NHS Data Model and DictionaryNHS Digital
Type:Patch
Reference:1789
Version No:1.0
Subject:Data Set Overviews Update
Effective Date:Immediate
Reason for Change:Patch
Publication Date:7 September 2020

Background:

Versions of the Data Dictionary from 3+ onwards will not have 3 frames for data sets. The current information on the overview page will display at the top of each data set.

To ensure the new data set page contains the correct mandation, XML Schema download and constraints information, the information will be added to the overview page.

This patch:

Note: the Commissioning Data Sets will be updated in CR1792.

To view a demonstration on "How to Read an NHS Data Model and Dictionary Change Request", visit the NHS Data Model and Dictionary help pages at: https://www.datadictionary.nhs.uk/Flash_Files/changerequest.htm.

Note: if the web page does not open, please copy the link and paste into the web browser.

Summary of changes:

Data Set
AGGREGATE CONTRACT MONITORING DATA SET   Changed Description
AIDC FOR PATIENT IDENTIFICATION DATA SET   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - BREAST   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - CENTRAL NERVOUS SYSTEM   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - CHILDREN TEENAGERS AND YOUNG ADULTS   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - COLORECTAL   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - CORE   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - GYNAECOLOGICAL   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - HAEMATOLOGICAL   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - HEAD AND NECK   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - LIVER   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - LUNG   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - PATHOLOGY   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - SARCOMA   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - SKIN   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - UPPER GASTROINTESTINAL   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET - UROLOGICAL   Changed Description
CHLAMYDIA TESTING ACTIVITY DATA SET   Changed Description
COMMUNITY SERVICES DATA SET   Changed Description
COVER OF VACCINATION EVALUATED RAPIDLY (COVER) DATA SET   Changed Description
CRITICAL CARE MINIMUM DATA SET   Changed Description
DEVICES PATIENT LEVEL CONTRACT MONITORING DATA SET   Changed Description
DIAGNOSTIC IMAGING DATA SET   Changed Description
DRUGS PATIENT LEVEL CONTRACT MONITORING DATA SET   Changed Description
FEMALE GENITAL MUTILATION DATA SET   Changed Description
GUMCAD SEXUALLY TRANSMITTED INFECTION SURVEILLANCE SYSTEM DATA SET   Changed Description
HIV AND AIDS REPORTING DATA SET   Changed Description
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DATA SET   Changed Description
INTER-PROVIDER TRANSFER ADMINISTRATIVE MINIMUM DATA SET   Changed Description
MATERNITY SERVICES DATA SET   Changed Description
MENTAL HEALTH SERVICES DATA SET   Changed Description
NATIONAL CANCER WAITING TIMES MONITORING DATA SET   Changed Description
NATIONAL JOINT REGISTRY DATA SET - ANKLE   Changed Description
NATIONAL JOINT REGISTRY DATA SET - COMMON DETAILS   Changed Description
NATIONAL JOINT REGISTRY DATA SET - ELBOW   Changed Description
NATIONAL JOINT REGISTRY DATA SET - HIP   Changed Description
NATIONAL JOINT REGISTRY DATA SET - KNEE   Changed Description
NATIONAL JOINT REGISTRY DATA SET - SHOULDER   Changed Description
NATIONAL NEONATAL DATA SET - EPISODIC AND DAILY CARE   Changed Description
NATIONAL NEONATAL DATA SET - TWO YEAR NEONATAL OUTCOMES ASSESSMENT   Changed Description
NATIONAL WORKFORCE DATA SET   Changed Description
NEONATAL CRITICAL CARE MINIMUM DATA SET   Changed Description
NHS BREAST SCREENING PROGRAMME CENTRAL RETURN DATA SET (KC62)   Changed Description
NHS BREAST SCREENING PROGRAMME CENTRAL RETURN DATA SET (KC63)   Changed Description
NHS CONTINUING HEALTHCARE DATA SET   Changed Description
NHS CONTINUING HEALTHCARE PATIENT LEVEL DATA SET   Changed Description
PAEDIATRIC CRITICAL CARE MINIMUM DATA SET   Changed Description
PATIENT LEVEL CONTRACT MONITORING DATA SET   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET - ADMITTED PATIENT CARE   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET - EMERGENCY CARE   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET - OUT-PATIENT CARE   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET - SPECIALIST WARD CARE   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET - SUPPLEMENTARY INFORMATION   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM DATA SET - RECONCILIATION   Changed Description
RADIOTHERAPY DATA SET   Changed Description
SEXUAL AND REPRODUCTIVE HEALTH ACTIVITY DATA SET   Changed Description
STOP SMOKING SERVICES QUARTERLY DATA SET   Changed Description
SYSTEMIC ANTI-CANCER THERAPY DATA SET   Changed Description
VENOUS THROMBOEMBOLISM RISK ASSESSMENT DATA SET   Changed Description
 
Supporting Information
AGGREGATE CONTRACT MONITORING DATA SET OVERVIEW   Changed Description
AIDC FOR PATIENT IDENTIFICATION DATA SET OVERVIEW   Changed Description
CANCER OUTCOMES AND SERVICES DATA SET OVERVIEW   Changed Description
CHLAMYDIA TESTING ACTIVITY DATA SET OVERVIEW   Changed Description
COMMUNITY SERVICES DATA SET OVERVIEW   Changed Description
COVER OF VACCINATION EVALUATED RAPIDLY (COVER) DATA SET OVERVIEW   Changed Description
CRITICAL CARE MINIMUM DATA SET OVERVIEW   Changed Description
DEVICES PATIENT LEVEL CONTRACT MONITORING DATA SET OVERVIEW   Changed Description
DIAGNOSTIC IMAGING DATA SET OVERVIEW   Changed Description
DRUGS PATIENT LEVEL CONTRACT MONITORING DATA SET OVERVIEW   Changed Description
FEMALE GENITAL MUTILATION DATA SET OVERVIEW   Changed Description
GUMCAD SEXUALLY TRANSMITTED INFECTION SURVEILLANCE SYSTEM DATA SET OVERVIEW   Changed Description
HIV AND AIDS REPORTING DATA SET OVERVIEW   Changed Description
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DATA SET OVERVIEW   Changed Description
INTER-PROVIDER TRANSFER ADMINISTRATIVE MINIMUM DATA SET OVERVIEW   Changed Description
MATERNITY SERVICES DATA SET OVERVIEW   Changed Description
MENTAL HEALTH SERVICES DATA SET OVERVIEW   Changed Description
NATIONAL CANCER WAITING TIMES MONITORING DATA SET OVERVIEW   Changed Description
NATIONAL JOINT REGISTRY DATA SET OVERVIEW   Changed Description
NATIONAL NEONATAL DATA SET OVERVIEW   Changed Description
NATIONAL WORKFORCE DATA SET OVERVIEW   Changed Description
NHS BREAST SCREENING PROGRAMME CENTRAL RETURN DATA SET (KC62) OVERVIEW   Changed Description
NHS BREAST SCREENING PROGRAMME CENTRAL RETURN DATA SET (KC63) OVERVIEW   Changed Description
NHS CONTINUING HEALTHCARE DATA SET OVERVIEW   Changed Description
NHS CONTINUING HEALTHCARE PATIENT LEVEL DATA SET OVERVIEW   Changed Description
PATIENT LEVEL CONTRACT MONITORING DATA SET OVERVIEW   Changed Description
PATIENT LEVEL INFORMATION COSTING SYSTEM ACUTE DATA SET OVERVIEW   Changed Description
RADIOTHERAPY DATA SET OVERVIEW   Changed Description
SEXUAL AND REPRODUCTIVE HEALTH ACTIVITY DATA SET OVERVIEW   Changed Description
STOP SMOKING SERVICE QUARTERLY DATA SET OVERVIEW   Changed Description
SYSTEMIC ANTI-CANCER THERAPY DATA SET OVERVIEW   Changed Description
VENOUS THROMBOEMBOLISM RISK ASSESSMENT DATA SET OVERVIEW   Changed Description
 

Date:7 September 2020
Sponsor:Nicholas Oughtibridge, Head of Clinical Data Architecture, NHS Digital

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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AGGREGATE CONTRACT MONITORING DATA SET

Change to Data Set: Changed Description

Aggregate Contract Monitoring Data Set Overview

For a "Full Screen" view, click Aggregate Contract Monitoring Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

SUBMISSION HEADER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MFINANCIAL MONTH
MFINANCIAL YEAR
MDATE AND TIME DATA SET CREATED

ORGANISATION DETAILS

To carry the organisation details of the provider and commissioner. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
RORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

CARE ACTIVITY DETAILS

To carry the care activity details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RACTIVITY TREATMENT FUNCTION CODE
OLOCAL SUB-SPECIALTY CODE
RWARD CODE

SERVICE AGREEMENT AND COMMISSIONING DETAILS

To carry the service agreement and commissioning details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCOMMISSIONED SERVICE CATEGORY CODE
RSPECIALISED SERVICE CODE
RSPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
MPOINT OF DELIVERY CODE
RPOINT OF DELIVERY FURTHER DETAIL CODE
RPOINT OF DELIVERY FURTHER DETAIL DESCRIPTION
OLOCAL POINT OF DELIVERY CODE
OLOCAL POINT OF DELIVERY DESCRIPTION
OCONTRACT MONITORING ADDITIONAL DETAIL (FIRST)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIRST)
OCONTRACT MONITORING ADDITIONAL DETAIL (SECOND)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (SECOND)
OCONTRACT MONITORING ADDITIONAL DETAIL (THIRD)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (THIRD)
OCONTRACT MONITORING ADDITIONAL DETAIL (FOURTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FOURTH)
OCONTRACT MONITORING ADDITIONAL DETAIL (FIFTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIFTH)

COST AND PRICING DETAILS

To carry the cost and pricing details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RTARIFF CODE
MNATIONAL TARIFF INDICATOR
MCONTRACT MONITORING PLANNED ACTIVITY
MCONTRACT MONITORING PLANNED PRICE
MCONTRACT MONITORING PLANNED MARKET FORCES FACTOR
MCONTRACT MONITORING ACTUAL ACTIVITY
MCONTRACT MONITORING ACTUAL PRICE
MCONTRACT MONITORING ACTUAL MARKET FORCES FACTOR

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AIDC FOR PATIENT IDENTIFICATION DATA SET

Change to Data Set: Changed Description

AIDC for Patient Identification Data Set Overview

For a "Full Screen" view, click AIDC for Patient Identification Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

IDENTIFIERS

To carry details for the GS1 Global Service Relation Number.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MGS1 APPLICATION IDENTIFIER (GLOBAL)
MGS1 UNIQUE ORGANISATION PREFIX NUMBER
RNHS NUMBER
MGS1 GLOBAL SERVICE RELATION NUMBER CHECK DIGIT

To carry details for the GS1 Service Relation Instance Number.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
OGS1 APPLICATION IDENTIFIER (GLOBAL)
OGS1 SERVICE RELATION INSTANCE NUMBER

To carry details of the hospital identifiers.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MGS1 APPLICATION IDENTIFIER (INTERNAL)
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MLOCAL PATIENT IDENTIFIER (EXTENDED)
OGS1 GLOBAL LOCATION NUMBER

PATIENT DETAILS

To carry the patient descriptive details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RGS1 APPLICATION IDENTIFIER (INTERNAL)
RPERSON FAMILY NAME
RPERSON GIVEN NAME
RDATE OF BIRTH (PATIENT IDENTIFICATION)
RTIME OF BIRTH (PATIENT IDENTIFICATION)

BABY DETAILS

To carry details if the patient is a neonate or newborn baby. 
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RGS1 APPLICATION IDENTIFIER (INTERNAL)
RNUMBER OF BABIES IDENTIFICATION CODE (PATIENT IDENTIFICATION)
RPERSON FAMILY NAME (MOTHER OF BABY)
OPERSON GIVEN NAME (MOTHER OF BABY)

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CANCER OUTCOMES AND SERVICES DATA SET - BREAST

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Breast.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

TRIPLE DIAGNOSTIC ASSESSMENT - BREAST

To carry diagnostic details for Breast cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
MBREAST TRIPLE DIAGNOSTIC ASSESSMENT INDICATOR

PROGNOSTIC INDEX - BREAST

To carry prognostic details for Breast cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
MNOTTINGHAM PROGNOSTIC INDEX SCORE

CLINICAL NURSE SPECIALIST AND RISK FACTOR ASSESSMENT: NATIONAL AUDIT OF BREAST CANCER IN OLDER PATIENTS (NABCOP) - BREAST

To carry National Audit of Breast Cancer in Older Patients assessment details for Breast cancer.
One occurrence of this group is permitted per Core Clinical Nurse Specialist and Risk Factor Assessment.
M/RData Set Data Elements
RFITNESS ASSESSMENT FOR OLDER PATIENTS WITH BREAST CANCER INDICATOR
RFITNESS ASSESSMENT FOR OLDER PATIENTS WITH BREAST CANCER COMPLETED DATE
RCLINICAL FRAILTY SCALE POINT
RABBREVIATED MENTAL TEST SCORE
RSEVERE CARDIORESPIRATORY DISEASE INDICATOR
ROTHER NON BREAST LOCALLY ADVANCED METASTATIC MALIGNANCY INDICATOR

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CANCER OUTCOMES AND SERVICES DATA SET - CENTRAL NERVOUS SYSTEM

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Central Nervous System.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

IMAGING - CENTRAL NERVOUS SYSTEM (CNS)

To carry imaging details for Central Nervous System (CNS) cancer.
One occurrence of this group is permitted per Core Imaging.
M/RData Set Data Elements
RLESION LOCATION (RADIOLOGICAL)
RNUMBER OF LESIONS (RADIOLOGICAL)
RLESION SIZE (RADIOLOGICAL)
RPRINCIPAL DIAGNOSTIC IMAGING TYPE

CANCER CARE PLAN - CENTRAL NERVOUS SYSTEM (CNS)

To carry cancer care plan details for Central Nervous System (CNS) cancer.
One occurrence of this group is permitted Core Cancer Care Plan.
M/RData Set Data Elements
RPROVISIONAL DIAGNOSIS (ICD)

SURGERY - TREATMENT - CENTRAL NERVOUS SYSTEM (CNS)

To carry surgery details for Central Nervous System (CNS) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RTUMOUR LOCATION (SURGICAL)
RBIOPSY TYPE (CENTRAL NERVOUS SYSTEM TUMOURS)
REXCISION TYPE (CENTRAL NERVOUS SYSTEM TUMOURS)

SURGERY - TREATMENT: CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA) - CENTRAL NERVOUS SYSTEM (CNS)

To carry surgery details for Children, Teenagers and Young Adults (CTYA) for Central Nervous System (CNS) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RRESECTION STATUS

DIAGNOSIS: LOW GRADE GLIOMA - CENTRAL NERVOUS SYSTEM (CNS)

To carry diagnostic Low Grade Glioma details for Central Nervous System (CNS) cancer.
One occurrence of this group is permitted per Core Diagnosis
.
M/RData Set Data Elements
RVISUAL ACUITY TEST RESULT (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
RVISUAL FIELD TEST RESULT (AT DIAGNOSIS)
Multiple occurrences of this item are permitted

SITE SPECIFIC STAGING: CEREBROSPINAL FLUID (CSF) - CENTRAL NERVOUS SYSTEM (CNS)

To carry site specific staging Cerebrospinal Fluid (CSF) details for Central Nervous System (CNS) cancer.
One occurrence of this group is required per Core Site Specific Staging.
M/RData Set Data Elements
MCHANG STAGING SYSTEM STAGE

LABORATORY RESULTS: GERM CELL CENTRAL NERVOUS SYSTEM (CNS) TUMOURS CHOICE - CENTRAL NERVOUS SYSTEM (CNS)

One occurrence of this group is permitted per Core Laboratory Results
One of the following Germ Cell Central Nervous System (CNS) tumour laboratory result details MUST be provided per Core Laboratory Results
CHOICE 1 - ALPHA FETOPROTEIN
To carry Germ Cell Central Nervous System (CNS) tumour laboratory result details.
One occurrence of this group is required per Core Laboratory Results if selected as the choice
.
M/RData Set Data Elements
MALPHA FETOPROTEIN (CEREBROSPINAL FLUID)
OR
CHOICE 2 - BETA HUMAN CHORIONIC GONADOTROPIN
To carry Germ Cell Central Nervous System (CNS) tumour laboratory result details.
One occurrence of this group is required per Core Laboratory Results if selected as the choice
.
M/RData Set Data Elements
MBETA HUMAN CHORIONIC GONADOTROPIN (CEREBROSPINAL FLUID)

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CANCER OUTCOMES AND SERVICES DATA SET - CHILDREN TEENAGERS AND YOUNG ADULTS

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Children, Teenagers and Young Adults.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

REFERRALS - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry referral details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted per Core Referrals and First Stage of Patient Pathway.
M/RData Set Data Elements
RCARE PROFESSIONAL MAIN SPECIALTY CODE (CANCER REFERRAL)

DIAGNOSIS - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry diagnostic details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RCARE PROFESSIONAL MAIN SPECIALTY CODE (DIAGNOSIS)
RCHILDREN TEENAGERS AND YOUNG ADULTS AGE CATEGORY (CONSULTANT AT DIAGNOSIS)

DIAGNOSIS: NEUROBLASTOMA - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry diagnostic Neuroblastoma details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RLIFE THREATENING SYMPTOMS AT DIAGNOSIS INDICATOR (NEUROBLASTOMA)

SITE SPECIFIC STAGING CHOICE - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

One of the following Site Specific Staging Sections MUST be provided per Core Site Specific Staging
CHOICE 1 - WILMS
To carry staging renal tumour details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Site Specific Staging group if selected as the choice.
M/RData Set Data Elements
MWILMS TUMOUR STAGE
OR
CHOICE 2 - INTERNATIONAL NEUROBLASTOMA RISK GROUP
To carry staging Neuroblastoma details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Site Specific Staging group if selected as the choice.
M/RData Set Data Elements
MINTERNATIONAL NEUROBLASTOMA RISK GROUP STAGING SYSTEM STAGE
OR
CHOICE 3 - INTERNATIONAL NEUROBLASTOMA RISK GROUP
To carry staging Hepatoblastoma details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Site Specific Staging group if selected as the choice.
M/RData Set Data Elements
MPRETEXT STAGING SYSTEM STAGE
MPRETEXT STAGING SYSTEM STAGE ANNOTATION FACTORS
OR
CHOICE 4 - RETINOBLASTOMA
To carry staging Retinoblastoma details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Site Specific Staging group if selected as the choice.
M/RData Set Data Elements
MINTERNATIONAL STAGING SYSTEM STAGE (RETINOBLASTOMA)

TREATMENT: PRINCIPAL TREATMENT CENTRE CHOICE - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

One of the following Principal Treatment Centre Sections MUST be provided per Core Treatment
CHOICE 1 - CHILDREN
To carry Treatment details for the nominated children's Principal Treatment Centre for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Treatment if selected as the choice.
M/RData Set Data Elements
MORGANISATION IDENTIFIER (CHILDRENS NOMINATED PRINCIPAL TREATMENT CENTRE)
Multiple occurrences of this item are permitted
OR
CHOICE 2 - TEENAGE YOUNG ADULT (TYA)
To carry Treatment details for the nominated Teenage Young Adult's (TYA) Principal Treatment Centre for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is required per Core Treatment if selected as the choice.
M/RData Set Data Elements
MORGANISATION IDENTIFIER (TEENAGE YOUNG ADULTS NOMINATED PRINCIPAL TREATMENT CENTRE)
Multiple occurrences of this item are permitted

TREATMENT: CHILDREN'S CANCER AND LEUKAEMIA GROUP (CCLG) - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry treatment details for the Children's Cancer and Leukaemia Group (CCLG) guidelines for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted per Core Treatment.
M/RData Set Data Elements
RPATIENT TREATED TO CHILDRENS CANCER AND LEUKAEMIA GROUP GUIDELINES INDICATOR
RCHILDRENS CANCER AND LEUKAEMIA GROUP GUIDELINE NAME

LABORATORY RESULTS: NEUROBLASTOMA - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry Neuroblastoma laboratory result details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted per Core Laboratory Results.
M/RData Set Data Elements
RURINE VANILLYLMANDELIC ACID CREATININE RATIO

RENAL TUMOURS - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry renal tumour details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RPATHOLOGICAL RISK CLASSIFICATION CODE (AFTER NEPHRECTOMY)
RPATHOLOGICAL RISK CLASSIFICATION CODE (AFTER PREOPERATIVE CHEMOTHERAPY)

RETINOBLASTOMA - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry Retinoblastoma details for Children, Teenagers and Young Adults (CTYA) cancer.
Multiple occurrences of this group are permitted.
M/RData Set Data Elements
RRETINOBLASTOMA ASSESSMENT LATERALITY
RINTERNATIONAL CLASSIFICATION FOR INTRAOCULAR RETINOBLASTOMA

CHEMOTHERAPY - CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA)

To carry chemotherapy details for Children, Teenagers and Young Adults (CTYA) cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RCHILDREN TEENAGERS AND YOUNG ADULTS AGE CATEGORY (CONSULTANT PRESCRIBING CHEMOTHERAPY)

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CANCER OUTCOMES AND SERVICES DATA SET - COLORECTAL

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Colorectal.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download. 

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

DIAGNOSIS - COLORECTAL

To carry diagnostic details for Colorectal cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RSYNCHRONOUS TUMOUR COLON LOCATION (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
RTUMOUR HEIGHT ABOVE ANAL VERGE

CLINICAL NURSE SPECIALIST - COLORECTAL

To carry details of the Clinical Nurse Specialist.
Multiple occurrences of this group are permitted per Core Clinical Nurse Specialist and Risk Factor.
M/RData Set Data Elements
RCLINICAL NURSE SPECIALIST TYPE

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CANCER OUTCOMES AND SERVICES DATA SET - CORE

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Core.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.


SUBMISSION HEADER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCOSDS SUBMISSION IDENTIFIER
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MCOSDS SUBMISSION RECORD COUNT
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATE AND TIME DATA SET CREATED

RECORD IDENTIFIER

To carry the record identifier details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCOSDS UNIQUE IDENTIFIER

LINKAGE: IDENTIFIER CHOICE - CORE

One of the following Core Linkage Identifier sections MUST be provided
CHOICE 1 - NHS NUMBER
To carry patient identity details for linkage.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MNHS NUMBER
OR
CHOICE 2 - LOCAL PATIENT IDENTIFIER
To carry patient identity details for linkage.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)

LINKAGE: PATIENT IDENTITY DETAILS - CORE

To carry patient identity details for linkage.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE
MPERSON BIRTH DATE
MORGANISATION IDENTIFIER (CODE OF PROVIDER)

DIAGNOSTIC: CANCER PATHWAY CHOICE - CORE

One of the following Cancer Pathway sections MUST be provided
CHOICE 1 - PRIMARY CANCER PATHWAY
To carry diagnostic details for linkage.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MPRIMARY DIAGNOSIS (ICD)
MTUMOUR LATERALITY
MDATE OF PRIMARY CANCER DIAGNOSIS (CLINICALLY AGREED)
OR
CHOICE 2 - NON PRIMARY CANCER PATHWAY
To carry diagnostic details for linkage.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MDATE OF NON PRIMARY CANCER DIAGNOSIS (CLINICALLY AGREED)

DIAGNOSTIC: NON PRIMARY CANCER PATHWAY - CORE

One of the following Core Diagnosis sections MUST be provided per Non Primary Cancer Pathway
CHOICE 1 - CANCER RECURRENCE
To carry patient pathway details required to define the Non Primary Cancer Pathway for Cancer Recurrence.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
RPRIMARY DIAGNOSIS (ICD ORIGINAL)
MCANCER METASTATIC DISEASE TYPE
Multiple occurrences of this item are permitted
MMETASTATIC SITE (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
RPALLIATIVE CARE SPECIALIST SEEN INDICATOR (CANCER RECURRENCE)
RRELAPSE METHOD DETECTION TYPE
Multiple occurrences of this item are permitted
OR
CHOICE 2 - CANCER PROGRESSION
To carry patient pathway details required to define the Non Primary Cancer Pathway for Cancer Progression.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MCANCER PROGRESSION (ICD ORIGINAL)
MCANCER METASTATIC DISEASE TYPE
Multiple occurrences of this item are permitted
MMETASTATIC SITE (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
OR
CHOICE 3 - CANCER TRANSFORMATION
To carry patient pathway details required to define the Non Primary Cancer Pathway for Cancer Transformation.
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
RMORPHOLOGY (ICD-O CANCER TRANSFORMATION ORIGINAL)
RMORPHOLOGY (SNOMED CANCER TRANSFORMATION ORIGINAL)

DIAGNOSTIC: NON PRIMARY CANCER PATHWAY: TRANSFORMATION CURRENT MORPHOLOGY CHOICE - CORE

At least one of the following MUST be provided per Cancer Transformation
CHOICE 1 - CANCER TRANSFORMATION: CURRENT MORPHOLOGY ICD
To carry patient pathway details required to define the Non Primary Cancer Pathway for Cancer Transformation Current Morphology (ICD).
One occurrence of this group is required if selected as the choice.
M/R/OData Set Data Elements
MMORPHOLOGY (ICD-O CANCER TRANSFORMATION)
OR
CHOICE 2 - CANCER TRANSFORMATION: CURRENT MORPHOLOGY SNOMED
To carry patient pathway details required to define the Non Primary Cancer Pathway for Cancer Transformation Current Morphology (SNOMED).
One occurrence of this group is permitted if selected as the choice.
M/R/OData Set Data Elements
MMORPHOLOGY (SNOMED CANCER TRANSFORMATION)
MSNOMED VERSION (CANCER TRANSFORMATION)

DEMOGRAPHICS - CORE

To carry patient demographic details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RPERSON FAMILY NAME
RPERSON GIVEN NAME
RPATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS STRUCTURED
or
PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS UNSTRUCTURED
RPOSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)
RPERSON STATED GENDER CODE
RPERSON STATED SEXUAL ORIENTATION CODE (AT DIAGNOSIS)`
RGENERAL MEDICAL PRACTITIONER (SPECIFIED)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
RPERSON FAMILY NAME (AT BIRTH)
RETHNIC CATEGORY

REFERRALS AND FIRST STAGE OF PATIENT PATHWAY - CORE

To carry patient referral details to the trust that receives the first referral.
These details include information relating to the first stage of the Patient Pathway.
One occurrence of this group is permitted per Primary Cancer Pathway.
M/R/OData Set Data Elements
RSOURCE OF REFERRAL FOR OUT-PATIENTS
RDATE FIRST SEEN
MPROFESSIONAL REGISTRATION ISSUER CODE (CANCER FIRST SEEN)
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (CANCER FIRST SEEN)
RORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST SEEN)
RDATE FIRST SEEN (CANCER SPECIALIST)
RORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST CANCER SPECIALIST)
RCANCER SYMPTOMS FIRST NOTED DATE

NON PRIMARY CANCER PATHWAY: REFERRAL - CORE

To carry non primary cancer pathway details.
One occurrence of this group is permitted per Non Primary Cancer Pathway.
M/R/OData Set Data Elements
RSOURCE OF REFERRAL FOR OUT-PATIENTS (NON PRIMARY CANCER PATHWAY)
RDATE FIRST SEEN (NON CANCER PRIMARY PATHWAY)
RORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST SEEN NON PRIMARY CANCER PATHWAY)

IMAGING - CORE

To carry imaging details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MORGANISATION SITE IDENTIFIER (OF IMAGING)
MPROCEDURE DATE (CANCER IMAGING)
RCANCER IMAGING OUTCOME

IMAGING: CANCER SITE LOCATION CHOICE - CORE

One of the following Core Imaging data items or sections can be provided per Core Imaging
CHOICE 1 - NICIP
To carry imaging NICIP details.
Multiple occurrences of this group are permitted per Core Imaging.
M/R/OData Set Data Elements
MIMAGING CODE (NICIP)
OR
CHOICE 2 - SNOMED CT
To carry imaging SNOMED CT details.
Multiple occurrences of this group are permitted per Core Imaging.
M/R/OData Set Data Elements
MIMAGING CODE (SNOMED CT)
OR
CHOICE 3 - CANCER SITE IMAGING LOCATION GROUP
To carry imaging details.
Multiple occurrences of this group are permitted per Core Imaging.
M/R/OData Set Data Elements
MCANCER IMAGING MODALITY
RIMAGING ANATOMICAL SITE
RANATOMICAL SIDE (IMAGING)

To carry imaging details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RIMAGING REPORT TEXT
RLESION SIZE (RADIOLOGICAL)

DIAGNOSTIC PROCEDURES - CORE

To carry diagnostic procedure details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MORGANISATION SITE IDENTIFIER (OF DIAGNOSTIC PROCEDURE)
MPROCEDURE DATE (DIAGNOSTIC PROCEDURE)

DIAGNOSTIC PROCEDURES: CHOICE - CORE

One of the following Core Diagnostic procedures data items MUST be provided per Core Diagnostic Procedures
CHOICE 1 - OPCS
To carry OPCS diagnostic procedure details.
Multiple occurrences of this group are permitted per Core Diagnostic Procedures.
M/R/OData Set Data Elements
MDIAGNOSTIC PROCEDURE (OPCS)
OR
CHOICE 2 - SNOMED CT
To carry SNOMED CT diagnostic procedure details.
Multiple occurrences of this group are permitted per Core Diagnostic Procedures.
M/R/OData Set Data Elements
MDIAGNOSTIC PROCEDURE (SNOMED CT)

DIAGNOSTIC PROCEDURES: SENTINEL NODE BIOPSY - CORE

To carry diagnostic details for Sentinel Node Biopsy.
One occurrence of this group is permitted per Core Diagnostic Procedures.
M/R/OData Set Data Elements
RSENTINEL LYMPH NODE BIOPSY OUTCOME

DIAGNOSIS - CORE

To carry diagnostic details for the Primary Diagnosis.
One occurrence of this group is permitted per Primary Cancer Pathway.
M/R/OData Set Data Elements
RORGANISATION SITE IDENTIFIER (OF DIAGNOSIS)
RBASIS OF DIAGNOSIS (CANCER)
RMORPHOLOGY (ICD-O DIAGNOSIS)
MMORPHOLOGY (SNOMED DIAGNOSIS)
MSNOMED VERSION (DIAGNOSIS)
RTOPOGRAPHY (ICD-O)
RGRADE OF DIFFERENTIATION (AT DIAGNOSIS)
RPERFORMANCE STATUS (ADULT)
RDIAGNOSIS (SNOMED CT)
MCANCER METASTATIC DISEASE TYPE
Multiple occurrences of this item are permitted
MMETASTATIC SITE (AT DIAGNOSIS)
Multiple occurrences of this item are permitted

DIAGNOSIS: ADDITIONAL ITEMS - CORE

To carry additional diagnostic details.
One occurrence of this group is permitted per Core Diagnosis.
M/R/OData Set Data Elements
RPRIMARY DIAGNOSIS (CANCER COMMENT)
RSECONDARY DIAGNOSIS (ICD)
Multiple occurrences of this item are permitted
RSECONDARY DIAGNOSIS (CANCER COMMENT)
RFAMILIAL CANCER SYNDROME INDICATOR
RFAMILIAL CANCER SYNDROME COMMENT

DIAGNOSIS: CANCER PROGRESSION - CORE

To carry additional diagnostic details for Cancer Progression.
May be multiple occurrences per Core Diagnosis.
M/R/OData Set Data Elements
MCANCER METASTATIC DISEASE TYPE
Multiple occurrences of this item are permitted
MMETASTATIC SITE (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
MCANCER PROGRESSION AGREED DATE (PRIMARY CANCER PATHWAY)

DIAGNOSIS: CANCER TRANSFORMATION - CORE

To carry additional diagnostic details for Cancer Transformation.
May be multiple occurrences per Core Diagnosis.
M/R/OData Set Data Elements
MCANCER TRANSFORMATION AGREED DATE (PRIMARY CANCER PATHWAY)

DIAGNOSIS: CANCER TRANSFORMATION CHOICE - CORE

At least one of the following MUST be provided per Cancer Transformation
CHOICE 1 - ICD
To carry ICD additional diagnostic details for Cancer Transformation.
One occurrence of this group is required per Core Diagnosis Cancer Transformation.
M/R/OData Set Data Elements
MMORPHOLOGY (ICD-O CANCER TRANSFORMATION)
OR
CHOICE 2 - SNOMED
To carry additional diagnostic details for Cancer Transformation.
One occurrence of this group is required per Core Diagnosis Cancer Transformation.
M/R/OData Set Data Elements
MMORPHOLOGY (SNOMED CANCER TRANSFORMATION)
MSNOMED VERSION (CANCER TRANSFORMATION)

DIAGNOSIS: BANKED TISSUE - CORE

To carry Banked Tissue details.
One occurrence of this group is permitted per Core Diagnosis.
M/R/OData Set Data Elements
RPATIENT CONSENT FOR TISSUE BANKED AT DIAGNOSIS INDICATION CODE
RTISSUE TYPE BANKED AT DIAGNOSIS (CANCER)
Multiple occurrences of this item are permitted

PERSON OBSERVATION - CORE

To carry person observation details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RPERSON HEIGHT IN METRES
RPERSON WEIGHT
RBODY MASS INDEX
MOBSERVATION DATE

CLINICAL NURSE SPECIALIST AND RISK FACTOR ASSESSMENT - CORE

To carry Clinical Nurse Specialist and risk factor assessment details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RCLINICAL NURSE SPECIALIST INDICATION CODE
RSMOKING STATUS (CANCER)
RTOBACCO SMOKING CESSATION TREATMENT INDICATION CODE
RALCOHOL HISTORY (CANCER IN LAST THREE MONTHS)
RALCOHOL HISTORY (CANCER BEFORE LAST THREE MONTHS)
RPATIENT DIAGNOSIS INDICATOR (DIABETES)
RMENOPAUSAL STATUS (AT DIAGNOSIS)
RPHYSICAL ACTIVITY VITAL SIGN LEVEL (CURRENT)

CLINICAL NURSE SPECIALIST: HOLISTIC NEEDS ASSESSMENT (HNA) - CORE

To carry details of Clinical Nurse Specialist, Holistic Needs Assessments.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
ROFFER STATUS (HOLISTIC NEEDS ASSESSMENT)
RHOLISTIC NEEDS ASSESSMENT COMPLETED DATE
RHOLISTIC NEEDS ASSESSMENT POINT OF PATHWAY (CANCER)
RSTAFF ROLE CARRYING OUT HOLISTIC NEEDS ASSESSMENT

CLINICAL NURSE SPECIALIST: PERSONALISED CARE AND SUPPORT PLANNING - CORE

To carry details of Clinical Nurse Specialist, Personalised Care and Supportive Planning Assessments.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
ROFFER STATUS (PERSONALISED CARE AND SUPPORT PLANNING)
RPERSONALISED CARE AND SUPPORT PLANNING COMPLETED DATE
RPERSONALISED CARE AND SUPPORT PLANNING POINT OF CANCER PATHWAY
RSTAFF ROLE CARRYING OUT PERSONALISED CARE AND SUPPORT PLANNING

MULTIDISCIPLINARY TEAM MEETINGS CHOICE - CORE

One of the following Core Multidisciplinary Team Meeting data items MUST be provided per Core Multidisciplinary Team Meeting
CHOICE 1 - NOT DISCUSSED
To carry details of all multidisciplinary team meetings where the patient was not discussed.
One occurrence of this group is required per Core Multidisciplinary Team Meetings if selected as the choice.
M/R/OData Set Data Elements
MMULTIDISCIPLINARY TEAM MEETING CANCER CARE PLAN NOT DISCUSSED INDICATION CODE
OR
CHOICE 2 - DISCUSSED
To carry details of all multidisciplinary team meetings where the patient was discussed.
One occurrence of this group is required per Core Multidisciplinary Team Meetings if selected as the choice.
M/R/OData Set Data Elements
MMULTIDISCIPLINARY TEAM MEETING CANCER CARE PLAN DISCUSSION TYPE
MMULTIDISCIPLINARY TEAM MEETING DATE (CANCER)
MORGANISATION SITE IDENTIFIER (OF MULTIDISCIPLINARY TEAM MEETING)
MMULTIDISCIPLINARY TEAM MEETING TYPE (CANCER)
RMULTIDISCIPLINARY TEAM MEETING TYPE COMMENT (CANCER)

CANCER CARE PLAN - CORE

To carry cancer care plan details.
One occurrence of this group is permitted per Primary Cancer Pathway.
M/R/OData Set Data Elements
RMULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER)
MPROFESSIONAL REGISTRATION ISSUER CODE (MULTIDISCIPLINARY TEAM LEAD)
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (MULTIDISCIPLINARY TEAM LEAD)
RCANCER CARE PLAN INTENT
RPLANNED CANCER TREATMENT TYPE
Multiple occurrences of this item are permitted
RNO CANCER TREATMENT REASON
OADULT COMORBIDITY EVALUATION - 27 SCORE

MOLECULAR AND BIOMARKERS - GERMLINE TESTING FOR CANCER PREDISPOSITION - CORE

To carry Molecular and Biomarkers (Germline Testing for Cancer Predisposition) details for a patient.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
ROFFER STATUS (GERMLINE GENETIC TEST)
RGERMLINE GENETIC TEST TYPE OFFERED
Multiple occurrences of this item are permitted
ROTHER GERMLINE GENETIC TEST TYPE OFFERED COMMENT
Multiple occurrences of this item are permitted
RACTIVITY OFFER DATE (GERMLINE GENETIC TEST)
RORGANISATION IDENTIFIER (REPORTING LABORATORY)
ROFFER STATUS (REFERRAL TO REGIONAL CLINICAL GENETICS SERVICE)

MOLECULAR AND BIOMARKERS - SOMATIC TESTING FOR TARGETED THERAPY AND PERSONALISED MEDICINE - CORE

To carry Molecular and Biomarkers (Somatic Testing for Targeted Therapy and Personalised Medicine) details for a patient, where these have been performed by the clinical teams.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RGENE OR STRATIFICATION BIOMARKER TYPE ANALYSED
Multiple occurrences of this item are permitted
ROTHER GENE OR STRATIFICATION BIOMARKER TYPE ANALYSED COMMENT
Multiple occurrences of this item are permitted
RGENE OR STRATIFICATION BIOMARKER REPORTED DATE
RORGANISATION IDENTIFIER (REPORTING LABORATORY)

CLINICAL TRIALS - CORE

To carry details for a patient who is eligible for a cancer clinical trial.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RPATIENT TRIAL STATUS (CANCER)
RCLINICAL TRIAL DECISION DATE
RCLINICAL TRIAL START DATE
RCANCER CLINICAL TRIAL TREATMENT TYPE

STAGING - CORE

To carry the staging details at the time that the first cancer care plan is agreed.
One occurrence of this group is permitted per Primary Cancer Pathway.
M/R/OData Set Data Elements
RT CATEGORY (FINAL PRETREATMENT)
RN CATEGORY (FINAL PRETREATMENT)
RM CATEGORY (FINAL PRETREATMENT)
RTNM STAGE GROUPING (FINAL PRETREATMENT)
RORGANISATION SITE IDENTIFIER (OF TNM STAGE GROUPING FINAL PRETREATMENT)
RTNM STAGE GROUPING DATE (FINAL PRETREATMENT)
RT CATEGORY (INTEGRATED STAGE)
RN CATEGORY (INTEGRATED STAGE)
RM CATEGORY (INTEGRATED STAGE)
RTNM STAGE GROUPING (INTEGRATED)
RORGANISATION SITE IDENTIFIER (OF TNM STAGE GROUPING INTEGRATED)
RTNM STAGE GROUPING DATE (INTEGRATED)
MTNM CODING EDITION
MTNM VERSION NUMBER (STAGING)

SITE SPECIFIC STAGING - CORE

To carry the site specific cancer staging details. These fields are only required where there is a site specific stage recorded for a patient and will not be applicable to every cancer.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MORGANISATION SITE IDENTIFIER (OF CANCER SITE SPECIFIC STAGE)
MSTAGE DATE (CANCER SITE SPECIFIC STAGE)

TREATMENT - CORE

To carry the cancer treatment details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RADJUNCTIVE THERAPY TYPE
RCANCER TREATMENT INTENT
MTREATMENT START DATE (CANCER)
MCANCER TREATMENT MODALITY (REGISTRATION)
MORGANISATION SITE IDENTIFIER (OF PROVIDER CANCER TREATMENT START DATE)
MPROFESSIONAL REGISTRATION ISSUER CODE (TREATMENT)
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (TREATMENT)
OCANCER END OF TREATMENT SUMMARY PLAN COMPLETION DATE
Multiple occurrences of this item are permitted
RDISCHARGE DATE (HOSPITAL PROVIDER SPELL)
RDISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL)

TREATMENT: SURGERY - CORE

To carry the surgery details.
One occurrence of this group is permitted per Core Treatment.
M/R/OData Set Data Elements
MPROCEDURE DATE
RCANCER SURGICAL ADMISSION TYPE
MPROFESSIONAL REGISTRATION ISSUER CODE (RESPONSIBLE SURGEON)
Multiple occurrences of this item are permitted
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (RESPONSIBLE SURGEON)
Multiple occurrences of this item are permitted
RPRIMARY PROCEDURE (OPCS)
RPRIMARY PROCEDURE (SNOMED CT)
RPROCEDURE (OPCS)
Multiple occurrences of this item are permitted
RPROCEDURE (SNOMED CT)
Multiple occurrences of this item are permitted
RADDITIONAL UNPLANNED PROCEDURE REQUIRED INDICATOR
RASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE
RSURGICAL ACCESS TYPE

TREATMENT: STEM CELL TRANSPLANTATION - CORE

To carry surgery Stem Cell Transplantation details.
One occurrence of this group is permitted per Core Treatment.
M/R/OData Set Data Elements
RSTEM CELL INFUSION SOURCE CODE
RSTEM CELL INFUSION DONOR TYPE
RSTEM CELL TRANSPLANT CONDITIONING REGIMEN

ACUTE ONCOLOGY - CORE

To carry Acute Oncology details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RACUTE ONCOLOGY ASSESSMENT COMPLETED DATE
RORGANISATION SITE IDENTIFIER (OF ACUTE ONCOLOGY ASSESSMENT)
RACUTE ONCOLOGY ASSESSMENT LOCATION
RACUTE ONCOLOGY ASSESSMENT PATIENT PRESENTATION TYPE
Multiple occurrences of this item are permitted
RACUTE ONCOLOGY EPISODE OUTCOME

LABORATORY RESULTS - CORE

To carry laboratory result details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLABORATORY RESULT AUTHORISED DATE
MORGANISATION IDENTIFIER (OF LABORATORY RESULT)

LABORATORY RESULTS: GENERAL - CORE

To carry general laboratory result details.
One occurrence of this group is permitted per Core Laboratory Results.
M/R/OData Set Data Elements
RLACTATE DEHYDROGENASE LEVEL (PEAK AT DIAGNOSIS)
RBETA HUMAN CHORIONIC GONADOTROPIN (MAXIMUM AT DIAGNOSIS)
RALPHA FETOPROTEIN (MAXIMUM AT DIAGNOSIS)

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CANCER OUTCOMES AND SERVICES DATA SET - GYNAECOLOGICAL

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Gynaecological.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download. 

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

SITE SPECIFIC STAGING - GYNAECOLOGICAL

To carry staging details for Gynaecological cancer.
One occurrence of this group is permitted per Core Site Specific Staging.
M/RData Set Data Elements
MFINAL FIGO STAGE

TREATMENT: SURGERY - GYNAECOLOGICAL

To carry surgery details for Gynaecological cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RCARE PROFESSIONAL SENIOR OPERATING SURGEON GRADE (CANCER)
RRESIDUAL DISEASE SIZE (GYNAECOLOGICAL CANCER)

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CANCER OUTCOMES AND SERVICES DATA SET - HAEMATOLOGICAL

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Haematological.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.


CANCER CARE PLAN CHOICE - HAEMATOLOGICAL

One of the following Cancer Care Plan Sections MUST be provided per Core Cancer Care Plan
CHOICE 1 - CHRONIC MYELOID LEUKAEMIA (CML)
To carry cancer care plan details specific to Chronic Myeloid Leukaemia (CML) for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
MCHRONIC MYELOID LEUKAEMIA INDEX SCORE (SOKAL)
OR
CHOICE 2 - MYELODYSPLASIA
To carry cancer care plan details specific to Myelodysplasia for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
MREVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM SCORE
OR
CHOICE 3 - CHRONIC LYMPHOID LEUKAEMIA (CLL)
To carry cancer care plan details specific to Chronic Lymphoid Leukaemia (CLL) for Haematological cancer. 
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
MSPLENOMEGALY INDICATOR
OR
CHOICE 4 - FOLLICULAR LYMPHOMA
To carry cancer care plan details specific to Follicular Lymphoma for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
RNUMBER OF ABNORMAL NODAL AREAS 
RFOLLICULAR LYMPHOMA INTERNATIONAL PROGNOSTIC INDEX 2 SCORE
OR
CHOICE 5 - DIFFUSE LARGE B-CELL LYMPHOMA (DLBCL)
To carry cancer care plan details specific to Diffuse Large B-Cell Lymphoma (DLBCL) for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
RNUMBER OF ABNORMAL NODAL AREAS 
RPRIMARY EXTRANODAL CANCER SITE
RNUMBER OF EXTRANODAL SITES CODE
RREVISED INTERNATIONAL PROGNOSTIC INDEX SCORE
OR
CHOICE 6 - HODGKIN LYMPHOMA
To carry cancer care plan details specific to Hodgkin Lymphoma for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
RNUMBER OF ABNORMAL NODAL AREAS 
RPRIMARY EXTRANODAL CANCER SITE
RHASENCLEVER INDEX SCORE
OR
CHOICE 7 - ACUTE LYMPHOBLASTIC LEUKAEMIA (ALL)
To carry cancer care plan details specific to Acute Lymphoblastic Leukaemia (ALL) for Haematological cancer.
One occurrence of this group is required per Core Cancer Care Plan if selected as the choice.
M/RData Set Data Elements
MEXTRAMEDULLARY DISEASE SITE
Multiple occurrences of this item are permitted

SITE SPECIFIC STAGING - HAEMATOLOGICAL

One of the following Site Specific Staging Sections MUST be provided per Core Site Specific Staging
CHOICE 1 - ANN ARBOR
To carry Ann Arbor site specific staging details for various haematological diseases for Haematological cancer.
One occurrence of this group is required per Core Site Specific Staging if selected as the choice.
M/RData Set Data Elements
MANN ARBOR STAGE
OR
CHOICE 2 - CHRONIC LYMPHOID LEUKAEMIA (CLL)
To carry Chronic Lymphoid Leukaemia (CLL) staging details for Haematological cancer.
One occurrence of this group is required per Core Site Specific Staging if selected as the choice.
M/RData Set Data Elements
MBINET STAGE
OR
CHOICE 3 - MYELOMA
To carry Myeloma staging details for Haematological cancer.
One occurrence of this group is permitted per Core Site Specific Staging if selected as the choice.
M/RData Set Data Elements
MREVISED INTERNATIONAL STAGING SYSTEM STAGE FOR MULTIPLE MYELOMA
OR
CHOICE 4 - NON HODGKIN LYMPHOMA (NHL)
To carry Non Hodgkin Lymphoma (NHL) staging details for Haematological cancer.
One occurrence of this group is required per Core Site Specific Staging if selected as the choice.
M/RData Set Data Elements
MMURPHY ST JUDE STAGE

ANN ARBOR: EXTENSIONS - HAEMATOLOGICAL

To carry supporting Ann Arbor staging details for various haematological diseases as specified.
One occurrence of this group is permitted.
M/RData Set Data Elements
RANN ARBOR SYMPTOMS INDICATION CODE
RANN ARBOR EXTRANODALITY INDICATION CODE
RANN ARBOR BULKY DISEASE INDICATION CODE
RANN ARBOR SPLENIC INDICATION CODE

LABORATORY RESULTS CHOICE - HAEMATOLOGICAL

One occurrence of this group is required per Core Laboratory Results
One of the following Laboratory Results MUST be provided per Core Laboratory Results
CHOICE 1 - VARIOUS HAEMATOLOGICAL DISEASES
To carry laboratory results for various haematological diseases for Haematological cancer.
One occurrence of this group is required per Core Laboratory Results if selected as the choice.
M/RData Set Data Elements
REUROPEAN LEUKAEMIA NET GENETIC RISK CODE
RWHITE BLOOD CELL COUNT (HIGHEST PRETREATMENT)
OR
CHOICE 2 - VARIOUS HAEMATOLOGICAL DISEASES: CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA).
To carry laboratory results for various haematological diseases for Children Teenagers and Young Adults (CTYA) Haematological cancer.
One occurrence of this group is required per Core Laboratory Results if selected as the choice.
M/RData Set Data Elements
RBONE MARROW BLAST CELLS PERCENTAGE
RCYTOGENETIC FINDINGS COMMENT
OR
CHOICE 3 - PAEDIATRIC MYELODYSPLASIA
To carry Paediatric Myelodysplasia laboratory result details for Haematological cancer.
One occurrence of this group is required per Core Laboratory Results if selected as the choice.
M/RData Set Data Elements
RCELLULARITY PERCENTAGE
RDIEPOXYBUTANE TEST RESULT
RDYSPLASTIC HAEMOPOIESIS TYPE
OR
CHOICE 4 - ACUTE LYMPHOBLASTIC LEUKAEMIA (ALL) - RESPONSE
To carry Acute Lymphoblastic Leukaemia (ALL) Response laboratory result details for Haematological cancer.
One occurrence of this group is required per Core Laboratory Results if selected as the choice.
M/RData Set Data Elements
MLEUKAEMIC CELLS PRESENT POST MINIMAL RESIDUAL DISEASE INDUCTION PERCENTAGE

DIAGNOSIS CHOICE - HAEMATOLOGICAL

One of the following can be provided per Core Diagnosis
CHOICE 1 - MIXED PHENOTYPE ACUTE LEUKAEMIA (MPAL)
To carry diagnostic Mixed Phenotype Acute Leukaemia (MPAL) details for Haematological cancer.
One occurrence of this group is required per Core Diagnosis if selected as the choice.
M/RData Set Data Elements
RMIXED PHENOTYPE ACUTE LEUKAEMIA SYMPTOMS (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
REUROPEAN GROUP FOR THE IMMUNOLOGICAL CLASSIFICATION OF LEUKAEMIA SCORING SYSTEM SCORE
OR
CHOICE 2 - ACUTE MYELOID LEUKAEMIA (AML)
To carry diagnostic Acute Myeloid Leukaemia (AML) details for Haematological cancer.
One occurrence of this group is required per Core Diagnosis if selected as the choice.
M/RData Set Data Elements
RFRENCH AMERICAN BRITISH CLASSIFICATION (ACUTE MYELOID LEUKAEMIA)
RCYTOGENETIC RISK GROUP (PAEDIATRIC MOLECULAR GENETIC ABNORMALITIES)
RACUTE MYELOID LEUKAEMIA RISK FACTORS (AT DIAGNOSIS)
OR
CHOICE 3 - PAEDIATRIC MYELODYSPLASIA
To carry diagnostic Paediatric Myelodysplasia details for Haematological cancer.
One occurrence of this group is required per Core Diagnosis if selected as the choice.
M/RData Set Data Elements
RPAEDIATRIC MYELODYSPLASIA CLINICAL FINDINGS (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
RUNDERLYING DISEASE ASSOCIATED WITH MYELODYSPLASIA (AT DIAGNOSIS)
Multiple occurrences of this item are permitted
RCONGENITAL ANOMALIES COMMENT
ROTHER MYELODYSPLASIA SYMPTOMS AT DIAGNOSIS
Multiple occurrences of this item are permitted

ACUTE LEUKAEMIAS - HAEMATOLOGICAL

To carry treatment details for Acute Leukaemias for Haematological cancer.
One occurrence of this group is permitted per Core Treatment.
M/RData Set Data Elements
RPRIMARY INDUCTION CHEMOTHERAPY FAILURE INDICATOR

MOLECULAR AND BIOMARKERS - SOMATIC TESTING FOR TARGETED THERAPY AND PERSONALISED THERAPY: NON HODGKIN LYMPHOMA - HAEMATOLOGICAL

To carry Molecular and Biomarkers Result details for Non Hodgkin Lymphoma (NML) for Haematological cancer.
One occurrence of this group is permitted per Core Molecular and Biomarkers - Somatic Testing for Targeted Therapy and Personalised Medicine.
M/RData Set Data Elements
MALK GENE FUSION STATUS (ANAPLASTIC LARGE CELL LYMPHOMA)

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CANCER OUTCOMES AND SERVICES DATA SET - HEAD AND NECK

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Head and Neck.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download. 

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

TREATMENT: SURGERY - HEAD AND NECK

To carry surgery details for Head and Neck cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RSURGICAL ACCESS TYPE (HEAD AND NECK CANCER)
ROTHER SURGICAL ACCESS TYPE (HEAD AND NECK CANCER)

PRE TREATMENT ASSESSMENT - HEAD AND NECK

To carry pre treatment assessment details for Head and Neck cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RCANCER DENTAL ASSESSMENT DATE
RCARE CONTACT DATE (DIETITIAN INITIAL)
RCARE CONTACT DATE (SPEECH AND LANGUAGE THERAPIST INITIAL)

POST TREATMENT ASSESSMENT - HEAD AND NECK

To carry post treatment assessment details for Head and Neck cancer.
Multiple occurrences of this group are permitted.
M/RData Set Data Elements
RCLINICAL STATUS ASSESSMENT DATE (CANCER)
RPRIMARY TUMOUR STATUS
RNODAL STATUS
RMETASTATIC STATUS
RSPEECH AND LANGUAGE ASSESSMENT DATE

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CANCER OUTCOMES AND SERVICES DATA SET - LIVER

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Liver.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.


DIAGNOSIS - LIVER

To carry diagnostic details for Liver cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RLIVER CANCER SURVEILLANCE SCAN INDICATOR
RLIVER CIRRHOSIS TYPE
RLIVER CIRRHOSIS CAUSE TYPE
Multiple occurrences of this item are permitted

DIAGNOSIS: CHOLANGIOCARCINOMA - LIVER

To carry diagnostic details for Cholangiocarcinoma for Liver cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
MCHOLANGIOCARCINOMA PRESENCE CATEGORY

SITE SPECIFIC STAGING - LIVER

To carry site specific staging details for Liver cancer.
One occurrence of this group is permitted per Core Site Specific Staging.
M/RData Set Data Elements
MBARCELONA CLINIC LIVER CANCER STAGE

TREATMENT AND PROGNOSTIC INDICATORS - LIVER

To carry treatment and prognostic details for Liver cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RPORTAL VEIN INVASION INDICATION CODE
RUNITED KINGDOM MODEL FOR END-STAGE LIVER DISEASE SCORE
RCHILD PUGH SCORE

TREATMENT - LIVER

To carry other procedure details for Liver Metastasis and Liver Hepatocellular Carcinoma (HCC) for Liver cancer.
One occurrence of this group is permitted per Core Treatment.
M/RData Set Data Elements
RABLATIVE THERAPY TYPE
RLIVER TRANSARTERIAL EMBOLISATION MATERIAL INJECTION TYPE

TRANSPLANTATION - LIVER

To carry liver transplantation details for Liver cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RLIVER TRANSPLANT WAITING LIST INDICATOR

TREATMENT: SURGERY - LIVER

To carry surgery details for Liver cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RLIVER SURGERY PERFORMED TYPE

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CANCER OUTCOMES AND SERVICES DATA SET - LUNG

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Lung.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

DIAGNOSTIC PROCEDURES CHOICE - LUNG

One of the following may be provided per Diagnostic Procedure
CHOICE 1 - TRANSTHORACIC ECHOCARDIOGRAM
To carry Transthoracic Echocardiogram details for the National Lung Cancer Audit (NLCA), to be captured once only for each care pathway for Lung cancer.
One occurrence of this group is required per Core Diagnostic Procedures if selected as the choice.
M/RData Set Data Elements
MTRANSTHORACIC ECHOCARDIOGRAM TEST RESULT
OR
CHOICE 2 - DIFFUSION CAPACITY
To carry Diffusion Capacity details for the National Lung Cancer Audit (NLCA), to be captured once only for each care pathway for Lung cancer.
One occurrence of this group is required per Core Diagnostic Procedures if selected as the choice.
M/RData Set Data Elements
MDIFFUSION CAPACITY TEST RESULT
OR
CHOICE 3 - FEV1
To carry FEV1 details for the National Lung Cancer Audit (NLCA), to be captured once only for each care pathway for Lung cancer.
One occurrence of this group is required per Core Diagnostic Procedures if selected as the choice.
M/RData Set Data Elements
RFORCED EXPIRATORY VOLUME IN 1 SECOND (PERCENTAGE)
RFORCED EXPIRATORY VOLUME IN 1 SECOND (ABSOLUTE AMOUNT)
OR
CHOICE 4 - CARDIOPULMONARY TEST
To carry Cardiopulmonary Test details required for the National Lung Cancer Audit (NLCA) for Lung cancer.
One occurrence of this group is required per Core Diagnostic Procedures if selected as the choice.
M/RData Set Data Elements
RCARDIOPULMONARY EXERCISE TEST TYPE
RCARDIOPULMONARY EXERCISE TEST RESULT
OR
CHOICE 5 - BRONCHOSCOPY
To carry bronchoscopy details for Lung cancer.
One occurrence of this group is required per Core Diagnostic Procedures if selected as the choice.
M/RData Set Data Elements
MBRONCHOSCOPY PERFORMED TYPE

MEDIASTINAL SAMPLING - LUNG

To carry Mediastinal Sampling details for the National Lung Cancer Audit (NLCA), to be captured once only for each care pathway for Lung cancer.
One occurrence of this group is permitted.
M/RData Set Data Elements
RMEDIASTINAL SAMPLING INDICATOR

MOLECULAR AND BIOMARKERS - SOMATIC TESTING FOR TARGETED THERAPY AND PERSONALISED MEDICINE - LUNG

To carry Molecular details for Lung cancer.
One occurrence of this group is permitted per Core - Molecular and Biomarkers - Somatic Testing for Targeted Therapy and Personalised Medicine.
M/RData Set Data Elements
REPIDERMAL GROWTH FACTOR RECEPTOR MUTATIONAL STATUS
RALK GENE FUSION STATUS (LUNG CANCER)
RROS1 FUSION STATUS
RPD-L1 EXPRESSION PERCENTAGE

TREATMENT - SURGERY: LUNG CANCER CONSULTANT OUTCOME PUBLICATION (LCCOP) - LUNG

To carry surgery details for the Lung Cancer Consultant Outcome Publication (LCCOP) for Lung cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RREGIONAL ANAESTHETIC TECHNIQUE (CANCER)

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CANCER OUTCOMES AND SERVICES DATA SET - PATHOLOGY

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Pathology.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.


SUBMISSION HEADER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCOSDS SUBMISSION IDENTIFIER
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MCOSDS SUBMISSION RECORD COUNT
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATE AND TIME DATA SET CREATED

RECORD IDENTIFIER

To carry the record identifier details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCOSDS UNIQUE IDENTIFIER

LINKAGE IDENTIFIER CHOICE - CORE - PATHOLOGY

One of the following Core Linkage sections MUST be provided
CHOICE 1 - NHS NUMBER
To carry patient identity details for linkage.
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
OR
CHOICE 2 - LOCAL PATIENT IDENTIFIER
To carry patient identity details for linkage.
One occurrence of this group is required.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)

LINKAGE IDENTIFIER - CORE - PATHOLOGY

To carry patient identity details for linkage.
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE
MPERSON BIRTH DATE
MORGANISATION IDENTIFIER (CODE OF PROVIDER)

DEMOGRAPHICS - CORE - PATHOLOGY

To carry patient demographic details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RPERSON FAMILY NAME
RPERSON GIVEN NAME
RPATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS STRUCTURED
or
PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS UNSTRUCTURED
RPOSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)
RPERSON STATED GENDER CODE

PATHOLOGY DETAILS PART 1 - CORE - PATHOLOGY
 
To carry pathology details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MINVESTIGATION RESULT DATE
MSERVICE REPORT IDENTIFIER
RPATHOLOGY OBSERVATION REPORT IDENTIFIER
RSERVICE REPORT STATUS
MPROFESSIONAL REGISTRATION ISSUER CODE (PATHOLOGY TEST REQUESTED BY)
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (PATHOLOGY TEST REQUESTED BY)
RORGANISATION SITE IDENTIFIER (OF PATHOLOGY TEST REQUEST)
RSAMPLE COLLECTION DATE
RSAMPLE RECEIPT DATE
RORGANISATION IDENTIFIER (OF AUTHORISING PATHOLOGIST)
MPROFESSIONAL REGISTRATION ISSUER CODE (PATHOLOGY REPORT AUTHORISED BY)
MPROFESSIONAL REGISTRATION ENTRY IDENTIFIER (PATHOLOGY REPORT AUTHORISED BY)
RCANCER SPECIMEN NATURE

TOPOGRAPHY/MORPHOLOGY - CORE - PATHOLOGY

To carry Topography/Morphology SNOMED pathology details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MSNOMED VERSION (PATHOLOGY)

TOPOGRAPHY/MORPHOLOGY CHOICE - CORE - PATHOLOGY

One of the following MUST be provided
CHOICE 1 - TOPOGRAPHY SNOMED
To carry pathology Topography SNOMED details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MTOPOGRAPHY (SNOMED PATHOLOGY)
Multiple occurrences of this item are permitted
OR
CHOICE 2 - MORPHOLOGY SNOMED
To carry pathology Morphology SNOMED details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MMORPHOLOGY (SNOMED PATHOLOGY)
Multiple occurrences of this item are permitted

PATHOLOGY DETAILS PART 2 CORE - PATHOLOGY

To carry pathology details.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RDIAGNOSIS (ICD PATHOLOGICAL)
Multiple occurrences of this item are permitted
RTUMOUR LATERALITY (PATHOLOGICAL)
RPATHOLOGY INVESTIGATION TYPE
RPATHOLOGY REPORT TEXT
RLESION SIZE (PATHOLOGICAL)
RGRADE OF DIFFERENTIATION (PATHOLOGICAL)
RCANCER VASCULAR OR LYMPHATIC INVASION
REXCISION MARGIN INDICATION CODE
RSYNCHRONOUS TUMOUR INDICATOR
RNUMBER OF NODES EXAMINED
RNUMBER OF NODES POSITIVE
RTNM CODING EDITION
RTNM VERSION NUMBER (PATHOLOGICAL)
RT CATEGORY (PATHOLOGICAL)
RN CATEGORY (PATHOLOGICAL)
RM CATEGORY (PATHOLOGICAL)
RTNM STAGE GROUPING (PATHOLOGICAL)
RNEOADJUVANT THERAPY INDICATOR
RKI-67 STAINING PERFORMED INDICATION CODE
RKI-67 PERCENTAGE RESULT
RMLH1 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
RPMS2 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
RMSH2 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
RMSH6 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
RMICROSATELLITE INSTABILITY TESTING RESULT

BREAST - PATHOLOGY

To carry pathology details for Breast cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RMULTIFOCAL TUMOUR INDICATOR (BREAST)
RDUCTAL CARCINOMA IN SITU GRADE
RNON INVASIVE TUMOUR SIZE
RWHOLE TUMOUR SIZE
RMETASTASIS EXTENT CODE
RDISTANCE TO MARGIN
OALLRED SCORE (ESTROGEN RECEPTOR)
RESTROGEN RECEPTOR STATUS
OALLRED SCORE (PROGESTERONE RECEPTOR)
OBREAST PROGESTERONE RECEPTOR STATUS
RHUMAN EPIDERMAL GROWTH FACTOR RECEPTOR STATUS (BREAST)
RHUMAN EPIDERMAL GROWTH FACTOR IN SITU HYBRIDISATION RECEPTOR STATUS (BREAST)
RCYTOLOGY RESULT CODE (BREAST)
RCYTOLOGY RESULT CODE (NODE)
RNEEDLE CORE BIOPSY RESULT CODE (BREAST)
RNEEDLE CORE BIOPSY RESULT CODE (AXILLARY LYMPH NODE)

CENTRAL NERVOUS SYSTEM (CNS) - PATHOLOGY

To carry pathology details for Central Nervous System (CNS) cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RMOLECULAR DIAGNOSTIC CODE
Multiple occurrences of this item are permitted
RHORMONE EXPRESSION TYPE
Multiple occurrences of this item are permitted

COLORECTAL - PATHOLOGY

To carry pathology details for Colorectal cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RMARGIN INVOLVED INDICATION CODE (COLORECTAL PROXIMAL OR DISTAL RESECTION MARGIN)
RDISTANCE TO CLOSEST NON PERITONEALISED RESECTION MARGIN
RPLANE OF SURGICAL EXCISION INDICATOR
RDISTANCE FROM DENTATE LINE
RDISTANCE BEYOND MUSCULARIS PROPRIA
RPREOPERATIVE THERAPY RESPONSE TYPE
RMARGIN INVOLVED INDICATION CODE (CIRCUMFERENTIAL MARGIN)

CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA): RENAL PATHOLOGY (PAEDIATRIC KIDNEY) - PATHOLOGY

To carry renal (paediatric kidney) pathology details for Children, Teenagers, and Young Adults (CTYA) cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RTUMOUR RUPTURE INDICATOR (PATHOLOGICAL)
RANAPLASTIC NEPHROBLASTOMA TYPE
RTUMOUR INVASION INDICATOR (PERIRENAL FAT)
RTUMOUR INVASION INDICATOR (RENAL SINUS)
RRENAL VEIN TUMOUR INDICATOR (PAEDIATRIC KIDNEY)
RVIABLE TUMOUR EVIDENCE AT RESECTION MARGIN
RINTERNATIONAL SOCIETY OF PAEDIATRIC ONCOLOGY TUMOUR LOCAL STAGE

GYNAECOLOGICAL - PATHOLOGY

To carry pathology details for Gynaecological cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RMICROSCOPIC INVOLVEMENT INDICATION CODE (FALLOPIAN TUBE)
RMICROSCOPIC INVOLVEMENT INDICATION CODE (OVARIAN)
RMICROSCOPIC INVOLVEMENT INDICATION CODE (UTERINE SEROSA)
ROMENTUM INVOLVEMENT INDICATION CODE

GYNAECOLOGICAL: FALLOPIAN TUBE, OVARIAN EPITHELIAL AND PRIMARY PERITONEAL - PATHOLOGY

To carry pathology details for Gynaecological cancer for Fallopian Tube, Ovarian Epithelial and Primary Peritoneal.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RGYNAECOLOGICIAL CAPSULE STATUS
ROVARY SURFACE INVOLVEMENT INDICATOR
RPERITONEAL CYTOLOGY RESULT CODE
RPERITONEAL INVOLVEMENT INDICATION CODE

GYNAECOLOGICAL: ENDOMETRIAL - PATHOLOGY

To carry pathology details for Gynaecological cancer for Endometrial.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RMICROSCOPIC INVOLVEMENT INDICATOR (CERVICAL STROMA)
RMYOMETRIAL INVASION IDENTIFICATION CODE
RMICROSCOPIC INVOLVEMENT INDICATOR (PARAMETRIUM)
RPERITONEAL WASHINGS IDENTIFIED
RPERITONEAL INVOLVEMENT INDICATOR (ENDOMETRIAL CANCER)
RGYNAECOLOGICIAL CANCER SITE OF PERITONEAL INVOLVEMENT

GYNAECOLOGICAL: CERVICAL - PATHOLOGY

To carry pathology details for Gynaecological cancer for Cervical.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RCERVICAL GLANDULAR INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE
RCERVICAL INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE
RSMILE INDICATION CODE
RRESECTION MARGIN INVOLVEMENT INDICATOR
RPARACERVICAL OR PARAMETRIAL INVOLVEMENT INDICATOR
RUNINVOLVED CERVICAL STROMA THICKNESS
RMICROSCOPIC INVOLVEMENT INDICATOR (VAGINAL)
RINVASIVE THICKNESS

GYNAECOLOGICAL: NODES - PATHOLOGY

To carry pathology details for Gynaecological cancer for Nodes.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RNUMBER OF NODES EXAMINED (PARA-AORTIC)
RNUMBER OF NODES POSITIVE (PARA-AORTIC)
RNUMBER OF NODES EXAMINED (PELVIC)
RNUMBER OF NODES POSITIVE (PELVIC)
RNUMBER OF NODES EXAMINED (INGUINO-FEMORAL)
RNUMBER OF NODES POSITIVE (INGUINO-FEMORAL)
REXTRANODAL SPREAD INDICATOR

HEAD AND NECK: VARIOUS - PATHOLOGY

To carry pathology details for various Head and Neck cancers.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RMAXIMUM DEPTH OF INVASION
RBONE INVASION INDICATION CODE
RCARTILAGE INVASION INDICATION CODE
RANATOMICAL SIDE (NECK DISSECTION)

HEAD AND NECK: SALIVARY - PATHOLOGY

To carry salivary pathology details for Head and Neck cancer.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MMACROSCOPIC EXTRAGLANDULAR EXTENSION INDICATION CODE

HEAD AND NECK: GENERAL AND SALIVARY - PATHOLOGY

To carry general and salivary pathology details for Head and Neck cancer.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RANATOMICAL SIDE (POSITIVE NODES)
RLARGEST METASTASIS (LEFT NECK)
RLARGEST METASTASIS (RIGHT NECK)
REXTRACAPSULAR SPREAD INDICATION CODE

HEAD AND NECK: HUMAN PAPILLOMAVIRUS (HPV) - PATHOLOGY

To carry human papilloma virus pathology details for Head and Neck cancer.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RP16 IMMUNOHISTOCHEMISTRY TEST RESULT
RHUMAN PAPILLOMAVIRUS IN SITU HYBRIDISATION TEST RESULT

LUNG - PATHOLOGY

To carry pathology details for Lung cancer.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
REXTENT OF ATELECTASIS
REXTENT OF PLEURAL INVASION
RTUMOUR INVASION INDICATOR (PERICARDIUM)
RTUMOUR INVASION INDICATOR (DIAPHRAGM)
RTUMOUR INVASION INDICATOR (GREAT VESSELS)
RTUMOUR INVASION INDICATOR (HEART)
RMALIGNANT PLEURAL EFFUSION INDICATOR
RTUMOUR INVASION INDICATOR (MEDIASTINUM) 
RSATELLITE TUMOUR NODULES LOCATION

SARCOMA: BONE AND SOFT TISSUE - PATHOLOGY

To carry pathology details for Sarcoma for Bone and Soft Tissue.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RGENETIC CONFIRMATION INDICATOR

SARCOMA: BONE - PATHOLOGY

To carry pathology details for Sarcoma for Bone.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RSARCOMA TUMOUR BREACH IDENTIFIER
RTUMOUR NECROSIS PERCENTAGE

SARCOMA: SOFT TISSUE - PATHOLOGY

To carry pathology details for Sarcoma for Soft Tissue.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RSARCOMA TUMOUR DEPTH
RMITOTIC RATE (SARCOMA)

SKIN: BASAL CELL CARCINOMAS (BCC) - PATHOLOGY

To carry pathology details for Basal Cell Carcinoma (BCC) for skin cancer.
One occurrence of this group is required.
M/R/OData Set Data Elements
RSKIN CANCER LESION SPECIMEN IDENTIFIER
RPERINEURAL INVASION INDICATOR (SKIN)  
RLESION DIAMETER GREATER THAN 20MM INDICATION CODE

SKIN: SQUAMOUS CELL CARCINOMA (SCC) - PATHOLOGY

To carry pathology details for Squamous Cell Carcinoma (SCC) for skin cancer.
One occurrence of this group is required.
M/R/OData Set Data Elements
RSKIN CANCER LESION SPECIMEN IDENTIFIER
RPERINEURAL INVASION INDICATOR (SKIN)  
RLESION DIAMETER GREATER THAN 20MM INDICATION CODE
RCLARKS LEVEL IV INDICATION CODE
RLESION VERTICAL THICKNESS GREATER THAN 2MM INDICATION CODE

SKIN: MALIGNANT MELANOMA (MM) - PATHOLOGY

To carry pathology details for Malignant Melanoma (MM) for skin cancer.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RSKIN CANCER LESION SPECIMEN IDENTIFIER
RSKIN ULCERATION INDICATION CODE
RMITOTIC RATE (SKIN)
RMICROSATELLITE OR IN-TRANSIT METASTASIS INDICATION CODE
RTUMOUR REGRESSION INDICATION CODE (SKIN)
RBRESLOW THICKNESS
RTUMOUR INFILTRATING LYMPHOCYTE TYPE
RNUMBER OF SENTINEL NODES SAMPLED
RNUMBER OF SENTINEL NODES POSITIVE
RNUMBER OF NODES SAMPLED (POST SENTINEL NODE COMPLETION LYMPHADENECTOMY)
RNUMBER OF NODES POSITIVE (POST SENTINEL NODE COMPLETION LYMPHADENECTOMY)

UPPER GASTROINTESTINAL (GI): VARIOUS - PATHOLOGY

To carry pathology details for various Upper Gastrointestinal (GI) cancers.
One occurrence of this data group is permitted.
M/R/OData Set Data Elements
RNUMBER OF COLORECTAL METASTASES IN LIVER
RMARGIN INVOLVED INDICATION CODE (PROXIMAL OR DISTAL RESECTION MARGIN)
RMARGIN INVOLVED INDICATION CODE (CIRCUMFERENTIAL MARGIN)

UROLOGICAL: BLADDER - PATHOLOGY

To carry pathology details for Urological cancer for the bladder.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RDETRUSOR MUSCLE PRESENCE INDICATION CODE
RTUMOUR GRADE (UROLOGY)

UROLOGICAL: KIDNEY - PATHOLOGY

To carry pathology details for Urological cancer for the kidney.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RTUMOUR NECROSIS INDICATION CODE
RTUMOUR INVASION INDICATOR (PERINEPHRIC FAT)
RTUMOUR INVASION INDICATION CODE (DIRECT ADRENAL)
RRENAL VEIN TUMOUR THROMBUS INDICATION CODE (UROLOGICAL)
RTUMOUR INVASION INDICATOR (GEROTAS FASCIA)

UROLOGICAL: PENIS - PATHOLOGY

To carry pathology details for Urological cancer for the penis.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RTUMOUR INVASION INDICATOR (CORPUS SPONGIOSUM)
RTUMOUR INVASION INDICATOR (CORPUS CAVERNOSUM)
RTUMOUR INVASION INDICATOR (URETHRA OR PROSTATE)

UROLOGICAL: PROSTATE - PATHOLOGY

To carry pathology details for Urological cancer for prostate.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RGLEASON GRADE (PRIMARY)
RGLEASON GRADE (SECONDARY)
RGLEASON GRADE (TERTIARY)
RPERINEURAL INVASION INDICATOR (UROLOGICAL)
RTURP TUMOUR PERCENTAGE

UROLOGICAL: TESTICULAR - PATHOLOGY

To carry pathology details for Urological cancer for testicular.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MTUMOUR INVASION INDICATOR (RETE TESTIS)

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CANCER OUTCOMES AND SERVICES DATA SET - SARCOMA

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Sarcoma.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

DIAGNOSIS - SARCOMA

To carry diagnostic details for Bone and Soft Tissue for Sarcoma cancer.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RSARCOMA TUMOUR SITE (BONE)
RSARCOMA TUMOUR SUBSITE (BONE)
RSARCOMA TUMOUR SITE (SOFT TISSUE)
RSARCOMA TUMOUR SUBSITE (SOFT TISSUE)
RMULTIFOCAL OR SYNCHRONOUS TUMOUR INDICATOR

DIAGNOSIS CHOICE - SARCOMA

One of the following can be provided per Core Diagnosis
CHOICE 1 - RHABDOMYOSARCOMA AND OTHER SOFT TISSUE SARCOMAS
To carry diagnostic Rhabdomyosarcoma and other Soft Tissue Sarcoma details for Sarcoma cancer.
One occurrence of this group is required per Core Diagnosis if selected as the choice.
M/RData Set Data Elements
RINTERGROUP RHABDOMYOSARCOMA STUDY POST SURGICAL GROUP
RINTERGROUP RHABDOMYOSARCOMA STUDY POST SURGICAL GROUP DATE
RRHABDOMYOSARCOMA SITE PROGNOSIS CODE
OR
CHOICE 2 - EWINGS
To carry diagnostic Ewings details for Sarcoma cancer.
One occurrence of this group is required per Core Diagnosis if selected as the choice.
M/RData Set Data Elements
MTUMOUR VOLUME AT DIAGNOSIS CODE

LABORATORY RESULTS CHOICE - SARCOMA

One of the following can be provided per Core Laboratory Results
CHOICE 1 - RHABDOMYOSARCOMA AND OTHER SOFT TISSUE SARCOMAS
To carry Rhabdomyosarcoma and other Soft Tissue Sarcoma laboratory result details for Sarcoma cancer.
One occurrence of this group is required per Core Laboratory Results
if selected as the choice.
M/RData Set Data Elements
MCYTOGENETIC PRESENCE TYPE (RHABDOMYOSARCOMA)
OR
CHOICE 2 - EWINGS
To carry Ewings laboratory result details for Sarcoma cancer.
One occurrence of this group is required per Core Laboratory Results
if selected as the choice.
M/RData Set Data Elements
MCYTOGENETIC ANALYSIS CODE

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CANCER OUTCOMES AND SERVICES DATA SET - SKIN

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Skin.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

TREATMENT - SURGERY: BASAL CELL CARCINOMAS (BCC), SQUAMOUS CELL CARCINOMA (SCC), MALIGNANT MELANOMA (MM) - SKIN

To carry surgery details for Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC) and Malignant Melanoma (MM) for Skin cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RCARE PROFESSIONAL OPERATING SURGEON TYPE (CANCER)
RMEMBER OF SPECIALIST MULTIDISCIPLINARY TEAM INDICATOR

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CANCER OUTCOMES AND SERVICES DATA SET - UPPER GASTROINTESTINAL

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Upper Gastrointestinal.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

TREATMENT - SURGERY: GENERAL - UPPER GASTROINTESTINAL (GI)

To carry surgery details for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
MPALLIATIVE TREATMENT REASON (UPPER GASTROINTESTINAL)

TREATMENT - SURGERY: OESO-GASTRIC - UPPER GASTROINTESTINAL (GI)

To carry surgery details for Oeso-Gastric for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
MPOST OPERATIVE TUMOUR SITE (UPPER GASTROINTESTINAL)

TREATMENT - SURGERY: ESODATA - UPPER GASTROINTESTINAL (GI)

To carry surgery details for the Esophageal Database (ESODATA) for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RINTERNATIONAL ESOPHAGEAL DATABASE SURGICAL COMPLICATIONS
Multiple occurrences of this item are permitted
ROESOPHAGOENTERIC LEAK SEVERITY TYPE
ROESOPHAGECTOMY OESOPHAGEAL CONDUIT NECROSIS FAILURE TYPE
RRECURRENT LARYNGEAL NERVE INJURY INVOLVEMENT TYPE
RCHYLE LEAK SEVERITY TYPE
RCALVIEN-DINDO CLASSIFICATION OF SURGICAL CLASSIFICATIONS
RADDITIONAL INTERNATIONAL ESOPHAGEAL DATABASE SURGICAL COMPLICATIONS
Multiple occurrences of this item are permitted

TREATMENT - SURGERY: OUTCOME MEASURES - UPPER GASTROINTESTINAL (GI)

To carry surgery outcome measures for the Esophageal Database (ESODATA) for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
RESCALATION IN LEVEL OF PATIENT CARE FOLLOWING OESOPHAGECTOMY INDICATOR
RBLOOD PRODUCTS REQUIRED FOLLOWING OESOPHAGECTOMY INDICATION CODE
RUNITS OF BLOOD TRANSFUSED FOLLOWING OESOPHAGECTOMY

TREATMENT - SURGERY: OESOPHAGECTOMY - UPPER GASTROINTESTINAL (GI)

To carry surgery details for the Oesophagectomy for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
ROESOPHAGECTOMY SURGICAL APPROACH TYPE
ROPEN OESOPHAGECTOMY SURGICAL APPROACH TYPE
RMINIMALLY INVASIVE OESOPHAGECTOMY SURGICAL APPROACH TYPE
ROESOPHAGECTOMY ANASTOMOSIS TYPE
ROESOPHAGECTOMY OESOPHAGEAL CONDUIT TYPE
ROESOPHAGECTOMY NECK DISSECTION INDICATOR

TREATMENT - SURGERY: LIVER CHOLANGIOCARCINOMA AND PANCREATIC - UPPER GASTROINTESTINAL (GI)

To carry surgery details for Liver Cholangiocarcinoma and Pancreatic for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
MSURGICAL PALLIATION TYPE

TREATMENT - SURGERY: ENDOSCOPIC OR RADIOLOGICAL PROCEDURES (PANCREATIC AND OESO-GASTRIC) - UPPER GASTROINTESTINAL (GI)

To carry surgery details for endoscopic and radiological procedures for Pancreatic and Oeso-Gastric for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
MENDOSCOPIC PROCEDURE TYPE
Multiple occurrences of this item are permitted

TREATMENT - SURGERY: ENDOSCOPIC OR RADIOLOGICAL PROCEDURES (MAIN) - UPPER GASTROINTESTINAL (GI)

To carry surgery details for endoscopic and radiological procedures for Upper Gastrointestinal (GI) cancer.
One occurrence of this group is permitted per Core Treatment Surgery.
M/RData Set Data Elements
MENDOSCOPIC OR RADIOLOGICAL COMPLICATION TYPE
Multiple occurrences of this item are permitted

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CANCER OUTCOMES AND SERVICES DATA SET - UROLOGICAL

Change to Data Set: Changed Description

Cancer Outcomes and Services Data Set Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

For a "Full Screen" view, click Cancer Outcomes and Services Data Set: Urological.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory or Required (M/R) column in the COSDS XML Schema indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc..) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

DIAGNOSTIC PROCEDURES: PROSTATE - UROLOGICAL

To carry cancer diagnostic procedure details for Urological cancer for the prostate.
One occurrence of this group is permitted per Core Diagnostic Procedures.
M/RData Set Data Elements
MPRETREATMENT PROSTATE BIOPSY TECHNIQUE TYPE
MBIOPSY ANAESTHETIC TYPE

DIAGNOSIS: PROSTATE - UROLOGICAL

To carry the diagnosis details for Urological cancer for the prostate.
One occurrence of this group is permitted per Core Diagnosis.
M/RData Set Data Elements
RMULTIPARAMETRIC MRI SCAN INDICATOR
RMRI ULTRASOUND FUSION GUIDED BIOPSY INDICATOR
RPROSTATE SPECIFIC ANTIGEN (DIAGNOSIS)

CANCER CARE PLAN - UROLOGICAL

To carry cancer care plan details for Urological cancer.
One occurrence of this group is permitted per Core Cancer Care Plan.
M/RData Set Data Elements
RESTIMATED GLOMERULAR FILTRATION RATE
RHYDRONEPHROSIS CODE
RS CATEGORY CODE

LABORATORY RESULTS - UROLOGICAL

To carry Laboratory Result details for Urological cancer.
One occurrence of this group is permitted per Core Laboratory Results.
M/RData Set Data Elements
RS CATEGORY (ALPHA FETOPROTEIN)
RS CATEGORY (HUMAN CHORIONIC GONADOTROPIN)
RS CATEGORY (LACTATE DEHYDROGENASE)
RLACTATE DEHYDROGENASE LEVEL (NORMAL UPPER LIMIT)

STAGING: TESTICULAR - UROLOGICAL

To carry staging details for Urological cancer for testicular.
One occurrence of this group is permitted per Core Site Specific Staging
.
M/RData Set Data Elements
RSTAGE GROUPING (TESTICULAR CANCER)
REXTENT OF METASTATIC SPREAD
Multiple occurrences of this item are permitted
RLUNG METASTASES SUB-STAGE GROUPING

TREATMENT: BLADDER CHOICE - UROLOGICAL

One of the following can be provided per Urological Treatment
CHOICE 1 - INTRAVESICAL CHEMOTHERAPY
To carry treatment details for Urological cancer for the bladder.
One occurrence of this group is required per Core Treatment if selected as the choice.
M/RData Set Data Elements
MINTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR
OR
CHOICE 2 - INTRAVESICAL IMMUNOTHERAPY
To carry treatment details for Urological cancer for the bladder.
One occurrence of this group is required per Core Treatment if selected as the choice.
M/RData Set Data Elements
MINTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR

TREATMENT: PROSTATE - UROLOGICAL

To carry cancer treatment details for Urological cancer for the prostate.
One occurrence of this group is required per Core Treatment.
M/RData Set Data Elements
RPROSTATE NERVE SPARING SURGERY TYPE
RRADICAL PROSTATECTOMY MARGIN STATUS

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CHLAMYDIA TESTING ACTIVITY DATA SET

Change to Data Set: Changed Description

Chlamydia Testing Activity Data Set Overview

The Mandatory or Required (M/R) column indicates the recommendation for the inclusion of data:

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

Organisation Details:
To carry the details of the reporting period and testing service.
M/R/OData Set Data Elements
RREPORTING PERIOD START DATE 
RREPORTING PERIOD END DATE 
MLABORATORY CODE
Person Demographics:
To carry the demographic details of the person tested. 
M/RData Set Data Elements
RLOCAL PATIENT IDENTIFIER (EXTENDED)
RNHS NUMBER
RNHS NUMBER STATUS INDICATOR CODE
MPERSON STATED GENDER CODE
RPERSON BIRTH DATE
METHNIC CATEGORY
MPOSTCODE OF USUAL ADDRESS
MPOSTCODE OF GENERAL MEDICAL PRACTICE (PATIENT REGISTRATION)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
Testing Service Provider Details:
To carry the details of the testing service provider.
M/RData Set Data Elements
MPOSTCODE OF TESTING SERVICE (CHLAMYDIA TESTING)

R

SITE CODE (PROVIDER OF CHLAMYDIA TEST)
or
ORGANISATION CODE (PROVIDER OF CHLAMYDIA TEST)
MSERVICE TYPE (CHLAMYDIA TESTING)
RCLINIC CODE (NATIONAL CHLAMYDIA SCREENING PROGRAMME)
Test Details:
To carry the details of the tests and results provided.
M/RData Set Data Elements
MTEST IDENTIFIER (CHLAMYDIA TESTING)
MSPECIMEN TYPE (CHLAMYDIA TESTING)
OSPECIMEN TYPE (CHLAMYDIA TESTING SNOMED CT)
RSAMPLE COLLECTION DATE
MSAMPLE RECEIPT DATE
RINVESTIGATION RESULT DATE
MCHLAMYDIA TEST RESULT
OCHLAMYDIA TEST RESULT (SNOMED CT)

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COMMUNITY SERVICES DATA SET

Change to Data Set: Changed Description

Community Services Data Set Overview

Due to Covid-19, the transition from Community Services Data Set v1.0 to v1.5 was postponed until 1 July 2020.

For a "Full Screen" view, click Community Services Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc.) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on the Data Set constraints, see the Community Services Data Set Constraints.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.


SUBMISSION IDENTIFIER

M/R/OData Set Data Elements
MDATA SET VERSION NUMBER
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MPRIMARY DATA COLLECTION SYSTEM IN USE
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATE AND TIME DATA SET CREATED

PATIENT DEMOGRAPHICS

Master Patient Index and Risk Indicators:
To carry the personal details of the patient and the associated mother's NHS number (where applicable).
One occurrence of this group is required for each patient.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER)
RORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY)
RORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT)
RNHS NUMBER
RNHS NUMBER STATUS INDICATOR CODE
RPERSON BIRTH DATE
RPOSTCODE OF USUAL ADDRESS
RPERSON STATED GENDER CODE
RETHNIC CATEGORY
RLANGUAGE CODE (PREFERRED)
RPERSON RELATIONSHIP (MAIN CARER)
RHEALTH VISITOR FIRST ANTENATAL VISIT DATE
RLOOKED AFTER CHILD INDICATOR
RSAFEGUARDING VULNERABILITY FACTORS INDICATOR
RCONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
REDUCATIONAL ASSESSMENT OUTCOME
RPREFERRED DEATH LOCATION DISCUSSED INDICATOR
RPERSON AT RISK OF UNEXPECTED DEATH INDICATOR
RDEATH LOCATION TYPE CODE (PREFERRED)
RPERSON DEATH DATE
RDEATH LOCATION TYPE CODE (ACTUAL)
RDEATH NOT AT PREFERRED LOCATION REASON
RNHS NUMBER (MOTHER)
RNHS NUMBER STATUS INDICATOR CODE (MOTHER)

GP Practice Registration:
To carry details of the GP Practice Registration of the patient.
One occurrence of this group is required for each change of GP Practice Registration.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
RSTART DATE (GMP PATIENT REGISTRATION)
REND DATE (GMP PATIENT REGISTRATION)
RORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)

Accommodation Type:
To carry details of the type of accommodation for the patient.
One occurrence of this group is permitted for each accommodation status.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MACCOMMODATION STATUS CODE
RACCOMMODATION STATUS RECORDED DATE

Care Plan Type:
To carry details of Care Plans created for a patient by the organisation.
One occurrence of this group is permitted for each Care Plan created for the patient.
M/R/OData Set Data Elements
MCARE PLAN IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MCARE PLAN TYPE (COMMUNITY CARE)
MCARE PLAN CREATION DATE
RCARE PLAN CREATION TIME
RCARE PLAN LAST UPDATED DATE
RCARE PLAN LAST UPDATED TIME
RCARE PLAN IMPLEMENTATION DATE

Care Plan Agreement:
To carry details of any agreements to a Care Plan by a patient, team or organisation.
One occurrence of this group is permitted for each agreement of a Care Plan.
M/R/OData Set Data Elements
MCARE PLAN IDENTIFIER
MCARE PLAN AGREED BY
RCARE PLAN AGREED DATE
RCARE PLAN AGREED TIME

Social and Personal Circumstances:
To carry details of social and personal circumstances of a patient.
One occurrence of this group is permitted for each social and personal circumstance recorded.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
MSOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE

Employment Status:
To carry details of the employment status of the patient.
One occurrence of this group is permitted for each employment status.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MEMPLOYMENT STATUS
REMPLOYMENT STATUS RECORDED DATE
RWEEKLY HOURS WORKED

REFERRALS

Service or Team Referral:
To carry details of the Service or Team referral that the patient is subject to.
One occurrence of this group is permitted for each referral.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MREFERRAL REQUEST RECEIVED DATE
RREFERRAL REQUEST RECEIVED TIME
ONHS SERVICE AGREEMENT LINE NUMBER
RSOURCE OF REFERRAL FOR COMMUNITY
RORGANISATION IDENTIFIER (REFERRING)
RREFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH AND COMMUNITY CARE)
RPRIORITY TYPE CODE
RPRIMARY REASON FOR REFERRAL (COMMUNITY CARE)
RSERVICE DISCHARGE DATE
RDISCHARGE LETTER ISSUED DATE (MENTAL HEALTH AND COMMUNITY CARE)

Service or Team Type Referred To:
To carry details of the Service or Team that the patient has been referred to.
One occurrence of this group is permitted for each service or team that a patient has been referred to.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MSERVICE OR TEAM TYPE REFERRED TO (COMMUNITY CARE)
RREFERRAL CLOSURE DATE
RREFERRAL REJECTION DATE
RREFERRAL CLOSURE REASON
RREFERRAL REJECTION REASON

Other Reason for Referral:
To carry details of additional reasons why a patient has been referred to a specific service.
One occurrence of this group is permitted for each additional referral reason.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MOTHER REASON FOR REFERRAL (COMMUNITY CARE)

Referral To Treatment (RTT):
To carry Referral to Treatment details for the patient referral.
One occurrence of this group is permitted for each change in Referral To Treatment Period Status.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
RUNIQUE BOOKING REFERENCE NUMBER (CONVERTED)
RPATIENT PATHWAY IDENTIFIER
RORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
RWAITING TIME MEASUREMENT TYPE
RREFERRAL TO TREATMENT PERIOD START DATE
RREFERRAL TO TREATMENT PERIOD START TIME
RREFERRAL TO TREATMENT PERIOD END DATE
RREFERRAL TO TREATMENT PERIOD END TIME
RREFERRAL TO TREATMENT PERIOD STATUS

Onward Referral:
To carry details of any onward referral of the patient which has taken place.
One occurrence of this group is permitted for each onward referral.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MONWARD REFERRAL DATE
RONWARD REFERRAL REASON
RORGANISATION IDENTIFIER (RECEIVING)

CARE CONTACT AND ACTIVITIES

Care Contact:
To carry details of any contacts with a patient which have taken place as result of a referral.
One occurrence of this group is permitted for each Care Contact.
M/R/OData Set Data Elements
MCARE CONTACT IDENTIFIER
MSERVICE REQUEST IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MCARE CONTACT DATE
RCARE CONTACT TIME
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RADMINISTRATIVE CATEGORY CODE
RCLINICAL CONTACT DURATION OF CARE CONTACT
RCONSULTATION TYPE
RCARE CONTACT SUBJECT
RCONSULTATION MEDIUM USED
RACTIVITY LOCATION TYPE CODE
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RGROUP THERAPY INDICATOR
RATTENDED OR DID NOT ATTEND CODE
REARLIEST REASONABLE OFFER DATE
REARLIEST CLINICALLY APPROPRIATE DATE
RCARE CONTACT CANCELLATION DATE
RCARE CONTACT CANCELLATION REASON
RREPLACEMENT APPOINTMENT DATE OFFERED
RREPLACEMENT APPOINTMENT BOOKED DATE

Care Activity:
To carry details of any activities which have taken place as part of a contact with a patient.
One occurrence of this group is permitted for each Care Activity.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCARE CONTACT IDENTIFIER
MCOMMUNITY CARE ACTIVITY TYPE
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCLINICAL CONTACT DURATION OF CARE ACTIVITY
RPROCEDURE SCHEME IN USE
RCODED PROCEDURE (CLINICAL TERMINOLOGY)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
ROBSERVATION SCHEME IN USE
RCODED OBSERVATION (CLINICAL TERMINOLOGY)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

GROUP SESSIONS

Group Session:
To carry details of any group sessions which have been provided to a group of people during the reporting period.
One occurrence of this group is permitted for each Group Session activity.
M/R/OData Set Data Elements
MGROUP SESSION IDENTIFIER
MGROUP SESSION DATE
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RCLINICAL CONTACT DURATION OF GROUP SESSION
RGROUP SESSION TYPE (COMMUNITY CARE)
RNUMBER OF GROUP SESSION PARTICIPANTS
OACTIVITY LOCATION TYPE CODE
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RCARE PROFESSIONAL LOCAL IDENTIFIER
ONHS SERVICE AGREEMENT LINE NUMBER

SOCIAL CIRCUMSTANCES

Special Educational Need Identified:
To carry details of the child's or young person's Special Educational Need.
One occurrence of this group is permitted for each Special Educational Need identified.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSPECIAL EDUCATIONAL NEED TYPE

Safeguarding Vulnerability Factor:
To carry details when the child's or young person is subject to any safeguarding concerns.
One occurrence of this group is permitted for each safeguarding concern.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSAFEGUARDING VULNERABILITY FACTORS TYPE

Child Protection Plan:
To carry details when the child or young person is subject to a child protection plan.
One occurrence of this group is permitted for each child protection plan.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MCHILD PROTECTION PLAN REASON CODE
MCHILD PROTECTION PLAN START DATE
RCHILD PROTECTION PLAN END DATE

Assistive Technology to Support Disability Type:
To carry details when assistive technology is used to help support a disabled child or young person.
One occurrence of this group is permitted for each assistive technology type.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
RPRESCRIPTION DATE (ASSISTIVE TECHNOLOGY)

IMMUNISATIONS

Coded Immunisation:
To carry details of coded immunisation activity for a patient.
One occurrence of this group is permitted for each coded immunisation activity.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MIMMUNISATION DATE
MPROCEDURE SCHEME IN USE
MIMMUNISATION PROCEDURE (CLINICAL TERMINOLOGY)
RORGANISATION IDENTIFIER (IMMUNISATION RESPONSIBLE ORGANISATION)

Immunisation:
To carry details of immunisation activity for a child or young person.
One occurrence of this group is permitted for each immunisation activity.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MIMMUNISATION DATE
MCHILDHOOD IMMUNISATION TYPE (CHILDREN AND YOUNG PEOPLE'S HEALTH SERVICES)
RORGANISATION IDENTIFIER (IMMUNISATION RESPONSIBLE ORGANISATION)

DIAGNOSES, TESTS AND OBSERVATIONS

Medical History (Previous Diagnosis):
To carry details of any previous diagnoses for a patient, which are stated by the patient or patient proxy or recorded in medical notes.
These do not have to have been diagnosed by the organisation submitting the data.
One occurrence of this group is permitted for each previous diagnosis.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MDIAGNOSIS SCHEME IN USE
MPREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Disability Type:
To carry details of the type of disability affecting a patient, based on their perception or the perception of a patient proxy.
One occurrence of this group is permitted for each disability identified.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MDISABILITY CODE
RDISABILITY IMPACT PERCEPTION

Newborn Hearing Screening Audiology Referral:
To carry details of how concerns following Newborn Hearing Screening are followed up.
One occurrence of this group is permitted for each newborn hearing audiology test.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
RNEWBORN HEARING SCREENING OUTCOME
RSERVICE REQUEST DATE (NEWBORN HEARING AUDIOLOGY)
RPROCEDURE DATE (NEWBORN HEARING AUDIOLOGY)
RNEWBORN HEARING AUDIOLOGY OUTCOME

Blood Spot Result:
To carry details of the results of newborn blood spot tests.
One occurrence of this group is permitted for each newborn blood spot test.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
RBLOOD SPOT CARD COMPLETION DATE
RNEWBORN BLOOD SPOT TEST RESULT RECEIVED DATE
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (PHENYLKETONURIA)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (SICKLE CELL DISEASE)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (CYSTIC FIBROSIS)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (CONGENITAL HYPOTHYROIDISM)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (MEDIUM CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (HOMOCYSTINURIA)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (MAPLE SYRUP URINE DISEASE)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (GLUTARIC ACIDURIA TYPE 1)
RNEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (ISOVALERIC ACIDURIA)

Infant Physical Examination (General Medical Practitioner Delivered):
To carry details of the Infant Physical Examination carried out by the General Medical Practitioner.
One occurrence of this group is permitted for each Infant Physical Examination.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MINFANT PHYSICAL EXAMINATION DATE
RINFANT PHYSICAL EXAMINATION RESULT (HIPS)
RINFANT PHYSICAL EXAMINATION RESULT (HEART)
RINFANT PHYSICAL EXAMINATION RESULT (EYES)
RINFANT PHYSICAL EXAMINATION RESULT (TESTES)

Provisional Diagnosis:
To carry details of a provisional diagnosis for a patient made by the service that the patient was referred to.
One occurrence of this group is permitted for each provisional diagnosis.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
RPROVISIONAL DIAGNOSIS DATE

Primary Diagnosis:
To carry details of the primary diagnosis for a patient made by the service that the patient was referred to.
One occurrence of this group is permitted for the primary diagnosis. The primary diagnosis can change during a reporting period.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPRIMARY DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Secondary Diagnosis:
To carry details of a secondary diagnosis for a patient made by the service that the patient was referred to.
One occurrence of this group is permitted for each secondary diagnosis.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MSECONDARY DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Coded Scored Assessment (Referral):
To carry details of scored assessments that are issued and completed as part of a referral period where a specific service or team is responsible for the patient, but do not take place at a specific contact.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured outside of a contact.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
RASSESSMENT TOOL COMPLETION DATE

Breastfeeding Status:
To carry details of a child's breastfeeding status as recorded at a contact.
One occurrence of this group is permitted containing the most recently recorded breastfeeding status.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MBREASTFEEDING STATUS

Observation:
To carry details of observations of a patient which take place at a contact.
One occurrence of this group is permitted containing the most recently recorded observation(s).
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
RPERSON WEIGHT
RPERSON HEIGHT IN METRES
RPERSON LENGTH IN CENTIMETRES

Coded Scored Assessment (Contact):
To carry details of scored assessments that are issued and completed as part of a specific contact.
One occurrence of this group is permitted for each coded scored assessment question or dimension.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

ANONYMOUS SELF-ASSESSMENT

Anonymous Self-Assessment:
To carry details of anonymous assessments that are issued by the Community Health Service.
One occurrence of this group is permitted when an anonymous self-assessment is received from a patient.
M/R/OData Set Data Elements
MASSESSMENT TOOL COMPLETION DATE
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
RACTIVITY LOCATION TYPE CODE
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)

STAFF DETAILS

Staff Details:
To carry details of the staff involved in the treatment of a patient.
One occurrence of this group is permitted for each staff member.
M/R/OData Set Data Elements
MCARE PROFESSIONAL LOCAL IDENTIFIER
RPROFESSIONAL REGISTRATION BODY CODE
RPROFESSIONAL REGISTRATION ENTRY IDENTIFIER
RCARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)
ROCCUPATION CODE
RCARE PROFESSIONAL (JOB ROLE CODE)

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COVER OF VACCINATION EVALUATED RAPIDLY (COVER) DATA SET

Change to Data Set: Changed Description

Cover of Vaccination Evaluated Rapidly (COVER) Data Set Overview

Click Cover of Vaccination Evaluated Rapidly (COVER) Data Set for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc.) cannot be completed without this data element being present

SUBMISSION IDENTIFIER

To carry the details of the providing organisation and reporting period.
One occurrence of this group is required.
MData Set Data Elements
MORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE

PRIMARY IMMUNISATIONS 12 MONTH COHORT

To carry details of completed primary immunisations at 12 months.
Multiple occurrences of this group are permitted, one for each Childhood Immunisation Type reported.
MData Set Data Elements
MCHILDHOOD IMMUNISATION TYPE (COVER)
or
CHILDHOOD IMMUNISATION TYPE COMBINED (COVER)
MELIGIBLE POPULATION TOTAL (COVER)
MELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER)

PRIMARY IMMUNISATIONS 24 MONTH COHORT

To carry details of completed primary immunisations at 24 months.
Multiple occurrences of this group are permitted, one for each Childhood Immunisation Type reported.
MData Set Data Elements
MCHILDHOOD IMMUNISATION TYPE (COVER)
or
CHILDHOOD IMMUNISATION TYPE COMBINED (COVER)
MELIGIBLE POPULATION TOTAL (COVER)
MELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER)

PRIMARY IMMUNISATIONS and BOOSTERS 5 YEAR COHORT

To carry details of completed primary immunisations and boosters at 5 years.
Multiple occurrences of this group are permitted, one for each Childhood Immunisation Type reported.
MData Set Data Elements
MCHILDHOOD IMMUNISATION TYPE (COVER)
or
CHILDHOOD IMMUNISATION TYPE COMBINED (COVER)
MELIGIBLE POPULATION TOTAL (COVER)
MELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER)

HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHERS 12 MONTH COHORT

To carry details of Neonatal Hepatitis B coverage at 12 months.
Multiple occurrences of this group are permitted, one for each Childhood Immunisation Type reported.
MData Set Data Elements
MCHILDHOOD IMMUNISATION TYPE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
or
CHILDHOOD IMMUNISATION TYPE COMBINED (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
MELIGIBLE POPULATION TOTAL (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
MELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)

HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHERS 24 MONTH COHORT

To carry details of Neonatal Hepatitis B coverage at 24 months.
Multiple occurrences of this group are permitted, one for each Childhood Immunisation Type reported.
MData Set Data Elements
MCHILDHOOD IMMUNISATION TYPE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
or
CHILDHOOD IMMUNISATION TYPE COMBINED (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
MELIGIBLE POPULATION TOTAL (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)
MELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER)

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CRITICAL CARE MINIMUM DATA SET

Change to Data Set: Changed Description

Critical Care Minimum Data Set Overview

Critical Care Minimum Data Set excludes neonatal and paediatric critical care. A subset of this minimum data set is used to derive Adult Critical Care HRGs. The subset is sent in the following Commissioning Data Set messages:


Data Set Data Elements
NHS NUMBER
LOCAL PATIENT IDENTIFIER
CRITICAL CARE LOCAL IDENTIFIER
SITE CODE (OF TREATMENT)
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
ACTIVITY TREATMENT FUNCTION CODE
PERSON BIRTH DATE
POSTCODE OF USUAL ADDRESS
CRITICAL CARE START DATE
CRITICAL CARE START TIME
CRITICAL CARE UNIT FUNCTION
CRITICAL CARE UNIT BED CONFIGURATION
CRITICAL CARE ADMISSION SOURCE
CRITICAL CARE SOURCE LOCATION
CRITICAL CARE ADMISSION TYPE
ADVANCED RESPIRATORY SUPPORT DAYS
BASIC RESPIRATORY SUPPORT DAYS
ADVANCED CARDIOVASCULAR SUPPORT DAYS
BASIC CARDIOVASCULAR SUPPORT DAYS
RENAL SUPPORT DAYS
NEUROLOGICAL SUPPORT DAYS
GASTRO-INTESTINAL SUPPORT DAYS
DERMATOLOGICAL SUPPORT DAYS
LIVER SUPPORT DAYS
ORGAN SUPPORT MAXIMUM
CRITICAL CARE LEVEL 2 DAYS
CRITICAL CARE LEVEL 3 DAYS
CRITICAL CARE DISCHARGE STATUS
CRITICAL CARE DISCHARGE DESTINATION
CRITICAL CARE DISCHARGE LOCATION
CRITICAL CARE DISCHARGE READY DATE
CRITICAL CARE DISCHARGE READY TIME
CRITICAL CARE DISCHARGE DATE
CRITICAL CARE DISCHARGE TIME

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DEVICES PATIENT LEVEL CONTRACT MONITORING DATA SET

Change to Data Set: Changed Description

Devices Patient Level Contract Monitoring Data Set Overview

For a "Full Screen" view, click Devices Patient Level Contract Monitoring Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on the Data Set constraints, see the Devices Patient Level Contract Monitoring Data Set Constraints.


SUBMISSION HEADER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MFINANCIAL MONTH
MFINANCIAL YEAR
MDATE AND TIME DATA SET CREATED

ORGANISATION DETAILS

To carry the Organisation details of the Provider and Commissioner. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

DEMOGRAPHICS

To carry the demographic details of the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
RWITHHELD IDENTITY REASON
RNHS NUMBER
RLOCAL PATIENT IDENTIFIER (EXTENDED)
RPOSTCODE OF USUAL ADDRESS
RPERSON BIRTH DATE
RAGE AT ACTIVITY DATE (CONTRACT MONITORING)
RPERSON STATED GENDER CODE

CARE ACTIVITY DETAILS

To carry the care activity details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RHOSPITAL PROVIDER SPELL NUMBER
RATTENDANCE IDENTIFIER
RCLINICAL INTERVENTION DATE (MEDICAL DEVICE IMPLEMENTATION)
OHIGH COST TARIFF EXCLUDED DEVICE CODE (SNOMED CT DM+D)
RHIGH LEVEL CODE (HIGH COST TARIFF EXCLUDED DEVICE)
RSUBSIDIARY LEVEL CODE (HIGH COST TARIFF EXCLUDED DEVICE)
OLOCAL CODE (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE PROCUREMENT ROUTE (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE MANUFACTURER (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE NAME (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE SERIAL NUMBER (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE SIZE (HIGH COST TARIFF EXCLUDED DEVICE)
RMEDICAL DEVICE QUANTITY (HIGH COST TARIFF EXCLUDED DEVICE)

SERVICE AGREEMENT AND COMMISSIONING DETAILS

To carry the details of the Service and Commissioning Agreement.
One occurrence of this group is required.
M/R/OData Set Data Elements
RPROVIDER REFERENCE NUMBER
MCOMMISSIONED SERVICE CATEGORY CODE
RSPECIALISED SERVICE CODE
MPOINT OF DELIVERY CODE
RPOINT OF DELIVERY FURTHER DETAIL CODE
RPOINT OF DELIVERY FURTHER DETAIL DESCRIPTION
OCONTRACT MONITORING ADDITIONAL DETAIL (FIRST)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIRST)
OCONTRACT MONITORING ADDITIONAL DETAIL (SECOND)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (SECOND)
OCONTRACT MONITORING ADDITIONAL DETAIL (THIRD)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (THIRD)
OCONTRACT MONITORING ADDITIONAL DETAIL (FOURTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FOURTH)
OCONTRACT MONITORING ADDITIONAL DETAIL (FIFTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIFTH)

COST AND PRICING DETAILS

To carry the cost and pricing details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MUNIT PRICE (SUPPLIER)
MUNIT PRICE (COMMISSIONER)
MVALUE ADDED TAX CHARGED INDICATOR (CONTRACT MONITORING)
MTOTAL COST

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DIAGNOSTIC IMAGING DATA SET

Change to Data Set: Changed Description

Diagnostic Imaging Data Set Overview

The Mandatory, Required or Optional (M/R) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the Diagnostic Imaging Data Set XML Schema Constraints.


PERSONAL AND DEMOGRAPHIC

To carry personal and demographic details.
One occurrence of this group is required.
Note: at least one of these data items must be present.
M/RData Set Data Elements
RNHS NUMBER
RNHS NUMBER STATUS INDICATOR CODE
RPERSON BIRTH DATE
RETHNIC CATEGORY
RPERSON GENDER CODE CURRENT
RPOSTCODE OF USUAL ADDRESS
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

REFERRALS

To carry referral details.
One occurrence of this group is required.
M/RData Set Data Elements
MPATIENT SOURCE SETTING TYPE (DIAGNOSTIC IMAGING)
RREFERRER CODE
RREFERRING ORGANISATION CODE
RDIAGNOSTIC TEST REQUEST DATE
RDIAGNOSTIC TEST REQUEST RECEIVED DATE

IMAGING ACTIVITY

To carry imaging details.
One occurrence of this group is required.
M/RData Set Data Elements
MIMAGING CODE (NICIP)
and/or
IMAGING CODE (SNOMED-CT)
MDIAGNOSTIC TEST DATE
RSERVICE REPORT ISSUE DATE
MSITE CODE (OF IMAGING)
MRADIOLOGICAL ACCESSION NUMBER

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DRUGS PATIENT LEVEL CONTRACT MONITORING DATA SET

Change to Data Set: Changed Description

Drugs Patient Level Contract Monitoring Data Set Overview

For a "Full Screen" view, click Drugs Patient Level Contract Monitoring Data Set. 

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on the Data Set constraints, see the Drugs Patient Level Contract Monitoring Data Set Constraints.

SUBMISSION HEADER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MFINANCIAL MONTH
MFINANCIAL YEAR
MDATE AND TIME DATA SET CREATED

ORGANISATION DETAILS

To carry the Organisation details of the Provider and Commissioner. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

DEMOGRAPHICS

To carry the demographic details of the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
RWITHHELD IDENTITY REASON
RNHS NUMBER
RLOCAL PATIENT IDENTIFIER (EXTENDED)
RPOSTCODE OF USUAL ADDRESS
RPERSON BIRTH DATE
RAGE AT ACTIVITY DATE (CONTRACT MONITORING)
RPERSON STATED GENDER CODE

CARE ACTIVITY DETAILS

To carry the care activity details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RACTIVITY TREATMENT FUNCTION CODE
RHOSPITAL PROVIDER SPELL NUMBER
RATTENDANCE IDENTIFIER
RCLINICAL INTERVENTION DATE (DRUG ADMINISTERED)
RTHERAPEUTIC INDICATION CODE (SNOMED CT)
OHIGH COST TARIFF EXCLUDED DRUG CODE (SNOMED CT DM+D)
ODM+D TAXONOMY CODE (HIGH COST TARIFF EXCLUDED DRUG)
RDRUG NAME (HIGH COST TARIFF EXCLUDED DRUG)
RROUTE OF ADMINISTRATION (SNOMED CT DM+D)
RDRUG STRENGTH (HIGH COST TARIFF EXCLUDED DRUG)
RDRUG VOLUME (HIGH COST TARIFF EXCLUDED DRUG)
ODRUG PACK SIZE (HIGH COST TARIFF EXCLUDED DRUG)
RDRUG QUANTITY OR WEIGHT PROPORTION (HIGH COST TARIFF EXCLUDED DRUG)
RUNIT OF MEASUREMENT (SNOMED CT DM+D)
RDISPENSING ROUTE (HIGH COST TARIFF EXCLUDED DRUG)

SERVICE AGREEMENT AND COMMISSIONING DETAILS

To carry the service agreement and commissioning details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RPROVIDER REFERENCE NUMBER
MCOMMISSIONED SERVICE CATEGORY CODE
RSPECIALISED SERVICE CODE
MPOINT OF DELIVERY CODE
RPOINT OF DELIVERY FURTHER DETAIL CODE
RPOINT OF DELIVERY FURTHER DETAIL DESCRIPTION
OCONTRACT MONITORING ADDITIONAL DETAIL (FIRST)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIRST)
OCONTRACT MONITORING ADDITIONAL DETAIL (SECOND)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (SECOND)
OCONTRACT MONITORING ADDITIONAL DETAIL (THIRD)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (THIRD)
OCONTRACT MONITORING ADDITIONAL DETAIL (FOURTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FOURTH)
OCONTRACT MONITORING ADDITIONAL DETAIL (FIFTH)
OCONTRACT MONITORING ADDITIONAL DESCRIPTION (FIFTH)

COST AND PRICING DETAILS

To carry the service cost and pricing details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MUNIT PRICE (SUPPLIER)
MUNIT PRICE (COMMISSIONER)
MHOME DELIVERY CHARGE (HIGH COST TARIFF EXCLUDED DRUG)
MVALUE ADDED TAX CHARGED INDICATOR (CONTRACT MONITORING)
MTOTAL COST

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FEMALE GENITAL MUTILATION DATA SET

Change to Data Set: Changed Description

Female Genital Mutilation Data Set Overview

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

PATIENT
 
To carry details pertaining to the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION CODE (CODE OF PROVIDER)
RNHS NUMBER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MPERSON BIRTH DATE
MPOSTCODE OF USUAL ADDRESS
MPERSON GIVEN NAME (FIRST)
MPERSON FAMILY NAME
RCOUNTRY CODE (BIRTH)
RCOUNTRY CODE (ORIGIN)
OREGION OF COUNTRY CODE FOR FEMALE GENITAL MUTILATION (ORIGIN)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

CARE CONTACT

To carry details of the care contact.
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION CODE (CODE OF PROVIDER)
RNHS NUMBER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MPERSON BIRTH DATE
MCARE CONTACT DATE
RSOURCE OF REFERRAL FOR FEMALE GENITAL MUTILATION
RREFERRING ORGANISATION CODE
RSITE CODE (OF TREATMENT)
RACTIVITY TREATMENT FUNCTION CODE
RPREGNANCY STATUS INDICATOR
OFEMALE GENITAL MUTILATION IDENTIFICATION METHOD CODE
RFEMALE GENITAL MUTILATION FAMILY HISTORY INDICATOR
RNUMBER OF DAUGHTERS UNDER 18
RADVISED OF HEALTH IMPLICATIONS INDICATOR
RADVISED OF LEGAL IMPLICATIONS INDICATOR
RDAUGHTER BORN AT THIS ENCOUNTER INDICATOR
OCOUNTRY CODE (FATHER BIRTH)
OCOUNTRY CODE (FATHER ORIGIN)

FEMALE GENITAL MUTILATION
 
To carry female genital mutilation details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MORGANISATION CODE (CODE OF PROVIDER)
RNHS NUMBER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MPERSON BIRTH DATE
MCARE CONTACT DATE
RFEMALE GENITAL MUTILATION IDENTIFIED TYPE CODE
OFEMALE GENITAL MUTILATION TYPE 4 CODE
RDEINFIBULATION UNDERTAKEN REASON
RFEMALE GENITAL MUTILATION AGE CATEGORY
RCOUNTRY CODE (FEMALE GENITAL MUTILATION PERFORMED)

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GUMCAD SEXUALLY TRANSMITTED INFECTION SURVEILLANCE SYSTEM DATA SET

Change to Data Set: Changed Description

GUMCAD Sexually Transmitted Infection Surveillance System Data Set Overview

For a "Full Screen" view, click GUMCAD Sexually Transmitted Infection Surveillance System Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required (M/R) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element

SERVICE INFORMATION DETAILS

To carry the service information details.
One occurrence of this group is required.
M/RData Set Data Elements
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
MCLINIC TYPE (SEXUAL HEALTH SERVICE)

PERSONAL AND DEMOGRAPHIC DETAILS

To carry personal and demographic details.
One occurrence of this group is required.
M/RData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MPERSON RISK FACTOR (SEXUALLY TRANSMITTED INFECTION)
MGENDER IDENTITY CODE (SEXUAL HEALTH)
MGENDER IDENTITY SAME AT BIRTH INDICATOR
MAGE AT ATTENDANCE DATE
MPERSON STATED SEXUAL ORIENTATION CODE
METHNIC CATEGORY
MCOUNTRY CODE (BIRTH)
MONS LOCAL GOVERNMENT GEOGRAPHIC AREA CODE (LOCAL AUTHORITY DISTRICT)
MLOWER LAYER SUPER OUTPUT AREA (PERSON RESIDENCE)

CLINIC ATTENDANCE AND ACTIVITY DETAILS
 
To carry clinic attendance and activity details. 
One occurrence of this group is required.
M/RData Set Data Elements
MSEXUAL HEALTH SERVICE ATTENDANCE SOURCE (SNOMED CT)
MATTENDANCE DATE
MCONSULTATION MEDIUM USED (SEXUAL HEALTH SERVICE)
MCONSULTATION TYPE
MSERVICE TYPE (SEXUAL HEALTH)
MPARTNER NOTIFICATION CONSULTATION INDICATOR (SEXUAL HEALTH SERVICE)
MPATIENT ATTENDANCE SYMPTOMATIC INDICATOR (SEXUAL HEALTH SERVICE)
RSEXUAL HEALTH AND HIV ACTIVITY PROPERTY TYPE
Multiple occurrences of this data item are permitted
or
DIAGNOSTIC OR PROCEDURE CODING (SEXUAL HEALTH AND HUMAN IMMUNODEFICIENCY VIRUS RELEVANT READ CODES)
Multiple occurrences of this data item are permitted
or
SEXUAL HEALTH AND HIV ACTIVITY HEALTH ISSUE (SNOMED CT)
Multiple occurrences of this data item are permitted
or
SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT)
MPATIENT DIAGNOSIS CONFIRMED INDICATION CODE (SEXUAL HEALTH SERVICE)
MPATIENT DIAGNOSIS SITE OF INFECTION (SEXUAL HEALTH SERVICE)
MPATIENT DIAGNOSIS TREATMENT PROVIDED INDICATION CODE (SEXUAL HEALTH SERVICE)

PARTNER DETAILS

To carry the opposite sex partnership details. 
One occurrence of this group is required.
M/RData Set Data Elements
MNUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (OPPOSITE SEX PARTNERS)
MNEW SEX PARTNERS IN LAST THREE MONTHS INDICATOR (OPPOSITE SEX PARTNERS)
MCONDOMLESS SEX INDICATOR (PENETRATIVE SEX OPPOSITE SEX PARTNERS FOR THE LAST TIME PERSON HAD SEX)

To carry the male same sex partnership details. 
One occurrence of this group is required.
M/RData Set Data Elements
MNUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (MALE SAME SEX PARTNERS)
MHIV POSITIVE PARTNERS IN LAST THREE MONTHS INDICATOR (PENETRATIVE SEX MALE SAME SEX PARTNERS)
MCONDOMLESS SEX INDICATOR (PENETRATIVE SEX MALE SAME SEX PARTNERS IN THE LAST THREE MONTHS)
MCONDOMLESS SEX INDICATOR (RECEPTIVE SEX MALE SAME SEX PARTNERS IN THE LAST THREE MONTHS)

To carry the female same sex partnership details. 
One occurrence of this group is required.
M/RData Set Data Elements
MNUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (FEMALE SAME SEX PARTNERS)
MNEW SEX PARTNERS IN LAST THREE MONTHS INDICATOR (FEMALE SAME SEX PARTNERS)

To carry the partner notification details. 
One occurrence of this group is required.
M/RData Set Data Elements
MINITIAL PARTNER NOTIFICATION DISCUSSION DATE
MNUMBER OF PATIENT REPORTED PARTNERS FOR DIAGNOSED SEXUALLY TRANSMITTED INFECTION
MNUMBER OF CONTACTABLE PATIENT REPORTED PARTNERS FOR DIAGNOSED SEXUALLY TRANSMITTED INFECTION
MNUMBER OF PATIENT PARTNERS REPORTED AS ATTENDED A SEXUAL HEALTH SERVICE
MNUMBER OF PATIENT PARTNERS CONFIRMED AS ATTENDED A SEXUAL HEALTH SERVICE

PRE-EXPOSURE PROPHYLAXIS (PrEP) DETAILS

To carry the Pre- Exposure Prophylaxis (PrEP) details. 
One occurrence of this group is required.
M/RData Set Data Elements
MPRE EXPOSURE PROPHYLAXIS ELIGIBILITY REASON
MPRE EXPOSURE PROPHYLAXIS OFFER STATUS CODE
MPRE EXPOSURE PROPHYLAXIS DRUG REGIMEN CODE
MPRESCRIBED ITEM QUANTITY (PRE EXPOSURE PROPHYLAXIS)
MPRE EXPOSURE PROPHYLAXIS STOPPED REASON

DRUG AND ALCOHOL USAGE DETAILS

To carry drug and alcohol usage details. 
One occurrence of this group is required.
M/RData Set Data Elements
MALCOHOL USE ASSESSED INDICATOR (SEXUAL HEALTH SERVICE)
MALCOHOL USE ASSESSED AS PROBLEMATIC INDICATOR (SEXUAL HEALTH SERVICE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (RECREATIONAL DRUGS)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (AMPHETAMINE OR SPEED)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (BENZODIAZEPINES NON PRESCRIBED)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (CANNABIS)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (COCAINE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (CRACK)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (CRYSTAL METH OR METHAMPHETAMINE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (ECSTASY OR METHYLENEDIOXYMETHAMPHETAMINE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (GAMMAHYDROXYBUTYRATE OR GAMMABUTYROLACTONE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (HEROIN)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (KETAMINE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (MEPHEDRONE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (METHADONE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (NOVEL PSYCHOACTIVE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (POPPERS)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (SOLVENTS OR GLUE)
MSUBSTANCE USE IN THE LAST THREE MONTHS INDICATOR (UNCLASSIFIED SUBSTANCE)
MSUBSTANCE INJECTED IN THE LAST THREE MONTHS INDICATOR
MSUBSTANCE INJECTED SHARED EQUIPMENT IN THE LAST THREE MONTHS INDICATOR
MSEXUAL INTERCOURSE UNDER THE INFLUENCE OF SUBSTANCE INDICATOR

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HIV AND AIDS REPORTING DATA SET

Change to Data Set: Changed Description

HIV and AIDS Reporting Data Set Overview

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the XML Schema constraints, see the HIV and AIDS Reporting Data Set XML Schema Constraints.


SUBMISSION IDENTIFIER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MHARS SUBMISSION IDENTIFIER
MHARS SUBMISSION RECORD COUNT
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MHARS MESSAGE VERSION IDENTIFIER
MORGANISATION CODE (CODE OF SUBMITTING ORGANISATION)
MDATE AND TIME DATA SET CREATED
MHARS TEST INDICATOR

RECORD IDENTIFIER

To carry the record identifier details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MHARS UNIQUE IDENTIFIER

PERSONAL AND DEMOGRAPHIC

To carry personal and demographic details for the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
RPATIENT CONSENT OBTAINED INDICATOR (CARE PROFESSIONAL CONTACT)
RYEAR AND MONTH OF LAST CARE PROFESSIONAL HIV COMMUNICATION
MPERSON SURNAME SOUNDEX CODE
RPERSON INITIAL (FIRST)
RPERSON BIRTH DATE
MGENDER IDENTITY CODE (SEXUAL HEALTH)
MGENDER IDENTITY SAME AT BIRTH INDICATOR
RETHNIC CATEGORY
RCOUNTRY CODE (BIRTH)
MLOWER LAYER SUPER OUTPUT AREA (PERSON RESIDENCE)
RPRISONER INDICATOR
RCURRENT SEX WORKER INDICATOR
RDISABILITY CODE
Multiple occurrences of this item are permitted

SERVICE INFORMATION

To carry service information details for the patient.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MORGANISATION CODE (CODE OF PROVIDER)
MSITE CODE (OF TREATMENT)
MPATIENT HIV CARE STATUS
RSITE CODE (OF PREVIOUS HIV CARE)
RSITE CODE (REFERRED TO FOR SHARED HIV CARE)

HIV CLINIC ATTENDANCE

To carry clinic attendance details for the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
RCONSULTATION MEDIUM USED
RCLINIC ATTENDANCE PURPOSE CODE (HIV)
RCARE PROFESSIONAL TYPE (HIV)
Multiple occurrences of this item are permitted
MATTENDANCE DATE

DIAGNOSIS

To carry diagnosis details for the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
MNEW HIV DIAGNOSIS IN UNITED KINGDOM INDICATOR
MDIAGNOSIS DATE IN UNITED KINGDOM (HIV)
OYEAR OF DIAGNOSIS OUTSIDE UNITED KINGDOM (HIV)
MDATE FIRST SEEN
MPATIENT EXPOSURE TO HIV
RCOUNTRY CODE (HIV INFECTION)
RYEAR OF UK ENTRY
RINITIAL DIAGNOSIS CARE SETTING OR SERVICE (HIV)
RPREVIOUS NEGATIVE HIV TEST INDICATOR
RYEAR AND MONTH OF LAST NEGATIVE HIV TEST
RPATIENT DIAGNOSIS INDICATOR (SEROCONVERSION ILLNESS)
RTEST OF RECENT INFECTION RESULT (HIV)
RNUMBER OF HIV CONTACTS
RNUMBER OF HIV CONTACTABLE CONTACTS
RNUMBER OF HIV CONTACTABLE CONTACTS TESTED FOR HIV

TREATMENT

To carry treatment details for the patient.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MFIRST ANTIRETROVIRAL THERAPY IN UNITED KINGDOM INDICATOR
RYEAR AND MONTH FIRST STARTED ANTIRETROVIRAL THERAPY
RSTART DATE (ANTIRETROVIRAL THERAPY AT CURRENT PROVIDER)
RPOST-EXPOSURE PROPHYLAXIS INDICATOR
RPRE-EXPOSURE PROPHYLAXIS INDICATOR
RANTIRETROVIRAL THERAPY DRUG (SNOMED CT DM+D)
Multiple occurrences of this item are permitted
MANTIRETROVIRAL THERAPY DRUG REGIMEN GROUP CODE
RANTIRETROVIRAL THERAPY HOME DELIVERY INDICATOR

CLINICAL INFORMATION

To carry clinical information details for the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCD4 CELL COUNT PERFORMED INDICATOR
RCD4 CELL COUNT
MVIRAL LOAD COUNT PERFORMED INDICATOR
RVIRAL LOAD COUNT
RAIDS DEFINING ILLNESS CODE ADULT (SNOMED CT)
Multiple occurrences of this item are permitted
MPATIENT DIAGNOSIS INDICATOR (VIRAEMIA)
MTUBERCULOSIS TREATMENT INDICATOR (HIV)
MCHRONIC VIRAL LIVER DISEASE TREATMENT INDICATOR (HIV)
MHEPATITIS B INFECTION INDICATION CODE
MHEPATITIS C INFECTION INDICATION CODE
MMALIGNANCY TREATMENT INDICATOR (HIV)
MPATIENT DIAGNOSIS INDICATOR (HIV END ORGAN DISEASE)
MPSYCHIATRIC CARE INDICATOR (HIV)
MPREGNANCY INDICATOR (HIV)
MSOCIAL WORKER CARE INDICATOR (HIV)
OLATENT TUBERCULOSIS TEST PERFORMED INDICATOR
ROFFER STATUS (HUMAN PAPILLOMAVIRUS VACCINATION)
RHUMAN PAPILLOMAVIRUS VACCINATION DOSE GIVEN

DEATH

To carry death details for the patient.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RPERSON DEATH DATE
RDEATH CAUSE ICD CODE (CARE PROFESSIONAL REPORTED)
Multiple occurrences of this item are permitted

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IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DATA SET

Change to Data Set: Changed Description

The Improving Access to Psychological Therapies Data Set will be in included in a future version of the Mental Health Services Data Set.

Improving Access to Psychological Therapies Data Set Overview

Due to the rapidly changing situation with Covid-19 for both providers and NHS Digital, the transition from Improving Access to Psychological Therapies (IAPT) Data Set v1.5 to v2.0 has been postponed until 1 September 2020.

September 2020 data will start being submitted from 1 October 2020.

For further information please contact: enquiries@nhsdigital.nhs.uk.

Version 1.5 of the data set can be found at: IAPT Data Set.

For a "Full Screen" view, click Improving Access to Psychological Therapies Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc.) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on the Data Set constraints, see the Improving Access to Psychological Therapies Data Set Constraints.


HEADER

Header:
To carry header details for the submission.
One occurrence of this group is required.
M/R/OData Set Data Elements
MDATA SET VERSION NUMBER
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MPRIMARY DATA COLLECTION SYSTEM IN USE
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATE AND TIME DATA SET CREATED

PATIENT DEMOGRAPHICS

Master Patient Index:
To carry personal details of the patient.
One occurrence of this group is required.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER)
RORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY)
RNHS NUMBER
RNHS NUMBER STATUS INDICATOR CODE
RPERSON BIRTH DATE
RPOSTCODE OF USUAL ADDRESS
RPERSON STATED GENDER CODE
RETHNIC CATEGORY
REX-BRITISH ARMED FORCES INDICATOR
RLANGUAGE CODE (PREFERRED)
REDUCATIONAL ESTABLISHMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)

GP Practice Registration:
To carry details of the GP Practice Registration of the patient.
One occurrence of this group is required for each change of GP Practice Registration.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
RSTART DATE (GMP PATIENT REGISTRATION)
REND DATE (GMP PATIENT REGISTRATION)
RORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)

Employment Status:
To carry details of the employment status of the patient.
One occurrence of this group is permitted for each employment status.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MEMPLOYMENT STATUS
REMPLOYMENT STATUS RECORDED DATE
RWEEKLY HOURS WORKED
RSELF EMPLOYED INDICATOR
RSICKNESS ABSENCE INDICATOR
RSTATUTORY SICK PAY RECEIPT INDICATOR
RBENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
RJOBSEEKERS ALLOWANCE RECEIPT INDICATOR
REMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR
RUNIVERSAL CREDIT RECEIPT INDICATOR
RPERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR
ROTHER BENEFITS RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
REMPLOYMENT SUPPORT SUITABILITY INDICATOR
REMPLOYMENT SUPPORT REFERRAL DATE

Disability Type:
To carry details of the type of disability affecting a patient, based on formal diagnoses, the patient’s perception or the perception of a patient proxy.
One occurrence of this group is permitted for each disability identified.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MDISABILITY CODE

Social and Personal Circumstances
To carry details of social and personal circumstances of a patient.
One occurrence of this group is permitted for each social and personal circumstance recorded.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
RSOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE

Overseas Visitor Charging Category
To carry details of the Overseas Visitor Charging Category of the patient.
Multiple occurrences of this group are permitted, one for each Overseas Visitor Charging Category recorded for the patient.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MOVERSEAS VISITOR CHARGING CATEGORY
ROVERSEAS VISITOR CHARGING CATEGORY APPLICABLE DATE

REFERRALS

Service or Team Referral:
To carry details of the Service or Team referral that the patient is subject to.
One occurrence of this group is required for each referral.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MREFERRAL REQUEST RECEIVED DATE
RSOURCE OF REFERRAL FOR MENTAL HEALTH
RYEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
RPREVIOUS DIAGNOSED CONDITION INDICATOR
RDISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON
RSERVICE DISCHARGE DATE

Onward Referral:
To carry details of any onward referral of the patient which has taken place.
One occurrence of this group is permitted for each onward referral.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MONWARD REFERRAL DATE
RONWARD REFERRAL TIME
RONWARD REFERRAL REASON
RORGANISATION IDENTIFIER (RECEIVING)

WAITING TIME PAUSES

Waiting Time Pauses:
To carry details of the Waiting Time Pauses.
One occurrence is permitted for each Waiting Time Pause.
M/RData Set Data Elements
MIMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER
MSERVICE REQUEST IDENTIFIER
MACTIVITY SUSPENSION START DATE
RACTIVITY SUSPENSION END DATE
RIMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON

CARE CONTACT, CARE ACTIVITIES AND INDIRECT ACTIVITIES

Care Contact:
To carry details of any contacts with a patient which have taken place as part of a referral.
One occurrence of this group is permitted for each Care Contact.
M/R/OData Set Data Elements
MCARE CONTACT IDENTIFIER
MSERVICE REQUEST IDENTIFIER
MCARE CONTACT DATE
RCARE CONTACT TIME
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RPLANNED CARE CONTACT INDICATOR
RATTENDED OR DID NOT ATTEND CODE
RAPPOINTMENT SLOT SHORT NOTICE CANCELLATION INDICATOR
RCLINICAL CONTACT DURATION OF CARE CONTACT
MINTEGRATED IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES LONG TERM CONDITION SERVICE INDICATOR
MAPPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
RCONSULTATION MEDIUM USED
RINTERNET ENABLED THERAPY PROGRAMME
RCARE CONTACT PATIENT THERAPY MODE
RNUMBER OF GROUP THERAPY PARTICIPANTS
RNUMBER OF GROUP THERAPY FACILITATORS
RPSYCHOTROPIC MEDICATION USAGE INDICATION CODE
RACTIVITY LOCATION TYPE CODE
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RLANGUAGE CODE (TREATMENT)
RINTERPRETER PRESENT AT CARE CONTACT INDICATION CODE

Care Activity:
To carry details of any activities which have taken place as part of a Care Contact.
One occurrence of this group is permitted for each Care Activity.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCARE CONTACT IDENTIFIER
RCARE PERSONNEL LOCAL IDENTIFIER
RCLINICAL CONTACT DURATION OF CARE ACTIVITY
RCODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
RCODED OBSERVATION (SNOMED CT)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

Internet Enabled Therapy Care Professional Activity Log:
To carry details of the summarised activity during a specified time period for the Care Professional supporting Internet Enabled Therapy for a patient.
One occurrence this group is permitted for each activity log.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MSTART DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
MEND DATE (INTERNET ENABLED THERAPY ACTIVITY LOG)
MINTERNET ENABLED THERAPY PROGRAMME
MDURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME
RCARE PERSONNEL LOCAL IDENTIFIER
RINTERNET ENABLED THERAPY INTEGRATED SOFTWARE ENGINE USED INDICATOR

CLINICALLY CODED TERMINOLOGY

Long Term Physical Health Condition:
To carry details of any Long Term Physical Health Conditions for a patient which are stated by the patient or recorded in medical notes
One occurrence of this group is permitted for each Long Term Physical Health Condition.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MFINDING SCHEME IN USE
MLONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY)

Presenting Complaints:
To carry details of the primary and any secondary presenting complaints recorded for a patient, made by the service that the patient was referred or admitted to.
One occurrence of this group is permitted for each presenting complaint.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MFINDING SCHEME IN USE
MPRESENTING COMPLAINT (CODED CLINICAL ENTRY)
RPRESENTING COMPLAINT CODING SIGNIFICANCE
RPRESENTING COMPLAINT RECORDED DATE

Coded Scored Assessment (Referral):
To carry details of scored assessments that are issued and completed as part of a Service Request, but do not take place at a specific contact.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured outside of a Care Contact.
M/R/OData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
MASSESSMENT TOOL COMPLETION DATE
RASSESSMENT TOOL COMPLETION TIME

Coded Scored Assessment (Care Activity):
To carry details of scored assessments that are issued and completed as part of a specific Care Activity.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured as part of a specific Care Activity.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

CARE CLUSTERS

Care Cluster:
To carry details of the Care Cluster resulting from a clustering tool assessment.
One occurrence of this group is permitted for each period of time that a patient was allocated to a Care Cluster.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL)
MSTART DATE (CARE CLUSTER ASSIGNMENT PERIOD)
RSTART TIME (CARE CLUSTER ASSIGNMENT PERIOD)
REND DATE (CARE CLUSTER ASSIGNMENT PERIOD)
REND TIME (CARE CLUSTER ASSIGNMENT PERIOD)

CARE PERSONNEL QUALIFICATION

Care Personnel:
To carry details of each qualification attained or planned to be attained by the Care Personnel.
One occurrence of this group is permitted for each qualification.
M/R/OData Set Data Elements
MCARE PERSONNEL LOCAL IDENTIFIER
MQUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
REMPLOYEE QUALIFICATION AWARDED DATE
REMPLOYEE QUALIFICATION PLANNED COMPLETION DATE

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INTER-PROVIDER TRANSFER ADMINISTRATIVE MINIMUM DATA SET

Change to Data Set: Changed Description

Inter-Provider Transfer Administrative Minimum Data Set Overview

The Opt (Optionality) column indicates the NHS recommendation for the inclusion of data:

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

OptData Set Data Elements
MandationData Set Data Elements
Patient details:
To carry patient demographic details
MPERSON FAMILY NAME 
MPERSON GIVEN NAME 
MPERSON TITLE 
MCORRESPONDENCE ADDRESS 
MPOSTCODE OF CORRESPONDENCE ADDRESS 
MPERSON BIRTH DATE 
MNHS NUMBER 
MLOCAL PATIENT IDENTIFIER 
Patient contact details:
The contact details of the patient or lead contact as applicable. If the name of a lead contact for the patient is present, the contact details apply to the lead contact and not the patient
OPERSON FULL NAME (PATIENT LEAD CONTACT) 
OCONTACT TELEPHONE NUMBER (HOME) 
OCONTACT TELEPHONE NUMBER (WORK) 
OCONTACT TELEPHONE NUMBER (MOBILE) 
OCONTACT EMAIL ADDRESS (PATIENT OR LEAD CONTACT) 
General Practitioner Details:
To carry details of the patient's specified General Medical Practitioner
MPERSON NAME (SPECIFIED GENERAL MEDICAL PRACTITIONER) 
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
Referring Organisation
MORGANISATION NAME (REFERRING) 
MREFERRING ORGANISATION CODE 
MCARE PROFESSIONAL NAME (REFERRING) 
MREFERRER CODE 
MTREATMENT FUNCTION CODE (REFERRING SERVICE) 
MPERSON FULL NAME (REFERRER CONTACT) 
OCONTACT TELEPHONE NUMBER (REFERRING ORGANISATION) 
OCONTACT EMAIL ADDRESS (REFERRING ORGANISATION) 
Referral To Treatment:
To carry details of the patient's Referral To Treatment Status and Patient Pathway Information
MPATIENT PATHWAY IDENTIFIER 
MORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER) 
MREFERRAL TO TREATMENT PERIOD STATUS (INTER-PROVIDER TRANSFER) 
MDECISION TO REFER DATE (INTER-PROVIDER TRANSFER) 
MREFERRAL TO TREATMENT PERIOD START DATE 
MREFERRAL RAISED REASON (INTER-PROVIDER TRANSFER) 
Organisation along the Patient Pathway - Repeating group to carry all the Organisations involved in the Pathway up until this Service Request
MORGANISATION CODE (ON PATHWAY) 
Receiving Organisation:
To carry details of the receiving Organisation and Care Professional
MORGANISATION NAME (RECEIVING) 
MORGANISATION CODE (RECEIVING) 
OCARE PROFESSIONAL NAME (RECEIVING) 
MTREATMENT FUNCTION CODE (RECEIVING SERVICE) 
Details of the dates of the transfer information was sent and received
MSERVICE REQUESTED DATE (INTER-PROVIDER TRANSFER) 
OREFERRAL REQUEST RECEIVED DATE (INTER-PROVIDER TRANSFER) 

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MATERNITY SERVICES DATA SET

Change to Data Set: Changed Description

Maternity Services Data Set Overview

For a "Full Screen" view, click Maternity Services Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data:

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

For guidance on the Data Set constraints, see the Maternity Services Data Set Constraints.

SUBMISSION IDENTIFIER

To carry the submission header details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MDATA SET VERSION NUMBER
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MPRIMARY DATA COLLECTION SYSTEM IN USE
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATA SET CREATED DATE
MDATA SET CREATED TIME

MOTHER'S DETAILS

Mother's Demographics:
To carry the demographic details for the mother's Maternity Episode.
One occurrence of this group is required.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER))
MORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER (MOTHER))
MPERSON BIRTH DATE (MOTHER)
RORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY)
RNHS NUMBER (MOTHER)
RNHS NUMBER STATUS INDICATOR CODE (MOTHER)
RPOSTCODE OF USUAL ADDRESS (MOTHER)
RETHNIC CATEGORY (MOTHER)
RPERSON DEATH DATE (MOTHER)
RPERSON DEATH TIME (MOTHER)

GP Practice Registration:
To carry details of the GP Practice Registration of the mother.
At least one occurrence of this group is required.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER))
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER))
RSTART DATE (GMP PATIENT REGISTRATION)
REND DATE (GMP PATIENT REGISTRATION)
RORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)

Social and Personal Circumstance:
To carry details of the mother's social and personal circumstances.
Multiple occurrences of this group are permitted for each Pregnancy Episode.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER))
MSOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
MSOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE

Overseas Visitor Charging Category:
To carry details of the Overseas Visitor Charging Category of the mother.
Multiple occurrences of this group are permitted for each pregnancy episode.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER))
MOVERSEAS VISITOR CHARGING CATEGORY
ROVERSEAS VISITOR CHARGING CATEGORY APPLICABLE DATE

MOTHER'S BOOKING AND DIAGNOSIS DETAILS

Pregnancy and Booking Details:
To carry the personal, social and other details of the mother at the formal antenatal booking appointment, during the Maternity Episode and at discharge from Maternity Services.
One occurrence of this group is required.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER))
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MAPPOINTMENT DATE (FORMAL ANTENATAL BOOKING)
RPREGNANCY FIRST CONTACT DATE
RESTIMATED DATE OF DELIVERY (AGREED)
RORGANISATION SITE IDENTIFIER (OF ANTENATAL BOOKING)
RMETHOD OF ESTIMATED DATE OF DELIVERY (AGREED)
RSOURCE OF REFERRAL FOR MATERNITY
RORGANISATION IDENTIFIER (PROVIDER OF ORIGIN)
RORGANISATION IDENTIFIER (RECEIVING)
RLATE ANTENATAL BOOKING APPOINTMENT REASON
RCARE PROFESSIONAL TYPE (PREGNANCY FIRST CONTACT)
RLAST MENSTRUAL PERIOD DATE
RDISABILITY INDICATOR (AT ANTENATAL BOOKING)
RLANGUAGE CODE (PREFERRED)
RMENTAL HEALTH PREDICTION AND DETECTION INDICATOR (AT ANTENATAL BOOKING)
RCOMPLEX SOCIAL FACTORS INDICATOR (AT ANTENATAL BOOKING)
REMPLOYMENT STATUS (MOTHER AT ANTENATAL BOOKING)
RSUPPORT STATUS INDICATOR (AT ANTENATAL BOOKING)
REMPLOYMENT STATUS (PARTNER AT ANTENATAL BOOKING)
RPREGNANCY TOTAL PREVIOUS CAESAREAN SECTIONS
RPREGNANCY TOTAL PREVIOUS LIVE BIRTHS
RPREGNANCY TOTAL PREVIOUS STILLBIRTHS
RPREGNANCY TOTAL PREVIOUS LOSSES LESS THAN 24 WEEKS
RFOLIC ACID SUPPLEMENT STATUS (AT ANTENATAL BOOKING)
RDISCHARGE DATE (MOTHER MATERNITY SERVICES)
RPRIMARY DISCHARGE REASON (MOTHER MATERNITY SERVICES)

Maternity Care Plan:
To carry details of the Care Plan during the current Maternity Episode.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MMATERNITY CARE PLAN DATE
RMATERNITY CARE PLAN TYPE
RMATERNITY PERSONALISED CARE PLAN INDICATOR
RCONTINUITY OF CARER PATHWAY INDICATOR
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
RORGANISATION SITE IDENTIFIER (OF PLANNED DELIVERY)
RMATERNITY CARE SETTING (OF PLANNED DELIVERY)
RPLANNED DELIVERY SETTING CHANGE REASON (ANTENATAL)

Dating Scan Procedure:
To carry details of the first ultrasound (dating) scan during the current Maternity Episode.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MACTIVITY OFFER DATE (DATING ULTRASOUND SCAN)
ROFFER STATUS (DATING ULTRASOUND SCAN)
RPROCEDURE DATE (DATING ULTRASOUND SCAN)
RGESTATION LENGTH (DATING ULTRASOUND SCAN)
RNUMBER OF FETUSES (DATING ULTRASOUND SCAN)
RLOCAL FETAL IDENTIFIER
RFETAL ORDER
RABNORMALITY DETECTED INDICATOR (DATING ULTRASOUND SCAN)
RORGANISATION IDENTIFIER (OF DATING ULTRASOUND SCAN)

Coded Scored Assessment (Pregnancy):
To carry details of coded scored assessments that are issued and completed as part of a Maternity Episode outside of a contact.
One occurrence of this group is permitted for each coded scored assessment question or dimension.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
RASSESSMENT TOOL COMPLETION DATE

Provisional Diagnosis (Pregnancy):
To carry details of a provisional diagnosis for a mother made by the Maternity Service.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
RPROVISIONAL DIAGNOSIS DATE
RLOCAL FETAL IDENTIFIER
RFETAL ORDER

Diagnosis (Pregnancy):
To carry details of a diagnosis for a mother made by the Maternity Service.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MDIAGNOSIS (CODED CLINICAL ENTRY)
RMATERNITY COMPLICATING DIAGNOSIS INDICATOR
RDIAGNOSIS DATE
RLOCAL FETAL IDENTIFIER
RFETAL ORDER

Medical History (Previous Diagnosis):
To carry details of any previous diagnoses for a mother, which are stated by the mother or mother's proxy or recorded in medical notes.
These do not have to have been diagnosed by the organisation submitting the data.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Family History at Booking:
To carry details of any family history of medical and obstetric conditions at booking.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
MSITUATION SCHEME IN USE
MCODED SITUATION (CLINICAL TERMINOLOGY)

Finding and Observation (Mother):
To carry details of findings and observations of a mother which have taken place during a Maternity Episode.
Multiple occurrences of this group are permitted when findings and observations are recorded.
M/R/OData Set Data Elements
MPREGNANCY IDENTIFIER
RLOCAL FETAL IDENTIFIER
RFETAL ORDER
RFINDING DATE
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
ROBSERVATION DATE
ROBSERVATION SCHEME IN USE
RCODED OBSERVATION (CLINICAL TERMINOLOGY)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

CARE CONTACT, CARE ACTIVITIES AND INDIRECT ACTIVITIES

Care Contact (Pregnancy):
To carry details of any contacts with a mother which have taken place as part of a Maternity Episode.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MCARE CONTACT IDENTIFIER
MPREGNANCY IDENTIFIER
MCARE CONTACT DATE
RCARE CONTACT TIME
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RADMINISTRATIVE CATEGORY CODE
RCLINICAL CONTACT DURATION OF CARE CONTACT
RCONSULTATION TYPE
RCARE CONTACT SUBJECT
RCONSULTATION MEDIUM USED
RACTIVITY LOCATION TYPE CODE
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RGROUP THERAPY INDICATOR
RATTENDED OR DID NOT ATTEND CODE
RCARE CONTACT CANCELLATION DATE
RCARE CONTACT CANCELLATION REASON
RREPLACEMENT APPOINTMENT DATE OFFERED
RREPLACEMENT APPOINTMENT BOOKED DATE

Care Activity (Pregnancy):
To carry details of any activities which have taken place as part of a contact with a mother during a Maternity Episode.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER (MOTHER)
MCARE CONTACT IDENTIFIER
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
RCLINICAL CONTACT DURATION OF CARE ACTIVITY
RLOCAL FETAL IDENTIFIER
RFETAL ORDER
RPROCEDURE SCHEME IN USE
RCODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
ROBSERVATION SCHEME IN USE
RCODED OBSERVATION (CLINICAL TERMINOLOGY)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

Coded Scored Assessment (Contact):
To carry details of scored assessments that are issued and completed as part of a specific contact during a Maternity Episode.
One occurrence of this group is permitted for each coded scored assessment question or dimension.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER (MOTHER)
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

Labour and Delivery:
To carry details of events during labour and delivery.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLABOUR AND DELIVERY IDENTIFIER
MPREGNANCY IDENTIFIER
RORGANISATION SITE IDENTIFIER (AT START OF INTRAPARTUM CARE)
RMATERNITY CARE SETTING (AT START OF INTRAPARTUM CARE)
RPLANNED DELIVERY SETTING CHANGE REASON (LABOUR)
RLABOUR OR DELIVERY ONSET METHOD CODE
RONSET OF ESTABLISHED LABOUR DATE
RONSET OF ESTABLISHED LABOUR TIME
RPROCEDURE DATE (CAESAREAN SECTION)
RPROCEDURE TIME (CAESAREAN SECTION)
RSTART DATE (MOTHER LABOUR AND DELIVERY HOSPITAL PROVIDER SPELL)
RSTART TIME (MOTHER LABOUR AND DELIVERY HOSPITAL PROVIDER SPELL)
RDECISION TO DELIVER DATE
RDECISION TO DELIVER TIME
RADMISSION METHOD CODE (MOTHER LABOUR AND DELIVERY HOSPITAL PROVIDER SPELL)
RDISCHARGE DATE (MOTHER POST LABOUR AND DELIVERY HOSPITAL PROVIDER SPELL)
RDISCHARGE TIME (MOTHER POST LABOUR AND DELIVERY HOSPITAL PROVIDER SPELL)
RDISCHARGE METHOD CODE (MOTHER POST DELIVERY HOSPITAL PROVIDER SPELL)
RDISCHARGE DESTINATION CODE (MOTHER POST DELIVERY HOSPITAL PROVIDER SPELL)
RORGANISATION IDENTIFIER (POSTNATAL PATHWAY LEAD PROVIDER)

Care Activity (Labour and Delivery):
To carry details of any activities which have taken place during labour and delivery.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLABOUR AND DELIVERY IDENTIFIER
MCLINICAL INTERVENTION DATE (MOTHER)
RCLINICAL INTERVENTION TIME (MOTHER)
MCLINICAL CONTACT DURATION OF CARE ACTIVITY
MCARE PROFESSIONAL LOCAL IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
RLOCAL FETAL IDENTIFIER
RFETAL ORDER
RMATERNAL CRITICAL INCIDENT INDICATOR
RPROCEDURE SCHEME IN USE
RCODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
ROBSERVATION SCHEME IN USE
RCODED OBSERVATION (CLINICAL TERMINOLOGY)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

BABY'S DETAILS

Baby's Demographic and Birth Details:
To carry details of the baby's demographics and birth.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (BABY))
MLABOUR AND DELIVERY IDENTIFIER
MORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER (BABY))
MPERSON BIRTH DATE (BABY)
MPERSON BIRTH TIME (BABY)
MPREGNANCY OUTCOME
MPERSON PHENOTYPIC SEX
RETHNIC CATEGORY (BABY)
RNHS NUMBER (BABY)
RNHS NUMBER STATUS INDICATOR CODE (BABY)
RLOCAL FETAL IDENTIFIER
RBIRTH ORDER (MATERNITY SERVICES)
RPERSON DEATH DATE (BABY)
RPERSON DEATH TIME (BABY)
RPRESENTATION OF FETUS AT ONSET OF LABOUR OR DELIVERY
RGESTATION LENGTH (AT BIRTH) 
RDELIVERY METHOD CODE
RDELIVERED IN WATER INDICATOR
RORGANISATION SITE IDENTIFIER (OF ACTUAL PLACE OF DELIVERY)
RCARE PROFESSIONAL LOCAL IDENTIFIER (DELIVERING BABY)
RMATERNITY CARE SETTING (ACTUAL PLACE OF BIRTH)
RBABY FIRST FEED DATE
RBABY FIRST FEED TIME
RBABY FIRST FEED BREAST MILK INDICATION CODE
RSKIN TO SKIN CONTACT INDICATOR (WITHIN ONE HOUR)
RDISCHARGE DATE (BABY POST DELIVERY HOSPITAL PROVIDER SPELL)
RDISCHARGE TIME (BABY POST DELIVERY HOSPITAL PROVIDER SPELL)

Neonatal Admission:
To carry details of neonatal admissions.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (BABY))
MTRANSFER START DATE (NEONATAL UNIT)
RTRANSFER START TIME (NEONATAL UNIT)
RORGANISATION SITE IDENTIFIER (OF ADMITTING NEONATAL UNIT)
RNEONATAL CRITICAL CARE ADMISSION INDICATOR

Provisional Diagnosis (Neonatal):
To carry details of provisional diagnoses made for the baby.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (BABY))
MDIAGNOSIS SCHEME IN USE
MPROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
RPROVISIONAL DIAGNOSIS DATE

Diagnosis (Neonatal):
To carry details of diagnoses made for the baby.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED (BABY))
MDIAGNOSIS SCHEME IN USE
MDIAGNOSIS (CODED CLINICAL ENTRY)
MDIAGNOSIS DATE

Care Activity (Baby):
To carry details of any activities for the baby which have taken place prior to discharge from Maternity Services.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER (BABY)
MLOCAL PATIENT IDENTIFIER (EXTENDED (BABY))
MCLINICAL INTERVENTION DATE (BABY)
RCLINICAL INTERVENTION TIME (BABY)
RCLINICAL CONTACT DURATION OF CARE ACTIVITY
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
RNEONATAL CRITICAL INCIDENT INDICATOR
RPROCEDURE SCHEME IN USE
RCODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
ROBSERVATION SCHEME IN USE
RCODED OBSERVATION (CLINICAL TERMINOLOGY)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT
ORGANISATION IDENTIFIER (NEWBORN BLOOD SPOT SCREENING LABORATORY)

Coded Scored Assessment (Baby):
To carry details of coded scored assessments that are completed for the baby prior to discharge from Maternity Services.
One occurrence of this group is permitted for each coded scored observation question or dimension.
M/R/OData Set Data Elements
MCARE ACTIVITY IDENTIFIER (BABY)
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

HOSPITAL PROVIDER SPELLS

Hospital Provider Spell:
To carry details of each Hospital Provider Spell for the mother. This includes any hospital admissions for the mother during the Maternity Episode, but does not include admission for labour and delivery.
One occurrence of this group is permitted for each Hospital Provider Spell.
M/R/OData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MPREGNANCY IDENTIFIER
MSTART DATE (HOSPITAL PROVIDER SPELL)
RSTART TIME (HOSPITAL PROVIDER SPELL)
RSOURCE OF ADMISSION CODE (HOSPITAL PROVIDER SPELL)
RPATIENT CLASSIFICATION CODE
RADMISSION METHOD CODE (HOSPITAL PROVIDER SPELL)
RDISCHARGE DATE (HOSPITAL PROVIDER SPELL)
RDISCHARGE TIME (HOSPITAL PROVIDER SPELL)
RDISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL)
RDISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL)

Hospital Spell Commissioner:
To carry details of each commissioner assignment for the mother.
One occurrence of this group is permitted for each commissioner assignment.
M/R/OData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MSTART DATE (COMMISSIONER ASSIGNMENT PERIOD)
REND DATE (COMMISSIONER ASSIGNMENT PERIOD)

Ward Stay:
To carry details of Ward Stays which occurred during a Hospital Provider Spell for the mother.
One occurrence of this group is permitted for each Ward Stay.
M/R/OData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MSTART DATE (WARD STAY)
RSTART TIME (WARD STAY)
REND DATE (WARD STAY)
REND TIME (WARD STAY)
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
OWARD CODE

Assigned Care Professional:
To carry details of the Care Professional Admitted Care Episodes during a Hospital Provider Spell for the mother.
One occurrence of this group is permitted for each Care Professional Admitted Care Episode.
M/R/OData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MCARE PROFESSIONAL LOCAL IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MSTART DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
REND DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
RTREATMENT FUNCTION CODE (MATERNITY)

ANONYMOUS SELF-ASSESSMENT

Anonymous Self-Assessment:
To carry details of anonymous self-assessments that are issued by Maternity Services.
One occurrence of this group is permitted when an anonymous self-assessment is received from a mother.
M/R/OData Set Data Elements
MASSESSMENT TOOL COMPLETION DATE
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
RACTIVITY LOCATION TYPE CODE
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)

Anonymous Findings:
To carry details of anonymous findings that are recorded by Maternity Services.
One occurrence of this group is permitted when an anonymous finding is recorded for a mother.
M/R/OData Set Data Elements
MCLINICAL INTERVENTION DATE
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)

STAFF DETAILS

Staff Details:
To carry details of the staff involved in the treatment of a mother.
One occurrence of this group is permitted for each staff member.
M/R/OData Set Data Elements
MCARE PROFESSIONAL LOCAL IDENTIFIER
RPROFESSIONAL REGISTRATION BODY CODE
RPROFESSIONAL REGISTRATION ENTRY IDENTIFIER
RCARE PROFESSIONAL STAFF GROUP (MATERNITY)
ROCCUPATION CODE
RCARE PROFESSIONAL (JOB ROLE CODE)

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MENTAL HEALTH SERVICES DATA SET

Change to Data Set: Changed Description

Mental Health Services Data Set Overview

For a "Full Screen" view, click Mental Health Services Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory, Required, Optional or Pilot (M/R/O/P) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes
  • P = Pilot: this data element is for piloting use only.

Note: items in the M/R/O/P column which are shown with notation P have not been approved by the Data Coordination Board and are included to facilitate piloting and testing of future data requirements, prior to formal inclusion in later versions of the Mental Health Services Data Set. These items have been included in the data set layout in order to provide advance notice to data providers and system suppliers of the intention to require these items at a later date. Unless ORGANISATIONS are engaged in piloting activities relating to these items, they should NOT submit any data item marked P.

For guidance on the Data Set constraints, see the Mental Health Services Data Set Constraints.


HEADER

Header:
To carry header details for the submission.
One occurrence of this group is required.
M/R/O/PData Set Data Elements
MDATA SET VERSION NUMBER
MORGANISATION IDENTIFIER (CODE OF PROVIDER)
MORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
MPRIMARY DATA COLLECTION SYSTEM IN USE
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
MDATE AND TIME DATA SET CREATED

PATIENT DEMOGRAPHICS

Master Patient Index:
To carry personal details of the patient.
One occurrence of this group is required.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER)
RORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY)
RORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT)
RNHS NUMBER
RNHS NUMBER STATUS INDICATOR CODE
RPERSON BIRTH DATE
RPOSTCODE OF USUAL ADDRESS
RPERSON STATED GENDER CODE
RPERSON MARITAL STATUS
RETHNIC CATEGORY
RLANGUAGE CODE (PREFERRED)
RPERSON DEATH DATE

GP Practice Registration:
To carry details of the GP Practice Registration of the patient.
One occurrence of this group is required for each change of GP Practice Registration.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)
RSTART DATE (GMP PATIENT REGISTRATION)
REND DATE (GMP PATIENT REGISTRATION)
RORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY)

Accommodation Status:
To carry accommodation details of the patient.
One occurrence of this group is permitted for each accommodation status.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MACCOMMODATION STATUS CODE
RSETTLED ACCOMMODATION INDICATOR
RACCOMMODATION STATUS RECORDED DATE
RSECURE CHILDRENS HOME PLACEMENT TYPE

Employment Status:
To carry details of the employment status of the patient.
One occurrence of this group is permitted for each employment status.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MEMPLOYMENT STATUS
REMPLOYMENT STATUS RECORDED DATE
RWEEKLY HOURS WORKED

Patient Indicators:
To carry details of specific indicators relating to a patient.
One occurrence of this group is permitted containing the current or most recently recorded status of indicator and psychosis information.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
RCONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
RPARENTAL RESPONSIBILITIES INDICATOR
RYOUNG CARER INDICATOR
RLOOKED AFTER CHILD INDICATOR
RCHILD PROTECTION PLAN INDICATION CODE
REX-BRITISH ARMED FORCES INDICATOR
ROFFENCE HISTORY INDICATION CODE
RPRODROME PSYCHOSIS DATE
REMERGENT PSYCHOSIS DATE
RMANIFEST PSYCHOSIS DATE
RFIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION)
RPSYCHOSIS FIRST TREATMENT START DATE

Mental Health Care Coordinator:
To carry details of the Mental Health Care Coordinator assigned to a patient.
One occurrence of this group is permitted for each Mental Health Care Coordinator assignment.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSTART DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
RCARE PROFESSIONAL LOCAL IDENTIFIER
REND DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD)
RCARE PROFESSIONAL SERVICE OR TEAM TYPE ASSOCIATION (MENTAL HEALTH)

Disability Type:
To carry details of the type of disability affecting a patient, based on their perception or the perception of a patient proxy.
One occurrence of this group is permitted for each disability identified.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MDISABILITY CODE
RDISABILITY IMPACT PERCEPTION

Care Plan Type:
To carry details of Care Plans created for a patient by the organisation.
One occurrence of this group is permitted for each Care Plan created for the patient.
M/R/O/PData Set Data Elements
MCARE PLAN IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MCARE PLAN TYPE (MENTAL HEALTH)
MCARE PLAN CREATION DATE
RCARE PLAN CREATION TIME
RCARE PLAN LAST UPDATED DATE
RCARE PLAN LAST UPDATED TIME
RCARE PLAN IMPLEMENTATION DATE

Care Plan Agreement:
To carry details of any agreements to a Care Plan by a person, team or organisation.
One occurrence of this group is permitted for each agreement of a Care Plan.
M/R/O/PData Set Data Elements
MCARE PLAN IDENTIFIER
MCARE PLAN AGREED BY
RCARE PLAN AGREED DATE
RCARE PLAN AGREED TIME

Assistive Technology to Support Disability Type:
To carry details of when assistive technology is used to support a disabled patient.
One occurrence of this group is permitted for each assistive technology type.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MASSISTIVE TECHNOLOGY FINDING (SNOMED CT)
RPRESCRIPTION DATE (ASSISTIVE TECHNOLOGY)

Social and Personal Circumstances:
To carry details of social and personal circumstances of a patient.
One occurrence of this group is permitted for each social and personal circumstance recorded.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT)
RSOCIAL AND PERSONAL CIRCUMSTANCE RECORDED DATE

Overseas Visitor Charging Category
To carry details of the Overseas Visitor Charging Category of the patient.
Multiple occurrences of this group are permitted, one for each Overseas Visitor Charging Category recorded for the patient.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MOVERSEAS VISITOR CHARGING CATEGORY
ROVERSEAS VISITOR CHARGING CATEGORY APPLICABLE DATE

REFERRALS

Service or Team Referral:
To carry details of the Service or Team referral that the patient is subject to.
One occurrence of this group is permitted for each referral.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MREFERRAL REQUEST RECEIVED DATE
RREFERRAL REQUEST RECEIVED TIME
RNHS SERVICE AGREEMENT LINE NUMBER
RSPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
RSOURCE OF REFERRAL FOR MENTAL HEALTH
RORGANISATION IDENTIFIER (REFERRING)
RREFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH AND COMMUNITY CARE)
RCLINICAL RESPONSE PRIORITY TYPE
RPRIMARY REASON FOR REFERRAL (MENTAL HEALTH)
RREASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH)
RDISCHARGE PLAN CREATION DATE
RDISCHARGE PLAN CREATION TIME
RDISCHARGE PLAN LAST UPDATED DATE
RDISCHARGE PLAN LAST UPDATED TIME
RSERVICE DISCHARGE DATE
RSERVICE DISCHARGE TIME
RDISCHARGE LETTER ISSUED DATE (MENTAL HEALTH AND COMMUNITY CARE)

Other Reason for Referral:
To carry details of additional reasons why a patient has been referred to a specific service.
One occurrence of this group is permitted for each additional referral reason.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MOTHER REASON FOR REFERRAL (MENTAL HEALTH)

Service or Team Type Referred To:
To carry details of the service or team that a patient is referred to.
One occurrence of this group is permitted for each service or team that a patient has been referred to.
M/R/O/PData Set Data Elements
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MSERVICE REQUEST IDENTIFIER
MSERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
RREFERRAL CLOSURE DATE
RREFERRAL CLOSURE TIME
RREFERRAL REJECTION DATE
RREFERRAL REJECTION TIME
RREFERRAL CLOSURE REASON
RREFERRAL REJECTION REASON

Referral to Treatment (RTT):
To carry Referral to Treatment details for the patient's referral.
One occurrence of this group is permitted for each change in Referral To Treatment Period Status.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
RPATIENT PATHWAY IDENTIFIER
RORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)
MWAITING TIME MEASUREMENT TYPE
RREFERRAL TO TREATMENT PERIOD START DATE
RREFERRAL TO TREATMENT PERIOD END DATE
RREFERRAL TO TREATMENT PERIOD STATUS

Onward Referral:
To carry details of any onward referral of the patient which has taken place.
One occurrence of this group is permitted for each onward referral.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
RDECISION TO REFER DATE (ONWARD REFERRAL)
RDECISION TO REFER TIME (ONWARD REFERRAL)
MONWARD REFERRAL DATE
RONWARD REFERRAL TIME
RONWARD REFERRAL REASON
RREFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH)
RORGANISATION IDENTIFIER (RECEIVING)

Discharge Plan Agreement:
To carry details of any agreements to a Discharge Plan by a person, team or organisation.
One occurrence of this group is permitted for each agreement of a Discharge Plan.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDISCHARGE PLAN AGREED BY
RDISCHARGE PLAN AGREED DATE
RDISCHARGE PLAN AGREED TIME

Medication Prescription:
To carry details of each Prescription of Medication for the patient.
One occurrence of this group is permitted for each Prescription.
M/R/O/PData Set Data Elements
PSERVICE REQUEST IDENTIFIER
PPRESCRIPTION IDENTIFIER
PPRESCRIPTION DATE (MEDICATION)
PPRESCRIPTION TIME (MEDICATION)

CARE CONTACT, CARE ACTIVITIES AND INDIRECT ACTIVITIES

Care Contact:
To carry details of any contacts with a patient which have taken place as part of a referral.
One occurrence of this group is permitted for each Care Contact.
M/R/O/PData Set Data Elements
MCARE CONTACT IDENTIFIER
MSERVICE REQUEST IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MCARE CONTACT DATE
RCARE CONTACT TIME
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RADMINISTRATIVE CATEGORY CODE
RSPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
RCLINICAL CONTACT DURATION OF CARE CONTACT
RCONSULTATION TYPE
RCARE CONTACT SUBJECT
RCONSULTATION MEDIUM USED
RACTIVITY LOCATION TYPE CODE
RPLACE OF SAFETY INDICATOR
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RGROUP THERAPY INDICATOR
RATTENDED OR DID NOT ATTEND CODE
REARLIEST REASONABLE OFFER DATE
REARLIEST CLINICALLY APPROPRIATE DATE
RCARE CONTACT CANCELLATION DATE
RCARE CONTACT CANCELLATION REASON
RREPLACEMENT APPOINTMENT DATE OFFERED
RREPLACEMENT APPOINTMENT BOOKED DATE

Care Activity:
To carry details of any Care Activity undertaken at a Care Contact.
One occurrence of this group is permitted for each Care Activity.
M/R/O/PData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCARE CONTACT IDENTIFIER
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCLINICAL CONTACT DURATION OF CARE ACTIVITY
RCODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)
RCODED OBSERVATION (SNOMED CT)
ROBSERVATION VALUE
RUCUM UNIT OF MEASUREMENT

Other in Attendance:
To carry details of any other people in attendance at a Care Contact.
One occurrence of this group is permitted for each other patient in attendance at a Care Contact.
M/R/O/PData Set Data Elements
MCARE CONTACT IDENTIFIER
MOTHER PERSON IN ATTENDANCE AT CARE CONTACT

Indirect Activity:
To carry details of indirect activity which takes place as a result of the referral.
One occurrence of this group is permitted for each instance of indirect activity taking place.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
RCARE PROFESSIONAL TEAM LOCAL IDENTIFIER
MINDIRECT ACTIVITY DATE
RINDIRECT ACTIVITY TIME
RDURATION OF INDIRECT ACTIVITY
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RCARE PROFESSIONAL LOCAL IDENTIFIER
RCODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)
RFINDING SCHEME IN USE
RCODED FINDING (CODED CLINICAL ENTRY)

GROUP SESSIONS

Group Session:
To carry details of any group sessions which have been provided to a group of patients.
One occurrence of this group is permitted for each Group Session activity.
M/R/O/PData Set Data Elements
MGROUP SESSION IDENTIFIER
MGROUP SESSION DATE
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
RCLINICAL CONTACT DURATION OF GROUP SESSION
RGROUP SESSION TYPE (MENTAL HEALTH)
RNUMBER OF GROUP SESSION PARTICIPANTS
RACTIVITY LOCATION TYPE CODE
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RCARE PROFESSIONAL LOCAL IDENTIFIER
RSERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH)
RNHS SERVICE AGREEMENT LINE NUMBER

MENTAL HEALTH ACT (MHA) EPISODES

Mental Health Act Legal Status Classification Assignment Period:
To carry details of Mental Health Act Legal Status Classification Assignment Periods for patients formally detained under the Mental Health Act 1983 or other Acts.
One occurrence of this group is permitted for each Mental Health Act Legal Status Classification Assignment Period identified.
M/R/O/PData Set Data Elements
MMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSTART DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
MSTART TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
RMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD START REASON
REXPIRY DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
REXPIRY TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION)
REND DATE (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
REND TIME (MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD)
RMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD END REASON
RMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION CODE
RMENTAL HEALTH ACT 2007 MENTAL CATEGORY

Mental Health Responsible Clinician Assignment:
To carry details of the assignment of a Mental Health Responsible Clinician to the patient.
One occurrence of this group is permitted for each assigned Mental Health Responsible Clinician to the Mental Health Act Legal Status Classification Assignment Period.
M/R/O/PData Set Data Elements
MMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
MSTART DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)
MCARE PROFESSIONAL LOCAL IDENTIFIER
REND DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD)

Conditional Discharge:
To carry details of each separate period of conditional discharge for the patient.
One occurrence of this group is permitted for each conditional discharge.
M/R/O/PData Set Data Elements
MMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
MSTART DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
REND DATE (MENTAL HEALTH CONDITIONAL DISCHARGE)
RMENTAL HEALTH CONDITIONAL DISCHARGE END REASON
RMENTAL HEALTH ABSOLUTE DISCHARGE RESPONSIBILITY

Community Treatment Order:
To carry details of each separate period of a Community Treatment Order under section 17a of the Mental Health Act 1983 for the patient.
One occurrence of this group is permitted whenever a patient on Community Treatment Order occurs.
M/R/O/PData Set Data Elements
MMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
MSTART DATE (COMMUNITY TREATMENT ORDER)
REXPIRY DATE (COMMUNITY TREATMENT ORDER)
REND DATE (COMMUNITY TREATMENT ORDER)
RCOMMUNITY TREATMENT ORDER END REASON

Community Treatment Order Recall:
To carry details of each separate period of of a recall into hospital for a patient on a Community Treatment Order under section 17a of the Mental Health Act 1983.
One occurrence of this group is permitted whenever a patient on a Community Treatment Order occurs.
M/R/O/PData Set Data Elements
MMENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER
MSTART DATE (COMMUNITY TREATMENT ORDER RECALL)
MSTART TIME (COMMUNITY TREATMENT ORDER RECALL)
REND DATE (COMMUNITY TREATMENT ORDER RECALL)
REND TIME (COMMUNITY TREATMENT ORDER RECALL)

HOSPITAL PROVIDER SPELLS

Hospital Provider Spell:
To carry details of each Hospital Provider Spell for a patient.
One occurrence of this group is permitted for each Hospital Provider Spell.
M/R/O/PData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MSERVICE REQUEST IDENTIFIER
MSTART DATE (HOSPITAL PROVIDER SPELL)
RSTART TIME (HOSPITAL PROVIDER SPELL)
RSOURCE OF ADMISSION CODE (HOSPITAL PROVIDER SPELL)
RADMISSION METHOD CODE (HOSPITAL PROVIDER SPELL)
RPOSTCODE OF MAIN VISITOR
RESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
RPLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
RPLANNED DISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL)
RDISCHARGE DATE (HOSPITAL PROVIDER SPELL)
RDISCHARGE TIME (HOSPITAL PROVIDER SPELL)
RDISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL)
RDISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL)
RPOSTCODE OF DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) 

Ward Stay:
To carry details of Ward Stays which occurred during a Hospital Provider Spell for the patient.
One occurrence of this group is permitted for each Ward Stay.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MHOSPITAL PROVIDER SPELL NUMBER
MSTART DATE (WARD STAY)
RSTART TIME (WARD STAY)
REND DATE (MENTAL HEALTH TRIAL LEAVE)
REND DATE (WARD STAY)
REND TIME (WARD STAY)
RORGANISATION SITE IDENTIFIER (OF TREATMENT)
RWARD SETTING TYPE (MENTAL HEALTH)
RINTENDED AGE GROUP (MENTAL HEALTH)
RSEX OF PATIENTS CODE
RINTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH)
RWARD SECURITY LEVEL
RLOCKED WARD INDICATOR
RMENTAL HEALTH ADMITTED PATIENT CLASSIFICATION
RSPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE
OWARD CODE

Assigned Care Professional:
To carry details of the Care Professional assigned responsibility for the care of the patient.
One occurrence of this group is permitted for each Care Professional Admitted Care Episode.
M/R/O/PData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MCARE PROFESSIONAL LOCAL IDENTIFIER
MSTART DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
REND DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE)
RTREATMENT FUNCTION CODE (MENTAL HEALTH)

Mental Health Delayed Discharge:
To carry details of the patient's Mental Health Delayed Discharge Periods which occurred during a Hospital Provider Spell.
One occurrence of this group is permitted whenever a patient is subject to a Mental Health Delayed Discharge Period.
M/R/O/PData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MSTART DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
REND DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD)
RMENTAL HEALTH DELAYED DISCHARGE REASON
RMENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE
RORGANISATION IDENTIFIER (RESPONSIBLE LOCAL AUTHORITY MENTAL HEALTH DELAYED DISCHARGE)

Restrictive Intervention:
To carry details of each separate reported incident of a Restrictive Intervention of the patient by one or more members of staff in response to aggressive behaviour or resistance to treatment during a Hospital Provider Spell.
One occurrence of this group is permitted whenever a Restrictive Intervention is carried out.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MSTART DATE (RESTRICTIVE INTERVENTION)
RSTART TIME (RESTRICTIVE INTERVENTION)
RRESTRICTIVE INTERVENTION TYPE
REND DATE (RESTRICTIVE INTERVENTION)
REND TIME (RESTRICTIVE INTERVENTION)
RRESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT)
RRESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL) 
RRESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON)
RRESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT)
RRESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT)
RRESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (CARE PERSONNEL)

Assault:
To carry details of each separate reported incident of assault on a patient by another patient during a Hospital Provider Spell.
One occurrence of this group is permitted whenever an assault on the patient occurs.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MDATE OF ASSAULT ON PATIENT

Self-Harm:
To carry details of each separate reported incident of self-harm by the patient during a Hospital Provider Spell.
One occurrence of this group is permitted whenever an incident of self-harm is reported.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MDATE OF SELF-HARM

Home Leave:
To carry details of each separate period of Home Leave from a Hospital Provider Spell for a patient who is NOT liable for detention under the Mental Health Act 1983 and who is NOT on a Community Treatment Order.
One occurrence of this group is permitted whenever a period of home leave takes place.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MSTART DATE (HOME LEAVE)
RSTART TIME (HOME LEAVE)
REND DATE (HOME LEAVE)
REND TIME (HOME LEAVE)

Mental Health Leave of Absence:
To carry details of each separate period of Mental Health Leave of Absence under section 17 of the Mental Health Act 1983 involving an overnight stay for the patient.
One occurrence of this group is permitted whenever a period of Mental Health Leave of Absence takes place.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MSTART DATE (MENTAL HEALTH LEAVE OF ABSENCE)
RSTART TIME (MENTAL HEALTH LEAVE OF ABSENCE)
REND DATE (MENTAL HEALTH LEAVE OF ABSENCE)
REND TIME (MENTAL HEALTH LEAVE OF ABSENCE)
RMENTAL HEALTH LEAVE OF ABSENCE END REASON
RESCORTED MENTAL HEALTH LEAVE OF ABSENCE INDICATOR

Mental Health Absence Without Leave:
To carry details of each separate period of Mental Health Absence Without Leave for the patient under section 18 of the Mental Health Act 1983, as amended by the Mental Health (Patients in the Community) Act 1995.
One occurrence of this group is permitted whenever a period of Mental Health Absence Without Leave takes place.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MSTART DATE (MENTAL HEALTH ABSENCE WITHOUT LEAVE)
RSTART TIME (MENTAL HEALTH ABSENCE WITHOUT LEAVE)
REND DATE (MENTAL HEALTH ABSENCE WITHOUT LEAVE)
REND TIME (MENTAL HEALTH ABSENCE WITHOUT LEAVE)
RMENTAL HEALTH ABSENCE WITHOUT LEAVE END REASON

Mental Health Trial Leave:
To carry details of each separate period of Mental Health Trial Leave for the patient.
One occurrence of this group is permitted whenever a period of Mental Health Trial Leave takes place.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MSTART DATE (MENTAL HEALTH TRIAL LEAVE)
RSTART TIME (MENTAL HEALTH TRIAL LEAVE)
REND DATE (MENTAL HEALTH TRIAL LEAVE)
REND TIME (MENTAL HEALTH TRIAL LEAVE)

Hospital Provider Spell Commissioner:
To carry details of each Commissioner Assignment Period during a Hospital Provider Spell.
One occurrence of this group is permitted for each Commissioner Assignment Period.
M/R/O/PData Set Data Elements
MHOSPITAL PROVIDER SPELL NUMBER
MORGANISATION IDENTIFIER (CODE OF COMMISSIONER)
MSTART DATE (COMMISSIONER ASSIGNMENT PERIOD)
REND DATE (COMMISSIONER ASSIGNMENT PERIOD)

Substance Misuse:
To carry observation details of evidence of substance misuse by a patient within a ward stay.
One occurrence of this group is permitted for each date that evidence was observed.
M/R/O/PData Set Data Elements
MWARD STAY IDENTIFIER
MOBSERVATION DATE (SUBSTANCE MISUSE EVIDENCE)

CLINICALLY CODED TERMINOLOGY

Medical History (Previous Diagnosis):
To carry details of any previous diagnoses for a patient which are stated by the patient or recorded in medical notes. These do not necessarily have been diagnosed by the organisation submitting the data.
One occurrence of this group is permitted for each Previous Diagnosis.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MDIAGNOSIS SCHEME IN USE
MPREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Provisional Diagnosis:
To carry details of a provisional diagnosis recorded for a patient made by the service that the patient was referred or admitted to.
One occurrence of this group is permitted for each Provisional Diagnosis.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY)
RPROVISIONAL DIAGNOSIS DATE

Primary Diagnosis:
To carry details of the primary diagnosis recorded for a patient made by the service that the patient was referred or admitted to. This can change during a reporting period.
One occurrence of this group is permitted for the Primary Diagnosis.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MPRIMARY DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Secondary Diagnosis:
To carry details of a secondary diagnosis recorded for a patient made by the service that the patient was referred or admitted to.
One occurrence of this group is permitted for each Secondary Diagnosis.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MDIAGNOSIS SCHEME IN USE
MSECONDARY DIAGNOSIS (CODED CLINICAL ENTRY)
RDIAGNOSIS DATE

Coded Scored Assessment (Referral):
To carry details of scored assessments that are issued and completed as part of a referral to a Mental Health Service, but do not take place at a specific contact.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured outside of a Care Contact.
M/R/O/PData Set Data Elements
MSERVICE REQUEST IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
MASSESSMENT TOOL COMPLETION DATE
RCARE PROFESSIONAL LOCAL IDENTIFIER

Coded Scored Assessment (Care Activity):
To carry details of scored assessments that are issued and completed as part of a specific Care Activity.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured as part of a specific Care Activity.
M/R/O/PData Set Data Elements
MCARE ACTIVITY IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

ANONYMOUS SELF-ASSESSMENT

Anonymous Self-Assessment:
To carry details of anonymous self-assessments that are issued and completed as part of a referral to a Mental Health Service.
One occurrence of this group is permitted for each coded anonymous self-assessment question or dimension captured.
M/R/O/PData Set Data Elements
MASSESSMENT TOOL COMPLETION DATE
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE
RACTIVITY LOCATION TYPE CODE
RORGANISATION IDENTIFIER (CODE OF COMMISSIONER)

CARE PROGRAMME APPROACH (CPA) CARE EPISODES

Care Programme Approach (CPA) Care Episode:
To carry details of the periods of time the patient spent on Care Programme Approach.
One occurrence of this group is required for each Care Programme Approach (CPA) care episode.
M/R/O/PData Set Data Elements
MCARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MSTART DATE (CARE PROGRAMME APPROACH CARE)
REND DATE (CARE PROGRAMME APPROACH CARE)

Care Programme Approach (CPA) Review:
To carry details of Care Programme Approach reviews undertaken for the patient.
One occurrence of this group is permitted for the most recent Care Programme Approach Review that has taken place.
M/R/O/PData Set Data Elements
MCARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER
MCARE PROGRAMME APPROACH REVIEW DATE
RCARE PROGRAMME APPROACH REVIEW ABUSE QUESTION ASKED INDICATOR
RCARE PROFESSIONAL LOCAL IDENTIFIER

CARE CLUSTERS

Clustering Tool Assessment:
To carry details of clustering tool assessments.
One occurrence of this group is permitted for each Clustering Tool assessment that takes place.
M/R/O/PData Set Data Elements
MCLUSTERING TOOL ASSESSMENT IDENTIFIER
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MCLUSTERING TOOL ASSESSMENT CATEGORY
MASSESSMENT TOOL COMPLETION DATE
RASSESSMENT TOOL COMPLETION TIME
RCLUSTERING TOOL ASSESSMENT REASON
RMENTAL HEALTH CARE CLUSTER SUPER CLASS CODE
RADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL)
PLEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)
PFORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL)

Coded Scored Assessment (Clustering Tool):
To carry details of scored assessments that are issued and completed as part of a Clustering Tool assessment.
One occurrence of this group is permitted for each coded scored assessment question or dimension captured as part of a Clustering Tool assessment.
M/R/O/PData Set Data Elements
MCLUSTERING TOOL ASSESSMENT IDENTIFIER
MCODED ASSESSMENT TOOL TYPE (SNOMED CT)
MPERSON SCORE

Care Cluster:
To carry details of the Care Cluster resulting from a clustering tool assessment.
One occurrence of this group is permitted for each period of time that a patient was allocated to a Care Cluster.
M/R/O/PData Set Data Elements
MCLUSTERING TOOL ASSESSMENT IDENTIFIER
MSTART DATE (CARE CLUSTER ASSIGNMENT PERIOD)
RSTART TIME (CARE CLUSTER ASSIGNMENT PERIOD)
RADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL)
RCHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE
PLEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
RFORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL)
PFORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL)
REND DATE (CARE CLUSTER ASSIGNMENT PERIOD)
REND TIME (CARE CLUSTER ASSIGNMENT PERIOD)

Five Forensic Pathways:
To carry details of the Five Forensic Pathways grouping allocated to the patient during a Five Forensic Pathways assessment.
One occurrence of this group is permitted for each initial assessment or review of the grouping allocation.
M/R/O/PData Set Data Elements
MLOCAL PATIENT IDENTIFIER (EXTENDED)
MFIVE FORENSIC PATHWAYS ASSESSMENT DATE
RFIVE FORENSIC PATHWAYS ASSESSMENT REASON
MFIVE FORENSIC PATHWAYS CODE

CARE PROFESSIONALS

Care Professionals:
To carry details of the staff involved in providing the patient's care.
One occurrence of this group is permitted for each staff member.
M/R/O/PData Set Data Elements
MCARE PROFESSIONAL LOCAL IDENTIFIER
RPROFESSIONAL REGISTRATION BODY CODE
RPROFESSIONAL REGISTRATION ENTRY IDENTIFIER
RCARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH)
RMAIN SPECIALTY CODE (MENTAL HEALTH)
ROCCUPATION CODE
RCARE PROFESSIONAL (JOB ROLE CODE)

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NATIONAL CANCER WAITING TIMES MONITORING DATA SET

Change to Data Set: Changed Description

National Cancer Waiting Times Monitoring Data Set Overview

For a "Full Screen" view, click National Cancer Waiting Times Monitoring Data Set.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button. 

See Patient Pathway Scenarios, for the scenarios which show:

  • the data items required for a range of health care scenarios and
  • information on how records will be validated to ensure these scenarios have been correctly reported.

The Mandatory or Required (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc.) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element.  Required data elements may not be applicable to all PATIENT PATHWAYS, see Patient Pathway Scenarios for further details
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

PATIENT AND PATHWAY IDENTIFICATION

To carry Patient and Pathway details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
MNHS NUMBER STATUS INDICATOR CODE
RPATIENT PATHWAY IDENTIFIER
RORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER)

OUTPATIENT SERVICES

To carry Outpatient Services details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RSOURCE OF REFERRAL FOR OUT-PATIENTS
RPRIORITY TYPE CODE
RDECISION TO REFER DATE (CANCER OR BREAST SYMPTOMS)
RCANCER REFERRAL TO TREATMENT PERIOD START DATE
RTWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE
RCONSULTANT UPGRADE DATE
RORGANISATION SITE IDENTIFIER (OF PROVIDER CONSULTANT UPGRADE)
RDATE FIRST SEEN
RORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST SEEN)
RWAITING TIME ADJUSTMENT (FIRST SEEN)
RWAITING TIME ADJUSTMENT REASON (FIRST SEEN)
RCANCER CARE SPELL DELAY REASON (FIRST SEEN)
OCANCER CARE SPELL DELAY REASON COMMENT (FIRST SEEN)

MULTIDISCIPLINARY TEAM ACTIVITY

To carry Multidisciplinary Team Activity details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RMULTIDISCIPLINARY TEAM CANCER CARE PLAN DISCUSSED INDICATOR
RMULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER)

PATIENT STATUS AND DIAGNOSIS

To carry Patient Status and Diagnosis details.
One occurrence of this group is required.
M/R/OData Set Data Elements
MCANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS
RPRIMARY DIAGNOSIS (ICD)
RTUMOUR LATERALITY
RCANCER TREATMENT PERIOD START DATE
RORGANISATION SITE IDENTIFIER (OF PROVIDER CANCER DECISION TO TREAT)
RSERVICE REQUESTED DATE (INTER-PROVIDER TRANSFER)
RREFERRAL REQUEST RECEIVED DATE (INTER-PROVIDER TRANSFER)
RORGANISATION IDENTIFIER (REFERRING)
RORGANISATION IDENTIFIER (RECEIVING)
RCANCER TRANSFER REFERRING REASON (INTER-PROVIDER TRANSFER)
RCANCER TRANSFER RECEIVING REASON (INTER-PROVIDER TRANSFER)
RCANCER FASTER DIAGNOSIS PATHWAY END REASON
RPRIMARY CANCER SITE (CANCER FASTER DIAGNOSIS PATHWAY)
RCANCER FASTER DIAGNOSIS PATHWAY END DATE
RCANCER CARE SPELL DELAY REASON (OUTCOME COMMUNICATION CANCER FASTER DIAGNOSIS PATHWAY)
OCANCER CARE SPELL DELAY REASON COMMENT (OUTCOME COMMUNICATION CANCER FASTER DIAGNOSIS PATHWAY)
RCANCER FASTER DIAGNOSIS PATHWAY EXCLUSION REASON
OCARE PROFESSIONAL TYPE CODE (OUTCOME COMMUNICATION CANCER FASTER DIAGNOSIS PATHWAY)
OMETHOD OF COMMUNICATION (END OF CANCER FASTER DIAGNOSIS PATHWAY)
RORGANISATION SITE IDENTIFIER (OF CANCER FASTER DIAGNOSIS PATHWAY END DATE)

TREATMENT EVENTS

To carry Treatment Event details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RTREATMENT START DATE (CANCER)
RORGANISATION SITE IDENTIFIER (OF PROVIDER CANCER TREATMENT START DATE)
RCANCER TREATMENT EVENT TYPE
RCANCER TREATMENT MODALITY
RCLINICAL TRIAL INDICATOR
RCANCER CARE SETTING (TREATMENT)
RRADIOTHERAPY PRIORITY
RCANCER CARE SPELL DELAY REASON (DECISION TO TREATMENT)
OCANCER CARE SPELL DELAY REASON COMMENT (DECISION TO TREATMENT)
RWAITING TIME ADJUSTMENT (TREATMENT)
RWAITING TIME ADJUSTMENT REASON (TREATMENT)
RCANCER CARE SPELL DELAY REASON (REFERRAL TO TREATMENT)
OCANCER CARE SPELL DELAY REASON COMMENT (REFERRAL TO TREATMENT)
RCANCER CARE SPELL DELAY REASON (CONSULTANT UPGRADE)
OCANCER CARE SPELL DELAY REASON COMMENT (CONSULTANT UPGRADE)

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NATIONAL JOINT REGISTRY DATA SET - ANKLE

Change to Data Set: Changed Description

National Joint Registry Data Set Overview

Click National Joint Registry Data Set - Ankle for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Optional (M/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory
  • O = Optional: this data element is optional.

ANKLE PRIMARY

M/OAnkle Primary Procedure Details:
One occurrence of this group is required.
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MPATIENT DIAGNOSIS INDICATION (PRIMARY ANKLE REPLACEMENT)
MPREVIOUS FRACTURE OF INDEX JOINT INDICATOR (ANKLE REPLACEMENT)
MPREVIOUS INDEX JOINT SURGERY TYPE (ANKLE REPLACEMENT)
MPREVIOUS BONY INFECTION INDICATOR (ANKLE REPLACEMENT TIBIA OR HINDFOOT)
MTIBIA-HINDFOOT ALIGNMENT CODE (PRIMARY ANKLE REPLACEMENT)
MANKLE DORSIFLEXION CODE (PRIMARY ANKLE REPLACEMENT)
MANKLE PLANTARFLEXION CODE (PRIMARY ANKLE REPLACEMENT)
MSUBTALAR JOINT MOVEMENT CODE (PRIMARY ANKLE REPLACEMENT)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (PRIMARY ANKLE REPLACEMENT)
MSURGICAL APPROACH (PRIMARY OR REVISION ANKLE REPLACEMENT)
MASSOCIATED PROCEDURE TYPE (ANKLE REPLACEMENT)
MCOMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (TIBIAL)
MBONE GRAFT STRUCTURE (TIBIAL)
MBONE GRAFT SOURCE (TIBIAL)
MBONE GRAFT INDICATOR (TALAR)
MBONE GRAFT STRUCTURE (TALAR)
MBONE GRAFT SOURCE (TALAR)
MBONE GRAFT INDICATOR (FIBULAR)
MBONE GRAFT STRUCTURE (FIBULAR)
MBONE GRAFT SOURCE (FIBULAR)

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (ANKLE REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

ANKLE REVISION

M/OAnkle Revision Procedure Details:
One occurrence of this group is required.
MREVISION PROCEDURE TYPE (ANKLE REPLACEMENT)
MARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT)
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MJOINT REPLACEMENT REVISION REASON CODE (ANKLE)

M/OPrimary Operation Details:
One occurrence of this group is required.
MPROCEDURE DATE (PRIMARY JOINT REPLACEMENT)
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
If the information is not available, select 'Not Available'

M/OComponents Removed:
One occurrence of this group is required.
MCOMPONENT REMOVAL INDICATOR (TIBIAL)
MCOMPONENT REMOVAL INDICATOR (TALAR)
MCOMPONENT REMOVAL INDICATOR (MENISCAL)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (REVISION ANKLE REPLACEMENT)
MSURGICAL APPROACH (PRIMARY OR REVISION ANKLE REPLACEMENT)
MASSOCIATED PROCEDURE TYPE (ANKLE REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (TIBIAL)
MBONE GRAFT STRUCTURE (TIBIAL)
MBONE GRAFT SOURCE (TIBIAL)
MBONE GRAFT INDICATOR (TALAR)
MBONE GRAFT STRUCTURE (TALAR)
MBONE GRAFT SOURCE (TALAR)
MBONE GRAFT INDICATOR (FIBULAR)
MBONE GRAFT STRUCTURE (FIBULAR)
MBONE GRAFT SOURCE (FIBULAR)

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (ANKLE REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

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NATIONAL JOINT REGISTRY DATA SET - COMMON DETAILS

Change to Data Set: Changed Description

National Joint Registry Data Set Overview

Click National Joint Registry Data Set - Common Details for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Required (M/R) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory
  • R = Required: this data element is not optional but should be supplied if this data is available.

COMMON DETAILS

M/RPatient Details:
One occurrence of this group is required.
MPATIENT CONSENT OBTAINED INDICATOR (NATIONAL JOINT REGISTRY RECORDING DATA)
MPERSON HEIGHT IN METRES
and
PERSON WEIGHT
or
BODY MASS INDEX
If the information is not available, select 'Not Available'

M/RPatient Identifiers:
One occurrence of this group is required.
MPERSON GIVEN NAME
MPERSON FAMILY NAME
MLOCAL PATIENT IDENTIFIER (NATIONAL JOINT REGISTRY)
MPERSON STATED GENDER CODE (NATIONAL JOINT REGISTRY)
RPERSON BIRTH DATE
MPOSTCODE OF USUAL ADDRESS
If the PATIENT is an Overseas Visitor, select 'Overseas Resident'
RNHS NUMBER (England and Wales)
or
HEALTH AND CARE NUMBER (Northern Ireland)

M/ROperation Details:
One occurrence of this group is required.
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
MPROCEDURE DATE
MANAESTHETIC TYPE (JOINT REPLACEMENT)
MASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE (NATIONAL JOINT REGISTRY)
MOPERATION FUNDING (NATIONAL JOINT REGISTRY)

M/RSurgeon Details:
One occurrence of this group is required.
MCONSULTANT CODE (RESPONSIBLE CONSULTANT)
MCARE PROFESSIONAL CODE (OPERATING SURGEON)
MCARE PROFESSIONAL LEAD OPERATING SURGEON GRADE (JOINT REPLACEMENT)
MCARE PROFESSIONAL FIRST ASSISTANT GRADE (JOINT REPLACEMENT)

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NATIONAL JOINT REGISTRY DATA SET - ELBOW

Change to Data Set: Changed Description

National Joint Registry Data Set Overview

Click National Joint Registry Data Set - Elbow for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Optional (M/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory
  • O = Optional: this data element is optional.

ELBOW PRIMARY

M/OPatient Details:
One occurrence of this group is required.
MHANDEDNESS CODE (JOINT REPLACEMENT)

M/OElbow Primary Procedure Details:
One occurrence of this group is required.
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MPATIENT DIAGNOSIS INDICATION (PRIMARY ELBOW REPLACEMENT)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (PRIMARY ELBOW REPLACEMENT)
MFIXATION TYPE (ELBOW)
MSURGICAL APPROACH (PRIMARY OR REVISION ELBOW REPLACEMENT)
MMINIMALLY INVASIVE SURGERY INDICATOR (JOINT REPLACEMENT)
MCOMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (HUMERAL)
MBONE GRAFT STRUCTURE (HUMERAL)
MBONE GRAFT SOURCE (HUMERAL)
MBONE GRAFT INDICATOR (ULNAR)
MBONE GRAFT STRUCTURE (ULNAR)
MBONE GRAFT SOURCE (ULNAR)

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (ELBOW REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

ELBOW REVISION

M/OPatient Details:
One occurrence of this group is required.
MHANDEDNESS CODE (JOINT REPLACEMENT)

M/OElbow Revision Procedure Details:
One occurrence of this group is required.
MREVISION PROCEDURE TYPE (ELBOW REPLACEMENT)
MARTHROPLASTY REVISION TYPE (SHOULDER AND ELBOW REPLACEMENT)
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MJOINT REPLACEMENT REVISION REASON CODE (ELBOW)

M/OPrimary Operation Details:
One occurrence of this group is required.
MPROCEDURE DATE (PRIMARY JOINT REPLACEMENT)
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
If the information is not available, select 'Not Available'

M/OComponents Removed:
One occurrence of this group is required.
MCOMPONENT REMOVAL INDICATOR (RADIAL)
MCOMPONENT REMOVAL INDICATOR (HUMERAL)
MCOMPONENT REMOVAL INDICATOR (ULNAR)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (REVISION ELBOW REPLACEMENT)
MFIXATION TYPE (ELBOW)
MSURGICAL APPROACH (PRIMARY OR REVISION ELBOW REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (HUMERAL)
MBONE GRAFT STRUCTURE (HUMERAL)
MBONE GRAFT SOURCE (HUMERAL)
MBONE GRAFT INDICATOR (ULNAR)
MBONE GRAFT STRUCTURE (ULNAR)
MBONE GRAFT SOURCE (ULNAR)

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (ELBOW REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

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NATIONAL JOINT REGISTRY DATA SET - HIP

Change to Data Set: Changed Description

National Joint Registry Data Set Overview

Click National Joint Registry Data Set - Hip for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Optional (M/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory
  • O = Optional: this data element is optional.

HIP PRIMARY

M/OHip Primary Procedure Details:
One occurrence of this group is required.
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MPATIENT DIAGNOSIS INDICATION (PRIMARY HIP REPLACEMENT)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (PRIMARY HIP REPLACEMENT)
MHIP JOINT SURGERY PATIENT POSITION
MSURGICAL APPROACH (PRIMARY HIP REPLACEMENT)
MMINIMALLY INVASIVE SURGERY INDICATOR (JOINT REPLACEMENT)
MCOMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (FEMORAL)
MBONE GRAFT STRUCTURE (FEMORAL)
MBONE GRAFT SOURCE (FEMORAL) 
MBONE GRAFT INDICATOR (ACETABULAR)
MBONE GRAFT STRUCTURE (ACETABULAR)
MBONE GRAFT SOURCE (ACETABULAR) 

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (HIP REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

HIP REVISION

M/OHip Revision Procedure Details:
One occurrence of this group is required.
MREVISION PROCEDURE TYPE (HIP REPLACEMENT)
MARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT)
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MJOINT REPLACEMENT REVISION REASON CODE (HIP)

M/OPrimary Operation Details:
One occurrence of this group is required.
MPROCEDURE DATE (PRIMARY JOINT REPLACEMENT)
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
If the information is not available, select 'Not Available'

M/OComponents Removed:
One occurrence of this group is required.
MCOMPONENT REMOVAL INDICATOR (FEMORAL)
MCOMPONENT REMOVAL INDICATOR (MODULAR HEAD)
MCEMENT REMOVAL INDICATOR (FEMORAL)
MCOMPONENT REMOVAL INDICATOR (ACETABULAR)
MLINER REMOVAL INDICATOR (ACETABULAR)
MCEMENT REMOVAL INDICATOR (ACETABULAR)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (REVISION HIP REPLACEMENT)
MHIP JOINT SURGERY PATIENT POSITION
MSURGICAL APPROACH (REVISION HIP REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (FEMORAL)
MBONE GRAFT STRUCTURE (FEMORAL)
MBONE GRAFT SOURCE (FEMORAL) 
MBONE GRAFT INDICATOR (ACETABULAR)
MBONE GRAFT STRUCTURE (ACETABULAR)
MBONE GRAFT SOURCE (ACETABULAR) 

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (HIP REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

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NATIONAL JOINT REGISTRY DATA SET - KNEE

Change to Data Set: Changed Description

National Joint Registry Data Set Overview

Click National Joint Registry Data Set - Knee for a "Full Screen" view.

In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.

The Mandatory or Optional (M/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory
  • O = Optional: this data element is optional.

KNEE PRIMARY

M/OKnee Primary Procedure Details:
One occurrence of this group is required.
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MPATIENT DIAGNOSIS INDICATION (PRIMARY KNEE REPLACEMENT)
MDEGREES OF FIXED FLEXION DEFORMITY (PRIMARY KNEE REPLACEMENT)
MDEGREES OF FLEXION RANGE (PRIMARY KNEE REPLACEMENT)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (PRIMARY KNEE REPLACEMENT)
MSURGICAL APPROACH (PRIMARY KNEE REPLACEMENT)
MMINIMALLY INVASIVE SURGERY INDICATOR (JOINT REPLACEMENT)
MCOMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT)
MPATIENT SPECIFIC INSTRUMENTS INDICATOR (SHOULDER OR KNEE REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
MMECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)

M/OBone Graft Used:
One occurrence of this group is required.
MBONE GRAFT INDICATOR (FEMORAL)
MBONE GRAFT STRUCTURE (FEMORAL)
MBONE GRAFT SOURCE (FEMORAL) 
MBONE GRAFT INDICATOR (TIBIAL)
MBONE GRAFT STRUCTURE (TIBIAL)
MBONE GRAFT SOURCE (TIBIAL)

M/OSurgeon Notes:
One occurrence of this group is required.
OSURGEON NOTES

M/OIntraoperative Event:
One occurrence of this group is required.
MUNTOWARD INTRAOPERATIVE EVENT CODE (KNEE REPLACEMENT)

M/OComponents:
One occurrence of this group is required.
MIMPLANT CATALOGUE NUMBER
MIMPLANT BATCH OR LOT NUMBER

KNEE REVISION

M/OKnee Revision Procedure Details:
One occurrence of this group is required.
MREVISION PROCEDURE TYPE (KNEE REPLACEMENT)
MARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT)
MANATOMICAL SIDE (NATIONAL JOINT REGISTRY)
MJOINT REPLACEMENT REVISION REASON CODE (KNEE)

M/OPrimary Operation Details:
One occurrence of this group is required.
MPROCEDURE DATE (PRIMARY JOINT REPLACEMENT)
MORGANISATION SITE IDENTIFIER (OF TREATMENT)
If the information is not available, select 'Not Available'

M/OComponents Removed:
One occurrence of this group is required.
MCOMPONENT REMOVAL INDICATOR (FEMORAL)
MCOMPONENT REMOVAL INDICATOR (TIBIAL)
MLINER REMOVAL INDICATOR (TIBIAL)
MCOMPONENT REMOVAL INDICATOR (PATELLA)

M/OSurgical Approach:
One occurrence of this group is required.
MPATIENT PROCEDURE TYPE (REVISION KNEE REPLACEMENT)
MSURGICAL APPROACH (REVISION KNEE REPLACEMENT)
MPATIENT SPECIFIC INSTRUMENTS INDICATOR (SHOULDER OR KNEE REPLACEMENT)

M/OThromboprophylaxis:
One occurrence of this group is required.
MCHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT)
M