DELIVERY METHOD TYPE CODE.
A categorisation of the method employed to deliver a TRAINING ACTIVITY.
Change to Data Element: Changed Description
| Format/length: | max 255 characters |
| HES item: | |
| National Codes: | See TRAINING ACTIVITY NAME |
| Default Codes: |
Notes:This is the same as attribute TRAINING ACTIVITY NAME.TRAINING ACTIVITY NAME is the same as attribute TRAINING ACTIVITY NAME.
The name or title of a TRAINING ACTIVITY.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | See TRAINING ACTIVITY TYPE CODE |
| Default Codes: |
Notes:This is the same as attribute TRAINING ACTIVITY TYPE CODE.TRAINING ACTIVITY TYPE CODE is the same as attribute TRAINING ACTIVITY TYPE CODE.
A classification of the type of TRAINING ACTIVITY.
Change to Data Element: Changed Description
| Format/length: | an3 |
| National Codes: | |
| Default codes: |
Notes:
This is the TREATMENT FUNCTION under which the PATIENT is to be treated or has been treated for the REFERRAL TO TREATMENT PERIOD. It may be the same as the MAIN SPECIALTY CODE of the CONSULTANT.
The valid codes for a REFERRAL TO TREATMENT PERIOD are:
National Codes:Permitted National Codes:
| 100 | General Surgery |
| 101 | Urology |
| 110 | Trauma & Orthopaedics |
| 120 | Ear,Nose & Throat (ENT) |
| 130 | Ophthalmology |
| 140 | Oral Surgery |
| 150 | Neurosurgery |
| 160 | Plastic Surgery |
| 170 | Cardiothoracic Surgery |
| 300 | General Medicine |
| 301 | Gastroenterology |
| 320 | Cardiology |
| 330 | Dermatology |
| 340 | Thoracic Medicine |
| 400 | Neurology |
| 410 | Rheumatology |
| 430 | Geriatric Medicine |
| 502 | Gynaecology |
| X01 | All other TREATMENT FUNCTIONS not reported individually |
Change to Data Element: Changed Description
| Format/length: | URL |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The syntax and semantics for a compact string representation for a resource available via the Internet. These strings are called 'UNIFORM RESOURCE LOCATORS (URLS)'. URLs are sequences of characters, i.e., letters, digits, and special characters. The characters ";", "/", "?", ":", "@", "=" and "&" are the characters which have been reserved for special meaning.
UNIFORM RESOURCE LOCATOR (URL) is the same as COMMUNICATION CONTACT STRING where the COMMUNICATION CONTACT METHOD equals 'e. Uniform Resource Locator (URL)'.
References:
The e-GIF version approved for use in NHS England is:
Government Data Standards Catalogue: (GDSC), Version 1.1, Agreed 1 September 2002.
GDSC: http://www.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards.aspx.
Change to Data Element: Changed Description
| Format/length: | n2 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
The method used to determine the PERSON OBSERVATION (URINARY ALBUMIN LEVEL).
The urine specimen used to check for albuminuria may be collected in several ways depending on local preference. Staging definitions vary by method so PERSON OBSERVATION (URINARY ALBUMIN LEVEL) must be accompanied by the method used.
Derive from the MEASURED OBSERVATION VALUE recorded for the MEASURED PERSON OBSERVATION TYPE 'Urinary Albumin level'.
The derived values are:01 - Albumin concentration (mg/L)02 - Albumin creatinine ratio (mg/mmol)03 - Timed overnight albumin (µg/min)04 - 24hr albumin excretion (mg/24hr)Permitted National Codes:
| 01 | Albumin concentration (mg/L) |
| 02 | Albumin creatinine ratio (mg/mmol) |
| 03 | Timed overnight albumin (µg/min) |
| 04 | 24hr albumin excretion (mg/24hr) |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
This is a grouping for specified INTENDED MANAGEMENT.
When the INTENDED MANAGEMENT matches the requirements of the specified WAITING FOR ADMISSION INTENDED MANAGEMENT for the sub group within the data set, the PATIENT should be included in the count providing all the other criteria of the count are also met.
One of the following values can be set:Permitted National Codes:
| 1 | Ordinary admission equivalent to INTENDED MANAGEMENT 'Patient to stay in hospital at least one night' |
| 2 | Day case admission equivalent to INTENDED MANAGEMENT ''Patient not to stay in hospital overnight'. ' |
| 6 | Ordinary admission and day case admission equivalent to INTENDED MANAGEMENT 'Patient to stay in hospital at least one night' or 'Patient not to stay in hospital overnight' |
Change to Data Element: Changed Description
| Format/length: | n1 |
| HES item: | |
| National Codes: | |
| Default Codes: |
Notes:
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For CDS message purposes therefore the constituent component WARD DAY PERIOD AVAILABILITY is required to be separately recorded.
The value for the number of days open only during the day is as recorded by attribute WARD DAY PERIOD AVAILABILITY, but with the addition of Home Leave:The value for the number of days open only during the day is as recorded by attribute WARD DAY PERIOD AVAILABILITY, but with the addition of Home Leave.
Permitted National Codes:
| 0-7 | |
| 9 | Home Leave |
WARD DAY PERIOD AVAILABILITY will be replaced with WARD DAY PERIOD AVAILABILITY CODE, which should be used for all new and developing data sets and for XML messages.
For enquiries, please email datastandards@nhs.net