Change Request
 

NHS Connecting for Health

NHS Data Model and Dictionary Service

Reference: Change Request 1259
Version No:1.0
Subject:July Release Patch
Effective Date:Immediate
Reason for Change:Patch
Publication Date:13 July 2011

Background:

This patch updates the NHS Data Model and Dictionary in preparation for the July 2011 Release and includes:

Summary of changes:

Data Set
ACUTE MYOCARDIAL INFARCTION DATA SET   Changed Description
 
Supporting Information
WHAT'S NEW: JULY 2011 renamed from WHAT'S NEW: JUNE 2011   Changed Description, Name
 
Attribute Definitions
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE   Changed Description
ASSESSMENT TOOL TYPE   Changed Description
CLINICAL CLASSIFICATION CODE   Changed Description
DELAY REASON TO TREATMENT (CANCER)   Changed Description
NUMBER OF TELETHERAPY FIELDS   Changed Description
PATIENT CLASSIFICATION   Changed Description
PRIORITY TYPE   Changed Description
SOURCE OF REFERRAL FOR MENTAL HEALTH   Changed Description
 
Data Elements
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE   Changed Description
DATE DETENTION COMMENCED   Changed Description
DATE OF ASSAULT ON PATIENT   Changed Description
DATE OF PATIENT TREATMENT OR INTERVENTION (READ)   Changed Description
DATE OF PHYSICAL RESTRAINT   Changed Description
DATE OF SECLUSION   Changed Description
DATE OF SELF HARM   Changed Description
HAEMOGLOBIN CONCENTRATION   Changed Description
PERSON HEIGHT IN CENTIMETRES   Changed Description
PERSON HEIGHT IN METRES   Changed Description
PERSON WEIGHT   Changed Description
SMOKING STATUS CODE   Changed Description
WHITE BLOOD CELL COUNT   Changed Description
 

Date:13 July 2011
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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ACUTE MYOCARDIAL INFARCTION DATA SET

Change to Data Set: Changed Description

Acute Myocardial Infarction Data Set Overview

Please note that the Acute Myocardial Infarction Data Set is being updated, therefore this information should not be used.

Data Set Data ElementsMINAP FIELD PROMPT
(Myocardial Infarction Audit Project)
 
CCAD HOSPITAL IDENTIFIER Hospital Identifier 
LOCAL PATIENT IDENTIFIER Patient Care Record Number 
NHS NUMBER NHS Number 
PERSON FAMILY NAME Patient Surname 
PERSON GIVEN NAME Patient Forename 
BIRTH DATE Patient date of Birth 
SEX Patient Gender 
PATIENT CLINICAL GROUP Patient Ethnic Group 
ADMINISTRATIVE CATEGORY Patient Admin Status 
POSTCODE OF USUAL ADDRESS Patient Post Code 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) GP Practice Code 
AMI ADMISSION DIAGNOSIS Admission Diagnosis 
INITIAL CONTACT TYPE Method of Admission 
ECG DETERMINING TREATMENT ECG Determining Treatment 
ASPIRIN THERAPY LOCATION Where was Aspirin Given 
PERSON OBSERVATION HISTORY (PREVIOUS AMI) Previous AMI 
PERSON OBSERVATION HISTORY (PREVIOUS ANGINA) Previous Angina 
PERSON OBSERVATION HISTORY (HYPERTENSION) Hypertension 
PERSON OBSERVATION HISTORY (HYPERCHOLESTEROLAEMIA) Hypercholesterloaemia 
PERSON OBSERVATION HISTORY (PERIPHERAL VASCULAR DISEASE) Peripheral Vascular Disease 
PERSON OBSERVATION HISTORY (CEREBROVASCULAR DISEASE) Cerebrovasular Disease 
PERSON OBSERVATION HISTORY (ASTHMA OR COPD) Asthma or COPD 
PERSON OBSERVATION HISTORY (CHRONIC RENAL FAILURE) Chronic Renal Failure 
PERSON OBSERVATION HISTORY (HEART FAILURE) Heart Failure 
CARDIAC ENZYMES OR MARKERS RAISED Cardiac Enzymes/Markers Raised 
SERUM CHOLESTEROL LEVEL Serum Cholesterol 
SMOKING STATUS Smoking Status 
PERSON OBSERVATION HISTORY (DIABETES TYPE) Diabetes 
PERSON HISTORY (PREVIOUS PCI) Previous PCI 
PERSON HISTORY (PREVIOUS CABG) Previous CABG 
SYSTOLIC PRESSURE (FIRST AFTER ADMISSION) Systolic BP 
AMI HEART RATE Heart Rate 
AMI ADMITTING CONSULTANT TYPE Admitting Consultant 
SYMPTOM ONSET DATE AND TIME (AMI) Date/time of symptom onset 
INITIAL PATIENT CONTACT DATE AND TIME Date/time of call for help 
PROFESSIONAL HELP ARRIVAL DATE AND TIME (AMI) Date/time of arrival of first professional help 
EMERGENCY SERVICES ARRIVAL DATE AND TIME (AMI) Date/time of arrival of emergency services 
START DATE (HOSPITAL PROVIDER SPELL) Date/time of arrival at hospital 
REPERFUSION TYPE (INITIAL STRATEGY) Was Reperfusion Attempted 
THROMBOLYTIC TREATMENT NOT GIVEN REASON Reason Thrombolytic Treatment Not Given 
REPERFUSION TREATMENT DATE AND TIME Date/time of reperfusion treatment 
THROMBOLYTIC TREATMENT DELAY REASON Justified Delay Before Thrombolytic Treatment 
REPERFUSION TREATMENT LOCATION Where was Initial Reperfusion Treatment Given 
REPERFUSION INITIAL DECISION Whose Initial Decision To Reperfuse 
CARDIAC ARREST FIRST VERIFIED DATE AND TIME Cardiac arrest date/time - First Arrest Only 
CARDIAC ARREST LOCATION Cardiac arrest location 
CARDIAC ARREST PRESENTING RHYTHM Arrest Presenting Rhythm 
CARDIAC ARREST OUTCOME (FIRST) Outcome of Arrest 
AMI ADMISSION WARD TYPE Admission Ward 
PEAK CREATINE KINASE Peak CK 
PEAK TROPONIN Peak Troponin 
AMI DRUG TREATMENT (UNFRACTIONATED HEPARIN) Unfractionated heparin 
AMI DRUG TREATMENT (LOW MOLECULAR WEIGHT HEPARIN) Low molecular weight heparin 
AMI DRUG TREATMENT (THIENOPYRIDINE PLATELET INHIBITOR) Thienopyridine platelet inhibitor 
AMI DRUG TREATMENT (ORAL ANTI-PLATELET AGENT) Other oral antiplatelet agent 
AMI DRUG TREATMENT (IV 2B AND (OR) 3B AGENT) IV 2b/3a Agent 
AMI DRUG TREATMENT (IV BETA BLOCKER) IB beta blocker 
AMI DRUG TREATMENT (CALCIUM CHANNEL BLOCKER) Calcium channel blocker 
AMI DRUG TREATMENT (IV NITRATE) IV Nitrate 
AMI DRUG TREATMENT (ORAL NITRATE) Oral Nitrate 
AMI DRUG TREATMENT (POTASSIUM CHANNEL MODULATOR) Potassium channel modulator 
AMI DRUG TREATMENT (WARFARIN) Warfarin 
AMI DRUG TREATMENT (ANGIOTENSIN II BLOCKER) Angiotensin II blocker (ARB) 
AMI DRUG TREATMENT (THIAZIDE DIURETIC) Thiazide diuretic 
AMI DRUG TREATMENT (LOOP DIURETIC) Loop diuretic 
AMI DRUG TREATMENT (SPIRONOLACTONE) Spironolactone 
THROMBOLYTIC DRUG Thrombolytic drug 
DISCHARGE DATE (HOSPITAL PROVIDER SPELL) Date of Discharge 
AMI DISCHARGE DIAGNOSIS Discharge Diagnosis 
BLEED COMPLICATION Bleeding complications 
AMI CAUSE OF DEATH IN HOSPITAL Death in Hospital 
DISCHARGED ON BETA BLOCKER Discharged On Beta Blocker 
DISCHARGED ON ANGIOTENSIN INHIBITOR Angiotensin Inhibitor 
DISCHARGED ON STATIN Discharged On Statin 
DISCHARGED ON ANTI-PLATELET DRUG Discharged On Aspirin Or Other Anti-Platelet 
REHABILITATION REFERRAL Cardiac Rehab 
EXERCISE TEST PERFORMED Exercise Test 
ECHOCARDIOGRAPHY PERFORMED Echocardiography 
RADIONUCLIDE STUDY Radionuclide Study 
CORONARY ANGIOGRAPHY PERFORMED Coronary Angiography at this Admission 
CORONARY INTERVENTION PERFORMED Coronary Intervention at this Admission 
REFERRAL REQUEST (AMI INVESTIGATION OR INTERVENTION) Date of referral for investigation/intervention 
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) Discharge destination 
INVESTIGATION TRANSFER DATE Transfer date for daycares investigation 
ANGIOGRAM DATE Date of angio performed locally 
INTERVENTION DATE (FIRST IN AMI CARE SPELL) Date of first intervention or surgery performed locally 
CCAD HOSPITAL IDENTIFIER (REFERRING) Referral centre 

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WHAT'S NEW: JULY 2011  renamed from WHAT'S NEW: JUNE 2011

Change to Supporting Information: Changed Description, Name

Release: July 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1249 (Immediate) - DDCN 1249/2011 General Pharmaceutical Council Registration Changes

The following has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 July 2012:

Release: June 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1256 (Immediate) - DDCN 1256/2011 School Definitions
  • CR1117 (26 August 2011) - ISB ISB 0090 Amd 94/2010 Organisation Data Service Identification Codes for Local Authorities in England and Wales
  • CR1117 (26 August 2011) - ISB 0090 Amd 94/2010 Organisation Data Service Identification Codes for Local Authorities in England and Wales
  • CR1251 (Immediate) - DDCN 1251/2011 Change to the Format/Length of Weekly Hours Worked
  • CR1243 (Immediate) - DDCN 1243/2011 National Interim Clinical Imaging Procedure (NICIP) Code Set

Release: April 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1154 (1 April 2011) - ISB 0011 Amd 87/2010 Mental Health Minimum Data Set Version 4.0
  • CR1234 (Immediate) - DDCN 1234/2011 Technology Reference Data Update Distribution Service (TRUD)
  • CR1168 (Immediate) - ISB 0097 Amd 140/2010 Genitourinary Medicine Access Monthly Monitoring Data Set Amendments - Removal of Human Immunodeficiency Virus data

The following has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012:

Release: March 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: January 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1116 (1 April 2010) - ISB 0003 Amd 79/2010 Immunisation Programmes Activity Data Set (KC50)
  • CR1112 (1 April 2010) - ISB 1511 Amd 26/2010 NHS Continuing Healthcare and NHS Funded Nursing Care
  • CR1068 (Immediate) - ISB 0133 Amd 161/2010 Change To Central Return: Human Papillomavirus (HPV) Immunisation Programme - Vaccine Monitoring Minimum Data Set
  • CR1211 (Immediate) - DDCN 1211/2010 Commissioning Data Set Addressing Grid / Organisation Code (Code of Commissioner) Update

Release: December 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: November 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1119 (Immediate) - DDCN 1119/2010 Organisation Codes Update 
  • CR1192 (Immediate) - DDCN 1192/2010 Change of name for "Health Solution Wales"
  • CR1199 (Immediate) - DDCN 1199/2010 General Pharmaceutical Council and Royal Pharmaceutical Society of Great Britain Update
  • CR1189 (Immediate) - DDCN 1189/2010 National Institute for Health and Clinical Excellence
  • CR1187 (Immediate) - DDCN 1187/2010 Introduction of the Department for Education

Release: September 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1128 (Immediate) - DDCN 1128/2010 Changes to reporting procedures for Overseas Visitors from the European Economic Area and Switzerland
  • CR1173 (Immediate) - DDCN 1173/2010 Care Quality Commission Update
  • CR1143 (Immediate) - DDCN 1143/2010 General Pharmaceutical Council
  • CR1061 (1 October 2010) - ISB 0092/2010 CDS Type 20: Out-patient: Retirement of Default Codes for Out-patient Procedures
  • CR1133 (Immediate) - ISB 00289/2010 National Specialty List

Release: August 2010

  • The August 2010 Release introduces the NHS Data Model and Dictionary Help Pages.

Release: July 2010

Information Standards Notices and Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

Release: May 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR957 (Immediate) - DSCN 19/2010 Central Returns: KA34 Ambulance Services

Release: March 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1123 (1 April 2010) - DSCN 18/2010 Information Standards Notice (ISN)
  • CR1139 (Immediate) - DSCN 16/2010 Person Weight
  • CR1130 (Immediate) - DSCN 15/2010 Change of name for "The NHS Information Centre for health and social care"
  • CR1013 (April 2010) - DSCN 14/2010 Sexual and Reproductive Health Activity Dataset (SRHAD)
  • CR1125 (Immediate) - DSCN 13/2010 NHS Data Model and Dictionary Maintenance Update - Policy Definitions
  • CR1122 (Immediate) - DSCN 11/2010 Changes to Family Planning References

Release: January 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1115 (Immediate) - DSCN 10/2010 Data Standards: Updating of e-Government Interoperability Framework and Government Data Standards Catalogue References

Release: December 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1100 (Immediate) - DSCN 25/2009 NHS Prescription Services Update
  • CR1045 (1 December 2009) - DSCN 17/2009 Referral to Treatment Clock Stop Administrative Event
  • CR1003 (1 December 2009) - DSCN 16/2009 Commissioning Data Sets: Mandation of 18 Week Referral To Treatment Data Items

Release: November 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1113 (Immediate) - DSCN 24/2009 Information Standards Board for Health and Social Care Update
  • CR1087 (Immediate) - DSCN 23/2009 Health Professions Council Update
  • CR1081 (Immediate) - DSCN 22/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
  • CR1019 (27 November 2009) - DSCN 21/2009 Data Standards: Organisation Data Service (ODS) - Optical Sites and Optical Headquarters
  • CR1034 (27 November 2009) - DSCN 20/2009 Data Standards: Organisation Data Service (ODS) - Care Homes in England and Wales and their Headquarters

Release: September 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1065 (1 October 2009) - DSCN 15/2009 Data Standards: Organisation Data Service, Local Health Boards

Release: June 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1014 (1 June 2009) - DSCN 13/2009 Religious and Other Belief System Affiliation
  • CR1074 (Immediate) - DSCN 12/2009 Data Standards: Care Quality Commission
  • CR1056 (Immediate) - DSCN 11/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
  • CR1072 (1 December 2009) - DSCN 10/2009 Data Standards: National Radiotherapy Data Set
  • CR1073 (Immediate) - DSCN 09/2009 Central Returns: Diagnostic Waiting Times and Activity Data Set
  • CR1066 (Immediate) - DSCN 08/2009 Data Standards: NHS Prescription Services and NHS Dental Services
  • CR1047 (1 April 2011) - DSCN 07/2009 Data Standards: Diabetic Retinopathy Screening Dataset v3.6 
  • CR1059 (Immediate) - DSCN 06/2009 Data Standard: National Workforce Data Set v2.1
  • CR914 (April 2008 (Retrospective)) - DSCN 05/2009 NHS Stop Smoking Services Quarterly Monitoring Return
  • CR899 (Immediate) - DSCN 02/2009 NHS Data Model and Dictionary Maintenance Update

Release: March 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1001 (1 April 2009) - DSCN 03/2009 Introduction of Commissioning Data Set Schema Version 6-1 (2008-04-01) and update to Commissioning Data Set Schema Version 6-0 (2008-01-14)
  • CR976 (31 March 2009) - DSCN 26/2008 Subject: KP90 - Admissions, Changes in Status and Detentions under the Mental Health Act
  • CR1017 (1 April 2009) - DSCN 25/2008 Critical Care Minimum Data Set
  • CR1002 (1 April 2009) - DSCN 24/2008 Data Standards: Introduction of Commissioning Dataset Version 6.1
  • CR1016 (Immediate) - DSCN 23/2008 4 Byte Version of the Read Codes - Withdrawal

Release: December 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1022 (1 January 2009) - DSCN 29/2008 Data Standards: 18 Weeks Referral to Treatment (RTT) Time, Performance Sharing
  • CR901 (Immediate) - DSCN 28/2008 Removal of references to EDIFACT and the NHS Wide Clearing Service (NWCS) 
  • CR843 (1 April 2009) - DSCN 22/2008 Data Standards: National Radiotherapy Data Set
  • CR1011 (1 January 2009) - DSCN 20/2008 Data Standards: National Cancer Waiting Times Minimum Data Set 

Release: November 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1026 (3 November 2008) - DSCN 21/2008 Information Standard: Mental Health Act 2007 Mental Category

Release: August 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1018 (Immediate) - DSCN 19/2008 Data Standards: Change of Name for National Administrative Code Services (NACS) to Organisation Data Service (ODS)
  • CR956 (1 September 2008) - DSCN 18/2008 Central Return: Human Papillomavirus (HPV) Immunisation Programme, Vaccine Monitoring Minimum Dataset
  • CR861 (Immediate) - DSCN 16/2008 Central Return:  Hospital and Community Services Complaints and General Practice (including Dental) Complaints - KO41(a) and KO 41(b)
  • CR964 (Immediate) - DSCN 14/2008 Central Return: 18 Weeks ‘Adjusted’ Referral to Treatment (RTT) Dataset
  • CR965 (Immediate) - DSCN 13/2008 Data Standards: Organisation Data Service (ODS) - Change to the Default Codes Set to Support Changes to GMS Contract
  • CR879 (Immediate) - DSCN 12/2008 Data Standards: Quarterly Monitoring: Cancelled Operations Data Set (QMCO)

Release: May 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR502 (Immediate) - DSCN 10/2008 Data Standards: National Workforce Data Definitions (v2.0)
  • CR910 (1 April 2008) - DSCN 08/2008 Data Standards: National Direct Access Audiology Patient Tracking List (PTL) and Waiting Times (WT) data sets
  • CR900 (Immediate) - DSCN 07/2008 Data Standards: Inter-Provider Transfer Administrative Minimum Data Set
  • CR934 (1 April 2008) - DSCN 06/2008 Data Standards: Mental Health Minimum Data Set (version 3.0)
  • CR935 (Immediate) - DSCN 05/2008 Data Standards: 18 Weeks Rules Suite
  • CR925 (1 September 2008) - DSCN 04/2008 Genitourinary Medicine Clinic Activity Data Set Change to an Information Standard
  • CR942 (1 June 2008) - DSCN 03/2008 General Practice and General Medical Practitioner (GMP) - changes resulting from the introduction of the General Medical Services (GMS) Contract

Release: February 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR812 (Immediate) - DSCN 01/2008 Central Return: Diagnostics Waiting Times Census Data Set
  • CR881 (31 December 2007) - DSCN 42/2007 Central Return: Referral To Treatment Summary Patient Tracking List
  • CR904 (Immediate) - DSCN 41/2007 Data Standards: Admission Intended Procedure Update
  • CR824 (1 February 2008) - DSCN 39/2007 Data Standards: 48 Hour Genitourinary Medicine Access Monthly Monitoring (GUMAMM)

Release: November 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR919 (Immediate) - DSCN 38/2007 Data Standards: Mental Health Minimum Data Set Schema
  • CR814 (1 April 2008) - DSCN 37/2007 Data Standards: Introduction of Mental Health Minimum Data Set version 2.1
  • CR930 (31 December 2007) - DSCN 35/2007 Data Standards: A correction to the version 6 Commissioning Data Set schema
  • CR834 (Immediate) - DSCN 34/2007 Data Standards: Referral Request Received Date
  • CR875 (Immediate) - DSCN 33/2007 Data Standards: National Administrative Codes Service: Introduction of codes for the new Pan SHAs
  • CR880 (Immediate) - DSCN 29/2007 Data Standards: Amendments to Doctor Index Number (DIN) Description

Release: August 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR845 (Immediate) - DSCN 28/2007 Data Standards: Treatment Function Code (Referral to Treatment Period)
  • CR831 (1 October 2007) - DSCN 27/2007 Data Standards: Update to Commissioning Data Set XML Schema v5
  • CR825 (1 October 2007) - DSCN 16/2007 Data Standards: Source of Referral for Outpatients (18 Weeks)

Release: June 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR799 (31 December 2007) - DSCN 18/2007 Data Standards: Introduction of Commissioning Data Set Version 6
  • CR833 (Immediate) - DSCN 17/2007 Data Standards: Introduction of Commissioning Data Set validation table
  • CR801 (Immediate) - DSCN 15/2007 Data Standards: Cover of Vaccination Evaluated Rapidly (COVER) Return

Release: May 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR800 (31 December 2007) - DSCN 14/2007 Commissioning Data Set Schema Version 6-0
  • CR856 (1 October 2007) - DSCN 13/2007 Data Standards: Discharge Ready Date
  • CR869 (Immediate) - DSCN 12/2007 Data Standards: Update to Clinical Coding Introduction
  • CR827 (1 October 2007) - DSCN 09/2007 Data Standards: Earliest Reasonable Offer Date
  • CR817 (1 October 2007) - DSCN 08/2007 Data Standards: Introduction of Age into Commissioning Data Sets
  • CR849 (May 2007) - DSCN 07/2007 National Administrative Codes Service: Introduction of new identification codes for Dental Consultants
  • CR822 (Immediate) - DSCN 06/2007 Data Standards: Update to Organisation Codes
  • CR850 (Immediate) - DSCN 05/2007 National Administrative Codes Service: Amendments to Default Codes
  • CR786 (1 April 2007) - DSCN 04/2007 Quarterly Monitoring Accident and Emergency Services (QMAE) Central Return

Release: February 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR811 (Immediate) - DSCN 03/2007 Diagnostic Waiting Times and Activity
  • CR826 (1 October 2007) - DSCN 02/2007 Extension of Treatment Function to Support the Measurement of 18 Week Referral to Treatment Periods
  • CR813 (1 April 2007) - DSCN 01/2007 Paediatric Critical Care Minimum Data Set
  • CR768 (1 January 2007) - DSCN 18/2006 Changes to the NHS Data Dictionary to support the measurement of 18 week referral to treatment periods
  • CR798 (6 November 2006) - DSCN 19/2006 Commissioning Data Set (CDS) Version 5 XML Message Schema
  • CR776 (1 October 2006) - DSCN 05/2006 Data Standards: Accident and Emergency Enhancements to Investigation and Treatment Codes

Release: September 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR795 (31 October 2006) - DSCN 22/2006 Organisation Codes / Organisation Site Codes
  • CR792 (1 April 2007) - DSCN 15/2006 Neonatal Critical Care
  • CR719 (1 April 2006) - DSCN 09/2006 Measuring and Recording of Waiting Times
  • CR791 (1 April 2007) - DSCN 13/2006 Priority Type
  • CR774 (1 September 2006) - DSCN 12/2006 Person Marital Status

Release: May 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR764 (1 April 2006) - DSCN 08/2006 Diagnostics waiting times and activity
  • Correction to menu structure to include Critical Care Minimum Data Set

Release: April 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR608 (1 October 2006) - DSCN 07/2006 Introduction of Commissioning Data Set Version 5 and its associated XML schema into the NHS Data Dictionary.
  • CR756 (1 September 2005) - DSCN 19/2005 PbR Commissioning for Out of Area Treatments (OATs) and Charge-Exempt Overseas Visitors
  • CR724 (1 April 2006) - DSCN 13/2005 Critical Care Minimum Data Set
  • CR754 (1 April 2006) - DSCN 17/2005 Treatment Function and Main Specialty Code Revisions
  • CR763 (1 April 2006) - DSCN 20/2005 New Treatment Functions for therapy services and anticoagulant service
  • CR767 (Immediate) - DSCN 02/2006 Referral Request Received Date
  • CR690 (1 September 2005) - DSCN 16/2005 Marital Status

Release: August 2005

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR555 (1 April 2005) - DSCN 11/2005 Data Standards: COVER - Hepatitis B immunisation for babies
  • CR715 (Immediate) - DSCN 10/2005 Data Standards: Treatment Function Codes - correction and clarification of names and descriptions
  • CR706 (1 April 2005) - DSCN 09/2005 Data Standards: Cancer Registration Data Set
  • CR691 (1 July 2005) - DSCN 06/2005 Data Standards: NSCAG Commissioner Code

For all Information Standards Notices and Data Set Change Notices, see the Information Standards Board for Health and Social Care Website

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ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE

Change to Attribute: Changed Description

This item is being updated for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

A classification of the physical status of the PATIENT as recorded by an anaesthetist for the operative procedure.

This is the American Society of Anesthesiologists (ASA) Physical Status Classification System, see the American Society of Anesthesiologists website.

National Codes:

01A normal healthy PATIENT
02A PATIENT with mild systemic disease
03A PATIENT with severe systemic disease
04A PATIENT with severe systemic disease that is a constant threat to life
05A moribund PATIENT who is not expected to survive without the operation
06A declared brain-dead PATIENT whose organs are being removed for donor purposes
1A normal healthy PATIENT
2A PATIENT with mild systemic disease
3A PATIENT with severe systemic disease
4A PATIENT with severe systemic disease that is a constant threat to life
5A moribund PATIENT who is not expected to survive without the operation
6A declared brain-dead PATIENT whose organs are being removed for donor purposes
 

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ASSESSMENT TOOL TYPE

Change to Attribute: Changed Description

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CLINICAL CLASSIFICATION CODE

Change to Attribute: Changed Description

A unique identifier for a CLINICAL CLASSIFICATION, for example this could be an OPCS-4 code or a Read code.

The codes for both OPCS-4 and Read are maintained by NHS Connecting for Health.

This could also be a PATIENT DIAGNOSIS.

See International Classification of Diseases (ICD-10) and Read Coded Clinical Terms.

Diagnoses should be classified where possible using ICD-10 or other classification codes approved centrally for mapping to ICD-10 codes. Clinical Terms (The Read Codes) can be used in addition to ICD-10 codes for Patient Diagnosis. Clinical Terms (The Read Codes) can be used in addition to ICD-10 codes for PATIENT DIAGNOSIS. However Clinical Terms (The Read Codes) are not accepted for the purposes of central Hospital Episode Statistics data, where ICD-10 is mandatory.

ICD-10 diagnostic codes are at least four characters in length. The first character is always alphabetic. Where an undivided three character code is used, the fourth character must be filled with 'X'.

Fifth characters should be used in accordance with the guidance in International Classification of Diseases (ICD-10). Where they are not used the character must be filled with a '-'. The sixth character of the code is used to designate an asterisk or dagger indicator in ICD-10; it may be an 'A' or 'D'.

 

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DELAY REASON TO TREATMENT (CANCER)

Change to Attribute: Changed Description

A classification of the reason why a Cancer Care Spell Delay was experienced with regard to a Cancer Care SpellThe national codes to be used are the same for delays between:

CANCER REFERRAL TO TREATMENT PERIOD START DATE and TREATMENT START DATE (CANCER)The national codes to be used are the same for delays between:

DECISION TO TREAT DATE and TREATMENT START DATE (CANCER)

CONSULTANT UPGRADE DATE and TREATMENT START DATE (CANCER).

This is the reason why the Health Care Provider was unable to offer a DATE within the service standard (31 days between DECISION TO TREAT DATE and TREATMENT START DATE (CANCER), and CONSULTANT UPGRADE DATE and TREATMENT START DATE (CANCER); or 62 days between the CANCER REFERRAL TO TREATMENT PERIOD START DATE and TREATMENT START DATE (CANCER) ).

National Codes:

01Clinic cancellation
02Out-patient capacity inadequate (i.e. no cancelled clinic, but not enough slots for this PATIENT)
02Out-patient capacity inadequate (i.e. no cancelled clinic, but not enough slots for this PATIENT)
03Administrative delay (e.g. failed to be rebooked after Did Not Attend, lost referral)
04Elective cancellation (for non-medical reason)
05Elective capacity inadequate (patient unable to be scheduled for treatment within standard time)
05Elective capacity inadequate (PATIENT unable to be scheduled for treatment within standard time)
06Delay to diagnostic test or treatment planning
07Complex diagnostic pathway (many, or complex, diagnostic tests required)
08Delay due to referral between Trusts
99Other reason

If National Code 99 - Other reason is used, the reason must be explained within DELAY REASON COMMENT (CONSULTANT UPGRADE), DELAY REASON COMMENT (REFERRAL TO TREATMENT) or DELAY REASON COMMENT (DECISION TO TREATMENT) as appropriate.

 

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NUMBER OF TELETHERAPY FIELDS

Change to Attribute: Changed Description

The actual prescribed number of fields of a Teletherapy Treatment Course .

 

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PATIENT CLASSIFICATION

Change to Attribute: Changed Description

A coded classification of PATIENTS who have been admitted to a Hospital Provider Spell

National Codes:

1Ordinary admission.
A PATIENT not admitted electively, and any PATIENT admitted electively with the expectation that they will remain in hospital for at least one night, including a PATIENT admitted with this intention who leaves hospital for any reason without staying overnight. A PATIENT admitted electively with the intent of not staying overnight, but who does not return home as scheduled, should be counted as an ordinary admission
2Day case admission.
A PATIENT admitted electively during the course of a day with the intention of receiving care who does not require the use of a Hospital Bed  overnight and who returns home as scheduled. If this original intention is not fulfilled and the PATIENT stays overnight, such a PATIENT should be counted as an ordinary admission
3Regular day admission.
A PATIENT admitted electively during the day, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged the same day. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the PATIENT no longer requires frequent admissions
4Regular night admission.
A PATIENT admitted electively for the night, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged in the morning. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions
5Mother and baby using delivery facilities only.
Mother and baby using delivery facilities only and not using a Hospital Bed in the antenatal or postnatal WARDS during the stay in hospital
1Ordinary admission
A PATIENT not admitted electively, and any PATIENT admitted electively with the expectation that they will remain in hospital for at least one night, including a PATIENT admitted with this intention who leaves hospital for any reason without staying overnight. A PATIENT admitted electively with the intent of not staying overnight, but who does not return home as scheduled, should be counted as an ordinary admission
2Day case admission
A PATIENT admitted electively during the course of a day with the intention of receiving care who does not require the use of a Hospital Bed  overnight and who returns home as scheduled. If this original intention is not fulfilled and the PATIENT stays overnight, such a PATIENT should be counted as an ordinary admission
3Regular day admission
A PATIENT admitted electively during the day, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged the same day. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the PATIENT no longer requires frequent admissions
4Regular night admission
A PATIENT admitted electively for the night, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged in the morning. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions
5Mother and baby using delivery facilities only
Mother and baby using delivery facilities only and not using a Hospital Bed in the antenatal or postnatal WARDS during the stay in hospital
 

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PRIORITY TYPE

Change to Attribute: Changed Description

This is the priority of a request for services; in the case of services to be provided by a CONSULTANT, it is as assessed by or on behalf of the CONSULTANT.

Priority Type 'Urgent' should be used where the request for services is defined as clinically urgent, but it does not fall under the criteria for 'Two Week Wait' (see below).

Priority Type 'Two Week Wait' should be used where either:

or

  • the PATIENT has been referred urgently for breast symptoms, but the referral does not meet the criteria for urgent GENERAL PRACTITIONER referrals for suspected cancer

National Codes:

1Routine
2Urgent
3Two Week Wait
 

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SOURCE OF REFERRAL FOR MENTAL HEALTH

Change to Attribute: Changed Description

A classification which identifies the source of referral of a Mental Health Care Spell.

National Codes:

 Primary Health Care 
A1GENERAL MEDICAL PRACTITIONER 
A2Health Visitor 
A3Other Primary Health Care
 Self Referral 
B1Self
B2Carer
 Local Authority Services 
C1Social Services
C2Education Service
 Employer 
D1Employer
 Justice System 
E1Police
E2Courts
E3Probation Service
E4Prison
E5Court Liaison and Diversion Service
 Child Health 
F1School Nurse 
F2Hospital-based Paediatrics
F3Community-based Paediatrics
 Independent/Voluntary Sector 
G1Independent sector - Medium Secure Inpatients
G2Independent Sector - Low Secure Inpatients
G3Other Independent Sector Mental Health Services
G4Voluntary Sector
 Acute Secondary Care 
H1Accident and Emergency Department 
H2Other secondary care specialty
 Other Mental Health NHS Trust 
I1Temporary transfer from another Mental Health NHS Trust
I2Permanent transfer from another Mental Health NHS Trust
 Internal referrals  from Community Mental Health Team (within own NHS Trust) 
J1Community Mental Health Team (Adult Mental Health)
J2Community Mental Health Team (Older People)
J3Community Mental Health Team (Learning Disabilities)
J4Community Mental Health Team (Child and Adolescent Mental Health)
 Internal referrals from Inpatient Service (within own NHS Trust) 
K1Inpatient Service (Adult Mental Health)
K2Inpatient Service (Older People)
K3Inpatient Service (Forensics)
K4Inpatient Service (Child and Adolescent Mental Health)
K5Inpatient Service (Learning Disabilities)
 Transfer by graduation (within own NHS Trust) 
L1Transfer by graduation from Child and Adolescent Mental Health Services to Adult Mental Health Services
L2Transfer by graduation from Adult Mental Health Services to Older Peoples Mental Health Services
 Other 
M1Asylum Services
M2NHS Direct
M3Out of Area Agency
M4Drug Action Team / Drug Misuse Agency
M5Jobcentre Plus**
M6Other service or agency

** Note: this National Code can only be used for the Mental Health Minimum Data Set and Child and Adolescent Mental Health Services Data Set, if referrals from Jobcentre Plus are accepted.** Note: this National Code can only be used for the Mental Health Minimum Data Set (Version 4-0) and Child and Adolescent Mental Health Services Data Set, if referrals from Jobcentre Plus are accepted.

National Codes: Retired
The retired codes are for use in all versions of the Mental Health Minimum Data Set prior to Mental Health Minimum Data Set version 4-0

00 GENERAL MEDICAL PRACTITIONER 
01 Self 
02 Local Authority Social Services 
03 Accident And Emergency Department 
04 Employer 
05 Education Service 
06 Police 
07 Other clinical specialty 
08 Carer 
09 Courts 
10 Probation Service 
11 High security 
12 Medium security 
13 Other 
20 Temporary transfer from mental health unit 
21 Permanent transfer from mental health unit 
22 Transfer by graduation from local child and adolescent mental health services 
 

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ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE

Change to Data Element: Changed Description

Format/Length:an2
Format/Length:an1
HES Item: 
National Codes:See ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE
Default Codes: 

This item is being updated for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE is the same as attribute ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE.

 

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DATE DETENTION COMMENCED

Change to Data Element: Changed Description

Format/length:see DATE 
HES item:DETNDATE
National Codes: 
Default Codes: 


Notes:
DATE DETENTION COMMENCED is the same as the attribute PERSON PROPERTY EFFECTIVE DATE.

This is the PERSON PROPERTY EFFECTIVE DATE of the Legal Status. It is the date on which the first order was made in this period of detention, even though the section of the Act under which the PATIENT is detained may have changed, the PATIENT may have been transferred to another provider or the PATIENT was detained under the Act after admission to the current provider. All changes in MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE should be recorded, and the continuous period of detention obtained by comparing the PERSON PROPERTY EFFECTIVE DATES for the historical Legal Status records. (Act refers to the 1983 Mental Health Act).

Where the detention order is held by a hospital other than that where the PATIENT is present at the date of the census, the latter should ensure the information relating to this detention order is obtained from the former hospital. Only the hospital where the PATIENT is treated should submit the data.

Legal Status is a CATEGORY VALUED PERSON OBSERVATION where CATEGORY VALUED PERSON OBSERVATION TYPE is National Code 07 'Legal Status Classification'.

 

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DATE OF ASSAULT ON PATIENT

Change to Data Element: Changed Description

Format/Length:See DATE
HES Item: 
National Codes: 
Default Codes: 


Notes:
The date of a reported instance of assault on the PATIENT by another PATIENT.

For the Mental Health Minimum Data Set (Version 4-0), assault is defined as:

The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort.

This data element is only reported in the Mental Health Minimum Data Set (Version 4-0) if the self-harm occurred during a Hospital Provider Spell

 

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DATE OF PATIENT TREATMENT OR INTERVENTION (READ)

Change to Data Element: Changed Description

Format/Length:See DATE
HES Item: 
National Codes: 
Default Codes: 


Notes:
The date of a PATIENT TREATMENT OR INTERVENTION (READ).

 

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DATE OF PHYSICAL RESTRAINT

Change to Data Element: Changed Description

Format/Length:See DATE
HES Item: 
National Codes: 
Default Codes: 


Notes:
The date of a reported incident of physical restraint of a PATIENT by one or more members of staff in response to aggressive behaviour or resistance to treatment.  Any incident of restraint resulting in the Trust Restraint Policy being invoked should be recorded.

This data element is only reported in the Mental Health Minimum Data Set (Version 4-0) if the physical restraint occurred during a Hospital Provider Spell

 

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DATE OF SECLUSION

Change to Data Element: Changed Description

Format/Length:See DATE
HES Item: 
National Codes: 
Default Codes: 


Notes:
The date of an incident of seclusion of a PATIENT.  Any incident of seclusion resulting in the Trust Seclusion Policy being invoked should be recorded.

The Mental Health Minimum Data Set (Version 4-0) uses the Mental Health Act 1983 Code of Practice definition of seclusion:

The supervised confinement of a PATIENT in a room, which may be locked.  Its sole aim is to contain severely disturbed behaviour which is likely to cause harm to others.

This data element is only reported in the Mental Health Minimum Data Set (Version 4-0) if the seclusion occurred during a Hospital Provider Spell.

 

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DATE OF SELF HARM

Change to Data Element: Changed Description

Format/Length:See DATE
HES Item: 
National Codes: 
Default Codes: 


Notes:
The date of a reported incident of self-harm by a PATIENT.

For the Mental Health Minimum Data Set (Version 4-0), self-harm is defined as:

Intentional self-poisoning or injury, irrespective of the apparent purpose of the act.  Self-harm includes poisoning, asphyxiation, cutting, burning and other self-inflicted injuries.

This data element is only reported in the Mental Health Minimum Data Set (Version 4-0) if the self-harm occurred during a Hospital Provider Spell.

 

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HAEMOGLOBIN CONCENTRATION

Change to Data Element: Changed Description

Format/Length:nn.n
Format/Length:max n2.n1
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:
HAEMOGLOBIN CONCENTRATION is the outcome of the Clinical Investigation which measures the PERSON's haemoglobin concentration in 'g/dl (grammes per decilitre).'

 

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PERSON HEIGHT IN CENTIMETRES

Change to Data Element: Changed Description

Format/Length:nnn.n
Format/Length:max n3.n1
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:
PERSON HEIGHT IN CENTIMETRES records the Height of the PERSON in centimetres.

This corresponds to MEASURED OBSERVATION VALUE where the MEASURED PERSON OBSERVATION TYPE CODE is 'Height' and MEASUREMENT VALUE TYPE CODE is 'Centimetres'.

 

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PERSON HEIGHT IN METRES

Change to Data Element: Changed Description

Format/Length:n.nn
Format/Length:n1.max n2
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:
PERSON HEIGHT IN METRES records the Height of the PERSON in metres.

This corresponds to MEASURED OBSERVATION VALUE where the MEASURED PERSON OBSERVATION TYPE CODE is 'Height' and MEASUREMENT VALUE TYPE CODE is 'Metres'.

 

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PERSON WEIGHT

Change to Data Element: Changed Description

Format/Length:n3.n3
Format/Length:max n3.max n3
HES Item: 
National Codes: 
Default Codes: 

Notes:
PERSON WEIGHT records the Weight of the PERSON.

This corresponds to MEASURED OBSERVATION VALUE where the MEASURED PERSON OBSERVATION TYPE CODE is 'Weight' and the MEASUREMENT VALUE TYPE CODE is 'Kilograms'.This corresponds to MEASURED OBSERVATION VALUE where the MEASURED PERSON OBSERVATION TYPE CODE is 'Weight' and the MEASUREMENT VALUE TYPE CODE is 'Kilogram'.

The field must be padded to match the Format/Length pattern of n3.n3, for example 001.100 is a valid entry (1.1 is invalid).Notes:

For neonatal critical care, this will be the last recorded Weight on a particular ACTIVITY DATE (CRITICAL CARE).

 
  • For the Commissioning Data Sets, the field must be padded to match the Format/Length pattern of n3.n3, for example 001.100 is a valid entry (1.1 is invalid)

  • For neonatal critical care, this will be the last recorded Weight on a particular ACTIVITY DATE (CRITICAL CARE).

  •  

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    SMOKING STATUS CODE

    Change to Data Element: Changed Description

    Format/Length:an1
    HES Item: 
    National Codes:See SMOKING STATUS
    Default Codes:9 - Unknown


    Notes:
    SMOKING STATUS CODE is the same as attribute SMOKING STATUS.

    Code '9 - Unknown' is not a valid code in the NHS Health Checks Data Set.

    SMOKING STATUS CODE replaces SMOKING STATUS and should be used for all new and developing data sets and for XML messages.

     

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    WHITE BLOOD CELL COUNT

    Change to Data Element: Changed Description

    Format/Length:nn.n
    Format/Length:max n2.n1
    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:
    WHITE BLOOD CELL COUNT is the outcome of the Clinical Investigation which measures the PERSON's white cell blood count in 'x109/l (i.e. times ten to the power 9 per litre).'

     

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