Community Services Data Set

SUBMISSION IDENTIFIER

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

PATIENT DEMOGRAPHICS

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

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

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

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

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

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

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

REFERRALS

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

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

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

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

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

CARE CONTACT AND ACTIVITIES

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

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

GROUP SESSIONS

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

SOCIAL CIRCUMSTANCES

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

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

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

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

IMMUNISATIONS

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

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

DIAGNOSES, TESTS AND OBSERVATIONS

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

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

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

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

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

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

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

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

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

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

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

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

ANONYMOUS SELF-ASSESSMENT

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

STAFF DETAILS

Staff Details:
To carry details of the staff involved in the treatment of a patient.
One occurrence of this group is permitted for each staff member.
M/R/OData Set Data Elements
MCARE PROFESSIONAL LOCAL IDENTIFIER
RPROFESSIONAL REGISTRATION BODY CODE
RPROFESSIONAL REGISTRATION ENTRY IDENTIFIER
RCARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)
ROCCUPATION CODE
RCARE PROFESSIONAL (JOB ROLE CODE)
ISO 9001 CERTIFICATION EUROPE