Data Set: Community Services Data Set

Community Services Data Set

SUBMISSION IDENTIFIER

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 and Risk Indicators: To carry the personal details of the patient and the associated mother's NHS number (where applicable). One occurrence of this group is required for each patient.
M/R/O	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	ETHNIC CATEGORY
R	LANGUAGE CODE (PREFERRED)
R	PERSON RELATIONSHIP (MAIN CARER)
R	HEALTH VISITOR FIRST ANTENATAL VISIT DATE
R	LOOKED AFTER CHILD INDICATOR
R	SAFEGUARDING VULNERABILITY FACTORS INDICATOR
R	CONSTANT SUPERVISION AND CARE REQUIRED DUE TO DISABILITY INDICATOR
R	EDUCATIONAL ASSESSMENT OUTCOME
R	PREFERRED DEATH LOCATION DISCUSSED INDICATOR
R	PERSON AT RISK OF UNEXPECTED DEATH INDICATOR
R	DEATH LOCATION TYPE CODE (PREFERRED)
R	PERSON DEATH DATE
R	DEATH LOCATION TYPE CODE (ACTUAL)
R	DEATH NOT AT PREFERRED LOCATION REASON
R	NHS NUMBER (MOTHER)
R	NHS NUMBER STATUS INDICATOR CODE (MOTHER)

GP Practice Registration: To carry details of the GP Practice Registration of the patient. One occurrence of this group is required for each change of GP Practice Registration.
M/R/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)