| 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:- Ensures that each overview page has an "Introduction" heading
- Adds the mandation, XML Schema download and constraints information to the end of each overview pagepage
- Removes the information from the top of each data set.
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:
| 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.
Click here for a printer friendly view of this page.
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | FINANCIAL MONTH |
| M | FINANCIAL YEAR |
| M | DATE 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/O | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | ORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | ACTIVITY TREATMENT FUNCTION CODE |
| O | LOCAL SUB-SPECIALTY CODE |
| R | WARD CODE |
| SERVICE AGREEMENT AND COMMISSIONING DETAILS |
|---|
| COST AND PRICING DETAILS |
|---|
| To carry the cost and pricing details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | TARIFF CODE |
| M | NATIONAL TARIFF INDICATOR |
| M | CONTRACT MONITORING PLANNED ACTIVITY |
| M | CONTRACT MONITORING PLANNED PRICE |
| M | CONTRACT MONITORING PLANNED MARKET FORCES FACTOR |
| M | CONTRACT MONITORING ACTUAL ACTIVITY |
| M | CONTRACT MONITORING ACTUAL PRICE |
| M | CONTRACT MONITORING ACTUAL MARKET FORCES FACTOR |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | GS1 APPLICATION IDENTIFIER (GLOBAL) |
| M | GS1 UNIQUE ORGANISATION PREFIX NUMBER |
| R | NHS NUMBER |
| M | GS1 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/O | Data Set Data Elements |
| O | GS1 APPLICATION IDENTIFIER (GLOBAL) |
| O | GS1 SERVICE RELATION INSTANCE NUMBER |
| To carry details of the hospital identifiers. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| M | GS1 APPLICATION IDENTIFIER (INTERNAL) |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| O | GS1 GLOBAL LOCATION NUMBER |
| PATIENT DETAILS |
|---|
| To carry the patient descriptive details. One occurrence of this group is permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | GS1 APPLICATION IDENTIFIER (INTERNAL) |
| R | PERSON FAMILY NAME |
| R | PERSON GIVEN NAME |
| R | DATE OF BIRTH (PATIENT IDENTIFICATION) |
| R | TIME 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/O | Data Set Data Elements |
| R | GS1 APPLICATION IDENTIFIER (INTERNAL) |
| R | NUMBER OF BABIES IDENTIFICATION CODE (PATIENT IDENTIFICATION) |
| R | PERSON FAMILY NAME (MOTHER OF BABY) |
| O | PERSON GIVEN NAME (MOTHER OF BABY) |
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 presentR = 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/R | Data Set Data Elements |
| M | BREAST TRIPLE DIAGNOSTIC ASSESSMENT INDICATOR |
| PROGNOSTIC INDEX - BREAST |
|---|
| To carry prognostic details for Breast cancer. One occurrence of this group is permitted. | |
| M/R | Data Set Data Elements |
| M | NOTTINGHAM 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/R | Data Set Data Elements |
| R | FITNESS ASSESSMENT FOR OLDER PATIENTS WITH BREAST CANCER INDICATOR |
| R | FITNESS ASSESSMENT FOR OLDER PATIENTS WITH BREAST CANCER COMPLETED DATE |
| R | CLINICAL FRAILTY SCALE POINT |
| R | ABBREVIATED MENTAL TEST SCORE |
| R | SEVERE CARDIORESPIRATORY DISEASE INDICATOR |
| R | OTHER NON BREAST LOCALLY ADVANCED METASTATIC MALIGNANCY INDICATOR |
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 presentR = 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/R | Data Set Data Elements |
| R | LESION LOCATION (RADIOLOGICAL) |
| R | NUMBER OF LESIONS (RADIOLOGICAL) |
| R | LESION SIZE (RADIOLOGICAL) |
| R | PRINCIPAL 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/R | Data Set Data Elements |
| R | PROVISIONAL 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/R | Data Set Data Elements |
| R | TUMOUR LOCATION (SURGICAL) |
| R | BIOPSY TYPE (CENTRAL NERVOUS SYSTEM TUMOURS) |
| R | EXCISION 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/R | Data Set Data Elements |
| R | RESECTION 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/R | Data Set Data Elements |
| R | VISUAL ACUITY TEST RESULT (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | VISUAL 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/R | Data Set Data Elements |
| M | CHANG 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/R | Data Set Data Elements |
| M | ALPHA FETOPROTEIN (CEREBROSPINAL FLUID) |
| 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/R | Data Set Data Elements |
| M | BETA HUMAN CHORIONIC GONADOTROPIN (CEREBROSPINAL FLUID) |
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 presentR = 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/R | Data Set Data Elements |
| R | CARE 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/R | Data Set Data Elements |
| R | CARE PROFESSIONAL MAIN SPECIALTY CODE (DIAGNOSIS) |
| R | CHILDREN 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/R | Data Set Data Elements |
| R | LIFE 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/R | Data Set Data Elements |
| M | WILMS TUMOUR STAGE |
| 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/R | Data Set Data Elements |
| M | INTERNATIONAL NEUROBLASTOMA RISK GROUP STAGING SYSTEM STAGE |
| 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/R | Data Set Data Elements |
| M | PRETEXT STAGING SYSTEM STAGE |
| M | PRETEXT STAGING SYSTEM STAGE ANNOTATION FACTORS |
| 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/R | Data Set Data Elements |
| M | INTERNATIONAL 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/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CHILDRENS NOMINATED PRINCIPAL TREATMENT CENTRE) Multiple occurrences of this item are permitted |
| 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/R | Data Set Data Elements |
| M | ORGANISATION 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/R | Data Set Data Elements |
| R | PATIENT TREATED TO CHILDRENS CANCER AND LEUKAEMIA GROUP GUIDELINES INDICATOR |
| R | CHILDRENS 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/R | Data Set Data Elements |
| R | URINE 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/R | Data Set Data Elements |
| R | PATHOLOGICAL RISK CLASSIFICATION CODE (AFTER NEPHRECTOMY) |
| R | PATHOLOGICAL 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/R | Data Set Data Elements |
| R | RETINOBLASTOMA ASSESSMENT LATERALITY |
| R | INTERNATIONAL 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/R | Data Set Data Elements |
| R | CHILDREN TEENAGERS AND YOUNG ADULTS AGE CATEGORY (CONSULTANT PRESCRIBING CHEMOTHERAPY) |
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 presentR = 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/R | Data Set Data Elements |
| R | SYNCHRONOUS TUMOUR COLON LOCATION (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | TUMOUR 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/R | Data Set Data Elements |
| R | CLINICAL NURSE SPECIALIST TYPE |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | COSDS SUBMISSION IDENTIFIER |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | COSDS SUBMISSION RECORD COUNT |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| RECORD IDENTIFIER |
|---|
| To carry the record identifier details. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | COSDS 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/O | Data Set Data Elements |
| M | NHS NUMBER |
| 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/O | Data Set Data Elements |
| M | LOCAL 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/O | Data Set Data Elements |
| M | NHS NUMBER STATUS INDICATOR CODE |
| M | PERSON BIRTH DATE |
| M | ORGANISATION 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/O | Data Set Data Elements |
| M | PRIMARY DIAGNOSIS (ICD) |
| M | TUMOUR LATERALITY |
| M | DATE OF PRIMARY CANCER DIAGNOSIS (CLINICALLY AGREED) |
| 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/O | Data Set Data Elements |
| M | DATE 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/O | Data Set Data Elements |
| R | PRIMARY DIAGNOSIS (ICD ORIGINAL) |
| M | CANCER METASTATIC DISEASE TYPE Multiple occurrences of this item are permitted |
| M | METASTATIC SITE (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | PALLIATIVE CARE SPECIALIST SEEN INDICATOR (CANCER RECURRENCE) |
| R | RELAPSE METHOD DETECTION TYPE Multiple occurrences of this item are permitted |
| 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/O | Data Set Data Elements |
| M | CANCER PROGRESSION (ICD ORIGINAL) |
| M | CANCER METASTATIC DISEASE TYPE Multiple occurrences of this item are permitted |
| M | METASTATIC SITE (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| 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/O | Data Set Data Elements |
| R | MORPHOLOGY (ICD-O CANCER TRANSFORMATION ORIGINAL) |
| R | MORPHOLOGY (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/O | Data Set Data Elements |
| M | MORPHOLOGY (ICD-O CANCER TRANSFORMATION) |
| 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/O | Data Set Data Elements |
| M | MORPHOLOGY (SNOMED CANCER TRANSFORMATION) |
| M | SNOMED VERSION (CANCER TRANSFORMATION) |
| DEMOGRAPHICS - CORE |
|---|
| To carry patient demographic details. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | PERSON FAMILY NAME |
| R | PERSON GIVEN NAME |
| R | PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS STRUCTURED or PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS UNSTRUCTURED |
| R | POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS) |
| R | PERSON STATED GENDER CODE |
| R | PERSON STATED SEXUAL ORIENTATION CODE (AT DIAGNOSIS)` |
| R | GENERAL MEDICAL PRACTITIONER (SPECIFIED) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| R | PERSON FAMILY NAME (AT BIRTH) |
| R | ETHNIC 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/O | Data Set Data Elements |
| R | SOURCE OF REFERRAL FOR OUT-PATIENTS |
| R | DATE FIRST SEEN |
| M | PROFESSIONAL REGISTRATION ISSUER CODE (CANCER FIRST SEEN) |
| M | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (CANCER FIRST SEEN) |
| R | ORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST SEEN) |
| R | DATE FIRST SEEN (CANCER SPECIALIST) |
| R | ORGANISATION SITE IDENTIFIER (OF PROVIDER FIRST CANCER SPECIALIST) |
| R | CANCER 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/O | Data Set Data Elements |
| R | SOURCE OF REFERRAL FOR OUT-PATIENTS (NON PRIMARY CANCER PATHWAY) |
| R | DATE FIRST SEEN (NON CANCER PRIMARY PATHWAY) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | ORGANISATION SITE IDENTIFIER (OF IMAGING) |
| M | PROCEDURE DATE (CANCER IMAGING) |
| R | CANCER 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/O | Data Set Data Elements |
| M | IMAGING CODE (NICIP) |
| CHOICE 2 - SNOMED CT | |
| To carry imaging SNOMED CT details. Multiple occurrences of this group are permitted per Core Imaging. | |
| M/R/O | Data Set Data Elements |
| M | IMAGING CODE (SNOMED CT) |
| CHOICE 3 - CANCER SITE IMAGING LOCATION GROUP | |
| To carry imaging details. Multiple occurrences of this group are permitted per Core Imaging. | |
| M/R/O | Data Set Data Elements |
| M | CANCER IMAGING MODALITY |
| R | IMAGING ANATOMICAL SITE |
| R | ANATOMICAL SIDE (IMAGING) |
| To carry imaging details. Multiple occurrences of this group are permitted. | |
| M/R/O | Data Set Data Elements |
| R | IMAGING REPORT TEXT |
| R | LESION SIZE (RADIOLOGICAL) |
| DIAGNOSTIC PROCEDURES - CORE |
|---|
| To carry diagnostic procedure details. Multiple occurrences of this group are permitted. | |
| M/R/O | Data Set Data Elements |
| M | ORGANISATION SITE IDENTIFIER (OF DIAGNOSTIC PROCEDURE) |
| M | PROCEDURE 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/O | Data Set Data Elements |
| M | DIAGNOSTIC PROCEDURE (OPCS) |
| CHOICE 2 - SNOMED CT | |
| To carry SNOMED CT diagnostic procedure details. Multiple occurrences of this group are permitted per Core Diagnostic Procedures. | |
| M/R/O | Data Set Data Elements |
| M | DIAGNOSTIC 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/O | Data Set Data Elements |
| R | SENTINEL 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/O | Data Set Data Elements |
| R | ORGANISATION SITE IDENTIFIER (OF DIAGNOSIS) |
| R | BASIS OF DIAGNOSIS (CANCER) |
| R | MORPHOLOGY (ICD-O DIAGNOSIS) |
| M | MORPHOLOGY (SNOMED DIAGNOSIS) |
| M | SNOMED VERSION (DIAGNOSIS) |
| R | TOPOGRAPHY (ICD-O) |
| R | GRADE OF DIFFERENTIATION (AT DIAGNOSIS) |
| R | PERFORMANCE STATUS (ADULT) |
| R | DIAGNOSIS (SNOMED CT) |
| M | CANCER METASTATIC DISEASE TYPE Multiple occurrences of this item are permitted |
| M | METASTATIC 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/O | Data Set Data Elements |
| R | PRIMARY DIAGNOSIS (CANCER COMMENT) |
| R | SECONDARY DIAGNOSIS (ICD) Multiple occurrences of this item are permitted |
| R | SECONDARY DIAGNOSIS (CANCER COMMENT) |
| R | FAMILIAL CANCER SYNDROME INDICATOR |
| R | FAMILIAL CANCER SYNDROME COMMENT |
| DIAGNOSIS: CANCER PROGRESSION - CORE |
|---|
| To carry additional diagnostic details for Cancer Progression. May be multiple occurrences per Core Diagnosis. | |
| M/R/O | Data Set Data Elements |
| M | CANCER METASTATIC DISEASE TYPE Multiple occurrences of this item are permitted |
| M | METASTATIC SITE (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| M | CANCER 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/O | Data Set Data Elements |
| M | CANCER 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/O | Data Set Data Elements |
| M | MORPHOLOGY (ICD-O CANCER TRANSFORMATION) |
| 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/O | Data Set Data Elements |
| M | MORPHOLOGY (SNOMED CANCER TRANSFORMATION) |
| M | SNOMED VERSION (CANCER TRANSFORMATION) |
| DIAGNOSIS: BANKED TISSUE - CORE |
|---|
| To carry Banked Tissue details. One occurrence of this group is permitted per Core Diagnosis. | |
| M/R/O | Data Set Data Elements |
| R | PATIENT CONSENT FOR TISSUE BANKED AT DIAGNOSIS INDICATION CODE |
| R | TISSUE 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/O | Data Set Data Elements |
| R | PERSON HEIGHT IN METRES |
| R | PERSON WEIGHT |
| R | BODY MASS INDEX |
| M | OBSERVATION 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/O | Data Set Data Elements |
| R | CLINICAL NURSE SPECIALIST INDICATION CODE |
| R | SMOKING STATUS (CANCER) |
| R | TOBACCO SMOKING CESSATION TREATMENT INDICATION CODE |
| R | ALCOHOL HISTORY (CANCER IN LAST THREE MONTHS) |
| R | ALCOHOL HISTORY (CANCER BEFORE LAST THREE MONTHS) |
| R | PATIENT DIAGNOSIS INDICATOR (DIABETES) |
| R | MENOPAUSAL STATUS (AT DIAGNOSIS) |
| R | PHYSICAL 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/O | Data Set Data Elements |
| R | OFFER STATUS (HOLISTIC NEEDS ASSESSMENT) |
| R | HOLISTIC NEEDS ASSESSMENT COMPLETED DATE |
| R | HOLISTIC NEEDS ASSESSMENT POINT OF PATHWAY (CANCER) |
| R | STAFF 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/O | Data Set Data Elements |
| R | OFFER STATUS (PERSONALISED CARE AND SUPPORT PLANNING) |
| R | PERSONALISED CARE AND SUPPORT PLANNING COMPLETED DATE |
| R | PERSONALISED CARE AND SUPPORT PLANNING POINT OF CANCER PATHWAY |
| R | STAFF 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/O | Data Set Data Elements |
| M | MULTIDISCIPLINARY TEAM MEETING CANCER CARE PLAN NOT DISCUSSED INDICATION CODE |
| 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/O | Data Set Data Elements |
| M | MULTIDISCIPLINARY TEAM MEETING CANCER CARE PLAN DISCUSSION TYPE |
| M | MULTIDISCIPLINARY TEAM MEETING DATE (CANCER) |
| M | ORGANISATION SITE IDENTIFIER (OF MULTIDISCIPLINARY TEAM MEETING) |
| M | MULTIDISCIPLINARY TEAM MEETING TYPE (CANCER) |
| R | MULTIDISCIPLINARY 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/O | Data Set Data Elements |
| R | MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) |
| M | PROFESSIONAL REGISTRATION ISSUER CODE (MULTIDISCIPLINARY TEAM LEAD) |
| M | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (MULTIDISCIPLINARY TEAM LEAD) |
| R | CANCER CARE PLAN INTENT |
| R | PLANNED CANCER TREATMENT TYPE Multiple occurrences of this item are permitted |
| R | NO CANCER TREATMENT REASON |
| O | ADULT 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/O | Data Set Data Elements |
| R | OFFER STATUS (GERMLINE GENETIC TEST) |
| R | GERMLINE GENETIC TEST TYPE OFFERED Multiple occurrences of this item are permitted |
| R | OTHER GERMLINE GENETIC TEST TYPE OFFERED COMMENT Multiple occurrences of this item are permitted |
| R | ACTIVITY OFFER DATE (GERMLINE GENETIC TEST) |
| R | ORGANISATION IDENTIFIER (REPORTING LABORATORY) |
| R | OFFER 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/O | Data Set Data Elements |
| R | GENE OR STRATIFICATION BIOMARKER TYPE ANALYSED Multiple occurrences of this item are permitted |
| R | OTHER GENE OR STRATIFICATION BIOMARKER TYPE ANALYSED COMMENT Multiple occurrences of this item are permitted |
| R | GENE OR STRATIFICATION BIOMARKER REPORTED DATE |
| R | ORGANISATION 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/O | Data Set Data Elements |
| R | PATIENT TRIAL STATUS (CANCER) |
| R | CLINICAL TRIAL DECISION DATE |
| R | CLINICAL TRIAL START DATE |
| R | CANCER 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/O | Data Set Data Elements |
| R | T CATEGORY (FINAL PRETREATMENT) |
| R | N CATEGORY (FINAL PRETREATMENT) |
| R | M CATEGORY (FINAL PRETREATMENT) |
| R | TNM STAGE GROUPING (FINAL PRETREATMENT) |
| R | ORGANISATION SITE IDENTIFIER (OF TNM STAGE GROUPING FINAL PRETREATMENT) |
| R | TNM STAGE GROUPING DATE (FINAL PRETREATMENT) |
| R | T CATEGORY (INTEGRATED STAGE) |
| R | N CATEGORY (INTEGRATED STAGE) |
| R | M CATEGORY (INTEGRATED STAGE) |
| R | TNM STAGE GROUPING (INTEGRATED) |
| R | ORGANISATION SITE IDENTIFIER (OF TNM STAGE GROUPING INTEGRATED) |
| R | TNM STAGE GROUPING DATE (INTEGRATED) |
| M | TNM CODING EDITION |
| M | TNM 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/O | Data Set Data Elements |
| M | ORGANISATION SITE IDENTIFIER (OF CANCER SITE SPECIFIC STAGE) |
| M | STAGE DATE (CANCER SITE SPECIFIC STAGE) |
| TREATMENT - CORE |
|---|
| To carry the cancer treatment details. Multiple occurrences of this group are permitted. | |
| M/R/O | Data Set Data Elements |
| R | ADJUNCTIVE THERAPY TYPE |
| R | CANCER TREATMENT INTENT |
| M | TREATMENT START DATE (CANCER) |
| M | CANCER TREATMENT MODALITY (REGISTRATION) |
| M | ORGANISATION SITE IDENTIFIER (OF PROVIDER CANCER TREATMENT START DATE) |
| M | PROFESSIONAL REGISTRATION ISSUER CODE (TREATMENT) |
| M | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (TREATMENT) |
| O | CANCER END OF TREATMENT SUMMARY PLAN COMPLETION DATE Multiple occurrences of this item are permitted |
| R | DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE 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/O | Data Set Data Elements |
| M | PROCEDURE DATE |
| R | CANCER SURGICAL ADMISSION TYPE |
| M | PROFESSIONAL REGISTRATION ISSUER CODE (RESPONSIBLE SURGEON) Multiple occurrences of this item are permitted |
| M | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (RESPONSIBLE SURGEON) Multiple occurrences of this item are permitted |
| R | PRIMARY PROCEDURE (OPCS) |
| R | PRIMARY PROCEDURE (SNOMED CT) |
| R | PROCEDURE (OPCS) Multiple occurrences of this item are permitted |
| R | PROCEDURE (SNOMED CT) Multiple occurrences of this item are permitted |
| R | ADDITIONAL UNPLANNED PROCEDURE REQUIRED INDICATOR |
| R | ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE |
| R | SURGICAL 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/O | Data Set Data Elements |
| R | STEM CELL INFUSION SOURCE CODE |
| R | STEM CELL INFUSION DONOR TYPE |
| R | STEM CELL TRANSPLANT CONDITIONING REGIMEN |
| ACUTE ONCOLOGY - CORE |
|---|
| To carry Acute Oncology details. Multiple occurrences of this group are permitted. | |
| M/R/O | Data Set Data Elements |
| R | ACUTE ONCOLOGY ASSESSMENT COMPLETED DATE |
| R | ORGANISATION SITE IDENTIFIER (OF ACUTE ONCOLOGY ASSESSMENT) |
| R | ACUTE ONCOLOGY ASSESSMENT LOCATION |
| R | ACUTE ONCOLOGY ASSESSMENT PATIENT PRESENTATION TYPE Multiple occurrences of this item are permitted |
| R | ACUTE ONCOLOGY EPISODE OUTCOME |
| LABORATORY RESULTS - CORE |
|---|
| To carry laboratory result details. Multiple occurrences of this group are permitted. | |
| M/R/O | Data Set Data Elements |
| M | LABORATORY RESULT AUTHORISED DATE |
| M | ORGANISATION 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/O | Data Set Data Elements |
| R | LACTATE DEHYDROGENASE LEVEL (PEAK AT DIAGNOSIS) |
| R | BETA HUMAN CHORIONIC GONADOTROPIN (MAXIMUM AT DIAGNOSIS) |
| R | ALPHA FETOPROTEIN (MAXIMUM AT DIAGNOSIS) |
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 presentR = 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/R | Data Set Data Elements |
| M | FINAL FIGO STAGE |
| TREATMENT: SURGERY - GYNAECOLOGICAL |
|---|
| To carry surgery details for Gynaecological cancer. One occurrence of this group is permitted per Core Treatment Surgery. | |
| M/R | Data Set Data Elements |
| R | CARE PROFESSIONAL SENIOR OPERATING SURGEON GRADE (CANCER) |
| R | RESIDUAL DISEASE SIZE (GYNAECOLOGICAL CANCER) |
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 presentR = 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/R | Data Set Data Elements |
| M | CHRONIC MYELOID LEUKAEMIA INDEX SCORE (SOKAL) |
| 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/R | Data Set Data Elements |
| M | REVISED INTERNATIONAL PROGNOSTIC SCORING SYSTEM SCORE |
| 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/R | Data Set Data Elements |
| M | SPLENOMEGALY INDICATOR |
| 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/R | Data Set Data Elements |
| R | NUMBER OF ABNORMAL NODAL AREAS |
| R | FOLLICULAR LYMPHOMA INTERNATIONAL PROGNOSTIC INDEX 2 SCORE |
| 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/R | Data Set Data Elements |
| R | NUMBER OF ABNORMAL NODAL AREAS |
| R | PRIMARY EXTRANODAL CANCER SITE |
| R | NUMBER OF EXTRANODAL SITES CODE |
| R | REVISED INTERNATIONAL PROGNOSTIC INDEX SCORE |
| 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/R | Data Set Data Elements |
| R | NUMBER OF ABNORMAL NODAL AREAS |
| R | PRIMARY EXTRANODAL CANCER SITE |
| R | HASENCLEVER INDEX SCORE |
| 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/R | Data Set Data Elements |
| M | EXTRAMEDULLARY 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/R | Data Set Data Elements |
| M | ANN ARBOR STAGE |
| 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/R | Data Set Data Elements |
| M | BINET STAGE |
| 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/R | Data Set Data Elements |
| M | REVISED INTERNATIONAL STAGING SYSTEM STAGE FOR MULTIPLE MYELOMA |
| 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/R | Data Set Data Elements |
| M | MURPHY 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/R | Data Set Data Elements |
| R | ANN ARBOR SYMPTOMS INDICATION CODE |
| R | ANN ARBOR EXTRANODALITY INDICATION CODE |
| R | ANN ARBOR BULKY DISEASE INDICATION CODE |
| R | ANN 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/R | Data Set Data Elements |
| R | EUROPEAN LEUKAEMIA NET GENETIC RISK CODE |
| R | WHITE BLOOD CELL COUNT (HIGHEST PRETREATMENT) |
| 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/R | Data Set Data Elements |
| R | BONE MARROW BLAST CELLS PERCENTAGE |
| R | CYTOGENETIC FINDINGS COMMENT |
| 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/R | Data Set Data Elements |
| R | CELLULARITY PERCENTAGE |
| R | DIEPOXYBUTANE TEST RESULT |
| R | DYSPLASTIC HAEMOPOIESIS TYPE |
| 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/R | Data Set Data Elements |
| M | LEUKAEMIC 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/R | Data Set Data Elements |
| R | MIXED PHENOTYPE ACUTE LEUKAEMIA SYMPTOMS (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | EUROPEAN GROUP FOR THE IMMUNOLOGICAL CLASSIFICATION OF LEUKAEMIA SCORING SYSTEM SCORE |
| 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/R | Data Set Data Elements |
| R | FRENCH AMERICAN BRITISH CLASSIFICATION (ACUTE MYELOID LEUKAEMIA) |
| R | CYTOGENETIC RISK GROUP (PAEDIATRIC MOLECULAR GENETIC ABNORMALITIES) |
| R | ACUTE MYELOID LEUKAEMIA RISK FACTORS (AT DIAGNOSIS) |
| 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/R | Data Set Data Elements |
| R | PAEDIATRIC MYELODYSPLASIA CLINICAL FINDINGS (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | UNDERLYING DISEASE ASSOCIATED WITH MYELODYSPLASIA (AT DIAGNOSIS) Multiple occurrences of this item are permitted |
| R | CONGENITAL ANOMALIES COMMENT |
| R | OTHER 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/R | Data Set Data Elements |
| R | PRIMARY 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/R | Data Set Data Elements |
| M | ALK GENE FUSION STATUS (ANAPLASTIC LARGE CELL LYMPHOMA) |
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 presentR = 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/R | Data Set Data Elements |
| R | SURGICAL ACCESS TYPE (HEAD AND NECK CANCER) |
| R | OTHER 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/R | Data Set Data Elements |
| R | CANCER DENTAL ASSESSMENT DATE |
| R | CARE CONTACT DATE (DIETITIAN INITIAL) |
| R | CARE 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/R | Data Set Data Elements |
| R | CLINICAL STATUS ASSESSMENT DATE (CANCER) |
| R | PRIMARY TUMOUR STATUS |
| R | NODAL STATUS |
| R | METASTATIC STATUS |
| R | SPEECH AND LANGUAGE ASSESSMENT DATE |
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 presentR = 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/R | Data Set Data Elements |
| R | LIVER CANCER SURVEILLANCE SCAN INDICATOR |
| R | LIVER CIRRHOSIS TYPE |
| R | LIVER 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/R | Data Set Data Elements |
| M | CHOLANGIOCARCINOMA 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/R | Data Set Data Elements |
| M | BARCELONA 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/R | Data Set Data Elements |
| R | PORTAL VEIN INVASION INDICATION CODE |
| R | UNITED KINGDOM MODEL FOR END-STAGE LIVER DISEASE SCORE |
| R | CHILD 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/R | Data Set Data Elements |
| R | ABLATIVE THERAPY TYPE |
| R | LIVER TRANSARTERIAL EMBOLISATION MATERIAL INJECTION TYPE |
| TRANSPLANTATION - LIVER |
|---|
| To carry liver transplantation details for Liver cancer. One occurrence of this group is permitted. | |
| M/R | Data Set Data Elements |
| R | LIVER 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/R | Data Set Data Elements |
| R | LIVER SURGERY PERFORMED TYPE |
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 presentR = 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/R | Data Set Data Elements |
| M | TRANSTHORACIC ECHOCARDIOGRAM TEST RESULT |
| 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/R | Data Set Data Elements |
| M | DIFFUSION CAPACITY TEST RESULT |
| 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/R | Data Set Data Elements |
| R | FORCED EXPIRATORY VOLUME IN 1 SECOND (PERCENTAGE) |
| R | FORCED EXPIRATORY VOLUME IN 1 SECOND (ABSOLUTE AMOUNT) |
| 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/R | Data Set Data Elements |
| R | CARDIOPULMONARY EXERCISE TEST TYPE |
| R | CARDIOPULMONARY EXERCISE TEST RESULT |
| 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/R | Data Set Data Elements |
| M | BRONCHOSCOPY 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/R | Data Set Data Elements |
| R | MEDIASTINAL 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/R | Data Set Data Elements |
| R | EPIDERMAL GROWTH FACTOR RECEPTOR MUTATIONAL STATUS |
| R | ALK GENE FUSION STATUS (LUNG CANCER) |
| R | ROS1 FUSION STATUS |
| R | PD-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/R | Data Set Data Elements |
| R | REGIONAL ANAESTHETIC TECHNIQUE (CANCER) |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | COSDS SUBMISSION IDENTIFIER |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | COSDS SUBMISSION RECORD COUNT |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| RECORD IDENTIFIER |
|---|
| To carry the record identifier details. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | COSDS 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/O | Data Set Data Elements |
| M | NHS NUMBER |
| CHOICE 2 - LOCAL PATIENT IDENTIFIER | |
| To carry patient identity details for linkage. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| LINKAGE IDENTIFIER - CORE - PATHOLOGY |
|---|
| To carry patient identity details for linkage. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | NHS NUMBER STATUS INDICATOR CODE |
| M | PERSON BIRTH DATE |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| DEMOGRAPHICS - CORE - PATHOLOGY |
|---|
| To carry patient demographic details. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | PERSON FAMILY NAME |
| R | PERSON GIVEN NAME |
| R | PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS STRUCTURED or PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS UNSTRUCTURED |
| R | POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS) |
| R | PERSON STATED GENDER CODE |
| PATHOLOGY DETAILS PART 1 - CORE - PATHOLOGY |
|---|
| TOPOGRAPHY/MORPHOLOGY - CORE - PATHOLOGY |
|---|
| To carry Topography/Morphology SNOMED pathology details. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| M | SNOMED 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/O | Data Set Data Elements |
| M | TOPOGRAPHY (SNOMED PATHOLOGY) Multiple occurrences of this item are permitted |
| CHOICE 2 - MORPHOLOGY SNOMED | |
| To carry pathology Morphology SNOMED details. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | MORPHOLOGY (SNOMED PATHOLOGY) Multiple occurrences of this item are permitted |
| PATHOLOGY DETAILS PART 2 CORE - PATHOLOGY |
|---|
| BREAST - PATHOLOGY |
|---|
| 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/O | Data Set Data Elements |
| R | MOLECULAR DIAGNOSTIC CODE Multiple occurrences of this item are permitted |
| R | HORMONE 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/O | Data Set Data Elements |
| R | MARGIN INVOLVED INDICATION CODE (COLORECTAL PROXIMAL OR DISTAL RESECTION MARGIN) |
| R | DISTANCE TO CLOSEST NON PERITONEALISED RESECTION MARGIN |
| R | PLANE OF SURGICAL EXCISION INDICATOR |
| R | DISTANCE FROM DENTATE LINE |
| R | DISTANCE BEYOND MUSCULARIS PROPRIA |
| R | PREOPERATIVE THERAPY RESPONSE TYPE |
| R | MARGIN 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/O | Data Set Data Elements |
| R | TUMOUR RUPTURE INDICATOR (PATHOLOGICAL) |
| R | ANAPLASTIC NEPHROBLASTOMA TYPE |
| R | TUMOUR INVASION INDICATOR (PERIRENAL FAT) |
| R | TUMOUR INVASION INDICATOR (RENAL SINUS) |
| R | RENAL VEIN TUMOUR INDICATOR (PAEDIATRIC KIDNEY) |
| R | VIABLE TUMOUR EVIDENCE AT RESECTION MARGIN |
| R | INTERNATIONAL 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/O | Data Set Data Elements |
| R | MICROSCOPIC INVOLVEMENT INDICATION CODE (FALLOPIAN TUBE) |
| R | MICROSCOPIC INVOLVEMENT INDICATION CODE (OVARIAN) |
| R | MICROSCOPIC INVOLVEMENT INDICATION CODE (UTERINE SEROSA) |
| R | OMENTUM 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/O | Data Set Data Elements |
| R | GYNAECOLOGICIAL CAPSULE STATUS |
| R | OVARY SURFACE INVOLVEMENT INDICATOR |
| R | PERITONEAL CYTOLOGY RESULT CODE |
| R | PERITONEAL INVOLVEMENT INDICATION CODE |
| GYNAECOLOGICAL: ENDOMETRIAL - PATHOLOGY |
|---|
| To carry pathology details for Gynaecological cancer for Endometrial. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | MICROSCOPIC INVOLVEMENT INDICATOR (CERVICAL STROMA) |
| R | MYOMETRIAL INVASION IDENTIFICATION CODE |
| R | MICROSCOPIC INVOLVEMENT INDICATOR (PARAMETRIUM) |
| R | PERITONEAL WASHINGS IDENTIFIED |
| R | PERITONEAL INVOLVEMENT INDICATOR (ENDOMETRIAL CANCER) |
| R | GYNAECOLOGICIAL 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/O | Data Set Data Elements |
| R | CERVICAL GLANDULAR INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE |
| R | CERVICAL INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE |
| R | SMILE INDICATION CODE |
| R | RESECTION MARGIN INVOLVEMENT INDICATOR |
| R | PARACERVICAL OR PARAMETRIAL INVOLVEMENT INDICATOR |
| R | UNINVOLVED CERVICAL STROMA THICKNESS |
| R | MICROSCOPIC INVOLVEMENT INDICATOR (VAGINAL) |
| R | INVASIVE THICKNESS |
| GYNAECOLOGICAL: NODES - PATHOLOGY |
|---|
| To carry pathology details for Gynaecological cancer for Nodes. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | NUMBER OF NODES EXAMINED (PARA-AORTIC) |
| R | NUMBER OF NODES POSITIVE (PARA-AORTIC) |
| R | NUMBER OF NODES EXAMINED (PELVIC) |
| R | NUMBER OF NODES POSITIVE (PELVIC) |
| R | NUMBER OF NODES EXAMINED (INGUINO-FEMORAL) |
| R | NUMBER OF NODES POSITIVE (INGUINO-FEMORAL) |
| R | EXTRANODAL 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/O | Data Set Data Elements |
| R | MAXIMUM DEPTH OF INVASION |
| R | BONE INVASION INDICATION CODE |
| R | CARTILAGE INVASION INDICATION CODE |
| R | ANATOMICAL 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/O | Data Set Data Elements |
| M | MACROSCOPIC 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/O | Data Set Data Elements |
| R | ANATOMICAL SIDE (POSITIVE NODES) |
| R | LARGEST METASTASIS (LEFT NECK) |
| R | LARGEST METASTASIS (RIGHT NECK) |
| R | EXTRACAPSULAR 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/O | Data Set Data Elements |
| R | P16 IMMUNOHISTOCHEMISTRY TEST RESULT |
| R | HUMAN 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/O | Data Set Data Elements |
| R | EXTENT OF ATELECTASIS |
| R | EXTENT OF PLEURAL INVASION |
| R | TUMOUR INVASION INDICATOR (PERICARDIUM) |
| R | TUMOUR INVASION INDICATOR (DIAPHRAGM) |
| R | TUMOUR INVASION INDICATOR (GREAT VESSELS) |
| R | TUMOUR INVASION INDICATOR (HEART) |
| R | MALIGNANT PLEURAL EFFUSION INDICATOR |
| R | TUMOUR INVASION INDICATOR (MEDIASTINUM) |
| R | SATELLITE 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/O | Data Set Data Elements |
| R | GENETIC CONFIRMATION INDICATOR |
| SARCOMA: BONE - PATHOLOGY |
|---|
| To carry pathology details for Sarcoma for Bone. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | SARCOMA TUMOUR BREACH IDENTIFIER |
| R | TUMOUR NECROSIS PERCENTAGE |
| SARCOMA: SOFT TISSUE - PATHOLOGY |
|---|
| To carry pathology details for Sarcoma for Soft Tissue. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | SARCOMA TUMOUR DEPTH |
| R | MITOTIC 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/O | Data Set Data Elements |
| R | SKIN CANCER LESION SPECIMEN IDENTIFIER |
| R | PERINEURAL INVASION INDICATOR (SKIN) |
| R | LESION 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/O | Data Set Data Elements |
| R | SKIN CANCER LESION SPECIMEN IDENTIFIER |
| R | PERINEURAL INVASION INDICATOR (SKIN) |
| R | LESION DIAMETER GREATER THAN 20MM INDICATION CODE |
| R | CLARKS LEVEL IV INDICATION CODE |
| R | LESION 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/O | Data Set Data Elements |
| R | SKIN CANCER LESION SPECIMEN IDENTIFIER |
| R | SKIN ULCERATION INDICATION CODE |
| R | MITOTIC RATE (SKIN) |
| R | MICROSATELLITE OR IN-TRANSIT METASTASIS INDICATION CODE |
| R | TUMOUR REGRESSION INDICATION CODE (SKIN) |
| R | BRESLOW THICKNESS |
| R | TUMOUR INFILTRATING LYMPHOCYTE TYPE |
| R | NUMBER OF SENTINEL NODES SAMPLED |
| R | NUMBER OF SENTINEL NODES POSITIVE |
| R | NUMBER OF NODES SAMPLED (POST SENTINEL NODE COMPLETION LYMPHADENECTOMY) |
| R | NUMBER 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/O | Data Set Data Elements |
| R | NUMBER OF COLORECTAL METASTASES IN LIVER |
| R | MARGIN INVOLVED INDICATION CODE (PROXIMAL OR DISTAL RESECTION MARGIN) |
| R | MARGIN 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/O | Data Set Data Elements |
| R | DETRUSOR MUSCLE PRESENCE INDICATION CODE |
| R | TUMOUR GRADE (UROLOGY) |
| UROLOGICAL: KIDNEY - PATHOLOGY |
|---|
| To carry pathology details for Urological cancer for the kidney. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | TUMOUR NECROSIS INDICATION CODE |
| R | TUMOUR INVASION INDICATOR (PERINEPHRIC FAT) |
| R | TUMOUR INVASION INDICATION CODE (DIRECT ADRENAL) |
| R | RENAL VEIN TUMOUR THROMBUS INDICATION CODE (UROLOGICAL) |
| R | TUMOUR 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/O | Data Set Data Elements |
| R | TUMOUR INVASION INDICATOR (CORPUS SPONGIOSUM) |
| R | TUMOUR INVASION INDICATOR (CORPUS CAVERNOSUM) |
| R | TUMOUR 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/O | Data Set Data Elements |
| R | GLEASON GRADE (PRIMARY) |
| R | GLEASON GRADE (SECONDARY) |
| R | GLEASON GRADE (TERTIARY) |
| R | PERINEURAL INVASION INDICATOR (UROLOGICAL) |
| R | TURP TUMOUR PERCENTAGE |
| UROLOGICAL: TESTICULAR - PATHOLOGY |
|---|
| To carry pathology details for Urological cancer for testicular. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| M | TUMOUR INVASION INDICATOR (RETE TESTIS) |
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 presentR = 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/R | Data Set Data Elements |
| R | SARCOMA TUMOUR SITE (BONE) |
| R | SARCOMA TUMOUR SUBSITE (BONE) |
| R | SARCOMA TUMOUR SITE (SOFT TISSUE) |
| R | SARCOMA TUMOUR SUBSITE (SOFT TISSUE) |
| R | MULTIFOCAL 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/R | Data Set Data Elements |
| R | INTERGROUP RHABDOMYOSARCOMA STUDY POST SURGICAL GROUP |
| R | INTERGROUP RHABDOMYOSARCOMA STUDY POST SURGICAL GROUP DATE |
| R | RHABDOMYOSARCOMA SITE PROGNOSIS CODE |
| 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/R | Data Set Data Elements |
| M | TUMOUR 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/R | Data Set Data Elements |
| M | CYTOGENETIC PRESENCE TYPE (RHABDOMYOSARCOMA) |
| 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/R | Data Set Data Elements |
| M | CYTOGENETIC ANALYSIS CODE |
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 presentR = 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/R | Data Set Data Elements |
| R | CARE PROFESSIONAL OPERATING SURGEON TYPE (CANCER) |
| R | MEMBER OF SPECIALIST MULTIDISCIPLINARY TEAM INDICATOR |
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 presentR = 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/R | Data Set Data Elements |
| M | PALLIATIVE 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/R | Data Set Data Elements |
| M | POST 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/R | Data Set Data Elements |
| R | INTERNATIONAL ESOPHAGEAL DATABASE SURGICAL COMPLICATIONS Multiple occurrences of this item are permitted |
| R | OESOPHAGOENTERIC LEAK SEVERITY TYPE |
| R | OESOPHAGECTOMY OESOPHAGEAL CONDUIT NECROSIS FAILURE TYPE |
| R | RECURRENT LARYNGEAL NERVE INJURY INVOLVEMENT TYPE |
| R | CHYLE LEAK SEVERITY TYPE |
| R | CALVIEN-DINDO CLASSIFICATION OF SURGICAL CLASSIFICATIONS |
| R | ADDITIONAL 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/R | Data Set Data Elements |
| R | ESCALATION IN LEVEL OF PATIENT CARE FOLLOWING OESOPHAGECTOMY INDICATOR |
| R | BLOOD PRODUCTS REQUIRED FOLLOWING OESOPHAGECTOMY INDICATION CODE |
| R | UNITS 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/R | Data Set Data Elements |
| R | OESOPHAGECTOMY SURGICAL APPROACH TYPE |
| R | OPEN OESOPHAGECTOMY SURGICAL APPROACH TYPE |
| R | MINIMALLY INVASIVE OESOPHAGECTOMY SURGICAL APPROACH TYPE |
| R | OESOPHAGECTOMY ANASTOMOSIS TYPE |
| R | OESOPHAGECTOMY OESOPHAGEAL CONDUIT TYPE |
| R | OESOPHAGECTOMY 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/R | Data Set Data Elements |
| M | SURGICAL 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/R | Data Set Data Elements |
| M | ENDOSCOPIC 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/R | Data Set Data Elements |
| M | ENDOSCOPIC OR RADIOLOGICAL COMPLICATION TYPE Multiple occurrences of this item are permitted |
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 presentR = 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/R | Data Set Data Elements |
| M | PRETREATMENT PROSTATE BIOPSY TECHNIQUE TYPE |
| M | BIOPSY 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/R | Data Set Data Elements |
| R | MULTIPARAMETRIC MRI SCAN INDICATOR |
| R | MRI ULTRASOUND FUSION GUIDED BIOPSY INDICATOR |
| R | PROSTATE 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/R | Data Set Data Elements |
| R | ESTIMATED GLOMERULAR FILTRATION RATE |
| R | HYDRONEPHROSIS CODE |
| R | S 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/R | Data Set Data Elements |
| R | S CATEGORY (ALPHA FETOPROTEIN) |
| R | S CATEGORY (HUMAN CHORIONIC GONADOTROPIN) |
| R | S CATEGORY (LACTATE DEHYDROGENASE) |
| R | LACTATE 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/R | Data Set Data Elements |
| R | STAGE GROUPING (TESTICULAR CANCER) |
| R | EXTENT OF METASTATIC SPREAD Multiple occurrences of this item are permitted |
| R | LUNG 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/R | Data Set Data Elements |
| M | INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR |
| 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/R | Data Set Data Elements |
| M | INTRAVESICAL 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/R | Data Set Data Elements |
| R | PROSTATE NERVE SPARING SURGERY TYPE |
| R | RADICAL PROSTATECTOMY MARGIN STATUS |
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 presentR = 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/O | Data Set Data Elements |
| R | REPORTING PERIOD START DATE |
| R | REPORTING PERIOD END DATE |
| M | LABORATORY CODE |
| Person Demographics: To carry the demographic details of the person tested. | |
| M/R | Data Set Data Elements |
| R | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| M | PERSON STATED GENDER CODE |
| R | PERSON BIRTH DATE |
| M | ETHNIC CATEGORY |
| M | POSTCODE OF USUAL ADDRESS |
| M | POSTCODE OF GENERAL MEDICAL PRACTICE (PATIENT REGISTRATION) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| Testing Service Provider Details: To carry the details of the testing service provider. | |
|---|---|
| M/R | Data Set Data Elements |
| M | POSTCODE OF TESTING SERVICE (CHLAMYDIA TESTING) |
R | SITE CODE (PROVIDER OF CHLAMYDIA TEST) or ORGANISATION CODE (PROVIDER OF CHLAMYDIA TEST) |
| M | SERVICE TYPE (CHLAMYDIA TESTING) |
| R | CLINIC CODE (NATIONAL CHLAMYDIA SCREENING PROGRAMME) |
| Test Details: To carry the details of the tests and results provided. | |
|---|---|
| M/R | Data Set Data Elements |
| M | TEST IDENTIFIER (CHLAMYDIA TESTING) |
| M | SPECIMEN TYPE (CHLAMYDIA TESTING) |
| O | SPECIMEN TYPE (CHLAMYDIA TESTING SNOMED CT) |
| R | SAMPLE COLLECTION DATE |
| M | SAMPLE RECEIPT DATE |
| R | INVESTIGATION RESULT DATE |
| M | CHLAMYDIA TEST RESULT |
| O | CHLAMYDIA TEST RESULT (SNOMED CT) |
Change to Data Set: Changed Description
Community Services Data Set Overview
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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 |
|---|
| PATIENT DEMOGRAPHICS |
|---|
| 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 | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| R | START DATE (GMP PATIENT REGISTRATION) |
| R | END DATE (GMP PATIENT REGISTRATION) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ACCOMMODATION STATUS CODE |
| R | ACCOMMODATION 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/O | Data Set Data Elements |
| M | CARE PLAN IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | CARE PLAN TYPE (COMMUNITY CARE) |
| M | CARE PLAN CREATION DATE |
| R | CARE PLAN CREATION TIME |
| R | CARE PLAN LAST UPDATED DATE |
| R | CARE PLAN LAST UPDATED TIME |
| R | CARE 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/O | Data Set Data Elements |
| M | CARE PLAN IDENTIFIER |
| M | CARE PLAN AGREED BY |
| R | CARE PLAN AGREED DATE |
| R | CARE 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) |
| M | SOCIAL 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | EMPLOYMENT STATUS |
| R | EMPLOYMENT STATUS RECORDED DATE |
| R | WEEKLY 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | REFERRAL REQUEST RECEIVED DATE |
| R | REFERRAL REQUEST RECEIVED TIME |
| O | NHS SERVICE AGREEMENT LINE NUMBER |
| R | SOURCE OF REFERRAL FOR COMMUNITY |
| R | ORGANISATION IDENTIFIER (REFERRING) |
| R | REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH AND COMMUNITY CARE) |
| R | PRIORITY TYPE CODE |
| R | PRIMARY REASON FOR REFERRAL (COMMUNITY CARE) |
| R | SERVICE DISCHARGE DATE |
| R | DISCHARGE 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | SERVICE OR TEAM TYPE REFERRED TO (COMMUNITY CARE) |
| R | REFERRAL CLOSURE DATE |
| R | REFERRAL REJECTION DATE |
| R | REFERRAL CLOSURE REASON |
| R | REFERRAL 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | OTHER 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| R | UNIQUE BOOKING REFERENCE NUMBER (CONVERTED) |
| R | PATIENT PATHWAY IDENTIFIER |
| R | ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) |
| R | WAITING TIME MEASUREMENT TYPE |
| R | REFERRAL TO TREATMENT PERIOD START DATE |
| R | REFERRAL TO TREATMENT PERIOD START TIME |
| R | REFERRAL TO TREATMENT PERIOD END DATE |
| R | REFERRAL TO TREATMENT PERIOD END TIME |
| R | REFERRAL 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 | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | ONWARD REFERRAL DATE |
| R | ONWARD REFERRAL REASON |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | CARE CONTACT IDENTIFIER |
| M | SERVICE REQUEST IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | CARE CONTACT DATE |
| R | CARE CONTACT TIME |
| R | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | ADMINISTRATIVE CATEGORY CODE |
| R | CLINICAL CONTACT DURATION OF CARE CONTACT |
| R | CONSULTATION TYPE |
| R | CARE CONTACT SUBJECT |
| R | CONSULTATION MEDIUM USED |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | GROUP THERAPY INDICATOR |
| R | ATTENDED OR DID NOT ATTEND CODE |
| R | EARLIEST REASONABLE OFFER DATE |
| R | EARLIEST CLINICALLY APPROPRIATE DATE |
| R | CARE CONTACT CANCELLATION DATE |
| R | CARE CONTACT CANCELLATION REASON |
| R | REPLACEMENT APPOINTMENT DATE OFFERED |
| R | REPLACEMENT 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CARE CONTACT IDENTIFIER |
| M | COMMUNITY CARE ACTIVITY TYPE |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| R | PROCEDURE SCHEME IN USE |
| R | CODED PROCEDURE (CLINICAL TERMINOLOGY) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | OBSERVATION SCHEME IN USE |
| R | CODED OBSERVATION (CLINICAL TERMINOLOGY) |
| R | OBSERVATION VALUE |
| R | UCUM 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/O | Data Set Data Elements |
| M | GROUP SESSION IDENTIFIER |
| M | GROUP SESSION DATE |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | CLINICAL CONTACT DURATION OF GROUP SESSION |
| R | GROUP SESSION TYPE (COMMUNITY CARE) |
| R | NUMBER OF GROUP SESSION PARTICIPANTS |
| O | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| O | NHS 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | SPECIAL 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | SAFEGUARDING 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | CHILD PROTECTION PLAN REASON CODE |
| M | CHILD PROTECTION PLAN START DATE |
| R | CHILD 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) |
| R | PRESCRIPTION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | IMMUNISATION DATE |
| M | PROCEDURE SCHEME IN USE |
| M | IMMUNISATION PROCEDURE (CLINICAL TERMINOLOGY) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | IMMUNISATION DATE |
| M | CHILDHOOD IMMUNISATION TYPE (CHILDREN AND YOUNG PEOPLE'S HEALTH SERVICES) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | DIAGNOSIS SCHEME IN USE |
| M | PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | DISABILITY CODE |
| R | DISABILITY 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | NEWBORN HEARING SCREENING OUTCOME |
| R | SERVICE REQUEST DATE (NEWBORN HEARING AUDIOLOGY) |
| R | PROCEDURE DATE (NEWBORN HEARING AUDIOLOGY) |
| R | NEWBORN 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | BLOOD SPOT CARD COMPLETION DATE |
| R | NEWBORN BLOOD SPOT TEST RESULT RECEIVED DATE |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (PHENYLKETONURIA) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (SICKLE CELL DISEASE) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (CYSTIC FIBROSIS) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (CONGENITAL HYPOTHYROIDISM) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (MEDIUM CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (HOMOCYSTINURIA) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (MAPLE SYRUP URINE DISEASE) |
| R | NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE (GLUTARIC ACIDURIA TYPE 1) |
| R | NEWBORN 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | INFANT PHYSICAL EXAMINATION DATE |
| R | INFANT PHYSICAL EXAMINATION RESULT (HIPS) |
| R | INFANT PHYSICAL EXAMINATION RESULT (HEART) |
| R | INFANT PHYSICAL EXAMINATION RESULT (EYES) |
| R | INFANT 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | PROVISIONAL 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| R | ASSESSMENT 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | BREASTFEEDING 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| R | PERSON WEIGHT |
| R | PERSON HEIGHT IN METRES |
| R | PERSON 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON 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/O | Data Set Data Elements |
| M | ASSESSMENT TOOL COMPLETION DATE |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | PROFESSIONAL REGISTRATION BODY CODE |
| R | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER |
| R | CARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE) |
| R | OCCUPATION CODE |
| R | CARE PROFESSIONAL (JOB ROLE CODE) |
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. | |
| M | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING 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. | |
| M | Data Set Data Elements |
| M | CHILDHOOD IMMUNISATION TYPE (COVER) or CHILDHOOD IMMUNISATION TYPE COMBINED (COVER) |
| M | ELIGIBLE POPULATION TOTAL (COVER) |
| M | ELIGIBLE 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. | |
| M | Data Set Data Elements |
| M | CHILDHOOD IMMUNISATION TYPE (COVER) or CHILDHOOD IMMUNISATION TYPE COMBINED (COVER) |
| M | ELIGIBLE POPULATION TOTAL (COVER) |
| M | ELIGIBLE 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. | |
| M | Data Set Data Elements |
| M | CHILDHOOD IMMUNISATION TYPE (COVER) or CHILDHOOD IMMUNISATION TYPE COMBINED (COVER) |
| M | ELIGIBLE POPULATION TOTAL (COVER) |
| M | ELIGIBLE 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. | |
| M | Data Set Data Elements |
| M | CHILDHOOD IMMUNISATION TYPE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) or CHILDHOOD IMMUNISATION TYPE COMBINED (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) |
| M | ELIGIBLE POPULATION TOTAL (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) |
| M | ELIGIBLE 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. | |
| M | Data Set Data Elements |
| M | CHILDHOOD IMMUNISATION TYPE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) or CHILDHOOD IMMUNISATION TYPE COMBINED (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) |
| M | ELIGIBLE POPULATION TOTAL (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) |
| M | ELIGIBLE POPULATION IMMUNISED PERCENTAGE (COVER HEPATITIS B SURFACE ANTIGEN POSITIVE MOTHER) |
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:
CDS V6-2 Type 120 - Admitted Patient Care - Finished Birth Episode Commissioning Data SetCDS V6-2 Type 130 - Admitted Patient Care - Finished General Episode Commissioning Data SetCDS V6-2 Type 140 - Admitted Patient Care - Finished Delivery Episode Commissioning Data SetCDS V6-2 Type 180 - Admitted Patient Care - Unfinished Birth Episode Commissioning Data SetCDS V6-2 Type 190 - Admitted Patient Care - Unfinished General Episode Commissioning Data SetCDS V6-2 Type 200 - Admitted Patient Care - Unfinished Delivery Episode Commissioning 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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | FINANCIAL MONTH |
| M | FINANCIAL YEAR |
| M | DATE 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/O | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | ORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| DEMOGRAPHICS |
|---|
| To carry the demographic details of the patient. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | WITHHELD IDENTITY REASON |
| R | NHS NUMBER |
| R | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | AGE AT ACTIVITY DATE (CONTRACT MONITORING) |
| R | PERSON STATED GENDER CODE |
| CARE ACTIVITY DETAILS |
|---|
| SERVICE AGREEMENT AND COMMISSIONING DETAILS |
|---|
| COST AND PRICING DETAILS |
|---|
| To carry the cost and pricing details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | UNIT PRICE (SUPPLIER) |
| M | UNIT PRICE (COMMISSIONER) |
| M | VALUE ADDED TAX CHARGED INDICATOR (CONTRACT MONITORING) |
| M | TOTAL COST |
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 presentR = 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/R | Data Set Data Elements |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | PERSON BIRTH DATE |
| R | ETHNIC CATEGORY |
| R | PERSON GENDER CODE CURRENT |
| R | POSTCODE OF USUAL ADDRESS |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| REFERRALS |
|---|
| To carry referral details. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | PATIENT SOURCE SETTING TYPE (DIAGNOSTIC IMAGING) |
| R | REFERRER CODE |
| R | REFERRING ORGANISATION CODE |
| R | DIAGNOSTIC TEST REQUEST DATE |
| R | DIAGNOSTIC TEST REQUEST RECEIVED DATE |
| IMAGING ACTIVITY |
|---|
| To carry imaging details. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | IMAGING CODE (NICIP) and/or IMAGING CODE (SNOMED-CT) |
| M | DIAGNOSTIC TEST DATE |
| R | SERVICE REPORT ISSUE DATE |
| M | SITE CODE (OF IMAGING) |
| M | RADIOLOGICAL ACCESSION NUMBER |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | FINANCIAL MONTH |
| M | FINANCIAL YEAR |
| M | DATE 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/O | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | ORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| DEMOGRAPHICS |
|---|
| To carry the demographic details of the patient. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | WITHHELD IDENTITY REASON |
| R | NHS NUMBER |
| R | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | AGE AT ACTIVITY DATE (CONTRACT MONITORING) |
| R | PERSON STATED GENDER CODE |
| CARE ACTIVITY DETAILS |
|---|
| SERVICE AGREEMENT AND COMMISSIONING DETAILS |
|---|
| COST AND PRICING DETAILS |
|---|
| To carry the service cost and pricing details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | UNIT PRICE (SUPPLIER) |
| M | UNIT PRICE (COMMISSIONER) |
| M | HOME DELIVERY CHARGE (HIGH COST TARIFF EXCLUDED DRUG) |
| M | VALUE ADDED TAX CHARGED INDICATOR (CONTRACT MONITORING) |
| M | TOTAL COST |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | ORGANISATION CODE (CODE OF PROVIDER) |
| R | NHS NUMBER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | PERSON BIRTH DATE |
| M | POSTCODE OF USUAL ADDRESS |
| M | PERSON GIVEN NAME (FIRST) |
| M | PERSON FAMILY NAME |
| R | COUNTRY CODE (BIRTH) |
| R | COUNTRY CODE (ORIGIN) |
| O | REGION OF COUNTRY CODE FOR FEMALE GENITAL MUTILATION (ORIGIN) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| CARE CONTACT |
|---|
| FEMALE GENITAL MUTILATION |
|---|
| To carry female genital mutilation details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | ORGANISATION CODE (CODE OF PROVIDER) |
| R | NHS NUMBER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | PERSON BIRTH DATE |
| M | CARE CONTACT DATE |
| R | FEMALE GENITAL MUTILATION IDENTIFIED TYPE CODE |
| O | FEMALE GENITAL MUTILATION TYPE 4 CODE |
| R | DEINFIBULATION UNDERTAKEN REASON |
| R | FEMALE GENITAL MUTILATION AGE CATEGORY |
| R | COUNTRY CODE (FEMALE GENITAL MUTILATION PERFORMED) |
Change to Data Set: Changed Description
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 presentR = 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/R | Data Set Data Elements |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| M | CLINIC TYPE (SEXUAL HEALTH SERVICE) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | PERSON RISK FACTOR (SEXUALLY TRANSMITTED INFECTION) |
| M | GENDER IDENTITY CODE (SEXUAL HEALTH) |
| M | GENDER IDENTITY SAME AT BIRTH INDICATOR |
| M | AGE AT ATTENDANCE DATE |
| M | PERSON STATED SEXUAL ORIENTATION CODE |
| M | ETHNIC CATEGORY |
| M | COUNTRY CODE (BIRTH) |
| M | ONS LOCAL GOVERNMENT GEOGRAPHIC AREA CODE (LOCAL AUTHORITY DISTRICT) |
| M | LOWER LAYER SUPER OUTPUT AREA (PERSON RESIDENCE) |
| CLINIC ATTENDANCE AND ACTIVITY DETAILS |
|---|
| PARTNER DETAILS |
|---|
| To carry the opposite sex partnership details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | NUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (OPPOSITE SEX PARTNERS) |
| M | NEW SEX PARTNERS IN LAST THREE MONTHS INDICATOR (OPPOSITE SEX PARTNERS) |
| M | CONDOMLESS 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/R | Data Set Data Elements |
| M | NUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (MALE SAME SEX PARTNERS) |
| M | HIV POSITIVE PARTNERS IN LAST THREE MONTHS INDICATOR (PENETRATIVE SEX MALE SAME SEX PARTNERS) |
| M | CONDOMLESS SEX INDICATOR (PENETRATIVE SEX MALE SAME SEX PARTNERS IN THE LAST THREE MONTHS) |
| M | CONDOMLESS 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/R | Data Set Data Elements |
| M | NUMBER OF SEX PARTNERS IN LAST THREE MONTHS CODE (FEMALE SAME SEX PARTNERS) |
| M | NEW 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/R | Data Set Data Elements |
| M | INITIAL PARTNER NOTIFICATION DISCUSSION DATE |
| M | NUMBER OF PATIENT REPORTED PARTNERS FOR DIAGNOSED SEXUALLY TRANSMITTED INFECTION |
| M | NUMBER OF CONTACTABLE PATIENT REPORTED PARTNERS FOR DIAGNOSED SEXUALLY TRANSMITTED INFECTION |
| M | NUMBER OF PATIENT PARTNERS REPORTED AS ATTENDED A SEXUAL HEALTH SERVICE |
| M | NUMBER 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/R | Data Set Data Elements |
| M | PRE EXPOSURE PROPHYLAXIS ELIGIBILITY REASON |
| M | PRE EXPOSURE PROPHYLAXIS OFFER STATUS CODE |
| M | PRE EXPOSURE PROPHYLAXIS DRUG REGIMEN CODE |
| M | PRESCRIBED ITEM QUANTITY (PRE EXPOSURE PROPHYLAXIS) |
| M | PRE EXPOSURE PROPHYLAXIS STOPPED REASON |
| DRUG AND ALCOHOL USAGE DETAILS |
|---|
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | HARS SUBMISSION IDENTIFIER |
| M | HARS SUBMISSION RECORD COUNT |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | HARS MESSAGE VERSION IDENTIFIER |
| M | ORGANISATION CODE (CODE OF SUBMITTING ORGANISATION) |
| M | DATE AND TIME DATA SET CREATED |
| M | HARS TEST INDICATOR |
| RECORD IDENTIFIER |
|---|
| To carry the record identifier details. One occurrence of this group is required. | |
| M/R/O | Data Set Data Elements |
| M | HARS UNIQUE IDENTIFIER |
| PERSONAL AND DEMOGRAPHIC |
|---|
| To carry personal and demographic details for the patient. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| R | PATIENT CONSENT OBTAINED INDICATOR (CARE PROFESSIONAL CONTACT) |
| R | YEAR AND MONTH OF LAST CARE PROFESSIONAL HIV COMMUNICATION |
| M | PERSON SURNAME SOUNDEX CODE |
| R | PERSON INITIAL (FIRST) |
| R | PERSON BIRTH DATE |
| M | GENDER IDENTITY CODE (SEXUAL HEALTH) |
| M | GENDER IDENTITY SAME AT BIRTH INDICATOR |
| R | ETHNIC CATEGORY |
| R | COUNTRY CODE (BIRTH) |
| M | LOWER LAYER SUPER OUTPUT AREA (PERSON RESIDENCE) |
| R | PRISONER INDICATOR |
| R | CURRENT SEX WORKER INDICATOR |
| R | DISABILITY 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/O | Data Set Data Elements |
| M | ORGANISATION CODE (CODE OF PROVIDER) |
| M | SITE CODE (OF TREATMENT) |
| M | PATIENT HIV CARE STATUS |
| R | SITE CODE (OF PREVIOUS HIV CARE) |
| R | SITE 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/O | Data Set Data Elements |
| R | CONSULTATION MEDIUM USED |
| R | CLINIC ATTENDANCE PURPOSE CODE (HIV) |
| R | CARE PROFESSIONAL TYPE (HIV) Multiple occurrences of this item are permitted |
| M | ATTENDANCE DATE |
| DIAGNOSIS |
|---|
| TREATMENT |
|---|
| To carry treatment details for the patient. One occurrence of this group is permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | FIRST ANTIRETROVIRAL THERAPY IN UNITED KINGDOM INDICATOR |
| R | YEAR AND MONTH FIRST STARTED ANTIRETROVIRAL THERAPY |
| R | START DATE (ANTIRETROVIRAL THERAPY AT CURRENT PROVIDER) |
| R | POST-EXPOSURE PROPHYLAXIS INDICATOR |
| R | PRE-EXPOSURE PROPHYLAXIS INDICATOR |
| R | ANTIRETROVIRAL THERAPY DRUG (SNOMED CT DM+D) Multiple occurrences of this item are permitted |
| M | ANTIRETROVIRAL THERAPY DRUG REGIMEN GROUP CODE |
| R | ANTIRETROVIRAL THERAPY HOME DELIVERY INDICATOR |
| CLINICAL INFORMATION |
|---|
| To carry clinical information details for the patient. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | CD4 CELL COUNT PERFORMED INDICATOR |
| R | CD4 CELL COUNT |
| M | VIRAL LOAD COUNT PERFORMED INDICATOR |
| R | VIRAL LOAD COUNT |
| R | AIDS DEFINING ILLNESS CODE ADULT (SNOMED CT) Multiple occurrences of this item are permitted |
| M | PATIENT DIAGNOSIS INDICATOR (VIRAEMIA) |
| M | TUBERCULOSIS TREATMENT INDICATOR (HIV) |
| M | CHRONIC VIRAL LIVER DISEASE TREATMENT INDICATOR (HIV) |
| M | HEPATITIS B INFECTION INDICATION CODE |
| M | HEPATITIS C INFECTION INDICATION CODE |
| M | MALIGNANCY TREATMENT INDICATOR (HIV) |
| M | PATIENT DIAGNOSIS INDICATOR (HIV END ORGAN DISEASE) |
| M | PSYCHIATRIC CARE INDICATOR (HIV) |
| M | PREGNANCY INDICATOR (HIV) |
| M | SOCIAL WORKER CARE INDICATOR (HIV) |
| O | LATENT TUBERCULOSIS TEST PERFORMED INDICATOR |
| R | OFFER STATUS (HUMAN PAPILLOMAVIRUS VACCINATION) |
| R | HUMAN PAPILLOMAVIRUS VACCINATION DOSE GIVEN |
| DEATH |
|---|
| To carry death details for the patient. One occurrence of this group is permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | PERSON DEATH DATE |
| R | DEATH CAUSE ICD CODE (CARE PROFESSIONAL REPORTED) Multiple occurrences of this item are permitted |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | DATA SET VERSION NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | PRIMARY DATA COLLECTION SYSTEM IN USE |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE 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 | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER) |
| R | ORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY) |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | PERSON BIRTH DATE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON STATED GENDER CODE |
| R | ETHNIC CATEGORY |
| R | EX-BRITISH ARMED FORCES INDICATOR |
| R | LANGUAGE CODE (PREFERRED) |
| R | EDUCATIONAL 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| R | START DATE (GMP PATIENT REGISTRATION) |
| R | END DATE (GMP PATIENT REGISTRATION) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | EMPLOYMENT STATUS |
| R | EMPLOYMENT STATUS RECORDED DATE |
| R | WEEKLY HOURS WORKED |
| R | SELF EMPLOYED INDICATOR |
| R | SICKNESS ABSENCE INDICATOR |
| R | STATUTORY SICK PAY RECEIPT INDICATOR |
| R | BENEFIT RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) |
| R | JOBSEEKERS ALLOWANCE RECEIPT INDICATOR |
| R | EMPLOYMENT AND SUPPORT ALLOWANCE RECEIPT INDICATOR |
| R | UNIVERSAL CREDIT RECEIPT INDICATOR |
| R | PERSONAL INDEPENDENCE PAYMENT RECEIPT INDICATOR |
| R | OTHER BENEFITS RECEIPT INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) |
| R | EMPLOYMENT SUPPORT SUITABILITY INDICATOR |
| R | EMPLOYMENT 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | DISABILITY 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) |
| R | SOCIAL 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 | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | OVERSEAS VISITOR CHARGING CATEGORY |
| R | OVERSEAS 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | REFERRAL REQUEST RECEIVED DATE |
| R | SOURCE OF REFERRAL FOR MENTAL HEALTH |
| R | YEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) |
| R | PREVIOUS DIAGNOSED CONDITION INDICATOR |
| R | DISCHARGE FROM IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES SERVICE REASON |
| R | SERVICE 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | ONWARD REFERRAL DATE |
| R | ONWARD REFERRAL TIME |
| R | ONWARD REFERRAL REASON |
| R | ORGANISATION 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/R | Data Set Data Elements |
| M | IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION IDENTIFIER |
| M | SERVICE REQUEST IDENTIFIER |
| M | ACTIVITY SUSPENSION START DATE |
| R | ACTIVITY SUSPENSION END DATE |
| R | IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES ACTIVITY SUSPENSION REASON |
| CARE CONTACT, CARE ACTIVITIES AND INDIRECT ACTIVITIES |
|---|
| 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CARE CONTACT IDENTIFIER |
| R | CARE PERSONNEL LOCAL IDENTIFIER |
| R | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| R | CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | CODED OBSERVATION (SNOMED CT) |
| R | OBSERVATION VALUE |
| R | UCUM 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | START DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) |
| M | END DATE (INTERNET ENABLED THERAPY ACTIVITY LOG) |
| M | INTERNET ENABLED THERAPY PROGRAMME |
| M | DURATION OF INTERNET ENABLED THERAPY IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE PROFESSIONAL CLINICAL TIME |
| R | CARE PERSONNEL LOCAL IDENTIFIER |
| R | INTERNET 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | FINDING SCHEME IN USE |
| M | LONG 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | FINDING SCHEME IN USE |
| M | PRESENTING COMPLAINT (CODED CLINICAL ENTRY) |
| R | PRESENTING COMPLAINT CODING SIGNIFICANCE |
| R | PRESENTING 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/O | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| M | ASSESSMENT TOOL COMPLETION DATE |
| R | ASSESSMENT 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) |
| M | START DATE (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | START TIME (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | END DATE (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | END 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/O | Data Set Data Elements |
| M | CARE PERSONNEL LOCAL IDENTIFIER |
| M | QUALIFICATION ATTAINMENT LEVEL (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) |
| R | EMPLOYEE QUALIFICATION AWARDED DATE |
| R | EMPLOYEE QUALIFICATION PLANNED COMPLETION DATE |
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 presentO = Optional: the inclusion of this data element is optional as required for local purposes.
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = 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/O | Data Set Data Elements |
| M | DATA SET VERSION NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | PRIMARY DATA COLLECTION SYSTEM IN USE |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATA SET CREATED DATE |
| M | DATA 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER)) |
| M | ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER (MOTHER)) |
| M | PERSON BIRTH DATE (MOTHER) |
| R | ORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY) |
| R | NHS NUMBER (MOTHER) |
| R | NHS NUMBER STATUS INDICATOR CODE (MOTHER) |
| R | POSTCODE OF USUAL ADDRESS (MOTHER) |
| R | ETHNIC CATEGORY (MOTHER) |
| R | PERSON DEATH DATE (MOTHER) |
| R | PERSON 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER)) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER)) |
| R | START DATE (GMP PATIENT REGISTRATION) |
| R | END DATE (GMP PATIENT REGISTRATION) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER)) |
| M | SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) |
| M | SOCIAL 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (MOTHER)) |
| M | OVERSEAS VISITOR CHARGING CATEGORY |
| R | OVERSEAS VISITOR CHARGING CATEGORY APPLICABLE DATE |
| MOTHER'S BOOKING AND DIAGNOSIS DETAILS |
|---|
| Maternity Care Plan: To carry details of the Care Plan during the current Maternity Episode. Multiple occurrences of this group are permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | MATERNITY CARE PLAN DATE |
| R | MATERNITY CARE PLAN TYPE |
| R | MATERNITY PERSONALISED CARE PLAN INDICATOR |
| R | CONTINUITY OF CARER PATHWAY INDICATOR |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| R | ORGANISATION SITE IDENTIFIER (OF PLANNED DELIVERY) |
| R | MATERNITY CARE SETTING (OF PLANNED DELIVERY) |
| R | PLANNED 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | ACTIVITY OFFER DATE (DATING ULTRASOUND SCAN) |
| R | OFFER STATUS (DATING ULTRASOUND SCAN) |
| R | PROCEDURE DATE (DATING ULTRASOUND SCAN) |
| R | GESTATION LENGTH (DATING ULTRASOUND SCAN) |
| R | NUMBER OF FETUSES (DATING ULTRASOUND SCAN) |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL ORDER |
| R | ABNORMALITY DETECTED INDICATOR (DATING ULTRASOUND SCAN) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| R | ASSESSMENT 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | PROVISIONAL DIAGNOSIS DATE |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | MATERNITY COMPLICATING DIAGNOSIS INDICATOR |
| R | DIAGNOSIS DATE |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| M | SITUATION SCHEME IN USE |
| M | CODED 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/O | Data Set Data Elements |
| M | PREGNANCY IDENTIFIER |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL ORDER |
| R | FINDING DATE |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | OBSERVATION DATE |
| R | OBSERVATION SCHEME IN USE |
| R | CODED OBSERVATION (CLINICAL TERMINOLOGY) |
| R | OBSERVATION VALUE |
| R | UCUM 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/O | Data Set Data Elements |
| M | CARE CONTACT IDENTIFIER |
| M | PREGNANCY IDENTIFIER |
| M | CARE CONTACT DATE |
| R | CARE CONTACT TIME |
| R | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | ADMINISTRATIVE CATEGORY CODE |
| R | CLINICAL CONTACT DURATION OF CARE CONTACT |
| R | CONSULTATION TYPE |
| R | CARE CONTACT SUBJECT |
| R | CONSULTATION MEDIUM USED |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | GROUP THERAPY INDICATOR |
| R | ATTENDED OR DID NOT ATTEND CODE |
| R | CARE CONTACT CANCELLATION DATE |
| R | CARE CONTACT CANCELLATION REASON |
| R | REPLACEMENT APPOINTMENT DATE OFFERED |
| R | REPLACEMENT 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER (MOTHER) |
| M | CARE CONTACT IDENTIFIER |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| R | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL ORDER |
| R | PROCEDURE SCHEME IN USE |
| R | CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | OBSERVATION SCHEME IN USE |
| R | CODED OBSERVATION (CLINICAL TERMINOLOGY) |
| R | OBSERVATION VALUE |
| R | UCUM 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER (MOTHER) |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| 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/O | Data Set Data Elements |
| M | LABOUR AND DELIVERY IDENTIFIER |
| M | CLINICAL INTERVENTION DATE (MOTHER) |
| R | CLINICAL INTERVENTION TIME (MOTHER) |
| M | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| R | LOCAL FETAL IDENTIFIER |
| R | FETAL ORDER |
| R | MATERNAL CRITICAL INCIDENT INDICATOR |
| R | PROCEDURE SCHEME IN USE |
| R | CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | OBSERVATION SCHEME IN USE |
| R | CODED OBSERVATION (CLINICAL TERMINOLOGY) |
| R | OBSERVATION VALUE |
| R | UCUM UNIT OF MEASUREMENT |
| BABY'S DETAILS |
|---|
| Neonatal Admission: To carry details of neonatal admissions. Multiple occurrences of this group are permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (BABY)) |
| M | TRANSFER START DATE (NEONATAL UNIT) |
| R | TRANSFER START TIME (NEONATAL UNIT) |
| R | ORGANISATION SITE IDENTIFIER (OF ADMITTING NEONATAL UNIT) |
| R | NEONATAL 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/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (BABY)) |
| M | DIAGNOSIS SCHEME IN USE |
| M | PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | PROVISIONAL DIAGNOSIS DATE |
| Diagnosis (Neonatal): To carry details of diagnoses made for the baby. Multiple occurrences of this group are permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (BABY)) |
| M | DIAGNOSIS SCHEME IN USE |
| M | DIAGNOSIS (CODED CLINICAL ENTRY) |
| M | DIAGNOSIS 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER (BABY) |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED (BABY)) |
| M | CLINICAL INTERVENTION DATE (BABY) |
| R | CLINICAL INTERVENTION TIME (BABY) |
| R | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| R | NEONATAL CRITICAL INCIDENT INDICATOR |
| R | PROCEDURE SCHEME IN USE |
| R | CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | OBSERVATION SCHEME IN USE |
| R | CODED OBSERVATION (CLINICAL TERMINOLOGY) |
| R | OBSERVATION VALUE |
| R | UCUM UNIT OF MEASUREMENT |
| R | 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/O | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER (BABY) |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON 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/O | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | PREGNANCY IDENTIFIER |
| M | START DATE (HOSPITAL PROVIDER SPELL) |
| R | START TIME (HOSPITAL PROVIDER SPELL) |
| R | SOURCE OF ADMISSION CODE (HOSPITAL PROVIDER SPELL) |
| R | PATIENT CLASSIFICATION CODE |
| R | ADMISSION METHOD CODE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE TIME (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE 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/O | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | START DATE (COMMISSIONER ASSIGNMENT PERIOD) |
| R | END 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/O | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | START DATE (WARD STAY) |
| R | START TIME (WARD STAY) |
| R | END DATE (WARD STAY) |
| R | END TIME (WARD STAY) |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| O | WARD 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/O | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) |
| R | END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) |
| R | TREATMENT 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/O | Data Set Data Elements |
| M | ASSESSMENT TOOL COMPLETION DATE |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | CLINICAL INTERVENTION DATE |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | ORGANISATION 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/O | Data Set Data Elements |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | PROFESSIONAL REGISTRATION BODY CODE |
| R | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER |
| R | CARE PROFESSIONAL STAFF GROUP (MATERNITY) |
| R | OCCUPATION CODE |
| R | CARE PROFESSIONAL (JOB ROLE CODE) |
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposesP = 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/P | Data Set Data Elements |
| M | DATA SET VERSION NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | PRIMARY DATA COLLECTION SYSTEM IN USE |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER) |
| R | ORGANISATION IDENTIFIER (RESIDENCE RESPONSIBILITY) |
| R | ORGANISATION IDENTIFIER (EDUCATIONAL ESTABLISHMENT) |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | PERSON BIRTH DATE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON STATED GENDER CODE |
| R | PERSON MARITAL STATUS |
| R | ETHNIC CATEGORY |
| R | LANGUAGE CODE (PREFERRED) |
| R | PERSON 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| R | START DATE (GMP PATIENT REGISTRATION) |
| R | END DATE (GMP PATIENT REGISTRATION) |
| R | ORGANISATION 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ACCOMMODATION STATUS CODE |
| R | SETTLED ACCOMMODATION INDICATOR |
| R | ACCOMMODATION STATUS RECORDED DATE |
| R | SECURE 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | EMPLOYMENT STATUS |
| R | EMPLOYMENT STATUS RECORDED DATE |
| R | WEEKLY 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR |
| R | PARENTAL RESPONSIBILITIES INDICATOR |
| R | YOUNG CARER INDICATOR |
| R | LOOKED AFTER CHILD INDICATOR |
| R | CHILD PROTECTION PLAN INDICATION CODE |
| R | EX-BRITISH ARMED FORCES INDICATOR |
| R | OFFENCE HISTORY INDICATION CODE |
| R | PRODROME PSYCHOSIS DATE |
| R | EMERGENT PSYCHOSIS DATE |
| R | MANIFEST PSYCHOSIS DATE |
| R | FIRST PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION) |
| R | PSYCHOSIS 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | START DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | END DATE (MENTAL HEALTH CARE COORDINATOR ASSIGNMENT PERIOD) |
| R | CARE 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | DISABILITY CODE |
| R | DISABILITY 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/P | Data Set Data Elements |
| M | CARE PLAN IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | CARE PLAN TYPE (MENTAL HEALTH) |
| M | CARE PLAN CREATION DATE |
| R | CARE PLAN CREATION TIME |
| R | CARE PLAN LAST UPDATED DATE |
| R | CARE PLAN LAST UPDATED TIME |
| R | CARE 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/P | Data Set Data Elements |
| M | CARE PLAN IDENTIFIER |
| M | CARE PLAN AGREED BY |
| R | CARE PLAN AGREED DATE |
| R | CARE 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) |
| R | PRESCRIPTION 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | SOCIAL AND PERSONAL CIRCUMSTANCE (SNOMED CT) |
| R | SOCIAL 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | OVERSEAS VISITOR CHARGING CATEGORY |
| R | OVERSEAS 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | REFERRAL REQUEST RECEIVED DATE |
| R | REFERRAL REQUEST RECEIVED TIME |
| R | NHS SERVICE AGREEMENT LINE NUMBER |
| R | SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE |
| R | SOURCE OF REFERRAL FOR MENTAL HEALTH |
| R | ORGANISATION IDENTIFIER (REFERRING) |
| R | REFERRING CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH AND COMMUNITY CARE) |
| R | CLINICAL RESPONSE PRIORITY TYPE |
| R | PRIMARY REASON FOR REFERRAL (MENTAL HEALTH) |
| R | REASON FOR OUT OF AREA REFERRAL (ADULT ACUTE MENTAL HEALTH) |
| R | DISCHARGE PLAN CREATION DATE |
| R | DISCHARGE PLAN CREATION TIME |
| R | DISCHARGE PLAN LAST UPDATED DATE |
| R | DISCHARGE PLAN LAST UPDATED TIME |
| R | SERVICE DISCHARGE DATE |
| R | SERVICE DISCHARGE TIME |
| R | DISCHARGE 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | OTHER 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/P | Data Set Data Elements |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | SERVICE REQUEST IDENTIFIER |
| M | SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) |
| R | REFERRAL CLOSURE DATE |
| R | REFERRAL CLOSURE TIME |
| R | REFERRAL REJECTION DATE |
| R | REFERRAL REJECTION TIME |
| R | REFERRAL CLOSURE REASON |
| R | REFERRAL 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| R | PATIENT PATHWAY IDENTIFIER |
| R | ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) |
| M | WAITING TIME MEASUREMENT TYPE |
| R | REFERRAL TO TREATMENT PERIOD START DATE |
| R | REFERRAL TO TREATMENT PERIOD END DATE |
| R | REFERRAL 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| R | DECISION TO REFER DATE (ONWARD REFERRAL) |
| R | DECISION TO REFER TIME (ONWARD REFERRAL) |
| M | ONWARD REFERRAL DATE |
| R | ONWARD REFERRAL TIME |
| R | ONWARD REFERRAL REASON |
| R | REFERRED OUT OF AREA REASON (ADULT ACUTE MENTAL HEALTH) |
| R | ORGANISATION 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DISCHARGE PLAN AGREED BY |
| R | DISCHARGE PLAN AGREED DATE |
| R | DISCHARGE 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/P | Data Set Data Elements |
| P | SERVICE REQUEST IDENTIFIER |
| P | PRESCRIPTION IDENTIFIER |
| P | PRESCRIPTION DATE (MEDICATION) |
| P | PRESCRIPTION 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/P | Data Set Data Elements |
| M | CARE CONTACT IDENTIFIER |
| M | SERVICE REQUEST IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | CARE CONTACT DATE |
| R | CARE CONTACT TIME |
| R | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | ADMINISTRATIVE CATEGORY CODE |
| R | SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE |
| R | CLINICAL CONTACT DURATION OF CARE CONTACT |
| R | CONSULTATION TYPE |
| R | CARE CONTACT SUBJECT |
| R | CONSULTATION MEDIUM USED |
| R | ACTIVITY LOCATION TYPE CODE |
| R | PLACE OF SAFETY INDICATOR |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | GROUP THERAPY INDICATOR |
| R | ATTENDED OR DID NOT ATTEND CODE |
| R | EARLIEST REASONABLE OFFER DATE |
| R | EARLIEST CLINICALLY APPROPRIATE DATE |
| R | CARE CONTACT CANCELLATION DATE |
| R | CARE CONTACT CANCELLATION REASON |
| R | REPLACEMENT APPOINTMENT DATE OFFERED |
| R | REPLACEMENT 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/P | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CARE CONTACT IDENTIFIER |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CLINICAL CONTACT DURATION OF CARE ACTIVITY |
| R | CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) |
| R | FINDING SCHEME IN USE |
| R | CODED FINDING (CODED CLINICAL ENTRY) |
| R | CODED OBSERVATION (SNOMED CT) |
| R | OBSERVATION VALUE |
| R | UCUM 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/P | Data Set Data Elements |
| M | CARE CONTACT IDENTIFIER |
| M | OTHER 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| R | CARE PROFESSIONAL TEAM LOCAL IDENTIFIER |
| M | INDIRECT ACTIVITY DATE |
| R | INDIRECT ACTIVITY TIME |
| R | DURATION OF INDIRECT ACTIVITY |
| R | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) |
| R | FINDING SCHEME IN USE |
| R | CODED 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/P | Data Set Data Elements |
| M | GROUP SESSION IDENTIFIER |
| M | GROUP SESSION DATE |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| R | CLINICAL CONTACT DURATION OF GROUP SESSION |
| R | GROUP SESSION TYPE (MENTAL HEALTH) |
| R | NUMBER OF GROUP SESSION PARTICIPANTS |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | SERVICE OR TEAM TYPE REFERRED TO (MENTAL HEALTH) |
| R | NHS SERVICE AGREEMENT LINE NUMBER |
| MENTAL HEALTH ACT (MHA) EPISODES |
|---|
| 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/P | Data Set Data Elements |
| M | MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER |
| M | START DATE (MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT PERIOD) |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | END 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/P | Data Set Data Elements |
| M | MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER |
| M | START DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) |
| R | END DATE (MENTAL HEALTH CONDITIONAL DISCHARGE) |
| R | MENTAL HEALTH CONDITIONAL DISCHARGE END REASON |
| R | MENTAL 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/P | Data Set Data Elements |
| M | MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER |
| M | START DATE (COMMUNITY TREATMENT ORDER) |
| R | EXPIRY DATE (COMMUNITY TREATMENT ORDER) |
| R | END DATE (COMMUNITY TREATMENT ORDER) |
| R | COMMUNITY 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/P | Data Set Data Elements |
| M | MENTAL HEALTH ACT LEGAL STATUS CLASSIFICATION ASSIGNMENT PERIOD IDENTIFIER |
| M | START DATE (COMMUNITY TREATMENT ORDER RECALL) |
| M | START TIME (COMMUNITY TREATMENT ORDER RECALL) |
| R | END DATE (COMMUNITY TREATMENT ORDER RECALL) |
| R | END 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/P | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | SERVICE REQUEST IDENTIFIER |
| M | START DATE (HOSPITAL PROVIDER SPELL) |
| R | START TIME (HOSPITAL PROVIDER SPELL) |
| R | SOURCE OF ADMISSION CODE (HOSPITAL PROVIDER SPELL) |
| R | ADMISSION METHOD CODE (HOSPITAL PROVIDER SPELL) |
| R | POSTCODE OF MAIN VISITOR |
| R | ESTIMATED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| R | PLANNED DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| R | PLANNED DISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE TIME (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL) |
| R | DISCHARGE DESTINATION CODE (HOSPITAL PROVIDER SPELL) |
| R | POSTCODE 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | START DATE (WARD STAY) |
| R | START TIME (WARD STAY) |
| R | END DATE (MENTAL HEALTH TRIAL LEAVE) |
| R | END DATE (WARD STAY) |
| R | END TIME (WARD STAY) |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| R | WARD SETTING TYPE (MENTAL HEALTH) |
| R | INTENDED AGE GROUP (MENTAL HEALTH) |
| R | SEX OF PATIENTS CODE |
| R | INTENDED CLINICAL CARE INTENSITY CODE (MENTAL HEALTH) |
| R | WARD SECURITY LEVEL |
| R | LOCKED WARD INDICATOR |
| R | MENTAL HEALTH ADMITTED PATIENT CLASSIFICATION |
| R | SPECIALISED MENTAL HEALTH SERVICE CATEGORY CODE |
| O | WARD 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/P | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| M | START DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) |
| R | END DATE (CARE PROFESSIONAL ADMITTED CARE EPISODE) |
| R | TREATMENT 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/P | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | START DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) |
| R | END DATE (MENTAL HEALTH DELAYED DISCHARGE PERIOD) |
| R | MENTAL HEALTH DELAYED DISCHARGE REASON |
| R | MENTAL HEALTH DELAYED DISCHARGE ATTRIBUTABLE TO INDICATION CODE |
| R | ORGANISATION 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | START DATE (RESTRICTIVE INTERVENTION) |
| R | START TIME (RESTRICTIVE INTERVENTION) |
| R | RESTRICTIVE INTERVENTION TYPE |
| R | END DATE (RESTRICTIVE INTERVENTION) |
| R | END TIME (RESTRICTIVE INTERVENTION) |
| R | RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (PATIENT) |
| R | RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (CARE PERSONNEL) |
| R | RESTRICTIVE INTERVENTION RESTRAINT INJURY INDICATOR (OTHER PERSON) |
| R | RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW HELD INDICATOR (PATIENT) |
| R | RESTRICTIVE INTERVENTION POST-INCIDENT REVIEW NOT HELD REASON (PATIENT) |
| R | RESTRICTIVE 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | DATE 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | DATE 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | START DATE (HOME LEAVE) |
| R | START TIME (HOME LEAVE) |
| R | END DATE (HOME LEAVE) |
| R | END 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | START DATE (MENTAL HEALTH LEAVE OF ABSENCE) |
| R | START TIME (MENTAL HEALTH LEAVE OF ABSENCE) |
| R | END DATE (MENTAL HEALTH LEAVE OF ABSENCE) |
| R | END TIME (MENTAL HEALTH LEAVE OF ABSENCE) |
| R | MENTAL HEALTH LEAVE OF ABSENCE END REASON |
| R | ESCORTED 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | START DATE (MENTAL HEALTH ABSENCE WITHOUT LEAVE) |
| R | START TIME (MENTAL HEALTH ABSENCE WITHOUT LEAVE) |
| R | END DATE (MENTAL HEALTH ABSENCE WITHOUT LEAVE) |
| R | END TIME (MENTAL HEALTH ABSENCE WITHOUT LEAVE) |
| R | MENTAL 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | START DATE (MENTAL HEALTH TRIAL LEAVE) |
| R | START TIME (MENTAL HEALTH TRIAL LEAVE) |
| R | END DATE (MENTAL HEALTH TRIAL LEAVE) |
| R | END 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/P | Data Set Data Elements |
| M | HOSPITAL PROVIDER SPELL NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | START DATE (COMMISSIONER ASSIGNMENT PERIOD) |
| R | END 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/P | Data Set Data Elements |
| M | WARD STAY IDENTIFIER |
| M | OBSERVATION 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | DIAGNOSIS SCHEME IN USE |
| M | PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | PROVISIONAL 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | DIAGNOSIS SCHEME IN USE |
| M | SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) |
| R | DIAGNOSIS 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/P | Data Set Data Elements |
| M | SERVICE REQUEST IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| M | ASSESSMENT TOOL COMPLETION DATE |
| R | CARE 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/P | Data Set Data Elements |
| M | CARE ACTIVITY IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON 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/P | Data Set Data Elements |
| M | ASSESSMENT TOOL COMPLETION DATE |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON SCORE |
| R | ACTIVITY LOCATION TYPE CODE |
| R | ORGANISATION 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/P | Data Set Data Elements |
| M | CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | START DATE (CARE PROGRAMME APPROACH CARE) |
| R | END 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/P | Data Set Data Elements |
| M | CARE PROGRAMME APPROACH CARE EPISODE IDENTIFIER |
| M | CARE PROGRAMME APPROACH REVIEW DATE |
| R | CARE PROGRAMME APPROACH REVIEW ABUSE QUESTION ASKED INDICATOR |
| R | CARE 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/P | Data Set Data Elements |
| M | CLUSTERING TOOL ASSESSMENT IDENTIFIER |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | CLUSTERING TOOL ASSESSMENT CATEGORY |
| M | ASSESSMENT TOOL COMPLETION DATE |
| R | ASSESSMENT TOOL COMPLETION TIME |
| R | CLUSTERING TOOL ASSESSMENT REASON |
| R | MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE |
| R | ADULT MENTAL HEALTH CARE CLUSTER CODE (INITIAL) |
| P | LEARNING DISABILITIES CARE CLUSTER CODE (INITIAL) |
| P | FORENSIC 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/P | Data Set Data Elements |
| M | CLUSTERING TOOL ASSESSMENT IDENTIFIER |
| M | CODED ASSESSMENT TOOL TYPE (SNOMED CT) |
| M | PERSON 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/P | Data Set Data Elements |
| M | CLUSTERING TOOL ASSESSMENT IDENTIFIER |
| M | START DATE (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | START TIME (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | ADULT MENTAL HEALTH CARE CLUSTER CODE (FINAL) |
| R | CHILD AND ADOLESCENT MENTAL HEALTH NEEDS BASED GROUPING CODE |
| P | LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) |
| R | FORENSIC MENTAL HEALTH CARE CLUSTER CODE (FINAL) |
| P | FORENSIC LEARNING DISABILITIES CARE CLUSTER CODE (FINAL) |
| R | END DATE (CARE CLUSTER ASSIGNMENT PERIOD) |
| R | END 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/P | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | FIVE FORENSIC PATHWAYS ASSESSMENT DATE |
| R | FIVE FORENSIC PATHWAYS ASSESSMENT REASON |
| M | FIVE 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/P | Data Set Data Elements |
| M | CARE PROFESSIONAL LOCAL IDENTIFIER |
| R | PROFESSIONAL REGISTRATION BODY CODE |
| R | PROFESSIONAL REGISTRATION ENTRY IDENTIFIER |
| R | CARE PROFESSIONAL STAFF GROUP (MENTAL HEALTH) |
| R | MAIN SPECIALTY CODE (MENTAL HEALTH) |
| R | OCCUPATION CODE |
| R | CARE PROFESSIONAL (JOB ROLE CODE) |
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 andinformation 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 presentR = Required: NHS business processes cannot be delivered without this data element. Required data elements may not be applicable to allPATIENT PATHWAYS, seePatient Pathway Scenariosfor further detailsO = 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/O | Data Set Data Elements |
| M | NHS NUMBER |
| M | NHS NUMBER STATUS INDICATOR CODE |
| R | PATIENT PATHWAY IDENTIFIER |
| R | ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) |
| OUTPATIENT SERVICES |
|---|
| MULTIDISCIPLINARY TEAM ACTIVITY |
|---|
| To carry Multidisciplinary Team Activity details. One occurrence of this group is permitted. | |
| M/R/O | Data Set Data Elements |
| R | MULTIDISCIPLINARY TEAM CANCER CARE PLAN DISCUSSED INDICATOR |
| R | MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) |
| PATIENT STATUS AND DIAGNOSIS |
|---|
| TREATMENT EVENTS |
|---|
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 mandatoryO = Optional: this data element is optional.
| ANKLE PRIMARY |
|---|
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (PRIMARY ANKLE REPLACEMENT) |
| M | SURGICAL APPROACH (PRIMARY OR REVISION ANKLE REPLACEMENT) |
| M | ASSOCIATED PROCEDURE TYPE (ANKLE REPLACEMENT) |
| M | COMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (TIBIAL) |
| M | BONE GRAFT STRUCTURE (TIBIAL) |
| M | BONE GRAFT SOURCE (TIBIAL) |
| M | BONE GRAFT INDICATOR (TALAR) |
| M | BONE GRAFT STRUCTURE (TALAR) |
| M | BONE GRAFT SOURCE (TALAR) |
| M | BONE GRAFT INDICATOR (FIBULAR) |
| M | BONE GRAFT STRUCTURE (FIBULAR) |
| M | BONE GRAFT SOURCE (FIBULAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (ANKLE REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
| ANKLE REVISION |
|---|
| M/O | Ankle Revision Procedure Details: One occurrence of this group is required. |
| M | REVISION PROCEDURE TYPE (ANKLE REPLACEMENT) |
| M | ARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT) |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | JOINT REPLACEMENT REVISION REASON CODE (ANKLE) |
| M/O | Primary Operation Details: One occurrence of this group is required. |
| M | PROCEDURE DATE (PRIMARY JOINT REPLACEMENT) |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) If the information is not available, select 'Not Available' |
| M/O | Components Removed: One occurrence of this group is required. |
| M | COMPONENT REMOVAL INDICATOR (TIBIAL) |
| M | COMPONENT REMOVAL INDICATOR (TALAR) |
| M | COMPONENT REMOVAL INDICATOR (MENISCAL) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (REVISION ANKLE REPLACEMENT) |
| M | SURGICAL APPROACH (PRIMARY OR REVISION ANKLE REPLACEMENT) |
| M | ASSOCIATED PROCEDURE TYPE (ANKLE REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (TIBIAL) |
| M | BONE GRAFT STRUCTURE (TIBIAL) |
| M | BONE GRAFT SOURCE (TIBIAL) |
| M | BONE GRAFT INDICATOR (TALAR) |
| M | BONE GRAFT STRUCTURE (TALAR) |
| M | BONE GRAFT SOURCE (TALAR) |
| M | BONE GRAFT INDICATOR (FIBULAR) |
| M | BONE GRAFT STRUCTURE (FIBULAR) |
| M | BONE GRAFT SOURCE (FIBULAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (ANKLE REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
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 mandatoryR = Required: this data element is not optional but should be supplied if this data is available.
| COMMON DETAILS |
|---|
| M/R | Patient Details: One occurrence of this group is required. |
| M | PATIENT CONSENT OBTAINED INDICATOR (NATIONAL JOINT REGISTRY RECORDING DATA) |
| M | PERSON HEIGHT IN METRES and PERSON WEIGHT or BODY MASS INDEX If the information is not available, select 'Not Available' |
| M/R | Patient Identifiers: One occurrence of this group is required. |
| M | PERSON GIVEN NAME |
| M | PERSON FAMILY NAME |
| M | LOCAL PATIENT IDENTIFIER (NATIONAL JOINT REGISTRY) |
| M | PERSON STATED GENDER CODE (NATIONAL JOINT REGISTRY) |
| R | PERSON BIRTH DATE |
| M | POSTCODE OF USUAL ADDRESS If the PATIENT is an Overseas Visitor, select 'Overseas Resident' |
| R | NHS NUMBER (England and Wales) or HEALTH AND CARE NUMBER (Northern Ireland) |
| M/R | Operation Details: One occurrence of this group is required. |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| M | PROCEDURE DATE |
| M | ANAESTHETIC TYPE (JOINT REPLACEMENT) |
| M | ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE (NATIONAL JOINT REGISTRY) |
| M | OPERATION FUNDING (NATIONAL JOINT REGISTRY) |
| M/R | Surgeon Details: One occurrence of this group is required. |
| M | CONSULTANT CODE (RESPONSIBLE CONSULTANT) |
| M | CARE PROFESSIONAL CODE (OPERATING SURGEON) |
| M | CARE PROFESSIONAL LEAD OPERATING SURGEON GRADE (JOINT REPLACEMENT) |
| M | CARE PROFESSIONAL FIRST ASSISTANT GRADE (JOINT REPLACEMENT) |
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 mandatoryO = Optional: this data element is optional.
| ELBOW PRIMARY |
|---|
| M/O | Patient Details: One occurrence of this group is required. |
| M | HANDEDNESS CODE (JOINT REPLACEMENT) |
| M/O | Elbow Primary Procedure Details: One occurrence of this group is required. |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | PATIENT DIAGNOSIS INDICATION (PRIMARY ELBOW REPLACEMENT) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (PRIMARY ELBOW REPLACEMENT) |
| M | FIXATION TYPE (ELBOW) |
| M | SURGICAL APPROACH (PRIMARY OR REVISION ELBOW REPLACEMENT) |
| M | MINIMALLY INVASIVE SURGERY INDICATOR (JOINT REPLACEMENT) |
| M | COMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (HUMERAL) |
| M | BONE GRAFT STRUCTURE (HUMERAL) |
| M | BONE GRAFT SOURCE (HUMERAL) |
| M | BONE GRAFT INDICATOR (ULNAR) |
| M | BONE GRAFT STRUCTURE (ULNAR) |
| M | BONE GRAFT SOURCE (ULNAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (ELBOW REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
| ELBOW REVISION |
|---|
| M/O | Patient Details: One occurrence of this group is required. |
| M | HANDEDNESS CODE (JOINT REPLACEMENT) |
| M/O | Elbow Revision Procedure Details: One occurrence of this group is required. |
| M | REVISION PROCEDURE TYPE (ELBOW REPLACEMENT) |
| M | ARTHROPLASTY REVISION TYPE (SHOULDER AND ELBOW REPLACEMENT) |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | JOINT REPLACEMENT REVISION REASON CODE (ELBOW) |
| M/O | Primary Operation Details: One occurrence of this group is required. |
| M | PROCEDURE DATE (PRIMARY JOINT REPLACEMENT) |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) If the information is not available, select 'Not Available' |
| M/O | Components Removed: One occurrence of this group is required. |
| M | COMPONENT REMOVAL INDICATOR (RADIAL) |
| M | COMPONENT REMOVAL INDICATOR (HUMERAL) |
| M | COMPONENT REMOVAL INDICATOR (ULNAR) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (REVISION ELBOW REPLACEMENT) |
| M | FIXATION TYPE (ELBOW) |
| M | SURGICAL APPROACH (PRIMARY OR REVISION ELBOW REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (HUMERAL) |
| M | BONE GRAFT STRUCTURE (HUMERAL) |
| M | BONE GRAFT SOURCE (HUMERAL) |
| M | BONE GRAFT INDICATOR (ULNAR) |
| M | BONE GRAFT STRUCTURE (ULNAR) |
| M | BONE GRAFT SOURCE (ULNAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (ELBOW REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
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 mandatoryO = Optional: this data element is optional.
| HIP PRIMARY |
|---|
| M/O | Hip Primary Procedure Details: One occurrence of this group is required. |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | PATIENT DIAGNOSIS INDICATION (PRIMARY HIP REPLACEMENT) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (PRIMARY HIP REPLACEMENT) |
| M | HIP JOINT SURGERY PATIENT POSITION |
| M | SURGICAL APPROACH (PRIMARY HIP REPLACEMENT) |
| M | MINIMALLY INVASIVE SURGERY INDICATOR (JOINT REPLACEMENT) |
| M | COMPUTER GUIDED SURGERY INDICATOR (JOINT REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (FEMORAL) |
| M | BONE GRAFT STRUCTURE (FEMORAL) |
| M | BONE GRAFT SOURCE (FEMORAL) |
| M | BONE GRAFT INDICATOR (ACETABULAR) |
| M | BONE GRAFT STRUCTURE (ACETABULAR) |
| M | BONE GRAFT SOURCE (ACETABULAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (HIP REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
| HIP REVISION |
|---|
| M/O | Hip Revision Procedure Details: One occurrence of this group is required. |
| M | REVISION PROCEDURE TYPE (HIP REPLACEMENT) |
| M | ARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT) |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | JOINT REPLACEMENT REVISION REASON CODE (HIP) |
| M/O | Primary Operation Details: One occurrence of this group is required. |
| M | PROCEDURE DATE (PRIMARY JOINT REPLACEMENT) |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) If the information is not available, select 'Not Available' |
| M/O | Components Removed: One occurrence of this group is required. |
| M | COMPONENT REMOVAL INDICATOR (FEMORAL) |
| M | COMPONENT REMOVAL INDICATOR (MODULAR HEAD) |
| M | CEMENT REMOVAL INDICATOR (FEMORAL) |
| M | COMPONENT REMOVAL INDICATOR (ACETABULAR) |
| M | LINER REMOVAL INDICATOR (ACETABULAR) |
| M | CEMENT REMOVAL INDICATOR (ACETABULAR) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (REVISION HIP REPLACEMENT) |
| M | HIP JOINT SURGERY PATIENT POSITION |
| M | SURGICAL APPROACH (REVISION HIP REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (FEMORAL) |
| M | BONE GRAFT STRUCTURE (FEMORAL) |
| M | BONE GRAFT SOURCE (FEMORAL) |
| M | BONE GRAFT INDICATOR (ACETABULAR) |
| M | BONE GRAFT STRUCTURE (ACETABULAR) |
| M | BONE GRAFT SOURCE (ACETABULAR) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (HIP REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
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 mandatoryO = Optional: this data element is optional.
| KNEE PRIMARY |
|---|
| M/O | Knee Primary Procedure Details: One occurrence of this group is required. |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | PATIENT DIAGNOSIS INDICATION (PRIMARY KNEE REPLACEMENT) |
| M | DEGREES OF FIXED FLEXION DEFORMITY (PRIMARY KNEE REPLACEMENT) |
| M | DEGREES OF FLEXION RANGE (PRIMARY KNEE REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (FEMORAL) |
| M | BONE GRAFT STRUCTURE (FEMORAL) |
| M | BONE GRAFT SOURCE (FEMORAL) |
| M | BONE GRAFT INDICATOR (TIBIAL) |
| M | BONE GRAFT STRUCTURE (TIBIAL) |
| M | BONE GRAFT SOURCE (TIBIAL) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (KNEE REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
| KNEE REVISION |
|---|
| M/O | Knee Revision Procedure Details: One occurrence of this group is required. |
| M | REVISION PROCEDURE TYPE (KNEE REPLACEMENT) |
| M | ARTHROPLASTY REVISION TYPE (HIP KNEE AND ANKLE REPLACEMENT) |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | JOINT REPLACEMENT REVISION REASON CODE (KNEE) |
| M/O | Primary Operation Details: One occurrence of this group is required. |
| M | PROCEDURE DATE (PRIMARY JOINT REPLACEMENT) |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) If the information is not available, select 'Not Available' |
| M/O | Components Removed: One occurrence of this group is required. |
| M | COMPONENT REMOVAL INDICATOR (FEMORAL) |
| M | COMPONENT REMOVAL INDICATOR (TIBIAL) |
| M | LINER REMOVAL INDICATOR (TIBIAL) |
| M | COMPONENT REMOVAL INDICATOR (PATELLA) |
| M/O | Surgical Approach: One occurrence of this group is required. |
| M | PATIENT PROCEDURE TYPE (REVISION KNEE REPLACEMENT) |
| M | SURGICAL APPROACH (REVISION KNEE REPLACEMENT) |
| M | PATIENT SPECIFIC INSTRUMENTS INDICATOR (SHOULDER OR KNEE REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (FEMORAL) |
| M | BONE GRAFT STRUCTURE (FEMORAL) |
| M | BONE GRAFT SOURCE (FEMORAL) |
| M | BONE GRAFT INDICATOR (TIBIAL) |
| M | BONE GRAFT STRUCTURE (TIBIAL) |
| M | BONE GRAFT SOURCE (TIBIAL) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (KNEE REPLACEMENT) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
Change to Data Set: Changed Description
National Joint Registry Data Set Overview
Click National Joint Registry Data Set - Shoulder 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 mandatoryO = Optional: this data element is optional.
| SHOULDER PRIMARY |
|---|
| M/O | Patient Details: One occurrence of this group is required. |
| M | HANDEDNESS CODE (JOINT REPLACEMENT) |
| M/O | Shoulder Primary Procedure Details: One occurrence of this group is required. |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | PATIENT DIAGNOSIS INDICATION (PRIMARY SHOULDER REPLACEMENT) |
| M | PREVIOUS SURGERY TYPE (SHOULDER REPLACEMENT) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (HUMERAL) |
| M | BONE GRAFT STRUCTURE (HUMERAL) |
| M | BONE GRAFT SOURCE (HUMERAL) |
| M | BONE GRAFT INDICATOR (GLENOID) |
| M | BONE GRAFT STRUCTURE (GLENOID) |
| M | BONE GRAFT SOURCE (GLENOID) |
| M/O | Rotator Cuff: One occurrence of this group is required. |
| M | ROTATOR CUFF CONDITION (SHOULDER REPLACEMENT) |
| M | ROTATOR CUFF REPAIRED INDICATOR (SHOULDER REPLACEMENT) |
| M | ROTATOR CUFF REPAIR TYPE (SHOULDER REPLACEMENT) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (SHOULDER REPLACEMENT) |
| M/O | Pre-Operative Oxford Scores: One occurrence of this group is required. |
| M | ASSESSMENT TOOL COMPLETION DATE If the information is not available, select 'Not Available' |
| O | OXFORD SHOULDER SCORE (QUESTION 1) |
| O | OXFORD SHOULDER SCORE (QUESTION 2) |
| O | OXFORD SHOULDER SCORE (QUESTION 3) |
| O | OXFORD SHOULDER SCORE (QUESTION 4) |
| O | OXFORD SHOULDER SCORE (QUESTION 5) |
| O | OXFORD SHOULDER SCORE (QUESTION 6) |
| O | OXFORD SHOULDER SCORE (QUESTION 7) |
| O | OXFORD SHOULDER SCORE (QUESTION 8) |
| O | OXFORD SHOULDER SCORE (QUESTION 9) |
| O | OXFORD SHOULDER SCORE (QUESTION 10) |
| O | OXFORD SHOULDER SCORE (QUESTION 11) |
| O | OXFORD SHOULDER SCORE (QUESTION 12) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
| SHOULDER REVISION |
|---|
| M/O | Patient Details: One occurrence of this group is required. |
| M | HANDEDNESS CODE (JOINT REPLACEMENT) |
| M/O | Shoulder Revision Procedure Details: One occurrence of this group is required. |
| M | REVISION PROCEDURE TYPE (SHOULDER REPLACEMENT) |
| M | ARTHROPLASTY REVISION TYPE (SHOULDER AND ELBOW REPLACEMENT) |
| M | ANATOMICAL SIDE (NATIONAL JOINT REGISTRY) |
| M | JOINT REPLACEMENT REVISION REASON CODE (SHOULDER) |
| M/O | Primary Operation Details: One occurrence of this group is required. |
| M | PROCEDURE DATE (PRIMARY JOINT REPLACEMENT) |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) If the information is not available, select 'Not Available' |
| M/O | Components Removed: One occurrence of this group is required. |
| M | COMPONENT REMOVAL INDICATOR (HUMERAL) |
| M | COMPONENT REMOVAL INDICATOR (HUMERAL ARTICULATING BEARING) |
| M | COMPONENT REMOVAL INDICATOR (GLENOID) |
| M | COMPONENT REMOVAL INDICATOR (GLENOID ARTICULATING BEARING) |
| M | COMPONENT REMOVAL INDICATOR (OTHER SHOULDER REVISION) |
| M/O | Thromboprophylaxis: One occurrence of this group is required. |
| M | CHEMICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M | MECHANICAL THROMBOPROPHYLAXIS REGIME TYPE (JOINT REPLACEMENT) |
| M/O | Bone Graft Used: One occurrence of this group is required. |
| M | BONE GRAFT INDICATOR (HUMERAL) |
| M | BONE GRAFT STRUCTURE (HUMERAL) |
| M | BONE GRAFT SOURCE (HUMERAL) |
| M | BONE GRAFT INDICATOR (GLENOID) |
| M | BONE GRAFT STRUCTURE (GLENOID) |
| M | BONE GRAFT SOURCE (GLENOID) |
| M/O | Rotator Cuff: One occurrence of this group is required. |
| M | ROTATOR CUFF CONDITION (SHOULDER REPLACEMENT) |
| M | ROTATOR CUFF REPAIRED INDICATOR (SHOULDER REPLACEMENT) |
| M | ROTATOR CUFF REPAIR TYPE (SHOULDER REPLACEMENT) |
| M/O | Surgeon Notes: One occurrence of this group is required. |
| O | SURGEON NOTES |
| M/O | Intraoperative Event: One occurrence of this group is required. |
| M | UNTOWARD INTRAOPERATIVE EVENT CODE (SHOULDER REPLACEMENT) |
| M/O | Pre-Operative Oxford Scores: One occurrence of this group is required. |
| M | ASSESSMENT TOOL COMPLETION DATE If the information is not available, select 'Not Available' |
| O | OXFORD SHOULDER SCORE (QUESTION 1) |
| O | OXFORD SHOULDER SCORE (QUESTION 2) |
| O | OXFORD SHOULDER SCORE (QUESTION 3) |
| O | OXFORD SHOULDER SCORE (QUESTION 4) |
| O | OXFORD SHOULDER SCORE (QUESTION 5) |
| O | OXFORD SHOULDER SCORE (QUESTION 6) |
| O | OXFORD SHOULDER SCORE (QUESTION 7) |
| O | OXFORD SHOULDER SCORE (QUESTION 8) |
| O | OXFORD SHOULDER SCORE (QUESTION 9) |
| O | OXFORD SHOULDER SCORE (QUESTION 10) |
| O | OXFORD SHOULDER SCORE (QUESTION 11) |
| O | OXFORD SHOULDER SCORE (QUESTION 12) |
| M/O | Components: One occurrence of this group is required. |
| M | IMPLANT CATALOGUE NUMBER |
| M | IMPLANT BATCH OR LOT NUMBER |
Change to Data Set: Changed Description
National Neonatal Data Set Overview
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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposesP = 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 Information Standards Board for Health and Social Care and are included to facilitate piloting and testing of future Neonatal Data Analysis Unit data requirements, prior to formal inclusion in later versions of the 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.
| DEMOGRAPHICS AND BIRTH INFORMATION (BABY) |
|---|
One of the following Baby Demographics Data Group Structures must be used:
| Baby Demographics (Standard): To carry the Baby's demographic details where anonymisation of the record is NOT required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | NHS NUMBER (BABY) |
| M | NHS NUMBER STATUS INDICATOR CODE (BABY) |
| R | COMMUNITY HEALTH INDEX NUMBER (BABY) |
| R | HEALTH AND CARE NUMBER (BABY) |
| M | BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET) |
| R | DATE TIME OF BIRTH (BABY) |
| M | SITE CODE (OF ACTUAL PLACE OF DELIVERY) or ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY) |
| R | BIRTH WEIGHT |
| O | BIRTH LENGTH |
| O | BIRTH HEAD CIRCUMFERENCE |
| O | GESTATION LENGTH (AT DELIVERY) |
| O | GESTATION LENGTH (REMAINING DAYS AT DELIVERY) |
| R | PERSON PHENOTYPIC SEX |
| P | PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET) |
| O | BLOOD GROUP (BABY) |
| O | RHESUS GROUP (BABY) |
| R | BASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH) |
OR
| Baby Demographics (Withheld): To carry the Baby's demographic details where anonymisation of the record IS required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| M | NHS NUMBER STATUS INDICATOR CODE (BABY) |
| M | BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET) |
| R | YEAR AND MONTH OF BIRTH (BABY) |
| M | SITE CODE (OF ACTUAL PLACE OF DELIVERY) or ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY) |
| R | BIRTH WEIGHT |
| O | BIRTH LENGTH |
| O | BIRTH HEAD CIRCUMFERENCE |
| O | GESTATION LENGTH (AT DELIVERY) |
| O | GESTATION LENGTH (REMAINING DAYS AT DELIVERY) |
| R | PERSON PHENOTYPIC SEX |
| P | PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET) |
| O | BLOOD GROUP (BABY) |
| O | RHESUS GROUP (BABY) |
| R | BASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH) |
| PARENTS |
|---|
One of the following Parent's Demographics Data Group Structures should be used:
| Parents Demographics (Standard): To carry the Parent's demographic details where anonymisation of the record is NOT required. One occurrence of this group is permitted. | |
| R | NHS NUMBER (MOTHER) |
| M | NHS NUMBER STATUS INDICATOR CODE (MOTHER) |
| R | COMMUNITY HEALTH INDEX NUMBER (MOTHER) |
| R | HEALTH AND CARE NUMBER (MOTHER) |
| R | YEAR OF BIRTH (MOTHER) |
| M | POSTCODE OF USUAL ADDRESS (MOTHER) |
| P | QUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET) |
| O | OCCUPATION MOTHER (SNOMED CT) |
| R | ETHNIC CATEGORY (MOTHER) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER)) |
| R | YEAR OF BIRTH (FATHER) |
| R | ETHNIC CATEGORY (FATHER) |
| R | PARENTS CONSANGUINEOUS INDICATOR |
OR
| Parents Demographics (Withheld): To carry the Parent's demographic details where anonymisation of the record IS required. One occurrence of this group is permitted. | |
| M | NHS NUMBER STATUS INDICATOR CODE (MOTHER) |
| R | YEAR OF BIRTH (MOTHER) |
| P | QUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET) |
| O | OCCUPATION MOTHER (SNOMED CT) |
| R | ETHNIC CATEGORY (MOTHER) |
| R | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER)) |
| R | YEAR OF BIRTH (FATHER) |
| R | ETHNIC CATEGORY (FATHER) |
| R | PARENTS CONSANGUINEOUS INDICATOR |
| ANTENATAL |
|---|
| LABOUR AND DELIVERY |
|---|
| ADMISSION TO NEONATAL CRITICAL CARE |
|---|
| DISCHARGE FROM NEONATAL CRITICAL CARE UNIT |
|---|
| Procedures Recorded At Discharge: To carry details of procedures recorded at discharge. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PROCEDURE (OPCS RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE) and/or PROCEDURE (SNOMED CT RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE) |
| R | PROCEDURE DATE AND TIME (DURING NEONATAL CRITICAL CARE PERIOD) or PROCEDURE YEAR AND MONTH (DURING NEONATAL CRITICAL CARE PERIOD) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| CLINICAL TRIALS (EPISODIC) |
|---|
| Clinical Trials Details: To carry details of Clinical Trial enrolment at any time during the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| O | CLINICAL TRIAL NAME |
| O | CLINICAL TRIAL MEDICATION ADMINISTERED NAME Multiple occurrences of this item are permitted |
| INFECTION CULTURES (EPISODIC) |
|---|
| Infection Culture Indicators: To carry indicators relating to Infection Cultures undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | INFECTION CULTURE TEST INDICATOR (BLOOD) |
| P | INFECTION CULTURE TEST INDICATOR (CEREBROSPINAL FLUID) |
| P | INFECTION CULTURE TEST INDICATOR (URINE) |
| Infection Cultures: To carry information relating to Infection Cultures at any time during the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | SAMPLE COLLECTION DATE AND TIME or SAMPLE COLLECTION YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | SAMPLE TYPE (NATIONAL NEONATAL DATA SET) |
| R | CLINICAL SIGN OBSERVED AT SAMPLE COLLECTION Multiple occurrences of this item are permitted |
| R | SAMPLE TEST RESULT ORGANISM TYPE (SNOMED CT) Multiple occurrences of this item are permitted |
| O | SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D) Multiple occurrences of this item are permitted |
| ABDOMINAL X-RAYS (EPISODIC) |
|---|
| Abdominal X-Ray Indicator: To carry an indicator relating to Abdominal X-Rays undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | ABDOMINAL X-RAY PERFORMED INDICATOR |
| Abdominal X-Rays: To carry information relating to Abdominal X-Rays at any time during the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PROCEDURE DATE AND TIME (ABDOMINAL X-RAY) or PROCEDURE YEAR AND MONTH (ABDOMINAL X-RAY) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | ABDOMINAL X-RAY PERFORMED TO INVESTIGATE ABDOMINAL SIGNS INDICATOR |
| R | CONDITION SEEN IN ABDOMEN DURING X-RAY Multiple occurrences of this item are permitted |
| R | ABDOMINAL X-RAY PERFORMED REASON Multiple occurrences of this item are permitted |
| R | TRANSFERRED FROM NEONATAL INTENSIVE CARE UNIT FOR NECROTISING ENTEROCOLITIS MANAGEMENT INDICATOR |
| R | LAPAROTOMY FOR NECROTISING ENTEROCOLITIS INDICATION CODE |
| R | VISUAL INSPECTION CONFIRMED NECROTISING ENTEROCOLITIS DURING LAPAROTOMY INDICATOR |
| R | HISTOLOGY CONFIRMED NECROTISING ENTEROCOLITIS FOLLOWING LAPAROTOMY INDICATOR |
| R | PERITONEAL DRAIN INSERTED FOLLOWING ABDOMINAL X-RAY INDICATOR |
| RETINOPATHY OF PREMATURITY SCREENING (EPISODIC) |
|---|
| Retinopathy of Prematurity Screening Indicator: To carry an indicator relating to Retinopathy of Prematurity Screening undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| M | RETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR |
| CRANIAL ULTRASOUND SCANS (EPISODIC) |
|---|
| Cranial Ultrasound Scan Indicator: To carry an indicator relating to Cranial Ultrasound Scans undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | CRANIAL ULTRASOUND SCAN PERFORMED INDICATOR |
| Cranial Ultrasound Scan: To carry information relating to Cranial Ultrasound Scans at any time during the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PROCEDURE DATE AND TIME (CRANIAL ULTRASOUND SCAN) or PROCEDURE YEAR AND MONTH (CRANIAL ULTRASOUND SCAN) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| O | INTRAVENTRICULAR HAEMORRHAGE GRADE (LEFT SIDE) |
| O | PORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE) |
| O | VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE) |
| O | INTRAVENTRICULAR HAEMORRHAGE GRADE (RIGHT SIDE) |
| O | PORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE) |
| O | VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE) |
| O | CYSTIC PERIVENTRICULAR LEUKOMALACIA OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR |
| O | POST HAEMORRHAGIC HYDROCEPHALUS OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR |
| NEWBORN BLOOD SPOT BIOCHEMICAL SCREENING (EPISODIC) |
|---|
| Newborn Blood Spot Test Indicator: To carry an indicator relating to Newborn Blood Spot Tests undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| M | NEWBORN BLOOD SPOT TEST PERFORMED INDICATOR |
| Newborn Blood Spot Screening: To carry details of Newborn Blood Spot Biochemical Screening undertaken at any time in the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | BLOOD SPOT CARD COMPLETION DATE or BLOOD SPOT CARD COMPLETION YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| NEWBORN HEARING SCREENING (EPISODIC) |
|---|
| Newborn Hearing Screening Indicator: To carry an indicator relating to Newborn Hearing Screening undertaken at any time during the Neonatal Critical Care Period. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | NEWBORN HEARING SCREENING PERFORMED INDICATOR |
| Newborn Hearing Screening: To carry information relating to Newborn Hearing Screening at any time during the Neonatal Critical Care Period. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PROCEDURE DATE AND TIME (NEWBORN HEARING SCREENING) or PROCEDURE YEAR AND MONTH (NEWBORN HEARING SCREENING) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| O | NEWBORN HEARING SCREENING OUTCOME LEFT EAR (NATIONAL NEONATAL DATA SET) |
| O | NEWBORN HEARING SCREENING OUTCOME RIGHT EAR (NATIONAL NEONATAL DATA SET) |
| O | NEWBORN HEARING SCREENING TEST TYPE |
| DAILY CARE INFORMATION |
|---|
| Daily Care Respiratory: To carry Respiratory information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| P | RESPIRATORY SUPPORT DEVICE TYPE (NATIONAL NEONATAL DATA SET) Multiple occurrences of this item are permitted |
| P | RESPIRATORY SUPPORT MODE (NATIONAL NEONATAL DATA SET) Multiple occurrences of this item are permitted |
| R | NITRIC OXIDE GIVEN INDICATOR |
| R | CHEST DRAIN IN SITU INDICATOR |
| R | TRACHEOSTOMY TUBE IN SITU INDICATOR |
| R | REPLOGLE TUBE IN SITU INDICATOR |
| R | SURFACTANT GIVEN INDICATOR (ON NEONATAL CRITICAL CARE DAILY CARE DATE) |
| P | FRACTION OF INSPIRED OXYGEN PERCENTAGE |
| Daily Care Cardiovascular: To carry Cardiovascular information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | CONTINUOUS INFUSION OF PULMONARY VASODILATOR RECEIVED INDICATOR |
| R | INOTROPE INFUSION RECEIVED INDICATOR |
| R | PROSTAGLANDIN INFUSION RECEIVED INDICATOR |
| R | TREATMENT TYPE FOR PATENT DUCTUS ARTERIOSUS Multiple occurrences of this item are permitted |
| Daily Care Gastrointestinal: To carry Gastrointestinal information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | PERITONEAL DIALYSIS RECEIVED INDICATOR |
| R | HAEMOFILTRATION RECEIVED INDICATOR |
| R | TREATMENT TYPE FOR NECROTISING ENTEROCOLITIS |
| R | MORE THAN THREE RECTAL WASHOUTS RECEIVED INDICATOR |
| R | STOMA PRESENT INDICATOR |
| Daily Care Blood Transfusion: To carry Blood Transfusion information relating to Daily Care. Multiple occurrences of this group are permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | BLOOD TRANSFUSION TYPE |
| R | BLOOD TRANSFUSION PRODUCT TYPE Multiple occurrences of this item are permitted |
| Daily Care Neurology: To carry Neurology information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | CENTRAL TONE STATUS |
| R | NEONATAL CONSCIOUSNESS STATUS |
| R | SEIZURE OCCURRED INDICATOR |
| R | NEONATAL ABSTINENCE SYNDROME OBSERVED INDICATOR |
| R | BRAIN ACTIVITY SCAN PERFORMED INDICATOR |
| R | THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR |
| R | HYPOXIC ISCHEMIC ENCEPHALOPATHY GRADE (HIGHEST ON NEONATAL CRITICAL CARE DAILY CARE DATE) |
| Daily Care Retinopathy of Prematurity Screening: To carry Retinopathy of Prematurity information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | RETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR |
| Daily Care Fluids and Feeding: To carry Fluids and Feeding information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | VASCULAR LINE TYPE IN SITU Multiple occurrences of this item are permitted |
| R | PARENTERAL NUTRITION RECEIVED INDICATOR |
| R | INTRAVENOUS INFUSION OF GLUCOSE AND ELECTROLYTE SOLUTION RECEIVED INDICATOR |
| R | ENTERAL FEED TYPE GIVEN Multiple occurrences of this item are permitted |
| R | FORMULA MILK OR MILK FORTIFIER TYPE Multiple occurrences of this item are permitted or FORMULA MILK OR MILK FORTIFIER TYPE (SNOMED CT DM+D) Multiple occurrences of this item are permitted |
| R | TOTAL VOLUME OF MILK RECEIVED |
| O | ENTERAL FEEDING METHOD Multiple occurrences of this item are permitted |
| Daily Care Infections: To carry Infection information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | SEPSIS SUSPECTED INDICATOR |
| Daily Care Jaundice: To carry Jaundice information relating to Daily Care. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | PHOTOTHERAPY RECEIVED INDICATOR |
| Daily Care Medication: To carry Medication Administered information relating to Daily Care. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | MEDICATION GIVEN DURING NEONATAL CRITICAL CARE DAILY CARE DATE (SNOMED CT DM+D) Multiple occurrences of this item are permitted |
Change to Data Set: Changed Description
National Neonatal Data Set Overview
The Mandatory, Required or Optional (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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposesP = 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 Information Standards Board for Health and Social Care and are included to facilitate piloting and testing of future Neonatal Data Analysis Unit data requirements, prior to formal inclusion in later versions of the 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.
| TWO YEAR NEONATAL OUTCOMES ASSESSMENT |
|---|
One of the following Child Demographics Data Group Structures must be used:
| Child Demographics (Standard): To carry the Child's demographic details where anonymisation of the record is NOT required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | NHS NUMBER |
| M | NHS NUMBER STATUS INDICATOR CODE |
| R | COMMUNITY HEALTH INDEX NUMBER |
| R | HEALTH AND CARE NUMBER |
| M | BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET) |
| R | DATE TIME OF BIRTH |
| M | SITE CODE (OF ACTUAL PLACE OF DELIVERY) or ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY) |
| O | GESTATION LENGTH (AT DELIVERY) |
| O | GESTATION LENGTH (REMAINING DAYS AT DELIVERY) |
| R | PERSON PHENOTYPIC SEX or PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET) |
OR
| Child's Demographics (Withheld): To carry the Child's demographic details where anonymisation of the record IS required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| M | NHS NUMBER STATUS INDICATOR CODE |
| M | BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET) |
| R | YEAR AND MONTH OF BIRTH |
| M | SITE CODE (OF ACTUAL PLACE OF DELIVERY) or ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY) |
| O | GESTATION LENGTH (AT DELIVERY) |
| O | GESTATION LENGTH (REMAINING DAYS AT DELIVERY) |
| R | PERSON PHENOTYPIC SEX or PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET) |
One of the following Two Year Assessment Administration Data Group Structures must be used:
| Two Year Assessment Administration (Standard): To carry administrative information relating to the Two Year Neonatal Outcomes Assessment where anonymisation of the record is NOT required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| M | TWO YEAR NEONATAL OUTCOMES ASSESSMENT DATE |
| O | CARE PROFESSIONAL JOB ROLE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| R | POSTCODE OF USUAL ADDRESS (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| M | SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) or ORGANISATION CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| R | TWO YEAR NEONATAL OUTCOMES ASSESSMENT NOT CARRIED OUT REASON |
| R | PERSON DEATH DATE (POST DISCHARGE FROM NEONATAL CRITICAL CARE) |
OR
| Two Year Administration (Withheld): To carry administrative information relating to the Two Year Neonatal Outcomes Assessment where anonymisation of the record IS required. One occurrence of this group is required. | |
| M/R/O/P | Data Set Data Elements |
| R | TWO YEAR NEONATAL OUTCOMES ASSESSMENT YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| O | CARE PROFESSIONAL JOB ROLE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| R | SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) or ORGANISATION CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| R | TWO YEAR NEONATAL OUTCOMES ASSESSMENT NOT CARRIED OUT REASON |
| R | PERSON DEATH YEAR AND MONTH (POST DISCHARGE FROM NEONATAL CRITICAL CARE) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| Two Year TPRG-SEND - Neuromotor: To carry information relating to TPRG-SEND Neuromotor at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION C) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION D) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION E) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION F) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION G) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION H) |
| Two Year TPRG-SEND - Malformations: To carry information relating to TPRG-SEND Malformations at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (MALFORMATIONS QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (MALFORMATIONS QUESTION B) |
| Two Year TPRG-SEND - Respiratory and Cardiovascular: To carry information relating to TPRG-SEND Respiratory and Cardiovascular System at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RESPIRATORY AND CARDIOVASCULAR SYSTEM QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RESPIRATORY AND CARDIOVASCULAR SYSTEM QUESTION B) |
| Two Year TPRG-SEND - Gastrointestinal Tract: To carry information relating to TPRG-SEND Gastrointestinal Tract at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION A) |
| R | SPECIAL DIET DESCRIPTION |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION C) |
| Two Year TPRG-SEND - Renal: To carry information relating to TPRG-SEND Renal at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION C) |
| Two Year TPRG-SEND - Neurology: To carry information relating to TPRG-SEND Neurology at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION C) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION D) |
| Two Year TPRG-SEND - Growth: To carry information relating to TPRG-SEND Growth at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PERSON WEIGHT (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| P | OBSERVATION DATE (WEIGHT) or OBSERVATION YEAR AND MONTH (WEIGHT) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | PERSON HEIGHT IN CENTIMETRES (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| P | OBSERVATION DATE (HEIGHT) or OBSERVATION YEAR AND MONTH (HEIGHT) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | HEAD CIRCUMFERENCE IN CENTIMETRES (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT) |
| P | OBSERVATION DATE (HEAD CIRCUMFERENCE) or OBSERVATION YEAR AND MONTH (HEAD CIRCUMFERENCE) and NUMBER OF MINUTES (BIRTH TO EVENT) |
| Two Year TPRG-SEND - Development: To carry information relating to TPRG-SEND Development at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT ADDITIONAL QUESTION FOR NATIONAL NEONATAL DATA SET) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION C) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION D) |
| R | NEURODEVELOPMENTAL ASSESSMENT ALREADY TAKEN INDICATOR |
| R | NEURODEVELOPMENTAL ASSESSMENT TEST NAME |
| Two Year TPRG-SEND - Neurosensory: To carry information relating to TPRG-SEND Neurosensory at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION C) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION D) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION E) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION F) |
| Two Year TPRG-SEND - Communication: To carry information relating to TPRG-SEND Communication at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION B) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION C) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION D) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION E) |
| Two Year TPRG-SEND - Special Questions: To carry information relating to TPRG-SEND Special Questions at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (SPECIAL QUESTIONS QUESTION A) |
| R | TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (SPECIAL QUESTIONS QUESTION B) |
| R | CHILD DIFFICULT TO TEST REASON CODE Multiple occurrences of this item are permitted |
| Two Year TPRG-SEND - Neurological Diagnosis: To carry information relating to TPRG-SEND Neurological Diagnosis at the Two Year Neonatal Outcomes Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | PATIENT DIAGNOSIS INDICATOR (CEREBRAL PALSY) |
| R | CEREBRAL PALSY TYPE CODE (NATIONAL NEONATAL DATA SET) |
| R | DIAGNOSIS (ICD NEUROLOGICAL) Multiple occurrences of this item are permitted |
| Two Year Bayley III Assessment: To carry information relating to the Bayley III Assessment. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | ASSESSMENT TOOL COMPLETION DATE or ASSESSMENT TOOL COMPLETION YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| Two Year Bayley III - Cognitive: To carry information relating to the Bayley III Cognitive sub-scale. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | BAYLEY III COGNITIVE TOTAL RAW SCORE |
| R | BAYLEY III COGNITIVE SCALE SCORE |
| R | BAYLEY III COGNITIVE DEVELOPMENTAL AGE EQUIVALENT SCORE |
| R | BAYLEY III COGNITIVE COMPOSITE SCORE |
| Two Year Bayley III - Neuromotor: To carry information relating to the Bayley III Neuromotor sub-scales. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | BAYLEY III NEUROMOTOR (FINE MOTOR) TOTAL RAW SCORE |
| R | BAYLEY III NEUROMOTOR (FINE MOTOR) SCALE SCORE |
| R | BAYLEY III NEUROMOTOR (FINE MOTOR) DEVELOPMENTAL AGE EQUIVALENT SCORE |
| R | BAYLEY III NEUROMOTOR (FINE MOTOR) COMPOSITE SCORE |
| R | BAYLEY III NEUROMOTOR (GROSS MOTOR) TOTAL RAW SCORE |
| R | BAYLEY III NEUROMOTOR (GROSS MOTOR) SCALE SCORE |
| R | BAYLEY III NEUROMOTOR (GROSS MOTOR) DEVELOPMENTAL AGE EQUIVALENT SCORE |
| R | BAYLEY III NEUROMOTOR (GROSS MOTOR) COMPOSITE SCORE |
| R | BAYLEY III NEUROMOTOR SUM TOTAL RAW SCORE |
| R | BAYLEY III NEUROMOTOR SUM TOTAL SCALE SCORE |
| R | BAYLEY III NEUROMOTOR SUM TOTAL DEVELOPMENTAL AGE EQUIVALENT SCORE |
| R | BAYLEY III NEUROMOTOR SUM TOTAL COMPOSITE SCORE |
| Two Year Bayley III - Social-Emotional: To carry information relating to the Bayley III Social-Emotional sub-scale. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| R | BAYLEY III SOCIAL-EMOTIONAL TOTAL RAW SCORE |
| R | BAYLEY III SOCIAL-EMOTIONAL SCALE SCORE |
| R | BAYLEY III SOCIAL-EMOTIONAL DEVELOPMENTAL AGE EQUIVALENT SCORE |
| R | BAYLEY III SOCIAL-EMOTIONAL COMPOSITE SCORE |
| Two Year Griffiths: To carry information relating to Griffiths Scale of Infant Development. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | ASSESSMENT TOOL COMPLETION DATE or ASSESSMENT TOOL COMPLETION YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | GRIFFITHS LOCOMOTOR SCALE SCORE |
| R | GRIFFITHS PERSONAL-SOCIAL SCALE SCORE |
| R | GRIFFITHS LANGUAGE SCALE SCORE |
| R | GRIFFITHS EYE AND HAND CO-ORDINATION SCALE SCORE |
| R | GRIFFITHS PERFORMANCE SCALE SCORE |
| R | GRIFFITHS PRACTICAL REASONING SCALE SCORE |
| Two Year Schedule of Growing: To carry information relating to Schedule of Growing Skills. One occurrence of this group is permitted. | |
| M/R/O/P | Data Set Data Elements |
| P | ASSESSMENT TOOL COMPLETION DATE or ASSESSMENT TOOL COMPLETION YEAR AND MONTH and NUMBER OF MINUTES (BIRTH TO EVENT) |
| R | SCHEDULE OF GROWING SKILLS (PASSIVE POSTURE) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (ACTIVE POSTURE) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (LOCOMOTOR) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (MANIPULATIVE) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (VISUAL) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (HEARING AND LANGUAGE) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (SPEECH AND LANGUAGE) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (INTERACTIVE SOCIAL) SCALE SCORE |
| R | SCHEDULE OF GROWING SKILLS (SELF-CARE SOCIAL) SCALE SCORE |
Change to Data Set: Changed Description
National Workforce Data Set Overview
For a "Full Screen" view, click National Workforce Data Set.
In the "Full Screen" view, to return to the "Data Set" view, click the browser "back" button.
| ORGANISATIONAL DETAILS |
|---|
| PERSONAL/OPERATIONAL DETAILS |
|---|
| DEPLOYMENT DETAILS |
|---|
| EDUCATION DETAILS |
|---|
| ABSENCE DETAILS |
|---|
| STAFF MOVEMENTS AND NUMBERS DETAILS |
|---|
Change to Data Set: Changed Description
Neonatal Critical Care Minimum Data Set Overview
The Neonatal Critical Care Minimum Data Set is sent as a part of the following Commissioning Data Set messages:
CDS V6-2 Type 120 - Admitted Patient Care - Finished Birth Episode Commissioning Data SetCDS V6-2 Type 130 - Admitted Patient Care - Finished General Episode Commissioning Data SetCDS V6-2 Type 180 - Admitted Patient Care - Unfinished Birth Episode Commissioning Data SetCDS V6-2 Type 190 - Admitted Patient Care - Unfinished General Episode Commissioning Data Set
| Data Set Data Elements |
|---|
| Person Group (Patient): To carry the personal details of the Patient (the baby). One occurrence of this Group is permitted. |
| PERSON BIRTH DATE |
| DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| DISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL) |
| Neonatal Critical Care Group: To carry the details of the Neonatal Critical Care Period. One occurrence of this Group is permitted. |
| CRITICAL CARE LOCAL IDENTIFIER |
| CRITICAL CARE START DATE |
| CRITICAL CARE START TIME |
| CRITICAL CARE DISCHARGE DATE |
| CRITICAL CARE DISCHARGE TIME |
| CRITICAL CARE UNIT FUNCTION |
| GESTATION LENGTH (AT DELIVERY) |
| Neonatal Critical Care Daily Activity Group: To carry the daily activity data for each day of the Neonatal Critical Care Period. 999 occurrences of this Group are permitted. |
| ACTIVITY DATE (CRITICAL CARE) |
| PERSON WEIGHT |
| 20 occurrences of Critical Care Activity Codes are permitted within the Neonatal Critical Care Daily Activity Group. All codes relate to care provided on the ACTIVITY DATE (CRITICAL CARE). |
| CRITICAL CARE ACTIVITY CODE |
| 20 occurrences of High Cost Drugs OPCS codes are permitted within the Neonatal Critical Care Daily Activity Group. All codes relate to drugs provided on the ACTIVITY DATE (CRITICAL CARE). |
| HIGH COST DRUGS (OPCS) |
Change to Data Set: Changed Description
NHS Breast Screening Programme Central Return Data Set (KC62) Overview
Change to Data Set: Changed Description
NHS Breast Screening Programme Central Return Data Set (KC63) Overview
Change to Data Set: Changed Description
NHS Continuing Healthcare Data Set Overview
Click NHS Continuing Healthcare 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 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 presentR = Required: NHS business processes cannot be delivered without this data element.
| SUBMISSION IDENTIFIER |
|---|
| To carry details of the providing organisation and reporting period. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | REPORTING PERIOD QUARTER END DATE |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | NHS CONTINUING HEALTHCARE COMMISSIONED SERVICES INDICATOR |
| TABLE 1 - NHS CONTINUING HEALTHCARE (NHS CHC) SNAPSHOT ACTIVITY |
|---|
| To carry details of the number of persons eligible for NHS Continuing Healthcare as at the last day of the quarter. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE TYPE Multiple occurrences of this item are permitted |
| M | PERSONS ELIGIBLE FOR NHS CONTINUING HEALTHCARE (LAST DAY OF PREVIOUS REPORTING PERIOD) Multiple occurrences of this item are permitted |
| M | PERSONS NEWLY ELIGIBLE FOR NHS CONTINUING HEALTHCARE Multiple occurrences of this item are permitted |
| M | PERSONS NO LONGER ELIGIBLE FOR NHS CONTINUING HEALTHCARE Multiple occurrences of this item are permitted |
| M | PERSONS ELIGIBLE FOR NHS CONTINUING HEALTHCARE (REPORTING PERIOD END) Multiple occurrences of this item are permitted |
| TABLE 2 - NHS CONTINUING HEALTHCARE (NHS CHC) CUMULATIVE YEAR TO DATE ACTIVITY |
|---|
| To carry details of the running total of all NHS Continuing Healthcare eligible cases for any period within the year to date, even if they also became no longer eligible within the year to date. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE TYPE Multiple occurrences of this item are permitted |
| M | PERSONS ELIGIBLE FOR NHS CONTINUING HEALTHCARE CUMULATIVE ACTIVITY (PREVIOUS REPORTING PERIOD END) Multiple occurrences of this item are permitted |
| M | PERSONS ELIGIBLE FOR NHS CONTINUING HEALTHCARE CUMULATIVE ACTIVITY (REPORTING PERIOD END) Multiple occurrences of this item are permitted |
| TABLE 3 - NHS CONTINUING HEALTHCARE (NHS CHC) REFERRALS IN QUARTER |
|---|
| To carry details of the number of referrals for NHS Continuing Healthcare in the quarter. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE TYPE Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE REFERRALS Multiple occurrences of this item are permitted |
| TABLE 4 - NHS CONTINUING HEALTHCARE (NHS CHC) REFERRAL OUTCOMES IN QUARTER |
|---|
| To carry details of the number of NHS Continuing Healthcare Referral Outcomes in the quarter. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE TYPE Multiple occurrences of this item are permitted |
| M | PERSONS ASSESSED AS NOT ELIGIBLE FOR NHS CONTINUING HEALTHCARE (STANDARD) |
| M | PERSONS ASSESSED FOR NHS CONTINUING HEALTHCARE Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE REFERRALS (DISCOUNTED BEFORE ASSESSMENT) Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE REFERRALS CONCLUDED Multiple occurrences of this item are permitted |
| TABLE 5 - NHS CONTINUING HEALTHCARE (NHS CHC) CONVERSION RATES IN QUARTER |
|---|
| To carry details of the NHS Continuing Healthcare Conversion Rates in the quarter. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE TYPE Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE ASSESSMENT CONVERSION RATE Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE REFERRAL CONVERSION RATE Multiple occurrences of this item are permitted |
| TABLE 6 - NHS CONTINUING HEALTHCARE (NHS CHC) DECISION SUPPORT TOOL |
|---|
| To carry details of the number of Decision Support Tools (DSTs) carried out in the quarter, for NHS Continuing Healthcare (Standard) only. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | DECISION SUPPORT TOOLS FOR NHS CONTINUING HEALTHCARE CARRIED OUT (STANDARD) |
| M | DECISION SUPPORT TOOLS FOR NHS CONTINUING HEALTHCARE CARRIED OUT (STANDARD ACUTE HOSPITAL SETTING) |
| M | PERCENTAGE OF DECISION SUPPORT TOOLS CARRIED OUT (STANDARD ACUTE HOSPITAL SETTING) |
| TABLE 7 - NHS CONTINUING HEALTHCARE (NHS CHC) 28 DAYS REFERRAL TIME |
|---|
| To carry details of the number of referrals concluded within 28 days in the quarter, for NHS Continuing Healthcare (Standard) only. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE REFERRALS CONCLUDED (WITHIN 28 DAYS STANDARD) |
| M | PERCENTAGE OF NHS CONTINUING HEALTHCARE REFERRALS CONCLUDED WITHIN 28 DAYS (STANDARD) |
| M | NHS CONTINUING HEALTHCARE INCOMPLETE REFERRALS (EXCEEDING 28 DAYS AT REPORTING PERIOD END STANDARD) |
| TABLE 8 - NHS CONTINUING HEALTHCARE (NHS CHC) CASES EXCEEDING 28 DAYS |
|---|
| To carry details of the number of incomplete referrals exceeding 28 days as at the end of the quarter by time band, for NHS Continuing Healthcare (Standard) only. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE REFERRAL EXCEEDING 28 DAYS TIME BAND CATEGORY (STANDARD) Multiple occurrences of this item are permitted |
| M | NHS CONTINUING HEALTHCARE REFERRALS (EXCEEDING 28 DAYS STANDARD) Multiple occurrences of this item are permitted |
| TABLE 9 - NHS CONTINUING HEALTHCARE (NHS CHC) LOCAL RESOLUTION: APPEALS (REQUESTS FOR A REVIEW OF AN ELIGIBILITY DECISION) |
|---|
| To carry details of the number of local appeals, for Standard and Fast Track. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE LOCAL APPEALS COMPLETED |
| M | NHS CONTINUING HEALTHCARE LOCAL APPEALS RESULTING IN ELIGIBILITY |
| M | PERCENTAGE OF NHS CONTINUING HEALTHCARE LOCAL APPEALS RESULTING IN ELIGIBILITY |
| M | NHS CONTINUING HEALTHCARE INCOMPLETE LOCAL APPEALS (REPORTING PERIOD END) |
| TABLE 10 - NHS CONTINUING HEALTHCARE (NHS CHC) PREVIOUSLY UNASSESSED PERIODS OF CARE |
|---|
| To carry details of the claims for Previously Un-assessed Periods of Care (PUPoC). One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS CONTINUING HEALTHCARE PREVIOUSLY UNASSESSED PERIODS OF CARE CLAIMS (YEAR TO DATE) |
| TABLE 11 - NHS-FUNDED NURSING CARE (NHS FNC) ACTIVITY |
|---|
| The number of cases eligible for NHS-funded Nursing Care. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | PERSONS ELIGIBLE FOR NHS FUNDED NURSING CARE (YEAR TO DATE) |
| M | PERSONS ELIGIBLE FOR NHS FUNDED NURSING CARE (REPORTING PERIOD END) |
Change to Data Set: Changed Description
NHS Continuing Healthcare Patient Level Data Set Overview
The NHS Continuing Healthcare Patient Level Data Set has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2021.
At the time of publication of the NHS Continuing Healthcare Patient Level Data Set version 1.0, the implementation and conformance dates are subject to change depending on the need for continuing frontline investment in COVID-19 activity. Any change will be agreed between the Data Coordination Board and the developers, and will be announced in due course.
For further information please contact: england.chcdata@nhs.net.
For a "Full Screen" view, click NHS Continuing Healthcare Patient Level 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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposes.
| HEADER |
|---|
| To carry header details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | DATA SET VERSION NUMBER |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | PRIMARY DATA COLLECTION SYSTEM IN USE (NHS CONTINUING HEALTHCARE) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| PERSONAL AND DEMOGRAPHIC |
|---|
| To carry personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | ORGANISATION IDENTIFIER (LOCAL PATIENT IDENTIFIER) |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | PERSON BIRTH DATE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON STATED GENDER CODE |
| R | PERSON STATED SEXUAL ORIENTATION CODE |
| R | ETHNIC CATEGORY |
| R | RELIGIOUS OR OTHER BELIEF SYSTEM AFFILIATION GROUP CODE (NHS CONTINUING HEALTHCARE) |
| R | PERSON DEATH DATE |
| REFERRALS, ASSESSMENTS AND OUTCOMES |
|---|
| CARE PACKAGES |
|---|
| REVIEWS |
|---|
Change to Data Set: Changed Description
Paediatric Critical Care Minimum Data Set Overview
The Paediatric Critical Care Minimum Data Set is sent as a part of the following Commissioning Data Set messages:
CDS V6-2 Type 120 - Admitted Patient Care - Finished Birth Episode Commissioning Data SetCDS V6-2 Type 130 - Admitted Patient Care - Finished General Episode Commissioning Data SetCDS V6-2 Type 140 - Admitted Patient Care - Finished Delivery Episode Commissioning Data SetCDS V6-2 Type 180 - Admitted Patient Care - Unfinished Birth Episode Commissioning Data SetCDS V6-2 Type 190 - Admitted Patient Care - Unfinished General Episode Commissioning Data SetCDS V6-2 Type 200 - Admitted Patient Care - Unfinished Delivery Episode Commissioning Data Set
| Data Set Data Elements |
|---|
| Person Group (Patient): To carry the personal details of the Patient. One occurrence of this Group is permitted. |
| PERSON BIRTH DATE |
| DISCHARGE DATE (HOSPITAL PROVIDER SPELL) |
| DISCHARGE METHOD CODE (HOSPITAL PROVIDER SPELL) |
| Paediatric Critical Care Group: To carry the details of the Paediatric Critical Care Period. |
| CRITICAL CARE LOCAL IDENTIFIER |
| CRITICAL CARE START DATE |
| CRITICAL CARE START TIME |
| CRITICAL CARE DISCHARGE DATE |
| CRITICAL CARE DISCHARGE TIME |
| CRITICAL CARE UNIT FUNCTION |
| Paediatric Critical Care Daily Activity Group: To carry the daily activity data for each day of the Paediatric Critical Care Period. 999 occurrences of this Group are permitted. |
| ACTIVITY DATE (CRITICAL CARE) |
| 20 occurrences of Critical Care Activity Codes are permitted within the Paediatric Critical Care Daily Activity Group. All codes relate to care provided on the CRITICAL CARE START DATE. |
| CRITICAL CARE ACTIVITY CODE |
| 2 HIGH COST DRUGS (OPCS) codes are permitted but there is the capacity for 20 codes within the Paediatric Critical Care Daily Activity Group, to allow future refinement. All codes relate to drugs provided on the CRITICAL CARE LOCAL IDENTIFIER. |
| HIGH COST DRUGS (OPCS) |
Change to Data Set: Changed Description
Patient Level Contract Monitoring Data Set Overview
For a "Full Screen" view, click 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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposes.
For guidance on the Data Set constraints, see the Patient Level Contract Monitoring Data Set Constraints.
| SUBMISSION HEADER |
|---|
| To carry the submission header details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| M | FINANCIAL MONTH |
| M | FINANCIAL YEAR |
| M | DATE 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/O | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| M | ORGANISATION IDENTIFIER (GP PRACTICE RESPONSIBILITY) |
| M | ORGANISATION IDENTIFIER (CODE OF COMMISSIONER) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| DEMOGRAPHICS |
|---|
| To carry the demographic details of the patient. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | WITHHELD IDENTITY REASON |
| R | NHS NUMBER |
| R | LOCAL PATIENT IDENTIFIER (EXTENDED) |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | AGE AT ACTIVITY DATE (CONTRACT MONITORING) |
| R | PERSON STATED GENDER CODE |
| R | ETHNIC CATEGORY |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is permitted. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | CDS UNIQUE IDENTIFIER |
| R | NON CDS UNIQUE IDENTIFIER |
| R | ACTIVITY TREATMENT FUNCTION CODE |
| O | LOCAL SUB-SPECIALTY CODE |
| R | HOSPITAL PROVIDER SPELL NUMBER |
| R | ATTENDANCE IDENTIFIER |
| R | EMERGENCY CARE ATTENDANCE IDENTIFIER |
| R | ACTIVITY START DATE (CONTRACT MONITORING) |
| R | ACTIVITY END DATE (CONTRACT MONITORING) |
| R | PACKAGE OF CARE OR YEAR OF CARE START DATE (CONTRACT MONITORING) |
| M | UNBUNDLED EPISODE INDICATOR |
| SERVICE AGREEMENT AND COMMISSIONING DETAILS |
|---|
| COST AND PRICING DETAILS |
|---|
| To carry the activity and costing details. One occurrence of this group is required. | |
|---|---|
| M/R/O | Data Set Data Elements |
| R | TARIFF CODE |
| M | NATIONAL TARIFF INDICATOR |
| M | ACTIVITY COUNT (POINT OF DELIVERY) |
| M | ACTIVITY UNIT PRICE |
| M | TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Acute Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Acute Data Set - Admitted Patient Care.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
For guidance on the Data Set constraints, see the PLICS Acute Admitted Patient Care Data Set Constraints.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | PLICS SUBMISSION RECORD COUNT |
| M | MONTHLY EXTRACT TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry the personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | PATIENT LEVEL INFORMATION COSTING CARE ACTIVITY IDENTIFIER |
| R | CDS UNIQUE IDENTIFIER |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | PERSON STATED GENDER CODE |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| R | PATIENT PATHWAY IDENTIFIER |
| R | ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) |
| M | POINT OF DELIVERY CODE (PATIENT LEVEL INFORMATION COSTING) |
| R | HOSPITAL PROVIDER SPELL NUMBER |
| R | EPISODE NUMBER |
| M | START DATE (EPISODE) |
| M | END DATE (EPISODE) |
| M | CONSULTANT EPISODE COMPLETION STATUS (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY TREATMENT FUNCTION CODE |
| R | CYSTIC FIBROSIS BANDING |
| CURRENCY DETAILS |
|---|
| To carry the currency details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | HEALTHCARE RESOURCE GROUP CODE (FINISHED CONSULTANT EPISODE) |
| M | HEALTHCARE RESOURCE GROUP CODE (HOSPITAL PROVIDER SPELL) |
| M | ADJUSTED LENGTH OF STAY (PATIENT LEVEL INFORMATION COSTING) |
| COSTING DETAILS |
|---|
| To carry the costing details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ACTIVITY IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY COUNT (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY RESOURCE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | PATIENT LEVEL INFORMATION COSTING TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Acute Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Acute Data Set - Emergency Care.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
For guidance on the Data Set constraints, see the PLICS Acute Emergency Care Data Set Constraints.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | PLICS SUBMISSION RECORD COUNT |
| M | MONTHLY EXTRACT TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry the personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | PATIENT LEVEL INFORMATION COSTING CARE ACTIVITY IDENTIFIER |
| R | CDS UNIQUE IDENTIFIER |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | PERSON STATED GENDER CODE |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| R | EMERGENCY CARE ATTENDANCE IDENTIFIER |
| M | EMERGENCY CARE ARRIVAL DATE |
| M | EMERGENCY CARE ARRIVAL TIME |
| M | EMERGENCY CARE DEPARTMENT TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | EMERGENCY CARE DEPARTURE DATE |
| M | EMERGENCY CARE DEPARTURE TIME |
| CURRENCY DETAILS |
|---|
| To carry the currency details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | HEALTHCARE RESOURCE GROUP CODE (EMERGENCY CARE) |
| COSTING DETAILS |
|---|
| To carry the costing details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ACTIVITY IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY COUNT (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY RESOURCE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | PATIENT LEVEL INFORMATION COSTING TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Acute Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Acute Data Set - Out-Patient Care.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
For guidance on the Data Set constraints, see the PLICS Acute Out-Patient Care Data Set Constraints.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | PLICS SUBMISSION RECORD COUNT |
| M | MONTHLY EXTRACT TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry the personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | PATIENT LEVEL INFORMATION COSTING CARE ACTIVITY IDENTIFIER |
| R | CDS UNIQUE IDENTIFIER |
| R | NHS NUMBER |
| R | NHS NUMBER STATUS INDICATOR CODE |
| R | POSTCODE OF USUAL ADDRESS |
| R | PERSON BIRTH DATE |
| R | PERSON STATED GENDER CODE |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| R | PATIENT PATHWAY IDENTIFIER |
| R | ORGANISATION IDENTIFIER (PATIENT PATHWAY IDENTIFIER ISSUER) |
| M | POINT OF DELIVERY CODE (PATIENT LEVEL INFORMATION COSTING) |
| R | ATTENDANCE IDENTIFIER |
| M | APPOINTMENT DATE |
| M | APPOINTMENT TIME |
| M | ACTIVITY TREATMENT FUNCTION CODE |
| R | CYSTIC FIBROSIS BANDING |
| CURRENCY DETAILS |
|---|
| To carry the currency details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | HEALTHCARE RESOURCE GROUP CODE (OUT-PATIENT CARE) |
| COSTING DETAILS |
|---|
| To carry the costing details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ACTIVITY IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY COUNT (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY RESOURCE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | PATIENT LEVEL INFORMATION COSTING TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Acute Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Acute Data Set - Specialist Ward Care.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | PLICS SUBMISSION RECORD COUNT |
| M | MONTHLY EXTRACT TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry the personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | PATIENT LEVEL INFORMATION COSTING CARE ACTIVITY IDENTIFIER |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | UNBUNDLED CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | CRITICAL CARE LOCAL IDENTIFIER |
| M | CRITICAL CARE UNIT FUNCTION |
| M | UNBUNDLED CARE ACTIVITY DATE |
| M | CRITICAL CARE PERIOD COMPLETION STATUS (PATIENT LEVEL INFORMATION COSTING) |
| R | NUMBER OF ORGAN SYSTEMS SUPPORTED CODE (PATIENT LEVEL INFORMATION COSTING) |
| CURRENCY DETAILS |
|---|
| To carry the currency details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | HEALTHCARE RESOURCE GROUP CODE (UNBUNDLED ACTIVITY) |
| COSTING DETAILS |
|---|
| To carry the costing details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ACTIVITY IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY COUNT (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY RESOURCE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | PATIENT LEVEL INFORMATION COSTING TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Acute Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Acute Data Set - Supplementary Information.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| M | PLICS SUBMISSION RECORD COUNT |
| M | MONTHLY EXTRACT TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
| PERSONAL AND DEMOGRAPHIC DETAILS |
|---|
| To carry the personal and demographic details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| R | PATIENT LEVEL INFORMATION COSTING CARE ACTIVITY IDENTIFIER |
| CARE ACTIVITY DETAILS |
|---|
| To carry the care activity details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | UNBUNDLED CARE ACTIVITY DATE |
| CURRENCY DETAILS |
|---|
| To carry the currency details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | UNBUNDLED ACTIVITY CURRENCY SCHEME IN USE |
| M | UNBUNDLED CURRENCY CODE |
| COSTING DETAILS |
|---|
| To carry the costing details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ACTIVITY IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY COUNT (PATIENT LEVEL INFORMATION COSTING) |
| M | ACTIVITY RESOURCE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | PATIENT LEVEL INFORMATION COSTING TOTAL COST |
Change to Data Set: Changed Description
Patient Level Information Costing System Reconciliation Data Set Overview
For a "Full Screen" view, click Patient Level Information Costing System Data Set - Reconciliation.
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 presentR = Required: NHS business processes cannot be delivered without this data element.
For guidance on the Data Set constraints, see the PLICS Reconciliation Data Set Constraints.
| MESSAGE HEADER |
|---|
| To carry the message header details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION) |
| M | FINANCIAL YEAR (PATIENT LEVEL INFORMATION COSTING) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | DATE AND TIME DATA SET CREATED |
| M | CARE ACTIVITY TYPE (PATIENT LEVEL INFORMATION COSTING) |
| FINAL AUDITED ACCOUNTS |
|---|
| To carry the final audited account details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | FINAL AUDIT ACCOUNTS IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | COST OR INCOME VALUE (PATIENT LEVEL INFORMATION COSTING) |
| SERVICE AND COST EXCLUSIONS |
|---|
| To carry the service and cost exclusion details. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | SERVICE AND COST EXCLUSION SERVICE IDENTIFIER (PATIENT LEVEL INFORMATION COSTING) |
| M | SERVICE AND COST EXCLUSION TOTAL COST (PATIENT LEVEL INFORMATION COSTING) |
Change to Data Set: Changed Description
Radiotherapy 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 presentR = Required: NHS business processes cannot be delivered without this data element.
| RADIOTHERAPY ATTENDANCE |
|---|
| To carry the details of whether the Radiotherapy Attendance requires an Out-Patient Attendance record. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | OUT-PATIENT ATTENDANCE INDICATOR (RADIOTHERAPY DATA SET) |
| ATTENDANCE IDENTIFICATION |
|---|
| To carry the details of the attendance identification, which may be used for Commissioning Data Set (CDS) linkage. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ATTENDANCE IDENTIFIER |
| M | ORGANISATION CODE (CODE OF PROVIDER) |
| M | APPOINTMENT DATE |
| RADIOTHERAPY EPISODE |
|---|
| To carry the details of the Radiotherapy Episode. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | RADIOTHERAPY EPISODE IDENTIFIER |
| M | DECISION TO TREAT DATE (RADIOTHERAPY TREATMENT EPISODE) |
| M | EARLIEST CLINICALLY APPROPRIATE DATE |
| M | RADIOTHERAPY PRIORITY |
| M | TREATMENT START DATE (RADIOTHERAPY TREATMENT EPISODE) |
| M | RADIOTHERAPY DIAGNOSIS (ICD) |
| M | RADIOTHERAPY INTENT |
| RADIOTHERAPY PRESCRIPTION |
|---|
| To carry the details of each Radiotherapy Prescription. Multiple occurrences of this group are required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | PRESCRIPTION IDENTIFIER |
| M | RADIOTHERAPY TREATMENT REGION |
| R | RADIOTHERAPY ANATOMICAL TREATMENT SITE (OPCS) |
| R | NUMBER OF TELETHERAPY FIELDS |
| M | RADIOTHERAPY PRESCRIBED DOSE |
| M | PRESCRIBED FRACTIONS |
| M | RADIOTHERAPY ACTUAL DOSE |
| M | ACTUAL FRACTIONS |
| M | RADIOTHERAPY TREATMENT MODALITY |
| RADIOTHERAPY EXPOSURE |
|---|
| To carry the details of each Radiotherapy Exposure delivered. Multiple occurrences of this group are required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | RADIOTHERAPY FIELD IDENTIFIER |
| M | MACHINE IDENTIFIER |
| R | RADIOISOTOPE |
| R | RADIOTHERAPY BEAM TYPE |
| R | RADIOTHERAPY BEAM ENERGY |
| M | TIME OF EXPOSURE |
Change to Data Set: Changed Description
Sexual and Reproductive Health Activity 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 presentR = Required: NHS business processes cannot be delivered without this data element.
| REPORTING PERIOD AND ORGANISATION DETAILS |
|---|
| To carry the details of the reporting period and the organisation providing Sexual and Reproductive Health Services. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| PERSON DEMOGRAPHICS |
|---|
| To carry the demographic details for the patient attending the appointment. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | LOCAL PATIENT IDENTIFIER |
| M | PERSON STATED GENDER CODE |
| M | ETHNIC CATEGORY |
| M | ONS LOCAL GOVERNMENT GEOGRAPHIC AREA CODE (LOCAL AUTHORITY DISTRICT) |
| M | GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) |
| M | LOWER LAYER SUPER OUTPUT AREA (PERSON RESIDENCE) |
| M | AGE AT ATTENDANCE DATE |
| ATTENDANCE |
|---|
| To carry the details of the attendance. One occurrence of this group is required. | |
|---|---|
| M/R | Data Set Data Elements |
| M | ATTENDANCE DATE |
| M | ORGANISATION SITE IDENTIFIER (OF TREATMENT) |
| M | INITIAL CONTACT INDICATOR |
| M | CONSULTATION MEDIUM USED |
| M | ACTIVITY LOCATION TYPE CODE (SEXUAL AND REPRODUCTIVE HEALTH SERVICE) |
| CONTRACEPTION SERVICES PROVIDED |
|---|
| To carry the details of Contraception Services provided at the attendance. One occurrence of this group is permitted. | |
|---|---|
| M/R | Data Set Data Elements |
| R | CONTRACEPTION METHOD STATUS |
| R | CONTRACEPTION PRINCIPAL METHOD |
| R | CONTRACEPTION OTHER METHOD (Two occurrences may be recorded for each attendance) |
| R | CONTRACEPTION METHOD POST COITAL (Two occurrences may be recorded for each attendance) |
| SEXUAL AND REPRODUCTIVE HEALTH - OTHER CARE ACTIVITY |
|---|
| To carry the details of other Sexual and Reproductive Health Care Activity provided at the attendance. Up to six occurrences of this group are permitted. | |
|---|---|
| M/R | Data Set Data Elements |
| R | SEXUAL AND REPRODUCTIVE HEALTH CARE ACTIVITY |
Change to Data Set: Changed Description
Stop Smoking Service Quarterly Data Set Overview
Click Stop Smoking Services Quarterly 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/ 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 presentR = Required: NHS business processes cannot be delivered without this data element
| SUBMISSION IDENTIFIER |
|---|
| To carry the submission identifier details. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (STOP SMOKING SERVICE PROVIDER) |
| M | REPORTING PERIOD QUARTER START DATE |
| M | REPORTING PERIOD QUARTER END DATE |
| PART 1 - SUMMARY DATA FOR INDIVIDUALS |
|---|
| Part 1A - Number of people setting a smoking quit date and number who have successfully quit by ethnic category and gender. One occurrence of this group is required per ethnic category and gender. | |
| M/R | Data Set Data Elements |
| M | ETHNIC CATEGORY |
| M | PERSON STATED GENDER CODE (STOP SMOKING) |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
| Part 1B - Number of people setting a smoking quit date by age, gender and outcome at 4 week follow-up. One occurrence of this group is required per age band and gender. | |
| M/R | Data Set Data Elements |
| M | AGE BAND AT SMOKING QUIT DATE |
| M | PERSON STATED GENDER CODE (STOP SMOKING) |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
| M | STOP SMOKING NOT QUIT TOTAL |
| M | STOP SMOKING LOST TO FOLLOW-UP TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT CARBON MONOXIDE VALIDATION TOTAL |
| Part 1C - Number of pregnant women setting a smoking quit date by outcome at 4 week follow-up. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL (PREGNANT WOMEN) |
| M | STOP SMOKING NOT QUIT TOTAL (PREGNANT WOMEN) |
| M | STOP SMOKING LOST TO FOLLOW-UP TOTAL (PREGNANT WOMEN) |
| M | STOP SMOKING SUCCESSFULLY QUIT CARBON MONOXIDE VALIDATION TOTAL (PREGNANT WOMEN) |
Part 1D - Number of people who receive free prescriptions setting a smoking quit date and the number of those who have successfully quit. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | STOP SMOKING SETTING QUIT DATE TOTAL (FREE PRESCRIPTION) |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL (FREE PRESCRIPTION) |
Part 1E - Number of people setting a smoking quit date and the number who have successfully quit by socio-economic classification. One occurrence of this group is required per socio-economic classification. | |
| M/R | Data Set Data Elements |
| M | SOCIO-ECONOMIC CLASSIFICATION CODE (STOP SMOKING) |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
Part 1F - Number of people setting a smoking quit date and the number who have successfully quit by pharmacotherapy stop smoking aid received. One occurrence of this group is required per pharmacotherapy stop smoking aid received. | |
| M/R | Data Set Data Elements |
| M | PHARMACOTHERAPY STOP SMOKING AID RECEIVED |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
Part 1G - Number of people setting a smoking quit date and number who have successfully quit by intervention session type used. One occurrence of this group is required per intervention session type. | |
| M/R | Data Set Data Elements |
| M | INTERVENTION SESSION TYPE (STOP SMOKING) |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
| R | STOP SMOKING INTERVENTION SESSION TYPE REASON FOR EXCEPTION |
Part 1H - Number of people setting a smoking quit date and number who have successfully quit by intervention setting type used. One occurrence of this group is required per intervention setting type. | |
| M/R | Data Set Data Elements |
| M | INTERVENTION SETTING TYPE (STOP SMOKING) |
| M | STOP SMOKING SETTING QUIT DATE TOTAL |
| M | STOP SMOKING SUCCESSFULLY QUIT TOTAL |
| R | STOP SMOKING INTERVENTION SETTING TYPE REASON FOR EXCEPTION |
| PART 2 - SUMMARY FINANCIAL ALLOCATION |
|---|
Part 2A - Financial allocation for the year. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | STOP SMOKING SERVICE LOCAL AUTHORITY FINANCIAL ALLOCATION |
Part 2B - Cumulative total spend on Stop Smoking Services for the year up to the end of the quarter by type of allocation. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | STOP SMOKING SERVICE CUMULATIVE SPEND |
| M | STOP SMOKING SERVICE PHARMACOTHERAPY SPEND |
| M | STOP SMOKING SERVICE OTHER FINANCIAL ALLOCATION |
Change to Data Set: Changed Description
Systemic Anti-Cancer Therapy Data Set Overview
For a "Full Screen" view, click Systemic Anti-Cancer Therapy 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 presentR = Required: NHS business processes cannot be delivered without this data elementO = Optional: the inclusion of this data element is optional as required for local purposesP = Pilot: this data element is for piloting use only.
For guidance on the Data Set constraints, see the Systemic Anti-Cancer Therapy Data Set Constraints.
| DEMOGRAPHICS AND CONSULTANT |
|---|
| To carry details for the demographics and consultant. One occurrence of this group is required. | |
| M/R | Data Set Data Elements |
| M | NHS NUMBER or LOCAL PATIENT IDENTIFIER (EXTENDED) |
| M | NHS NUMBER STATUS INDICATOR CODE |
| M | PERSON FAMILY NAME |
| M | PERSON GIVEN NAME |
| M | PERSON BIRTH DATE |
| R | PERSON STATED GENDER CODE |
| M | POSTCODE OF USUAL ADDRESS |
| R | CONSULTANT CODE (INITIATED SYSTEMIC ANTI-CANCER THERAPY) |
| R | CARE PROFESSIONAL MAIN SPECIALTY CODE (START SYSTEMIC ANTI-CANCER THERAPY) |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| CLINICAL STATUS |
|---|
| To carry the clinical status details. One occurrence of this group is required. | |
| M/O | Data Set Data Elements |
| M | PRIMARY DIAGNOSIS (ICD AT START SYSTEMIC ANTI-CANCER THERAPY) and/or MORPHOLOGY (ICD-O AT START SYSTEMIC ANTI-CANCER THERAPY) |
| O | DIAGNOSIS (SNOMED CT) |
| REGIMEN |
|---|
| To carry details of the Systemic Anti-Cancer Drug Regimen. One occurrence of this group is permitted. | |
| M/R | Data Set Data Elements |
| R | ADJUNCTIVE THERAPY TYPE |
| R | SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN TREATMENT INTENT Up to four occurrences of this item are permitted |
| M | SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN ACRONYM |
| R | PERSON HEIGHT IN METRES (START OF SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN) |
| R | PERSON WEIGHT (START OF SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN) |
| R | PERFORMANCE STATUS (ADULT START OF SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN) |
| R | CO-MORBIDITY ADJUSTMENT INDICATOR |
| R | DECISION TO TREAT DATE (SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN) |
| M | START DATE (SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN) |
| R | CLINICAL TRIAL INDICATOR |
| CYCLE |
|---|
| To carry details of each Systemic Anti-Cancer Therapy Cycle. Multiple occurrences of this group are permitted. One for each Systemic Anti-Cancer Therapy Cycle. | |
| M/R | Data Set Data Elements |
| R | SYSTEMIC ANTI-CANCER THERAPY DRUG CYCLE IDENTIFIER |
| M | START DATE (SYSTEMIC ANTI-CANCER THERAPY DRUG CYCLE) |
| R | PERSON WEIGHT (START OF SYSTEMIC ANTI-CANCER THERAPY DRUG CYCLE) |
| R | PERFORMANCE STATUS (ADULT START OF SYSTEMIC ANTI-CANCER THERAPY DRUG CYCLE) |
| DRUG DETAILS |
|---|
| To carry details of the Systemic Anti-Cancer Therapy Drugs for the patients treatment. Multiple occurrences of this group are permitted. One for each Systemic Anti-Cancer Therapy Drug. | |
| M/R/O/P | Data Set Data Elements |
| M | SYSTEMIC ANTI-CANCER THERAPY DRUG NAME |
| P | SYSTEMIC ANTI-CANCER THERAPY DRUG (SNOMED CT DM+D) |
| R | SYSTEMIC ANTI-CANCER THERAPY ACTUAL DOSE |
| R | UNIT OF MEASUREMENT (SYSTEMIC ANTI-CANCER THERAPY) |
| R | OTHER UNIT OF MEASUREMENT DESCRIPTION (SYSTEMIC ANTI-CANCER THERAPY) |
| O | UNIT OF MEASUREMENT (SNOMED CT DM+D) |
| R | SYSTEMIC ANTI-CANCER THERAPY DRUG ROUTE OF ADMINISTRATION |
| O | ROUTE OF ADMINISTRATION (SNOMED CT DM+D) |
| M | SYSTEMIC ANTI-CANCER THERAPY ADMINISTRATION DATE |
| R | ORGANISATION IDENTIFIER (OF SYSTEMIC ANTI-CANCER THERAPY ADMINISTRATION) |
| OUTCOME |
|---|
| To carry details of the outcome applicable to the patient's treatment. One occurrence of this group is permitted. | |
| R/P | Data Set Data Elements |
| R | SYSTEMIC ANTI-CANCER THERAPY DRUG REGIMEN MODIFICATION INDICATOR (DOSE REDUCTION) |
| R | SYSTEMIC ANTI-CANCER THERAPY CURATIVE TREATMENT COMPLETED AS PLANNED INDICATOR |
| R | SYSTEMIC ANTI-CANCER THERAPY CURATIVE TREATMENT NOT COMPLETED OUTCOME REASON Up to four occurrences of this item are permitted |
| R | OTHER SYSTEMIC ANTI-CANCER THERAPY CURATIVE TREATMENT NOT COMPLETED OUTCOME REASON |
| R | SYSTEMIC ANTI-CANCER THERAPY NON CURATIVE TREATMENT PATIENT BENEFIT INDICATOR |
| P | SYSTEMIC ANTI-CANCER THERAPY TOXICITY MODIFICATION INDICATOR |
Change to Data Set: Changed Description
Venous Thromboembolism Risk Assessment Data Set Overview
Click Venous Thromboembolism Risk Assessment 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 (M) 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 submission identifier details. One occurrence of this group is required. | |
| M | Data Set Data Elements |
| M | ORGANISATION IDENTIFIER (CODE OF PROVIDER) |
| M | REPORTING PERIOD START DATE |
| M | REPORTING PERIOD END DATE |
| VENOUS THROMBOEMBOLISM RISK ASSESSMENTS |
|---|
Venous Thromboembolism Risk Assessments: To carry the numbers of Venous Thromboembolism Risk Assessments carried out in the month and the total patients admitted. | |
| M | Data Set Data Elements |
| M | ADMITTED PATIENTS RISK ASSESSED FOR VENOUS THROMBOEMBOLISM IN MONTH TOTAL |
| M | ADMITTED PATIENTS IN MONTH TOTAL |
Change to Supporting Information: Changed Description
Introduction
The Aggregate Contract Monitoring Data Set is to enable the interchange, in a uniform and consistent format, of monthly aggregate Contract Monitoring data between all purchasers and Health Care Providers. This will ensure that Contract Monitoring and reporting is consistent, comparable and fit for purpose across all commissioning ORGANISATIONS.
Submission of the Aggregate Contract Monitoring Data Set is a contractual requirement and a recognised monthly reconciliation statement. It demonstrates the aggregated cost of commissioned clinical care provided to PATIENTS as well as financial adjustments not attributed directly to clinical care. The totality of expenditure documented in the Aggregate Contract Monitoring Data Set must be equivalent to the monetary value of the invoice raised by the Health Care Provider and presented to the commissioner.
Scope
The scope of the Aggregate Contract Monitoring Data Set is all NHS-funded clinical care provided (including drugs and MEDICAL DEVICES not covered by the National Tariff Payment System) provided to PATIENTS as well as financial adjustments not attributed directly to clinical care, for all commissioners. This covers:
- All NHS and Independent Sector Healthcare Providers, secondary Health Care Providers, (acute, mental health and community services), but not primary care, from whom the NHS commissions healthcare.
- All NHS commissioners (Clinical Commissioning Groups or their equivalents and NHS England)
The Aggregate Contract Monitoring Data Set is an aggregation of the three separate patient-level Contract Monitoring data set flows:
Submission
The Aggregate Contract Monitoring Data Set is submitted on a monthly basis to the respective Data Services for Commissioners Regional Office (DSCRO) as nominated by each commissioning function in line with the dates documented in the data submission timetable within Schedule 6 of the NHS Standard Contract.
The completed monthly Aggregate Contract Monitoring Data Set should be transmitted using the NHS Digital Data Landing Portal (DLP).
For further information on the Aggregate Contract Monitoring Data Set, see the NHS England website at: Specialised Services Reporting Requirements.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Introduction
The purpose of the Automatic Identification and Data Capture for Patient Identification Data Set is to support the accurate, timely and, therefore, safer identification of NHS PATIENTS in England, by encoding the key PATIENT identifiers into a GS1 DataMatrix 2D barcode which is printed on the PATIENT identity band.
Implementation of this Information Standard enables subsequent processes involving the PATIENT and care provided to the PATIENT (where these processes are also uniquely identified and barcoded) to be automatically identified using Automatic Identification and Data Capture (AIDC) techniques, e.g. bed management, phlebotomy, theatre management and medications administration.
The Automatic Identification and Data Capture for Patient Identification Data Set provides an agreed national standard for how to encode a GS1 DataMatrix with the key PATIENT identifiers on the identity wristband and covers production, printing and verification rules for the barcode.
Further guidance can be found on the NHS Digital website at: DCB1077: AIDC for Patient Identification.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.
Introduction
The Cancer Outcomes and Services Data Set is a compiled data set which provides the standard for secondary uses information required to support national cancer registration and associated analysis (at local, regional, national and international level), as well as other national cancer audit programmes
The standard and XML Schema consists of:
- a set of individual data items, with their definitions
- the assemblage of data items into discrete data sets
- the means of flowing the data items
- compilation of the data items into a reconciled and verified data set.
Additionally, the output supports commissioning and service development through provision of relevant information on service delivery and outcomes.
All PATIENTS diagnosed with or receiving cancer treatment in or funded by the NHS in England are covered by the standard. This includes adult and paediatric cancer PATIENTS. The standard applies to all ORGANISATIONS providing Cancer Services within secondary care. It does not apply to general practice ORGANISATIONS.
The Cancer Outcomes and Services Data Set covers diseases as defined by the United Kingdom and Ireland Association of Cancer Registries (UKIACR) as described in the User Guide at Appendix A and B.
Unless otherwise specified, the term cancer is used throughout the standard and related documents to cover all conditions registerable by the United Kingdom and Ireland Association of Cancer Registries.
Submission Information:Submission Information
Providers of Cancer Services are required to provide a monthly return on all cancer PATIENTS using the Cancer Outcomes and Services Data Set.
The Cancer Outcomes and Services Data Set is submitted to the National Cancer Registration and Analysis Service (NCRAS) using the COSDS XML Schema.
While the core and cancer site specific data sets are shown as separate data sets within the NHS Data Model and Dictionary, the COSDS XML Schema integrates each core and cancer site specific set of data elements. Documentation provided on the Technology Reference Data Update Distribution (TRUD) page at: NHS Data Model and Dictionary: DD XML Schemas gives full details of the specification.
For all diagnoses not covered by a cancer site specific data set, only the Core Data Set should be completed. A full list of diagnoses mapped to the appropriate data set is provided in the National Cancer Registration and Analysis Service User Guide.
Pathology:Pathology
From January 2016 Pathology Laboratories across England were mandated through SCCI1521 17/2014, to collect and return structured pathology using the COSDS XML Schema.
This replaced the current reporting to the National Cancer Registration and Analysis Service of electronic pathology reports which were then transcribed by the National Cancer Registration and Analysis Service into the Cancer Registration Reports. This also prevented Cancer Service teams, for example, Multidisciplinary Teams, Pathway Co-ordinators, duplicating the work, which had been happening as part of their data collection process.
From April 2020, the pathology data can only be collected and submitted using the separate Pathology Data Set and Pathology XML Schema. Pathology data items have been removed from the main Cancer Outcomes and Services Data Set.
This allows the Cancer Service teams to concentrate on collecting and reporting all the other clinical data required for the Cancer Outcomes and Services Data Set and the Pathologists to collect and report the pathology items. This will reduce the burden of data collection for the Cancer Service teams and allow for more accurate pathology reporting to be submitted to the National Cancer Registration and Analysis Service.
There will be no requirement for Pathology Laboratories to double report. Once their Laboratory Information Management Systems (LIMS) are updated to report in the COSDS XML Schema, all other pathology reporting can cease.
Further Guidance:Further Guidance
Further guidance for submission of the Cancer Outcomes and Services Data Set is provided by the National Cancer Registration and Analysis Service at Cancer Outcomes and Services Dataset.
Mandation
The Mandation 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.
XML Schema
For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: Changed Description
Introduction
Public Health England (PHE) is required to monitor and evaluate the NHS National Chlamydia Screening Programme (NCSP) through the reporting of data.
The Chlamydia Testing Activity Data Set collects information on all chlamydia testing commissioned by the NHS and carried out in all Laboratory settings in England. It includes results taken from all PATIENTS tested for Chlamydia in all NHS settings, or in non-healthcare settings and as part of the NHS National Chlamydia Screening Programme in England.
DATA EXTRACT SPECIFICATIONData Extract Specification
Description: Each Laboratory will be required to generate a quarterly disaggregated data extract of all chlamydia tests carried out using Nucleic Acid Amplification Testing (NAAT).
Time period: The extract will cover one calendar quarter, based on the date the SAMPLE is received at the Laboratory.
Frequency: Extracts will run quarterly, 6 weeks after the end of the quarter.
Format: Data returned should be formatted to a comma separated variable (CSV) or MS Excel file.
Transmission: Electronic files will be transmitted to Public Health England through the secure Microbiology and Epidemiology of STI's and HIV (MESH) Departments web portal. Connection to the portal requires a login account name and password which are available from Public Health England.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Contextual OverviewDue to Covid-19, the transition from Community Services Data Set v1.0 to v1.5 was postponed until 1 July 2020.
Introduction
The Community Services Data Set (CSDS) is a PATIENT level, output based, secondary uses data set which will deliver robust, comprehensive, nationally consistent and comparable person-centred information for people who are in contact with NHS-funded Community Health Services. As a secondary uses data set it intends to re-use clinical and operational data for purposes other than direct PATIENT care. It defines the data items, definitions and associated value sets to be extracted or derived from local systems.
The data collected in the Community Services Data Set covers all NHS-funded Community Health Services provided by Health Care Providers in England. This includes all SERVICES listed in the SERVICE OR TEAM TYPE REFERRED TO FOR COMMUNITY CARE within the Community Services Data Set, including any SERVICES that have transitioned into new organisational forms as a result of the Transforming Community Services (TCS) programme. This includes acute and Independent Sector Healthcare Providers that provide NHS-funded Community Health Services.
The Community Services Data Set is used by the Department of Health and Social Care, commissioners and Health Care Providers of Community Health Services and PATIENTS, as the data set provides:
- National, comparable, standardised data about Community Health Services that are being delivered, which will support intelligent commissioning decisions and SERVICE provision
- Information on the use of resources to improve the operational management of SERVICES
- Information on outcomes, to help to address health inequalities
- Support for current national outcome indicators for Community Health Services
- Traceability and visibility of Community Health Service expenditure, allowing the implementation of new payment approaches for Community Health Services through the development of defined currencies which are underpinned by consistent data
- Information to improve reference costs for Community Health Services, to ensure that these are reported consistently
- Support for a nationally consistent clinical record for all PATIENTS across England, which can be used to support national research projects
- Information for the future development of Community Health Services.
Data Collection
The Community Services Data Set provides the definitions for data to provide timely, pseudonymised PATIENT-based data and information for purposes other than direct clinical care, e.g. planning, commissioning, public health, clinical audit, performance improvement, research, clinical governance.
Data is expected to be collected from various clinical systems, collated and assembled. This standard is intended to facilitate electronic data recording and reporting but it is not intended to create clinical records for Community Health Services or to enable systems used by Community Health Services to interoperate with other clinical systems.
Submission Information
The Community Services Data Set is submitted via the Strategic Data Collection Service in the Cloud (SDCS Cloud) maintained by NHS Digital using the Community Services Data Set (CSDS) XML Schema.
Format Information
Data for submission will be formatted into an XML file as per the Technology Reference Data Update Distribution (TRUD) page at: NHS Data Model and Dictionary: DD XML Schemas.
For enquiries regarding the XML Schema, please contact NHS Digital at enquiries@nhsdigital.nhs.uk.
Further Guidance
Further information and implementation guidance has been produced by NHS Digital and is available at:
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Community Services Data Set Constraints.
XML Schema
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: Changed Description
Introduction
The Cover of Vaccination Evaluated Rapidly (COVER) Data Set is used to evaluate the routine childhood Immunisation Programme in England for children up to 5 years of age. The aim is to collect and report vaccine uptake data for all children at one, two and five years of age on a quarterly and annual basis.
The Cover of Vaccination Evaluated Rapidly (COVER) Data Set is also used to evaluate the neonatal hepatitis B Immunisation Programme in England for babies born to hepatitis B surface antigen (HBsAg) positive mothers.
The information is used:
- to reliably measure vaccine coverage
- to evaluate the success of a vaccination programme
- to identify susceptible populations for further interventions
- and to inform future vaccine policy decisions.
NHS Digital is mandated to produce the annual Cover of Vaccination Evaluated Rapidly (COVER) statistics. Cover of Vaccination Evaluated Rapidly (COVER) statistics enable the monitoring of the contribution of the routine childhood Immunisation Programme towards protecting and improving the nation’s health and are used to address inequalities.
Public Health England and the Department of Health and Social Care also have commitments to report vaccine coverage figures to international organisations such as the World Health Organisation, and the European Centre for Disease Prevention and Control.
Submission
Immunisation records are held in Child Health Information Systems (CHIS). Quarterly and annual returns are transmitted by Child Health Record Departments (who operate local Child Health Information Systems (CHIS)) or other local Health Care Providers to the NHS Digital Strategic Data Collection Service (SDCS).
Further Guidance
For further guidance see the Public Health England part of the gov.uk website at Vaccine uptake guidance and the latest coverage data.
Mandation
The Mandation 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
Change to Supporting Information: Changed Description
Introduction
The Critical Care Minimum Data Set was developed by the Critical Care Information Advisory Group (CCIAG) and endorsed by the Intensive Care Society.
The Critical Care Minimum Data Set contains a subset of mandatory items for the generation of Critical Care Healthcare Resource Groups (HRGs). The Critical Care HRG subset replaced the Augmented Care Period data elements in the Commissioning Data Sets.
The purpose of the Critical Care Minimum Data Set is to provide a standardised set of data to support National Tariff Payment System, Healthcare Resource Groups, Resource Management, Commissioning and national policy analysis. The full Critical Care Minimum Data Set has been incorporated into and is consistent with the ICNARC (Intensive Care National Audit and Research Centre) data collection.
The Critical Care Minimum Data Set has been developed to be used in all units where Critical Care is provided. That is where the CRITICAL CARE LEVEL is National Code:
- 02 Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care
- 03 Patients requiring advanced respiratory support alone or monitoring and support for two or more organ systems. This level includes all complex patients requiring support for multi-organ failure.
Neonates are excluded from the data set. The recording of Critical Care Minimum Data Set for older babies (over 28 days) on Neonatal and Paediatric Intensive Care Units is optional. However, the activity for children treated on adult critical care units should be recorded.
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:
- CDS V6-2 Type 120 - Admitted Patient Care - Finished Birth Episode Commissioning Data Set
- CDS V6-2 Type 130 - Admitted Patient Care - Finished General Episode Commissioning Data Set
- CDS V6-2 Type 140 - Admitted Patient Care - Finished Delivery Episode Commissioning Data Set
- CDS V6-2 Type 180 - Admitted Patient Care - Unfinished Birth Episode Commissioning Data Set
- CDS V6-2 Type 190 - Admitted Patient Care - Unfinished General Episode Commissioning Data Set
- CDS V6-2 Type 200 - Admitted Patient Care - Unfinished Delivery Episode Commissioning Data Set
Change to Supporting Information: Changed Description
Introduction
The purpose of the Devices Patient Level Contract Monitoring Data Set (DePLCM) is to enable the interchange, in a uniform format, of monthly PATIENT level device Contract Monitoring data between all purchasers and Health Care Providers. This will ensure that device Contract Monitoring and reporting is consistent, comparable and fit for purpose across all commissioning ORGANISATIONS.
The Devices Patient Level Contract Monitoring Data Set is a PATIENT level report containing PATIENT identifiers relating to High Cost Tariff Excluded Devices. Its purpose is to substantiate and provide detail to the information contained within the Aggregate Contract Monitoring Data Set (ACM).
Scope
The scope of the Devices Patient Level Contract Monitoring Data Set is all NHS-funded MEDICAL DEVICES not reimbursed through the National Tariff Payment System, as defined in the NHS Improvement National Tariff Payment System High Cost Devices list and any high cost devices not associated with a National Tariff, provided to PATIENTS for all NHS commissioners.
This covers:
- All acute and community NHS and Independent Sector Healthcare Provider secondary Health Care Providers, but not primary care, from whom the NHS commissions healthcare;
- All NHS commissioners (Clinical Commissioning Groups or their equivalents and NHS England).
Note that the totality of expenditure in the Devices Patient Level Contract Monitoring Data Set must be equivalent to the aggregate monetary value shown relating to High Cost Tariff Excluded Devices in the Aggregate Contract Monitoring Data Set.
Submission
The Devices Patient Level Contract Monitoring Data Set is submitted on a monthly basis to the respective Data Services for Commissioners Regional Office (DSCRO) as nominated by each commissioning function in line with the dates documented in the data submission timetable within Schedule 6 of the NHS Standard Contract.
The completed monthly Devices Patient Level Contract Monitoring Data Set should be transmitted using the NHS Digital Data Landing Portal (DLP).
For further information on the Devices Patient Level Contract Monitoring Data Set, see the NHS England website at: Specialised Services Reporting Requirements.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Devices Patient Level Contract Monitoring Data Set Constraints.
Change to Supporting Information: Changed Description
Introduction
The Diagnostic Imaging Data Set was introduced by ISB 1577 Diagnostic Imaging Data Set, in response to the lack of detailed data on national data on Diagnostic Imaging tests for NHS PATIENTS. The original requirement came from the cancer strategy to improve GP direct access to certain Diagnostic Imaging tests, as a method was required to monitor implementation of this policy.
The Diagnostic Imaging Data Set, however, has many benefits for example, to:
- Provide NHS data on GPs’ direct access to tests, as well as tests requested via other referral sources. Benchmarking data will be fed back to GPs and, where appropriate, used to encourage increased use of tests, leading to earlier diagnosis and hence improved outcomes
- Provide more detailed NHS data than is currently available on test type (modality), body site of test and PATIENT demographics
- Enable analysis of turnaround times for tests
- Enable better analysis of cancer pathways by linking the National Cancer Registration and Analysis Service data to Diagnostic Imaging test data for cancer PATIENTS
- Allow Public Health England (PHE) to calculate more accurate estimates of the distribution of individual radiation dose estimates from medical exposures.
From April 2012 it became a mandatory requirement that all providers of NHS-funded Diagnostic Imaging tests for NHS PATIENTS in England submit the central Diagnostic Imaging Data Set on a monthly basis.
The Diagnostic Imaging Data Set facilitates the collection of clinical data and the sharing of such data to underpin the delivery of effective Diagnostic Imaging. It is structured around the clinical processes of local Radiology Information Systems (RISs) used by NHS Trusts and NHS Foundation Trusts. It records administrative data relating to Diagnostic Imaging test ACTIVITY.
Information is collected relating exclusively to Diagnostic Imaging test ACTIVITY. The Diagnostic Imaging Data Set describes Diagnostic Imaging tests that have taken place as part of a broader PATIENT PATHWAY. This includes PATIENTS referred from within the ORGANISATION, either as an out-patient, in-patient or from Accident and Emergency Departments, or referred directly from their GP or another Health Care Provider.
The Diagnostic Imaging Data Set is collected from NHS funded providers of Diagnostic Imaging test SERVICES and submitted via a portal on the NHS Digital website. The submissions are processed and aggregate extracts are produced for provider and commissioner ORGANISATIONS and national groups such as the Department of Health and Social Care and Public Health England. This also allows linkage to the National Cancer Registration and Analysis Service.
Please note that the collection of the Diagnostic Imaging Data Set does not replace any other collection of diagnostic data such as the Diagnostics Waiting Times and Activity Data Set (DM01), which should continue to be collected.
Data Set Order:Data Set Order
- The transmission order of the Diagnostic Imaging Data Set is different to the order of the items in the NHS Data Model and Dictionary and XML Schema.
- Please see the "Guidance Notes" at: Diagnostic Imaging Dataset: Guidance for Data Submitters, which contains a full list of Diagnostic Imaging Data Set fields in the order they are submitted.
- Work is planned to amend some of the Diagnostic Imaging Data Set items and when this is approved by the Data Coordination Board (DCB), the NHS Data Model and Dictionary will be updated to match.
Mandation
The Mandation 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.
XML Schema
For guidance on the XML Schema constraints, see the Diagnostic Imaging Data Set XML Schema Constraints.
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: Changed Description
Introduction
The purpose of the Drugs Patient Level Contract Monitoring Data Set (DrPLCM) is to enable the interchange, in a uniform format, of monthly PATIENT level drug Contract Monitoring data between all purchasers and Health Care Providers. This will ensure that drug Contract Monitoring and reporting is consistent, comparable and fit for purpose across all commissioning ORGANISATIONS.
The Drugs Patient Level Contract Monitoring Data Set is a PATIENT level report containing PATIENT identifiers relating to high cost (National Tariff-excluded) drugs. Its purpose is to substantiate and provide detail to the aggregate information contained within the Aggregate Contract Monitoring Data Set (ACM).
Scope
The scope of the Drugs Patient Level Contract Monitoring Data Set is all NHS-funded PRESCRIBED ITEMS not reimbursed through National Tariff Payment System, as defined by the NHS Improvement National Tariff Payment System High Cost Tariff Excluded Drugs list, provided to PATIENTS for all NHS commissioners.
This covers:
- All acute and community NHS and Independent Sector Healthcare Provider secondary Health Care Providers, but not primary care, from whom the NHS commissions healthcare;
- All NHS commissioners (Clinical Commissioning Groups or their equivalents and NHS England).
Note that the totality of expenditure in the Drugs Patient Level Contract Monitoring Data Set must be equivalent to the aggregate monetary value shown relating to High Cost Tariff Excluded Drugs in the Aggregate Contract Monitoring Data Set.
Submission
The Drugs Patient Level Contract Monitoring Data Set is required to be submitted on a monthly basis to the respective Data Services for Commissioners Regional Office (DSCRO) as nominated by each commissioning function in line with the dates documented in the data submission timetable within Schedule 6 of the NHS Standard Contract.
The completed monthly Drugs Patient Level Contract Monitoring Data Set should be transmitted using the NHS Digital Data Landing Portal (DLP).
For further information on the Drugs Patient Level Contract Monitoring Data Set, see the NHS England website at: Directly Commissioned Services Reporting Requirements.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Drugs Patient Level Contract Monitoring Data Set Constraints.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The Female Genital Mutilation Data Set provides essential information in relation to the female genital mutilation population across England.
The Female Genital Mutilation Data Set is used:
- To publish Official Statistics which will inform the Department of Health and Social Care, NHS England, other Government Agencies and the public, about female genital mutilation when it has been identified
- To identify the potential risk of female genital mutilation to young girls and vulnerable women
- For better planning and management of female genital mutilation SERVICES at a local level and across England
Data may be input immediately using an input screen via the NHS Digital Clinical Audit Platform when female genital mutilation is identified, or data extracts for Patients, can be submitted as a bulk upload on a monthly basis for each ORGANISATION.
CARE CONTACT activities undertaken for female genital mutilation PATIENTS during the REPORTING PERIOD are reported in the data upload. This includes any attendances at an Out-Patient Clinic led by any type of CARE PROFESSIONAL, Hospital Provider Spells, Accident and Emergency Attendances, Group Therapy, Ward Attendances; or any other type of direct PATIENT-facing CARE CONTACT, with an exception to Sexual and Reproductive Health Clinics and Genitourinary Medicine (GUM) clinics, who are not required to submit the Female Genital Mutilation Data Set to the NHS Digital.
SNOMED CT Refset Metadata:
- Female genital mutilation related findings:
For further details relating to the SNOMED CT Refset Metadata, see the Data Dictionary for Care (DD4C) website at: Female genital mutilation related findings.
- Female genital mutilation related procedures:
For further details relating to the SNOMED CT Refset Metadata, see the Data Dictionary for Care (DD4C) website at: Female genital mutilation related procedures.
DATA EXTRACT SPECIFICATIONData Extract Specification
Description:Description
The Department of Health and Social Care requires all NHS Trusts, NHS Foundation Trusts and GENERAL MEDICAL PRACTITIONERS to generate and provide a data extract in accordance with the Female Genital Mutilation Data Set. This requirement is applicable to all CARE PROFESSIONALS in these ORGANISATIONS whenever it has been identified that a woman or young girl has undergone female genital mutilation.
Further information is available on the NHS Digital website at: Female Genital Mutilation Datasets.Time period:Time period
Data extracted from systems can be submitted as a bulk upload on a quarterly basis for each ORGANISATION.
Format
Data submitted by the bulk upload facility must be formatted in 3 separate comma separated variable (csv) files (i.e. Patient, Attendance or Female Genital Mutilation), which are used to populate the NHS Digital Clinical Audit Platform. The data elements should be transmitted in the order specified in the Female Genital Mutilation Data Set.
Transmission
Electronic files must be transmitted to NHS Digital via the Clinical Audit Platform which is a secure web portal.
Connection to the web portal requires registration to the Clinical Audit Platform, which will include the provision of a login account name and password.
Further information about the Clinical Audit Platform and the data upload facility can be found on the NHS Digital website: at Clinical Audit Platform.
Further guidance on the Female Genital Mutilation Data Set can be found on the on the NHS Digital website at: SCCI2026: Female Genital Mutilation Enhanced Dataset.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The GUMCAD Sexually Transmitted Infection Surveillance System Data Set provides essential public health information about Sexually Transmitted Infection (STI) diagnoses, treatments and SERVICES provided by Level 3 Genitourinary Medicine Services and commissioned Level 2 Sexual Health Services.
The GUMCAD Sexually Transmitted Infection Surveillance System Data Set is used:
- To inform public health response and policy formulation for England
- To monitor the effectiveness of the policies introduced as part of the National Strategy for Sexual Health and Human Immunodeficiency Virus (HIV)
- For performance management at local and national level to ensure delivery of the national Public Service Agreement target on Sexual Health Services
- For better planning and management of Sexual Health Services at local level
- To adapt and refine clinical interventions, as appropriate
DATA EXTRACT SPECIFICATIONData Extract Specification
Description:
Public Health England require Sexual Health Services to generate and provide a data extract in accordance with the GUMCAD Sexually Transmitted Infection Surveillance System Data Set. These SERVICES include:
- NHS providers of specialised Level 3 Genitourinary Medicine Services, where the primary function of the specialist clinical multidisciplinary team is concerned with the provision of screening, diagnosis and management of Sexually Transmitted Infections and related genital medical conditions.
- All Level 2 Sexual Health Services commissioned by the NHS who offer testing, diagnostic and/or treatment of Sexually Transmitted Infections.
It should be noted that General Practitioners with Extended Roles (GPwERs) will only be included if they operate from a General Medical Practitioner Practice that has been commissioned to provide a Level 2 Sexual Health Service.
Time period: The extract must cover one calendar quarter.
Frequency: Reports must be run quarterly, 6 weeks after the end of the quarter.
Format: Data returned must be formatted into a single comma separated variable (csv) file. The data elements should be transmitted in the order specified in the GUMCAD Sexually Transmitted Infection Surveillance System Data Set.
Transmission: Electronic files must be transmitted to Public Health England through a secure web portal on the Public Health England website. This web portal enables ORGANISATIONS to submit data files in a secure manner to the HIV and STI Department of Public Health England. The web portal can be found at HIV & STI web portal.
Connection to the web portal requires a login account name and password at Public Health England. Please contact gumcad@phe.org.uk for access or more information.
Further guidance on the GUMCAD Sexually Transmitted Infection Surveillance System Data Set can be found on the Public Health England part of the gov.uk website at: STI Surveillance, data, screening and management.Mandation
The Mandation 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
Change to Supporting Information: Changed Description
Background:Introduction
The scope of the HIV and AIDS Reporting Data Set is all PATIENTS who are diagnosed with Human Immunodeficiency Virus (HIV) and receive HIV care from Health Care Providers.
NHS Health Care Providers are required to generate the HIV and AIDS Reporting Data Set.
The HIV and AIDS Reporting Data Set is used to:
- Identify the groups at risk of HIV infection in England
- Monitor the short and long term clinical outcomes of people living with HIV infection
- Monitor the effectiveness of the national policies and guidance
- Adapt and refine interventions, as appropriate.
Secondary analyses of aggregate outputs from the HIV and AIDS Reporting Data Set will be used to:
- Support the commissioning of HIV Services through collation of data to inform the national HIV outpatient tariff for the National Tariff Payment System
- Conduct performance management at the Local Authority and national level.
For further information on Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV), see the Public Health England part of the gov.uk website.
Time period:Time period
The extract covers one calendar quarter.
Frequency:
The HIV and AIDS Reporting Data Set is attendance based and should be submitted quarterly, 2 weeks after the end of the quarter.
Format:Format
Data for submission will be formatted into an xml file as per the HIV and AIDS Reporting Data Set XML Schema.
Transmission:Transmission
Submissions should be transmitted to Public Health England through a secure web portal on the Public Health England (PHE) website, using the HARS Data Set XML Schema.
The web portal enables ORGANISATIONS to submit data files in a secure manner to the HIV and STI Department of Public Health England across the internet and can be found at HIV & STI web portal.
For further information on the HIV and AIDS Reporting Data Set, see the Public Health England part of the gov.uk website at: HIV surveillance systems.
Mandation
The Mandation 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.
XML Schema
For guidance on the XML Schema constraints, see the HIV and AIDS Reporting Data Set XML Schema Constraints.
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: 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.
Background:Due to Covid-19, the transition from from Improving Access to Psychological Therapies (IAPT) Data Set v1.5 to v2.0 was postponed until 1 September 2020.
Introduction
The Adult Improving Access to Psychological Therapies Programme is an NHS programme in England, which started in 2008, that has transformed treatment of anxiety disorders and depression through the delivery of interventions approved by the National Institute for Health and Care Excellence (NICE).
Improving Access to Psychological Therapies Data Set
The Improving Access to Psychological Therapies Data Set has been developed to support the Adult Improving Access to Psychological Therapies Programme through a regular national return of data. This includes for example: supporting commissioning, service improvement and service design.
The Improving Access to Psychological Therapies Data Set is a PATIENT level, output based, secondary uses data set which aims to deliver robust, comprehensive, nationally consistent and comparable information for PATIENTS accessing NHS-funded Improving Access to Psychological Therapies Services located in England.
As a secondary uses data set, the Improving Access to Psychological Therapies Data Set re-uses clinical and operational data for purposes other than direct PATIENT care. It defines the data items, definitions and associated value sets to be extracted or derived from local information systems. These national definitions allow Health Care Providers to extract data from their local systems in a consistent manner, which supports national and local reporting to be undertaken.
The Improving Access to Psychological Therapies Data Set includes information on:
- PATIENT Demographics: including geographical, gender, age, ethnicity, religion, sexual orientation and DISABILITY
- Care Pathways: referral details, Mental Health Care Cluster details and Presenting Complaints information
- CARE CONTACTS and CARE ACTIVITIES: SESSION details and any clinical, economic and social outcomes recorded relating to the interventions and coded scored assessments provided
- Waiting Time Pauses: ACTIVITY SUSPENSION periods across the PATIENT's care pathway
- Improving Access to Psychological Therapies Patient Experience Questionnaires: Improving Access to Psychological Therapies treatment and assessment questionnaires
- National Tariff Payment System: Additional data items to support the introduction and development of a payment system for Improving Access to Psychological Therapies Services
- Care Personnel: Qualifications of the Care Personnel delivering treatment.
Submission Information:Submission Information
The Improving Access to Psychological Therapies Data Set is submitted centrally on a monthly basis via the Strategic Data Collection Service in the Cloud (SDCS Cloud) maintained by NHS Digital.
Further guidance relating to the Improving Access to Psychological Therapies Data Set is available on the NHS Digital website: at Improving Access to Psychological Therapies Data Set.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Contextual Overview
Introduction
The NHS need to measure and monitor the REFERRAL TO TREATMENT PERIOD within PATIENT PATHWAYS to ensure that they are progressing as planned to achieve the 18 weeks target.
In an estimated 10% to 20% of cases, responsibility for the PATIENT PATHWAY will be transferred between Health Care Providers. The receiving Health Care Provider would be unable to report on the 18 weeks target for these cases unless the referring Health Care Provider supplied the PATIENT PATHWAY information at the time of transfer.
This data set specifies the data necessary to permit the receiving Health Care Provider to be able to report the PATIENT's progress along their PATIENT PATHWAY and, in particular, their REFERRAL TO TREATMENT PERIOD.
Scope and Collection
Scope and Collection- Completion is mandatory for all PATIENTS with a REFERRAL TO TREATMENT PERIOD where there has been a transfer of care to an alternative Health Care Provider.
- Completion is advisable for PATIENTS without a REFERRAL TO TREATMENT PERIOD, where there has been a transfer of care to an alternative Health Care Provider, but this is voluntary.
- The referring ORGANISATION should send the data set within 48 hours of DECISION TO REFER DATE (INTER-PROVIDER TRANSFER).
- Inter-provider transfer SERVICE REQUESTS for clinical opinion or diagnostics, where the care of the PATIENT remains with the referring Health Care Provider, are voluntary.
- SERVICE REQUESTS associated with the following PATIENT PATHWAYS are also not currently included:
- Non-elective PATIENTS
- Planned admissions (usually part of a planned sequence of clinical care determined mainly on social or clinical criteria, for example, a check cystoscopy).
Where the Inter-Provider Transfer Administrative Minimum Data Set is sent WITH the clinical referral letter it is considered to be complete if the following key data items are included:
- PATIENT PATHWAY IDENTIFIER
- ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER)
- REFERRING ORGANISATION CODE
- REFERRAL TO TREATMENT PERIOD START DATE
- REFERRAL TO TREATMENT PERIOD STATUS (INTER-PROVIDER TRANSFER)
Where the Inter-Provider Transfer Administrative Minimum Data Set is sent independently of the clinical referral letter, ALL mandated Inter-Provider Transfer Administrative Minimum Data Set data items must be completed.
Further Guidance
Further GuidanceFurther guidance on the data set can be found in 'The Inter-Provider Transfer Administrative Data Set Operational Information Standard' and in DSCN 30/2007.
Further guidance and definitions on REFERRAL TO TREATMENT PERIODS and those PATIENT PATHWAYS included within the Consultant-Led Referral to Treatment Waiting Times can be found on the NHS England website at: Consultant-led Referral to Treatment Waiting Times.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The Maternity Services Data Set (MSDS) is a PATIENT-level data set that captures key information at each stage of the maternity care pathway including mother’s demographics, Antenatal Booking Appointments, admissions and re-admissions, Screening Tests, Labour and Delivery along with baby’s demographics, admissions, diagnoses and Screening Tests.
As a secondary uses data set the Maternity Services Data Set re-uses clinical and operational data for purposes other than direct PATIENT care. It defines the data items, definitions and associated value sets extracted or derived from local information systems.
The Maternity Services Data Set is designed to meet requirements that resulted from the National Maternity Review, which led to the publication of the Better Births report in February 2016. Better Births highlighted the need for Maternity Services in England to become safer, more personalised and provide better access to information for pregnant women. The publication of Better Births resulted in the establishment of the Maternity Transformation Programme, and the data set forms part of the ‘Sharing Data and Information’ workstream of the programme.
Data Collection
The Maternity Services Data Set collects information on each stage of care for women as they go through pregnancy.
The Maternity Services Data Set Information Standards Notice (ISN) mandates the central flow of administrative and clinical information for secondary uses purposes. The scope of the data set includes all ACTIVITY carried out by NHS-funded Maternity Services relating to the mother and baby or babies, from the point of the first Antenatal Booking Appointment until the mother and baby are discharged from Maternity Services.
The Maternity Services Data Set provides the definitions for data:
- to be lodged in the central data warehouse regularly and routinely e.g. monthly. Extracts will be taken at prearranged intervals for publication
- to be assembled, compiled and to flow into a secondary uses data warehouse
- to provide timely, pseudonymised PATIENT-based data and information for purposes other than direct clinical care, e.g. planning, commissioning, public health, clinical audit, performance improvement, research, clinical governance.
The Maternity Services Data Set enables standardised collection of data from various services to be assembled for reporting purposes.
Submission information
The Maternity Services Data Set is submitted centrally via the Data Processing Services (DPS) maintained by NHS Digital.
The Maternity Services Data Set is submitted to NHS Digital using the Maternity Services Data Set XML Schema.
A conversion tool has also been developed which enables the loading or copying of data into the provided table structure. Once populated, the tool can export the data in the required XML format, ready for submission.
Format information
Data for submission will be formatted into an XML file as per Technology Reference Data Update Distribution (TRUD) at: NHS Data Model and Dictionary: DD XML Schemas.
For enquiries regarding the XML Schema, please contact NHS Digital at enquiries@nhsdigital.nhs.uk.
Further guidance
Further guidance has been produced by NHS Digital and is available at Maternity Services Data Set.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Maternity Services Data Set Constraints.
XML Schema
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The Mental Health Services Data Set (MHSDS) is a PATIENT level, output based, secondary uses data set which aims to deliver robust, comprehensive, nationally consistent and comparable person-based information for children, young people and adults (including elderly people) who are in contact with specialist secondary Mental Health Services located in England, or located outside England but treating PATIENTS commissioned by an English Clinical Commissioning Group (CCG) or NHS England specialised commissioner.
As a secondary uses data set, the Mental Health Services Data Set re-uses clinical and operational data for purposes other than direct PATIENT care and defines the data items, definitions and associated value sets to be extracted or derived from local information systems.
All ACTIVITY relating to PATIENTS who receive specialist secondary Mental Health Services and have, or are thought to have:
- A mental illness
- Any combination of mental health, Learning Disability or Autistic Spectrum Disorder needs
is within scope of the Mental Health Services Data Set.
The scope of the Mental Health Services Data Set requires PATIENT record level data submission from SERVICES as follows:
For each PATIENT attending a SERVICE located in England:
- If the care is wholly funded by the NHS: the data submission for that PATIENT is mandatory
- If the care is partially funded by the NHS: the data submission for that PATIENT is mandatory
- If the care is wholly funded by any means that is not NHS: the data submission for that PATIENT is optional.
For each PATIENT attending a SERVICE located outside England, but commissioned by an English Clinical Commissioning Group or NHS England specialised commissioner:
- The data submission is optional.
The Mental Health Services Data Set is used across the range of Health Care Providers and ORGANISATIONS that provide specialist secondary mental health and/or Learning Disabilities and/or Autistic Spectrum Disorder SERVICES (irrespective of funding arrangements) including:
- NHS Mental Health Trusts
- NHS Learning Disabilities Trusts
- NHS Acute Trusts
- NHS Care Trusts
- Independent Sector Healthcare Providers offering a service model that includes NHS funded and non-NHS funded PATIENTS
- Any qualified provider offering specialist secondary mental health, Learning Disability or Autistic Spectrum Disorder SERVICES
- Community SERVICES offering secondary care to children.
Submission information
The Mental Health Services Data Set is submitted centrally via the Strategic Data Collection Service in the Cloud (SDCS Cloud) maintained by NHS Digital.
The Mental Health Services Data Set has historically been submitted using two submission windows, primary and refresh. This has changed to a multiple submission window model which gives submitters the opportunity to resubmit throughout the submission year. Guidance on the new submission model can be found on the NHS Digital website at: How to submit to the MHSDS.
Further guidance
Further information regarding the structure and submission of the Mental Health Services Data Set can be found on the NHS Digital website at: Mental Health Services Data Set (MHSDS).
Mandation
The Mandation 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 Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Mental Health Services Data Set Constraints.
Change to Supporting Information: Changed Description
Introduction:Introduction
The information in the National Cancer Waiting Times Monitoring Data Set is required to provide details on cancer SERVICES in England. This enables the performance monitoring of Health Care Providers and Clinical Commissioning Groups in order to maintain and increase standards across England.
Cancer Waiting Times data relates to:
- the waiting time requirements outlined in the 'NHS Cancer Plan (2000)' and the 'Cancer Reform Strategy (2007)' and
- a performance standard that PATIENTS should wait no longer than 28 days from initial referral by a GENERAL PRACTITIONER to diagnosis or ruling out of cancer (the 28 Day Faster Diagnosis Standard) introduced by the Independent Cancer Taskforce, 'Achieving World-Class Cancer Outcomes'.
The 'Cancer Reform Strategy (2007)' introduced new and changed commitments in terms of service standards for cancer PATIENTS that must be met. A Review of Cancer Waiting Times Standards was carried out by the Department of Health and Social Care and published alongside 'Improving Outcomes: A Strategy for Cancer (2011)'.
The National Cancer Waiting Times Monitoring Data Set supports the continued management and monitoring of the following waiting times:
- A maximum two week wait from an urgent GENERAL PRACTITIONER referral for suspected cancer to DATE FIRST SEEN by a specialist for all suspected cancers
- A maximum 28 day wait from an urgent GENERAL PRACTITIONER referral for suspected cancer to having cancer either diagnosed or ruled out (CANCER FASTER DIAGNOSIS PATHWAY END DATE), or DECISION TO TREAT DATE, whichever comes first, for all suspected cancers
- A maximum 28 day wait from referral for breast symptoms (where cancer is not initially suspected) to having cancer either diagnosed or ruled out (CANCER FASTER DIAGNOSIS PATHWAY END DATE), or DECISION TO TREAT DATE, whichever comes first, for all suspected cancers
- A maximum 28 day wait from a referral to an Assessment CLINIC OR FACILITY following the identification of an abnormality by an NHS Cancer Screening Service to having cancer either diagnosed or ruled out (CANCER FASTER DIAGNOSIS PATHWAY END DATE), or DECISION TO TREAT DATE, whichever comes first, for all suspected cancers
- A maximum one month (31-day) wait from diagnosis (CANCER TREATMENT PERIOD START DATE) to First Definitive Treatment for all cancers
- A maximum two month (62-day) wait from urgent GENERAL PRACTITIONER referral for suspected cancer to First Definitive Treatment for all cancers
- A maximum one month (31-day) wait from urgent GENERAL PRACTITIONER referral for suspected cancer to First Definitive Treatment for children’s cancers, testicular cancers and acute leukaemia
- A maximum 62-day wait from referral from an NHS Cancer Screening Programme to First Definitive Treatment for all cancers
- A maximum 62-day wait from a CONSULTANTS decision to upgrade the urgency of a PATIENT they suspect to have cancer to First Definitive Treatment for all cancers
- A maximum 31-day wait for all subsequent treatments for new cases of primary and Recurrent Cancer where an Anti-Cancer Drug Regimen, surgery or Radiotherapy is the chosen CANCER TREATMENT MODALITY
- A maximum two week wait from referral for breast symptoms (where cancer is not initially suspected) to DATE FIRST SEEN.
Patient Pathway Scenarios:Patient Pathway Scenarios
The Patient Pathway Scenarios for the National Cancer Waiting Times Monitoring Data Set are to be used to manage the collection of data for all PATIENTS suspected of having, or diagnosed with cancer.
Transmission:Transmission
- Data can be transmitted to the Cancer Waiting Times System through any of three routes:
- Bulk upload via an XML file
- Bulk upload via a CSV file
- Single record entry through the Cancer Waiting Times Submission portal
- The specification for CSV upload file is detailed in the ‘National Cancer Waiting Times User Manual’ available on the NHS Digital website
- Data for XML submission will be formatted into an XML file as per Technology Reference Data Update Distribution (TRUD) at: NHS Data Model and Dictionary: DD XML Schemas
- Once data is transmitted to the Cancer Waiting Times system it will undergo further validation. Details of this validation is available on the NHS Digital website at: Cancer Waiting Times.
Further guidance:Further guidance
- Further guidance relating to the National Cancer Waiting Times Monitoring Data Set is available on the NHS Digital website at: Cancer Waiting Times.
- Queries regarding the National Cancer Waiting Times Monitoring Data Set should be addressed to england.cancerwaitsdata@nhs.net.
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.
Mandation
The Mandation 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.
XML Schema
For guidance on downloading the XML Schema, see XML Schema TRUD Download.
Change to Supporting Information: Changed Description
Background:Introduction
The National Joint Registry Data Set collects information on primary Joint Replacement Surgery and revision Joint Replacement Surgery.
The majority of National Joint Registry Data Set items relate to the PATIENT's operation details and are collected in the OPERATING THEATRE.
The National Codes for National Joint Registry items match the National Joint Registry bulk upload codes / system generated codes.
PATIENTS must give their consent for this data to be recorded on the National Joint Registry Data Entry System (the electronic system for collection and transfer of data).
Note: the consent is for data in the 'Patient Identifiers' group. Where consent is not given, the 'Patient Details' group and the operation details are still recorded.
Operations included in the National Joint Registry database:Operations included in the National Joint Registry database
- Primary Hip Replacement Surgery
- Primary Knee Replacement Surgery
- Revision Knee Replacement Surgery
- Primary Shoulder Replacement Surgery
- Revision Shoulder Replacement Surgery
Further Guidance:Further Guidance
Further guidance can be found:
- Relating to the data set on the National Joint Registry website at: NJR data set.
Mandation
The Mandation column indicates the recommendation for the inclusion of data.
- M = Mandatory: this data element is mandatory
- Optional: this data element is optional.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The National Neonatal Data Set consists of a defined list of data items that are extracted from electronic clinical records created by clinical staff on all admissions to Neonatal Critical Care Units in England.
The National Neonatal Data Set is in two parts:
- The National Neonatal Data Set - Episodic and Daily Care covers the period of time a baby is cared for in Neonatal Critical Care, Transitional Care, or other non-standard critical care settings
- The National Neonatal Data Set - Two Year Neonatal Outcomes Assessment, carries data relating to a Two Year Neonatal Outcomes Assessment carried out on the same child approximately two years after their treatment. The Two Year Neonatal Outcomes Assessment may be carried out by the same ORGANISATION who was responsible for the neonatal CRITICAL CARE PERIOD, or by a different ORGANISATION.
The two neonatal data sets comprise data items relating to PATIENT demographics, CLINICAL INTERVENTIONS, outcomes, and PATIENT DIAGNOSES. Each data item is mapped where possible to existing ISB / SCCI / DCB Information Standards and Collections (including Extractions) (such as the Neonatal Critical Care Minimum Data Set and Maternity Services Data Set Version 1) as well as to SNOMED CT and ICD codes.
The aim of the National Neonatal Data Set is to extract data items from electronic clinical records, create a database of these items, and make this available as a national resource to serve a variety of needs, so avoiding duplicate data collections for different purposes, minimising the burden placed upon clinical teams, and promoting data quality and completeness.
ORGANISATIONS involved in the collection may choose whether to allow identifiable or unidentifiable (anonymised) information to flow to the Neonatal Data Analysis Unit. Where anonymised data is to flow, the appropriate 'withheld' patient and parents demographic structures should be used (i.e. those with no PERSON IDENTIFIERS, such as NHS NUMBER or PERSON BIRTH DATE).
In addition, where anonymisation is required, the dates and times of events carried throughout the data set (such as SAMPLE COLLECTION DATE AND TIME, PROCEDURE DATE AND TIME (ABDOMINAL X-RAY)) should be replaced with the specific relevant year and month of the event and the NUMBER OF MINUTES (BIRTH TO EVENT). The National Neonatal Data Set structure allows an either/or choice for these event items throughout the data set.
Data Collection
The National Neonatal Data Set consists of a defined list of data items that are extracted from electronic clinical records created by clinical staff relating to all neonatal critical care delivered in England. The Neonatal Data Analysis Unit has established a database, the National Neonatal Research Database (NNRD) to hold data comprising the National Neonatal Data Set, as a national resource.
Submission Information
For submission information, see the NDAU website. Note that all date and time fields in the National Neonatal Data Set should be in Co-ordinated Universal Time (UTC) for submission purposes.
Further Guidance
Further guidance has been produced by the Neonatal Data Analysis Unit and is available on their website at: NDAU website.
Mandation
The Mandation 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 Mandation column which are shown with notation P have not been approved by the Information Standards Board for Health and Social Care and are included to facilitate piloting and testing of future Neonatal Data Analysis Unit data requirements, prior to formal inclusion in later versions of the 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.
Change to Supporting Information: Changed Description
Introduction
The National Workforce Data Set (NWD) is a reference Data Set comprising standardised definitions to facilitate the capture of nationally consistent information relating to the NHS and wider healthcare workforce. National Workforce data items and definitions support a variety of workforce based collections. They are also embedded within operational HR/workforce systems including Electronic Staff Record (ESR), and the NHS Jobs web system.
The National Workforce Data Set provides common definitions for those data items that are needed to support workforce planning for the NHS workforce and is intended as a reference with an agreed set of data definitions for people who plan workforce at strategic, national and local level.
The changing nature of the provision of NHS funded care is leading to plurality of supply, and therefore a National Workforce Data Set ensures that all suppliers of NHS care provide workforce information in an agreed and pre-determined format. This provides a practical means for the consistent collection of this information from all providers of NHS funded care to enable comprehensive Healthcare Workforce planning going forwards.
The information captured using the values defined in the National Workforce Data Set will also be used locally within ORGANISATIONS by a range of people in addition to those mentioned above, such as in Training and Development, Workforce Information and Planning and Equality and Diversity. The accuracy and relevance of the data captured using the National Workforce Data Set values will therefore impact on a number of issues at local level and beyond.
Further guidance has been produced by NHS Digital and is available on their website at: National Workforce Data Set (NWD) and NHS occupation codes.
Change to Supporting Information: Changed Description
Introduction
The NHS Breast Screening Programme Central Return Data Set (KC62) provides information to the NHS Breast Screening Programme from Breast Screening Units on the processes and outcomes of the call and recall system. Screening Programmes are supported by the UK National Screening Committee.
The information is used:
- to monitor progress towards achieving the cancer targets
- to ensure that the NHS Breast Screening Programme is monitored and managed effectively.
The NHS Breast Screening Programme Central Return Data Set (KC62) is analysed by NHS Digital and also used by the Public Health Research Unit to evaluate the effectiveness of Breast Screening. It is also used by the Regional Breast Screening Quality Assurance Reference Centres as part of the quality assurance process, and enables on-going monitoring of their individual programmes and comparisons within their regions and with England overall.
Collection
The NHS Breast Screening Programme Central Return Data Set (KC62) requires information on women invited for Breast Screening, the outcome of the Breast Screening and further information on each cancer detected. It is completed annually and submitted by the end of the October following the end of the REPORTING PERIOD to which the data relates.
Women are included in the NHS Breast Screening Programme Central Return Data Set (KC62) only if the test date offered or SCREENING TEST DATE was within the review period. All Screening Tests taking place within the REPORTING PERIOD are counted. One woman may not have more than one outcome of cancer in the REPORTING PERIOD. Women who are referred directly for a Screening Test (rather than an invitation as part of a Screening Programme) are also included if the SCREENING TEST DATE is within the REPORTING PERIOD.
Submission
Parts One to Five of the NHS Breast Screening Programme Central Return Data Set (KC62) should be reported for Tables A to T.
| TABLE | DESCRIPTION |
| A* | First invitation for routine screening |
| B* | Routine invitation to previous non-attenders |
| C1* | Return invitation to previous attenders (last screen within 5 years) |
| C2 | Return invitation to previous attenders (last screen more than 5 years) |
| D | Short term recall |
| E | Self/GP referrals of women not previously screened |
| F1 | Self/GP referrals of women previously screened (last screen within 5 years) |
| F2 | Self/GP referrals of women previously screened (last screen more than 5 years previously) |
| T | All invitations and screenings: Sum of Tables A - F2 |
* INVASIVE BREAST CANCER TOTAL OBSERVED, INVASIVE BREAST CANCER TOTAL EXPECTED and STANDARDISED DETECTION RATIO TOTAL are only appropriate for tables A, B and C1.
The NHS Breast Screening Programme Central Return Data Set (KC62) is submitted in csv file format.
Change to Supporting Information: Changed Description
Introduction
The NHS Breast Screening Programme Central Return Data Set (KC63) provides information to the NHS Breast Screening Programme from Upper Tier Local Authorities on the Breast Screening history of their residents. Screening Programmes are supported by the UK National Screening Committee.
The information is used to:
- assess coverage of Breast Screening and monitor standards of the SERVICES provided
- monitor progress towards achieving the Government's objective of reducing the death rate in the population invited for Breast Screening
- provide data for the Public Expenditure Survey (PES) negotiations, resource allocation to the NHS and Departmental accountability
- provide data published annually by the Department of Health and Social Care in the statistical Bulletin 'Breast Screening Programme'.
Collection
Data on Breast Screening should be readily available from the Primary Care Organisation's computerised call and recall system designed for Breast Screening. A national computer program is provided and maintained by NHS Digital.
The NHS Breast Screening Programme Central Return Data Set (KC63) reports information on the Breast Screening history of women who were resident in the Upper Tier Local Authority, including Unitary Local Authorities at 31 March. It is completed annually and submitted by the end of the October following the end of the REPORTING PERIOD to which the data relates.
Submission
The NHS Breast Screening Programme Central Return Data Set (KC63) is submitted in csv file format.
Change to Supporting Information: Changed Description
Introduction
The Department of Health and Social Care introduced the National framework for NHS continuing healthcare and NHS-funded nursing care in 2007 to establish a consistent and standardised guide to implementing the delivery of NHS Continuing Healthcare (NHS CHC). This was last revised in March 2018 and replaces the previous 2012 version. The National Framework sets out NHS Continuing Healthcare and assessment processes. The latest version places a strong focus on moving assessments outside of an acute setting.
NHS Continuing Healthcare is a package of ongoing care that is 100% funded solely by the NHS where the PERSON has been found to have a ‘primary health need’ as set out in the National framework for NHS continuing healthcare and NHS funded nursing care. Such care is provided to a PERSON aged 18 or over, to meet needs that have arisen as a result of disability, accident or illness.
In order to monitor the implementation and effectiveness of the Framework, a mandatory collection requires the submission of quarterly figures on NHS Continuing Healthcare and NHS-funded Nursing Care activity.
The collection includes:The collection includes
- PERSONS aged 18 or over eligible for NHS Continuing Healthcare as defined by the National framework for NHS continuing healthcare and NHS-funded nursing care.
- PERSONS still recognised as eligible under the former Strategic Health Authorities' eligibility criteria.
- PERSONS identified as eligible for NHS Continuing Healthcare following assessment of eligibility for Previously Unassessed Period of Care (PUPoC). This includes Previously Unassessed Periods of Care related to the ‘closedown’ announcement made by the Department of Health and Social Care in 2012 in which deadlines were introduced for requesting assessments of eligibility for past periods of care falling between 1st April 2004 and 31st March 2012. This also includes non-closedown Previously Unassessed Periods of Care relating to assessments of eligibility for past periods of care falling after 31st March 2012.
The collection excludes:
- PERSONS funded through other NHS funding streams which are not NHS Continuing Healthcare or NHS-funded Nursing CarePERSONS funded under any section of the Mental Health Act. The exception to this is if an individual is funded under a Mental Health Section and eligible for NHS Continuing Healthcare under the National Framework eligibility criteria. In these instances the activity related to the NHS Continuing Healthcare package is still included but any activity covered by the Mental Health section should be excluded
- Interim Cases - PERSONS receiving temporary NHS Continuing Healthcare funding pending eligibility decision or PERSONS who have ceased being eligible but are still being funded
- PERSONS under 18 years of age. NHS Continuing Healthcare packages are funded for individuals aged 18 and over only therefore only individuals aged 18 years or over are included in this return.
The NHS Continuing Healthcare Data Set is transmitted at aggregate level to the NHS Digital Strategic Data Collection Service (SDCS) with publication outputs available on the NHS England website at: NHS Continuing Healthcare and NHS-funded Nursing Care.
For further information on the NHS Continuing Healthcare Data Set, see the Department of Health and Social Care part of the gov.uk website at: National framework for NHS continuing healthcare and NHS-funded nursing care.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
The NHS Continuing Healthcare Patient Level Data Set has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2021.
At the time of publication of the NHS Continuing Healthcare Patient Level Data Set version 1.0, the implementation and conformance dates are subject to change depending on the need for continuing frontline investment in COVID-19 activity. Any change will be agreed between the Data Coordination Board and the developers, and will be announced in due course.
For further information please contact: england.chcdata@nhs.net.
Introduction
The NHS Continuing Healthcare Patient Level Data Set is PATIENT level, output based, secondary user data set. It delivers robust, comprehensive, nationally consistent and comparable PERSON centred information for people who are in receipt of, or whose eligibility is being assessed for, NHS Continuing Healthcare or NHS-funded Nursing Care. The data set does not include information about requests for an independent review of an NHS Continuing Healthcare eligibility decision.
As a secondary uses data set the NHS Continuing Healthcare Patient Level Data Set re-uses operational data for purposes other than direct PATIENT care. It defines the data items, definitions and associated value sets to be extracted or derived from local systems.
The data collected in the NHS Continuing Healthcare Patient Level Data Set covers all NHS Continuing Healthcare and NHS-funded Nursing Care ACTIVITY undertaken by Clinical Commissioning Groups (or other ORGANISATIONS acting on their behalf), in line with the NHS Continuing Healthcare (National Framework) in England.
The NHS Continuing Healthcare Patient Level Data Set is used by the Department of Health and Social Care, NHS England and NHS Improvement, commissioners and PATIENTS, as the data set provides:
- National, comparable, standardised data about NHS Continuing Healthcare and NHS-funded Nursing Care, which will support intelligent commissioning decisions and SERVICE provision
- Information on the use of resources to improve the operational management of SERVICES
- Support for current national performance indicators for NHS Continuing Healthcare
- Information for the future development of NHS Continuing Healthcare and NHS-funded Nursing Care.
Data Collection
The NHS Continuing Healthcare Patient Level Data Set provides the definitions for data to:
- be lodged in the data warehouse regularly and routinely,
- be assembled, compiled and to flow into a secondary uses data warehouse,
- provide timely, pseudonymised PATIENT based data and information for purposes other than direct clinical care, e.g. planning, commissioning, public health, performance improvement, research, clinical governance.
Data is expected to be extracted and collated from the NHS Continuing Healthcare management systems used by Clinical Commissioning Groups to manage their NHS Continuing Healthcare function.
Data will be reported monthly.
Submission Information
The NHS Continuing Healthcare Patient Level Data Set is submitted to NHS Digital using the NHS Continuing Healthcare Patient Level Data Set XML Schema.Format Information
Data for submission will be formatted into an XML file as per the Technology Reference Data Update Distribution (TRUD) page at: NHS Data Model and Dictionary: DD XML Schemas.
For enquiries regarding the XML Schema, please contact NHS Digital at enquiries@nhsdigital.nhs.uk.
Further Guidance
Further information and implementation guidance has been produced by NHS Digital and is available at: NHS Continuing Healthcare and NHS-funded Nursing Care (CHC).
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Introduction
The purpose of the Patient Level Contract Monitoring Data Set (PLCM) is to enable the interchange, in a uniform format, of monthly PATIENT level Contract Monitoring data between all purchasers and Health Care Providers. This will ensure that Contract Monitoring and reporting is consistent, comparable and fit for purpose across all commissioning ORGANISATIONS.
The Patient Level Contract Monitoring Data Set is a PATIENT level report containing PATIENT identifiers. Its purpose is to substantiate and provide detail to the information contained within the Aggregate Contract Monitoring Data Set (ACM). It will contain details of PATIENT level clinical activities that are not found in flows of standard Commissioning Data Sets (CDS) submitted to the Secondary Uses Service.
Scope
The scope of the Patient Level Contract Monitoring Data Set Information Standard is all NHS-funded acute and community clinical care (excluding drugs and MEDICAL DEVICES not covered by the National Tariff Payment System) provided to PATIENTS, as well as financial adjustments not attributed directly to clinical care, for all commissioners.
This covers:
- All acute and community NHS and secondary care Independent Sector Healthcare Providers, but not primary care, from whom the NHS commissions healthcare
Note that the totality of expenditure in the Patient Level Contract Monitoring Data Set must be equivalent to the monetary value (excluding drugs and MEDICAL DEVICES not covered by the National Tariff Payment System) shown in the Aggregate Contract Monitoring Data Set.
Submission
The Patient Level Contract Monitoring Data Set is submitted on a monthly basis to the respective Data Services for Commissioners Regional Office (DSCRO) as nominated by each commissioning function in line with the dates documented in the data submission timetable within Schedule 6 of the NHS Standard Contract.
The completed monthly Patient Level Contract Monitoring Data Set should be transmitted using the NHS Digital Data Landing Portal (DLP).
For further information on the Patient Level Contract Monitoring Data Set, see the NHS England website at: Directly Commissioned Services Reporting Requirements.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Patient Level Contract Monitoring Data Set Constraints.
Change to Supporting Information: Changed Description
Contextual OverviewIntroduction
The Patient Level Information Costing System Acute Data Set is used to standardise the method of reporting cost information at PATIENT level. All designated NHS Health Care Providers of acute activity are required to submit Patient Level Information Costing data.
The Patient Level Information Costing System Acute Data Set is used to
- inform new methods of pricing NHS SERVICES;
- inform new approaches and other changes to the design of the currencies used to price NHS SERVICES;
- contribute to NHS Improvement's strategic objective of a ‘single national cost collection by 2020’ inform the relationship between provider characteristics and cost;
- help NHS Trusts to maximise use of their resources and improve efficiencies, as required by the provider licence;
- identify the relationship between PATIENT characteristics and cost;
- support an approach to benchmarking for regulatory purposes.
Data Extract Specification
Description
NHS Improvement has mandated designated NHS Trusts and NHS Foundation Trust to record and report:
Reporting is required at the end of each financial year, consistent with the methodologies and submission processes in the Approved Costing Guidance. This only includes those NHS Health Care Providers noted in the Costing Mandation Timetable and does not include non-NHS Health Care Providers.
Time
The data is collected annually. It must be submitted in accordance with the timetable set out by NHS Improvement in the National Cost Collection Guidance (part of the Approved Costing Guidance).
Format
The data should be submitted in an XML file, created by NHS Improvement's Data Validation Tool (DVT). Information on how to access and use this tool is included in the National Cost Collection Guidance (part of the Approved Costing Guidance).
Transmission
Patient Level Information Costing data will be submitted to NHS Digital using Secure Electronic File Transfer (SEFT). Secure Electronic File Transfer (SEFT) can only be accessed by registered and approved users and NHS Improvement will invite relevant people to register for the service and provide details of the log in process.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the:
Change to Supporting Information: Changed Description
BackgroundIntroduction
Radiotherapy is a major modality in the treatment of cancer and also represents a significant sector within the NHS, in terms of both workforce and capital investment.
The Radiotherapy Data Set (RTDS) allows for the routine collection of clinically and managerially relevant ACTIVITY data from Radiotherapy facilities, in order to commission or monitor Radiotherapy Services in an evidence-based manner.
All NHS funded facilities in England providing Radiotherapy Services are required to return data to Public Health England (PHE) for all ACTIVITY undertaken on Teletherapy and Brachytherapy MACHINES, or with radioisotopes not contained within a Teletherapy or Brachytherapy MACHINE.
The Radiotherapy Data Set accompanies the Out-Patient Commissioning Data Set for PATIENTS attending for Radiotherapy.
Where in-patients attend for Radiotherapy, a Radiotherapy Attendance record should be submitted to Public Health England along with the Out-Patient Commissioning Data Set for the In-Patient Attendance.
For further guidance, see the National Cancer Registration and Analysis Service website at: National Radiotherapy Data Set (RTDS).
Data Submission
The Radiotherapy Data Set should be submitted to Public Health England by the 15th working day of each month. The extracts should include all Radiotherapy Attendance records for the previous calendar month.
The Radiotherapy Data Set should be submitted in the approved format and accompanied by the Out-Patient Commissioning Data Set.
Data should be submitted using the National Cancer Registration and Analysis Service (NCRAS) upload portal on the National Cancer Registration and Analysis Service website at: National Radiotherapy Data Set (RTDS).
Further Guidance
Further guidance for submission of the Radiotherapy Data Set is provided by the National Cancer Registration and Analysis Service at: National Radiotherapy Data Set (RTDS).
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Introduction
Public Health England requires the mandatory collection of information on the SERVICES provided by Sexual and Reproductive Health Services.
The Sexual and Reproductive Health Activity Data Set provides essential data to:
- Ensure a relevant collection of electronic data to support local service development
- Allow monitoring of key policy initiatives and indicators such as: The Public Health Outcome Framework Indicator on under 18 conceptions; increasing access to all methods of contraception, including Long Acting Reversible Contraceptions (LARC) methods and emergency contraception for women of all ages and their partners; reducing teenage conceptions; reducing the rate of unintended pregnancies and modernisation of Sexual and Reproductive Health Services
- Provide appropriate definitions and guidance material to enable a standardised data set from Sexual and Reproductive Health Services
- Support commissioners in understanding which population groups are accessing Sexual and Reproductive Health Services and which SERVICES they are receiving, including the LARC methods as recommended by National Institute for Health and Care Excellence (NICE), and therefore allowing for long-term commissioning of SERVICES
- Develop, over time, indicators of quality and outcome in SERVICE delivery (especially in comparative reports). For example the removal and length of use for LARC devices, provision of emergency CONTRACEPTION, the provision of CONTRACEPTION post abortion and referrals to secondary care, the comparison of attendance rates for selected care and the diversity of young PERSON provision by Sexual and Reproductive Health Services including social referrals
- Reflect current data collection practices and requirements at Sexual and Reproductive Health Services.
The Sexual and Reproductive Health Activity Data Set covers PATIENT contact with the Sexual and Reproductive Health Services whether in a clinic setting, in the PATIENT's home or at an alternative location.
DATA EXTRACT SPECIFICATIONData Extract Specification
Description: The Sexual and Reproductive Health Activity Data Set return includes PATIENT ACTIVITY provided by Sexual and Reproductive Health Services in clinics and non-clinic venues (e.g. outreach facilities or domiciliary visits). Also included are Sexual and Reproductive Health Services provided by non - NHS clinics funded wholly or in part by Local Authorities and/or Clinical Commissioning Groups (e.g. Brook). It does not include SERVICES provided by CONSULTANTS in Outpatient Clinics or those provided by GENERAL MEDICAL PRACTITIONERS.
Data collected will be used by the NHS, Care Quality Commission, Local Authorities Clinical Commissioning Groups, Public Health England and other appropriate ORGANISATIONS to support the monitoring of the National Strategies on Sexual and Reproductive Health Services, service provision, benchmarking and development of commissioning.
Time period: The extract will cover one financial year.
Frequency: Extracts run annually, six weeks after the end of the financial year.
Format: Data returned should be formatted to a comma separated variable (CSV) or in a MS Excel file. The data variables should be transmitted in the order specified in the Sexual and Reproductive Health Activity Data Set.
Transmission: Data is submitted via an on-line process to NHS Digital.
For further information on the Sexual and Reproductive Health Activity Data Set see the NHS Digital website at: Sexual and Reproductive Health Activity Data Set (SRHAD) Collection.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Introduction
The Stop Smoking Services Quarterly Data Set is used to monitor and evaluate the effectiveness and coverage of Stop Smoking Services. It is designed to provide consistent information on people who have sought and received quitting help from an evidence-based service.
Collection and Submission
The Stop Smoking Services Quarterly Data Set is required by Public Health England and is collected from Local Authorities.
The Stop Smoking Services Quarterly Data Set relates to ACTIVITY taking place over a 3 month period and should be submitted by the thirty second working day after the end of the quarter to which it relates.
The Stop Smoking Services Quarterly Data Set is transmitted at aggregate level to the NHS Digital Strategic Data Collection Service (SDCS) available at NHS Stop Smoking Services Collection.
Further guidance
Further information on the NHS Stop Smoking Services and the monitoring guidance can be found on the National Centre for Smoking Cessation and Training website at Local Stop Smoking Services: Service and Delivery Guidance 2014.
Mandation
The Mandation 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.
Change to Supporting Information: Changed Description
Introduction:Introduction
The Systemic Anti-Cancer Therapy Data Set collects clinical management information on PATIENTS undergoing Systemic Anti-Cancer Therapy in (or funded by) the NHS in England.
In the clinical setting its primary use is in prescribing and administering Systemic Anti-Cancer Therapy. The standard also specifies secondary uses information about Systemic Anti-Cancer Therapy which is required to assist in achieving, supporting and monitoring the NHS Operating Framework, specialised commissioning and related policy.
Details of Standard:Details of Standard
The Systemic Anti-Cancer Therapy Data Set relates to all cancer PATIENTS, both adult and paediatric, in both admitted PATIENT care and outpatient and community settings, who are receiving Systemic Anti-Cancer Therapy for all solid Tumour and haematological malignancies, including those treated in CLINICAL TRIALS.
The Systemic Anti-Cancer Therapy Data Set covers the period from the Start Date of the Systemic Anti-Cancer Therapy Drug Regimen to the Start Date of the last Systemic Anti-Cancer Therapy Drug Cycle.
Note: PATIENTS may end their treatment with an oral or other component taken at home. Although the dispensing of this will be recorded in the final Systemic Anti-Cancer Therapy Drug Cycle, it is not possible to confirm that the PATIENT has taken the medication.
Data Set Structure and Transmission:Data Set Structure and Transmission
Systemic Anti-Cancer Therapy is given over a prolonged period of time, often months or years, comprising repeating and sequential elements. The PATIENT may attend two or more Health Care Providers during the course of treatment.
In order to track the PATIENT during treatment, the data set must be capable of linking all the elements of care in a consistent and ordered way. In order to achieve this, the Systemic Anti-Cancer Therapy Data Set has a branching structure which links the initial data fields, which will remain constant during the treatment, with detail of each Systemic Anti-Cancer Therapy Drug Regimen, Systemic Anti-Cancer Therapy Drug Cycle and Systemic Anti-Cancer Therapy Drug Administration. At the completion or cessation of a Systemic Anti-Cancer Therapy Drug Regimen, the outcome section must link back to all previous fields. It must be possible to reconstitute details of each PATIENT’s sequential management from the serial downloads received.
All NHS Trusts and NHS Foundation Trusts providing Systemic Anti-Cancer Therapy Services are required to submit monthly data downloads to an agreed timetable, two months in arrears. These data must represent all treatment activity in the month period, including Systemic Anti-Cancer Therapy Drug Regimens started and completed or ceased in the REPORTING PERIOD.
The data repository is hosted by the National Cancer Registration and Analysis Service (NCRAS) and the data is held under their section 251 of the National Health Service Act 2006.
Data downloads is by csv and will uniquely identify the Health Care Provider.
Further Guidance:Further Guidance
Detailed technical guidance on the processes required, and any required updates, is available from the National Cancer Registration and Analysis Service in the Technical Guidance documents supporting the programme.
Mandation
The Mandation 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.
Data Set Constraints
For guidance on the Data Set constraints, see the Systemic Anti-Cancer Therapy Data Set Constraints.
Change to Supporting Information: Changed Description
Introduction
The purpose of the Venous Thromboembolism Risk Assessment Data Set is to quantify the number of PATIENTS (aged 16 and over) admitted to hospital, who are risk assessed for Venous Thromboembolism using the Venous Thromboembolism Risk Assessment Tool to allow appropriate preventative treatment based on guidance from the National Institute for Health and Care Excellence (NICE).
Collection and submission:Collection and submission
All providers of NHS funded acute hospital care (including NHS Foundation Trusts and Independent Providers of acute NHS services) must complete this data collection.
Data on Venous Thromboembolism risk assessments is uploaded onto the Strategic Data Collection Service (SDCS) each month no later than 20 working days after the month end. Revisions to the data set before the cut off date are allowed, however revisions made after the cut off date must be made in liaison with NHS Improvement.
Further guidance:Further guidance
For further guidance on the Venous Thromboembolism Risk Assessment Data Set, see the:
Mandation
The Mandation 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.
For enquiries about this Change Request, please email information.standards@nhs.net