SUBMISSION IDENTIFIER |
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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 |
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Mother's Demographics: To carry the demographic details for the mother's Maternity Episode. One occurrence of this group is required. | |
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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. | |
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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. | |
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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. | |
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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 |
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Maternity Care Plan: To carry details of the Care Plan during the current Maternity Episode. Multiple occurrences of this group are permitted. | |
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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. | |
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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. | |
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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. | |
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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. | |
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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. | |
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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. | |
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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. | |
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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 |
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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. | |
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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. | |
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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. | |
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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. | |
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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 |
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Neonatal Admission: To carry details of neonatal admissions. Multiple occurrences of this group are permitted. | |
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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. | |
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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. | |
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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. | |
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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. | |
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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 |
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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. | |
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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. | |
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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. | |
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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. | |
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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 |
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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. | |
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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. | |
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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 |
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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. | |
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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) |