Change Request
 

NHS Connecting for Health

NHS Data Model and Dictionary Service

Reference: Change Request 1060
Version No:1.0
Subject:Change Package 1060
Effective Date:Immediate
Reason for Change:Patch
Publication Date:28 January 2009

Background:

A number of issues have been raised with the structure of the NHS Data Dictionary following implementation of the new software.

This patch:

Summary of changes:

Data Set
ACCIDENT AND EMERGENCY QUARTERLY MONITORING DATA SET (QMAE) renamed from ACCIDENT & EMERGENCY QUARTERLY MONITORING DATA SET (QMAE)   Changed Name
CDS V6 TYPE 110   Changed Aliases
DIAGNOSTICS WAITING TIMES AND ACTIVITY DATA SET renamed from DIAGNOSTICS WAITING TIMES & ACTIVITY DATA SET   Changed Name
GENITOURINARY MEDICINE ACCESS MONTHLY MONITORING DATA SET   Changed Description
 
Supporting Information
ABOUT THE NHS DATA MODEL AND DICTIONARY VERSION 3 renamed from ABOUT THE NHS DATA MODEL & DICTIONARY VERSION 3   Changed Name, Description
ACCIDENT AND EMERGENCY CODING TABLES renamed from ACCIDENT & EMERGENCY CODING TABLES   Changed Name, Description
ACCIDENT AND EMERGENCY DIAGNOSIS TABLES renamed from ACCIDENT & EMERGENCY DIAGNOSIS TABLES   Changed Name, Description
ACCIDENT AND EMERGENCY INVESTIGATION TABLE renamed from ACCIDENT & EMERGENCY INVESTIGATION TABLE   Changed Name, Description
ACCIDENT AND EMERGENCY QUARTERLY MONITORING DATA SET (QMAE) OVERVIEW  renamed from ACCIDENT & EMERGENCY QUARTERLY MONITORING DATA SET (QMAE) OVERVIEW    Changed Name
ACCIDENT AND EMERGENCY TREATMENT TABLES renamed from ACCIDENT & EMERGENCY TREATMENT TABLES   Changed Name, Description
ADMINISTRATIVE CODES AND CLASSIFICATIONS renamed from ADMINISTRATIVE CODES & CLASSIFICATIONS   Changed Name
ADMINISTRATIVE DATA SETS INTRODUCTION   Changed Description
CENTRAL RETURN DATA SETS INTRODUCTION   Changed Description
CENTRAL RETURN FORMS INTRODUCTION   Changed Description
CLINICAL CODING MENU renamed from CLINICAL CODING   Changed Name, Description
CRITICAL CARE PERIOD (RETIRED)   Changed Description
DEFAULT CODES SUMMARY TABLE   Changed Description
DEFINITIONS INTRODUCTION   Changed Description
DIAGNOSTICS WAITING TIMES CENSUS DATA SET OVERVIEW   Changed Description
DISCLAIMER   Changed Description
GENITOURINARY MEDICINE ACCESS MONTHLY MONITORING DATA SET OVERVIEW   Changed Description
GLOSSARY OF TERMS   Changed Description
HEALTH AND SOCIAL CARE INFORMATION CENTRE   Changed Description
INFORMATION STANDARDS BOARD FOR HEALTH AND SOCIAL CARE   Changed Description
LOCATION TYPE CODES   Changed Aliases, Description
MAIN SPECIALTY AND TREATMENT FUNCTION CODES   Changed Description
MENTAL HEALTH ACT TABLE   Changed Description
MESSAGES MENU (RETIRED) renamed from MESSAGES MENU   Changed Name, status to Retired
METADATA FILES   Changed Description
META MODEL MENU renamed from META MODEL   Changed Name
NATIONAL DIRECT ACCESS AUDIOLOGY PATIENT TRACKING LIST DATA SET OVERVIEW   Changed Description
NAVIGATION   Changed Description
NHS DATA MODEL AND DICTIONARY ELEMENTS renamed from THE NHS DATA MODEL & DICTIONARY ELEMENTS   Changed Name, Aliases, Description
NHS TRUST MERGERS   Changed Description
OPCS CLASSIFICATION OF INTERVENTIONS AND PROCEDURES   Changed Description
ORGANISATIONS MENU   Changed Description
PUBLICATION DETAIL   Changed Description
PUBLICATION FEEDBACK   Changed Aliases
PUBLICATION INFORMATION CONTACT DETAILS   Changed Description
PUBLICATION VERSION   Changed Description
QUARTERLY MONITORING CANCELLED OPERATIONS DATA SET (QMCO) OVERVIEW   Changed Description
SUMMARISED ACTIVITY FLOWS DATA SET OVERVIEW   Changed Description
SUMMARISED STOCKS DATA SET OVERVIEW   Changed Description
SUPPORTING INFORMATION INTRODUCTION   Changed Description
SUPPORTING INFORMATION MENU   Changed Description
TOP INDEX LEFT PANE   Changed Description
WARD ATTENDER   Changed Description
 
Class Definitions
HEALTH PROGRAMME POPULATION   Changed Attributes
 
Attribute Definitions
ADMISSION METHOD   Changed Description
 
Data Elements
ETHNIC GROUP   Changed Description
HEALTHCARE RESOURCE GROUP CODE   Changed Description
HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER   Changed Description
LOCATION TYPE   Changed Description
LOCATION TYPE (HUMAN PAPILLOMAVIRUS VACCINE)   Changed Description
 
Packages
AMBULANCE TOP INDEX   Changed Description
CENTRAL RETURN FORMS renamed from CENTRAL RETURNS   Changed Name
CLINICAL CODING   Changed Description
COMMISSIONING DATA SET V5 renamed from COMMISSIONING DATA SET   Changed Name
DATA SETS   New Package
DATA SETS   New Package
DATA SETS   New Package
DATA SETS   New Package
DIAGRAMS   New Package
OVERVIEWS   New Package
OVERVIEWS   New Package
OVERVIEWS   New Package
OVERVIEWS   New Package
OVERVIEWS   New Package
OVERVIEWS   New Package
PUBLICATION INFORMATION renamed from GENERAL PUBLICATION INFORMATION   Changed Name
SUPPORTING INFORMATION   New Package
 

Date:28 January 2009
Sponsor:Richard Kavanagh, NHS Connecting for Health

Note: New text is shown with a blue background. Deleted text is crossed out. Within the Diagrams deleted classes and relationships are red, changed items are blue and new items are green.

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ACCIDENT AND EMERGENCY QUARTERLY MONITORING DATA SET (QMAE)  renamed from ACCIDENT & EMERGENCY QUARTERLY MONITORING DATA SET (QMAE)

Change to Data Set: Changed Name

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CDS V6 TYPE 110

Change to Data Set: Changed Aliases


DIAGNOSTICS WAITING TIMES AND ACTIVITY DATA SET  renamed from DIAGNOSTICS WAITING TIMES & ACTIVITY DATA SET

Change to Data Set: Changed Name

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GENITOURINARY MEDICINE ACCESS MONTHLY MONITORING DATA SET

Change to Data Set: Changed Description

Genitourinary Medicine Access Monthly Monitoring Data Set OverviewGenitourinary Medicine Access Monthly Monitoring Data Set Overview

This data set carries the data for monitoring access to Genitourinary Medicine services.
Genitourinary Medicine Access Monthly Monitoring Central Return Data Element

To carry the details of the reporting period and the organisations providing and commissioning Genitourinary Medicine Services by site code of treatment.

One occurrence per site code of treatment is required.

REPORTING PERIOD START DATE 
REPORTING PERIOD END DATE 
ORGANISATION CODE (CODE OF PROVIDER) 
ORGANISATION CODE (CODE OF COMMISSIONER) 
SITE CODE (OF TREATMENT) 
Attendances:
GENITOURINARY ALL ATTENDANCES TOTAL 
GENITOURINARY FIRST ATTENDANCES TOTAL 
GENITOURINARY FIRST ATTENDANCES SEEN WITHIN 2 DAYS TOTAL 
GENITOURINARY FIRST ATTENDANCES SEEN AFTER 10 DAYS TOTAL 
GENITOURINARY FIRST ATTENDANCES - UNSCHEDULED TOTAL 
First Appointments Missed:
GENITOURINARY FIRST APPOINTMENTS MISSED TOTAL 
GENITOURINARY FIRST APPOINTMENTS MISSED WITHIN 2 DAYS TOTAL 
First appointments offered within 2 normal working days (excludes bank holidays and weekends):
GENITOURINARY FIRST APPOINTMENTS OFFERED WITHIN 2 DAYS TOTAL 
Patients reporting symptoms:
PATIENTS REPORTING SYMPTOMS TOTAL 
First attendances seen after 2 normal working days (excludes bank holidays and weekends):
GENITOURINARY FIRST APPOINTMENTS SEEN AFTER 2 DAYS - PATIENT CHOICE TOTAL 
GENITOURINARY FIRST APPOINTMENTS SEEN AFTER 2 DAYS - CLINICAL REASON TOTAL 
GENITOURINARY FIRST APPOINTMENTS SEEN AFTER 2 DAYS - SPECIALIST CLINIC TOTAL 
HIV Clinic Attendances:
CLINIC ATTENDANCES (HIV) TOTAL 
CLINIC FIRST ATTENDANCES (HIV) TOTAL 
Patient perspective:
PATIENT PERSPECTIVE ON WAITING TIMES - UNSCHEDULED ATTENDANCES WITHIN 2 DAYS TOTAL 
PATIENT PERSPECTIVE ON WAITING TIMES - SCHEDULED ATTENDANCES WITHIN 2 DAYS TOTAL 
UNSCHEDULED ATTENDANCES - RESPONSES TO PATIENT WAIT QUESTION TOTAL 
SCHEDULED ATTENDANCES - RESPONSES TO PATIENT WAIT QUESTION TOTAL 
GENITOURINARY FIRST ATTENDANCES - PATIENT PREFERRED CLINIC TOTAL 
Patients registered but not seen:
PATIENTS REGISTERED BUT NOT OFFERED AN APPOINTMENT TOTAL 

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ABOUT THE NHS DATA MODEL AND DICTIONARY VERSION 3  renamed from ABOUT THE NHS DATA MODEL & DICTIONARY VERSION 3

Change to Supporting Information: Changed Name, Description

The About the NHS Data Model and Dictionary Version 3About the NHS Data Model and Dictionary Version 3

Following the issue of DSCN 07/2004 'Data Standards: Meta Model' the NHS Data Model and Dictionary has been changed to reflect and be based upon a more generic logical data model which will better support the strategic way forward. This NHS Data Model and Dictionary will be published as the NHS Data Model and Dictionary Version 3.

There has been extensive quality assurance of Version 3 including involvement of the Data Definition Group. All Version 3 contents have been cross mapped and checked to ensure consistency with the current Version 2 contents. With the completion of the final quality assurance, Version 3 is now ready for live publication and will completely supersede the current Version 2 on 1st May 2005.

Version 3 supports all the messages, data sets and central returns supported by Version 2 but the underlying structure has been genericised. No changes have been made to business definitions.

Version 3 introduces a new UML (Unified Modelling Language) Generic Model which is 'person based' rather than 'organisation based'. The model has been developed around generic 'care activity' for a patient at 'service point' facility or location with each event transaction being recorded. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP.Version 3 introduces a new UML (Unified Modelling Language) Generic Model which is 'PERSON' based rather than 'ORGANISATION' based. The model has been developed around generic 'CARE ACTIVITY' for a PATIENT at 'SERVICE POINT' facility or location with each event transaction being recorded. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail or approved definitions or value sets in Version 2 has been lost although some of the old class definitions will now be found in the new 'NHS Business Definitions'.

The NHS Data Dictionary Version 2 will be frozen and made available for archive information purposes only and will be watermarked accordingly. All future changes to NHS data standards and the supporting DSCNs will be made or be consistent only with Version 3.

Summary of main changes and enhancements incorporated within Version 3

• Introduction of the capability of holding Retired Items
• Introduction of NHS Business Definitions, which allow specific business areas to be defined in a more flexible manner
• New ‘All Items Index’ which lists all the contents held within the NHS Data Model and Dictionary
• Reduction in the number of data model diagrams making them more comprehensible
• Introduction of Domains, which are conceptual logical modelling objects which identify the logical format, length and value set attributable to one or more attribute/s• Introduction of Domains, which are conceptual logical modelling objects which identify the logical format, length and value set attributable to one or more attribute(s)
• Where Used list expanded to include a description of usage column
• Creation of a separate Meta Model area within the publication

The introduction of Version 3 has no impact on current data standards or system suppliers.

About the Generic Model

We have been working on supporting the principles of RoWBI (Review of Waiting and Booking Information), the emerging Secondary Uses Service (SUS), the national data warehouse and the migration of the CDS messages.We have been working on supporting the principles of RoWBI (Review of Waiting and Booking Information), the emerging Secondary Uses Service (SUS), the national data warehouse and the migration of the Commissioning Data Set messages. This has included rationalising the existing data standards so that the NHS Data Model and Dictionary can support both the 'legacy' systems and data needs, as well as new and emerging systems and data needs.

It supports all the messages, data sets and central returns which the current model supports but the underlying structure has been genericised. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail has been lost and most of the old class definitions can be found in the new 'Business Definitions'. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail has been lost and most of the old class definitions can be found in the new 'NHS Business Definitions'. The number of diagrams has been greatly reduced and they now describe coherent areas of the model which is a far more useful approach for data modellers.

This has led to the creation of a new UML (Unified Modelling Language) Generic Model which is 'person based' rather than 'organisation based'. The model has been developed around generic 'care activity' for a patient at 'service point' facility or location with each event transaction being recorded.This has led to the creation of a new UML (Unified Modelling Language) Generic Model which is 'PERSON' based rather than 'ORGANISATION' based. The model has been developed around generic 'CARE ACTIVITY' for a PATIENT at 'SERVICE POINT' facility or location with each event transaction being recorded.

The Model will form the underpinning common structure which can be used by all future data sets related to patients and care activity, whether they be 'administrative', 'clinical', 'management' etc. The data elements specified within the model and within attached data set modules will form the basis for XML message exchanges.The Model will form the underpinning common structure which can be used by all future data sets related to patients and CARE ACTIVITY, whether they be 'administrative', 'clinical', 'management' etc. The data elements specified within the model and within attached data set modules will form the basis for XML message exchanges.

The model is aimed at enabling all 'care activities' related to the same condition for the same patient to be recorded and linked across organisations. The different states of the same 'care activity' are recorded as event transactions e.g. requested, intended, scheduled, provided, cancelled, etc. These different state events also drive the scheduling and capacity planning of resources (people, equipment, facilities, etc.) to deliver the care.

Contact us for more information: For more information contact the NHS Data Model and Dictionary ServiceContact us for more information: datastandards@nhs.net.

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ACCIDENT AND EMERGENCY CODING TABLES  renamed from ACCIDENT & EMERGENCY CODING TABLES

Change to Supporting Information: Changed Name, Description

The Accident and Emergency Commissioning Data Set identified the need for a national set of codes to to be used in Accident And Emergency Departments  to reflect ACTIVITY relating to Diagnosis, Investigation and Treatment. These are presented in the following tables:

Accident and Emergency Diagnosis TablesThese are presented in the following tables:

Accident and Emergency Investigation Table

Accident and Emergency Treatment Tables

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ACCIDENT AND EMERGENCY DIAGNOSIS TABLES  renamed from ACCIDENT & EMERGENCY DIAGNOSIS TABLES

Change to Supporting Information: Changed Name, Description

ACCIDENT AND EMERGENCY CLINICAL CODES

  1. Accident and Emergency Diagnosis

    A broad classification of types of diagnoses which may be made as a result of Accident And Emergency Attendance. The full description is made up of codes from three tables - ACCIDENT AND EMERGENCY DIAGNOSIS, Accident And Emergency Attendance: ANATOMICAL AREAS and Accident And Emergency Attendance: ANATOMICAL SIDE. ANATOMICAL AREA (a classification of parts of the human body) and ANATOMICAL SIDE (an indication of the side of the human body) together give the Anatomical Site of clinical problems presented at an Accident And Emergency Attendance.


    • A broad classification of types of diagnoses which may be made as a result of Accident And Emergency Attendance. The full description is made up of codes from three tables - ACCIDENT AND EMERGENCY DIAGNOSIS, Accident And Emergency Attendance: ANATOMICAL AREAS and Accident And Emergency Attendance: ANATOMICAL SIDE. ANATOMICAL AREA (a classification of parts of the human body) and ANATOMICAL SIDE (an indication of the side of the human body) together give the Anatomical Site of clinical problems presented at an Accident And Emergency Attendance.

    • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

    • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
    • ACCIDENT AND EMERGENCY DIAGNOSIS is a six character code, comprising:
      Diagnosis Conditionn2
      Sub-Analysisn1
      Accident And Emergency Attendance - ANATOMICAL AREA n2
      Accident And Emergency Attendance - ANATOMICAL SIDE an1

      Accident and Emergency Diagnosis - Diagnosis Condition

      Diagnosis ConditionCode
      Laceration01
      Contusion/abrasion*02
      Soft tissue inflammation03
      Head injury*04
      Dislocation/fracture/joint injury/amputation*05
      Sprain/ligament injury06
      Muscle/tendon injury07
      Nerve injury08
      Vascular injury09
      Burns and scalds*10
      Electric shock11
      Foreign body12
      Bites/stings13
      Poisoning* (including overdose)14
      Near drowning15
      Visceral injury16
      Infectious disease*17
      Local infection18
      Septicaemia19
      Cardiac conditions*20
      Cerebro-vascular conditions21
      Other vascular conditions22
      Haematological conditions23
      Central Nervous System conditions* (excluding strokes)24
      Respiratory conditions*25
      Gastrointestinal conditions*26
      Urological conditions (including cystitis)27
      Obstetric conditions28
      Gynaecological conditions29
      Diabetes and other endocrinological conditions*30
      Dermatological conditions31
      Allergy (including anaphylaxis)32
      Facio-maxillary conditions33
      ENT conditions34
      Psychiatric conditions35
      Ophthalmological conditions36
      Social problem (includes chronic alcoholism and homelessness)37
      Diagnosis not classifiable38
      Nothing abnormal detected39
      *Item sub-analysed

      Accident and Emergency Diagnosis - Sub-analysis

      Sub-analysis Code
      Contusion/abrasion- contusion
      - abrasion
      1
      2
      Head Injury- concussion
      - other head injury
      1
      2
      Dislocation/fracture/joint injury/amputation- dislocation
      - open fracture
      - closed fracture
      - joint injury
      - amputation
      1
      2
      3
      4
      5
      Burns and scalds- electric
      - thermal
      - chemical
      - radiation
      1
      2
      3
      4
      Poisoning- prescriptive drugs
      - proprietary drugs
      - controlled drugs
      - other, including alcohol
      1
      2
      3
      4
      Infectious disease- notifiable disease
      - non-notifiable disease
      1
      2
      Cardiac conditions- myocardial ischaemia & infarction
      - other non-ischaemia
      1
      2
      Respiratory conditions- bronchial asthma
      - other non-asthma
      1
      2
      Central Nervous System conditions- epilepsy
      - other non-epilepsy
      1
      2
      Gastrointestinal conditions- haemorrhage
      - acute abdominal pain
      - other
      1
      2
      3
      Diabetes and other endocrinological conditions- diabetic
      - other non-diabetic
      1
      2

      Anatomical Site

      Accident And Emergency Anatomical Area - Area

      Anatomical AreaCode
      Head and Neck 
      Brain01
      Head02
      Face03
      Eye04
      Ear05
      Nose06
      Mouth, Jaw, Teeth07
      Throat08
      Neck09
      Upper Limb 
      Shoulder10
      Axilla11
      Upper Arm12
      Elbow13
      Forearm14
      Wrist15
      Hand16
      Digit17
      Trunk 
      Cervical spine18
      Thoracic19
      Lumbosacral spine20
      Pelvis21
      Chest22
      Breast23
      Abdomen24
      Back/buttocks25
      Ano/rectal26
      Genitalia27
      Lower Limb 
      Hip28
      Groin29
      Thigh30
      Knee31
      Lower leg32
      Ankle33
      Foot34
      Toe35
      Multiple Site36
      Accident and Emergency Anatomical Side 
      LeftL
      RightR
      BilateralB
      Not applicable8

  • ACCIDENT AND EMERGENCY DIAGNOSIS is a six character code, comprising:

    Diagnosis Conditionn2
    Sub-Analysisn1
    Accident And Emergency Attendance - ANATOMICAL AREA n2
    Accident And Emergency Attendance - ANATOMICAL SIDE an1

    Accident and Emergency Diagnosis - Diagnosis Condition

    Diagnosis ConditionCode
    Laceration01
    Contusion/abrasion*02
    Soft tissue inflammation03
    Head injury*04
    Dislocation/fracture/joint injury/amputation*05
    Sprain/ligament injury06
    Muscle/tendon injury07
    Nerve injury08
    Vascular injury09
    Burns and scalds*10
    Electric shock11
    Foreign body12
    Bites/stings13
    Poisoning* (including overdose)14
    Near drowning15
    Visceral injury16
    Infectious disease*17
    Local infection18
    Septicaemia19
    Cardiac conditions*20
    Cerebro-vascular conditions21
    Other vascular conditions22
    Haematological conditions23
    Central Nervous System conditions* (excluding strokes)24
    Respiratory conditions*25
    Gastrointestinal conditions*26
    Urological conditions (including cystitis)27
    Obstetric conditions28
    Gynaecological conditions29
    Diabetes and other endocrinological conditions*30
    Dermatological conditions31
    Allergy (including anaphylaxis)32
    Facio-maxillary conditions33
    ENT conditions34
    Psychiatric conditions35
    Ophthalmological conditions36
    Social problem (includes chronic alcoholism and homelessness)37
    Diagnosis not classifiable38
    Nothing abnormal detected39
    *Item sub-analysed

    Accident and Emergency Diagnosis - Sub-analysis

    Sub-analysis Code
    Contusion/abrasion- contusion
    - abrasion
    1
    2
    Head Injury- concussion
    - other head injury
    1
    2
    Dislocation/fracture/joint injury/amputation- dislocation
    - open fracture
    - closed fracture
    - joint injury
    - amputation
    1
    2
    3
    4
    5
    Burns and scalds- electric
    - thermal
    - chemical
    - radiation
    1
    2
    3
    4
    Poisoning- prescriptive drugs
    - proprietary drugs
    - controlled drugs
    - other, including alcohol
    1
    2
    3
    4
    Infectious disease- notifiable disease
    - non-notifiable disease
    1
    2
    Cardiac conditions- myocardial ischaemia & infarction
    - other non-ischaemia
    1
    2
    Respiratory conditions- bronchial asthma
    - other non-asthma
    1
    2
    Central Nervous System conditions- epilepsy
    - other non-epilepsy
    1
    2
    Gastrointestinal conditions- haemorrhage
    - acute abdominal pain
    - other
    1
    2
    3
    Diabetes and other endocrinological conditions- diabetic
    - other non-diabetic
    1
    2

    Anatomical Site

    Accident And Emergency Anatomical Area - Area

    Anatomical AreaCode
    Head and Neck 
    Brain01
    Head02
    Face03
    Eye04
    Ear05
    Nose06
    Mouth, Jaw, Teeth07
    Throat08
    Neck09
    Upper Limb 
    Shoulder10
    Axilla11
    Upper Arm12
    Elbow13
    Forearm14
    Wrist15
    Hand16
    Digit17
    Trunk 
    Cervical spine18
    Thoracic19
    Lumbosacral spine20
    Pelvis21
    Chest22
    Breast23
    Abdomen24
    Back/buttocks25
    Ano/rectal26
    Genitalia27
    Lower Limb 
    Hip28
    Groin29
    Thigh30
    Knee31
    Lower leg32
    Ankle33
    Foot34
    Toe35
    Multiple Site36
    Accident and Emergency Anatomical Side 
    LeftL
    RightR
    BilateralB
    Not applicable8
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    ACCIDENT AND EMERGENCY INVESTIGATION TABLE  renamed from ACCIDENT & EMERGENCY INVESTIGATION TABLE

    Change to Supporting Information: Changed Name, Description

    ACCIDENT AND EMERGENCY CLINICAL CODES

    1. Accident and Emergency Investigation

      • A broad classification of types of investigation which may be requested to assist with diagnosis as a result of Accident And Emergency Attendance.

      • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

      • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

      • ACCIDENT AND EMERGENCY INVESTIGATION is a six character code, comprising:
      Investigationn2 (see Table below)
      Local sub-Analysisup to an4

      A broad classification of types of investigation which may be requested to assist with diagnosis as a result of Accident And Emergency Attendance.Accident And Emergency Investigation Table

    2. Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

    3. It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

    4. ACCIDENT AND EMERGENCY INVESTIGATION is a six character code, comprising:

      Investigationn2 (see Table below)
      Local sub-Analysisup to an4

      Accident And Emergency Investigation Table

      InvestigationCode
      X-ray plain film01
      Electrocardiogram02
      Haematology03
      Cross match blood/group and save serum for later cross match04
      Biochemistry05
      Urinalysis06
      Bacteriology07
      Histology08
      Computerised Tomography - Retired 2006-04-0109
      Ultrasound10
      Magnetic Resonance Imaging11
      Computerised Tomography (excludes genitourinary contrast examination/tomography)12
      Genitourinary contrast examination/tomography13
      Clotting studies14
      Immunology15
      Cardiac enzymes16
      Arterial/capillary blood gas17
      Toxicology18
      Blood culture19
      Serology20
      Pregnancy test21
      Dental investigation22
      Refraction, orthoptic tests and computerised visual fields23
      None24
      Other99

      Items expected to be sub-analysed at discretion of individual Accident And Emergency Departments.

    InvestigationCode
    X-ray plain film01
    Electrocardiogram02
    Haematology03
    Cross match blood/group and save serum for later cross match04
    Biochemistry05
    Urinalysis06
    Bacteriology07
    Histology08
    Computerised Tomography - Retired 2006-04-0109
    Ultrasound10
    Magnetic Resonance Imaging11
    Computerised Tomography (excludes genitourinary contrast examination/tomography)12
    Genitourinary contrast examination/tomography13
    Clotting studies14
    Immunology15
    Cardiac enzymes16
    Arterial/capillary blood gas17
    Toxicology18
    Blood culture19
    Serology20
    Pregnancy test21
    Dental investigation22
    Refraction, orthoptic tests and computerised visual fields23
    None24
    Other99

    Items expected to be sub-analysed at discretion of individual Accident And Emergency Departments.

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    ACCIDENT AND EMERGENCY QUARTERLY MONITORING DATA SET (QMAE) OVERVIEW  renamed from ACCIDENT & EMERGENCY QUARTERLY MONITORING DATA SET (QMAE) OVERVIEW

    Change to Supporting Information: Changed Name

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    ACCIDENT AND EMERGENCY TREATMENT TABLES  renamed from ACCIDENT & EMERGENCY TREATMENT TABLES

    Change to Supporting Information: Changed Name, Description

    ACCIDENT AND EMERGENCY CLINICAL CODES

    1. Accident and Emergency Treatment

      • A broad classification of types of treatment or guidance which may be provided to a PATIENT as a result of Accident And Emergency Attendance.

      • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

      • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

      • ACCIDENT AND EMERGENCY TREATMENT is a six character code, comprising:
      Conditionn2 (see Treatment Table below)
      Sub-Analysisn1 (see Sub-analysis Table below)
      Local useup to an3

      A broad classification of types of treatment or guidance which may be provided to a PATIENT as a result of Accident And Emergency Attendance.Accident and Emergency Treatment - Treatment

    2. Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

    3. It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

    4. ACCIDENT AND EMERGENCY TREATMENT is a six character code, comprising:

      Conditionn2 (see Treatment Table below)
      Sub-Analysisn1 (see Sub-analysis Table below)
      Local useup to an3

      Accident and Emergency Treatment - Treatment

      TreatmentCode
      Dressing*01
      Bandage/support02
      Sutures*03
      Wound closure (excluding sutures)*04
      Plaster of Paris*05
      Splint06
      Prescription - Retired 2006-04-0107
      Removal foreign body08
      Physiotherapy*09
      Manipulation*10
      Incision & drainage11
      Intravenous cannula12
      Central line13
      Lavage/emesis/charcoal/eye irrigation14
      Intubation & Endotracheal tubes/laryngeal mask airways/rapid sequence induction15
      Chest drain16
      Urinary catheter/suprapubic17
      Defibrillation/pacing*18
      Resuscitation/cardiopulmonary resuscitation19
      Minor surgery20
      Observation/electrocardiogram, pulse oximetry/head injury/trends21
      Guidance/advice only*22
      Anaesthesia*23
      Tetanus*24
      Nebuliser/spacer25
      Parenteral thrombolysis*28
      Other Parenteral drugs*29
      Recording vital signs30
      Burns review31
      Recall/x-ray review32
      Fracture review33
      Wound cleaning34
      Dressing/wound review35
      Sling/collar cuff/broad arm sling36
      Epistaxis control37
      Nasal airway38
      Oral airway39
      Supplemental oxygen40
      Continuous positive airways pressure/nasal intermittent positive pressure ventilation/bag valve mask41
      Arterial line42
      Infusion fluids43
      Blood product transfusion44
      Pericardiocentesis45
      Lumbar puncture46
      Joint aspiration47
      Minor plastic procedure/split skin graft48
      Active rewarming of the hypothermic patient49
      Cooling - control body temperature50
      Medication administered*51
      Occupational Therapy*52
      Loan of walking aid (crutches)53
      Social work intervention54
      Eye*55
      Dental treatment56
      Prescription\medicines prepared to take away57
      Other (consider alternatives)27
      None (consider guidance/advice option)99

      Items sub-analysed in Table below

      Accident and Emergency Treatment - Sub-analysis

      Sub-analysis Treatment Code
      Dressing- dressing minor wound/burn/eye
      - dressing major wound/burn
      1
      2
      Sutures- primary sutures
      - secondary/complex suture
      - removal of sutures/clips
      1
      2
      3
      Wound closure (excluding sutures)- steristrips
      - wound glue
      - other (e.g. clips)
      1
      2
      3
      Plaster of Paris- application Plaster of Paris
      - removal Plaster of Paris
      1
      2
      Physiotherapy-strapping, ultra sound treatment, short wave diathermy, manipulation
      - gait re-education, falls prevention
      1


      2
      Manipulation- manipulation of upper limb fracture
      - manipulation of lower limb fracture
      - manipulation of dislocation
      1
      2
      3
      Defibrillation/pacing- defibrillation
      - external pacing
      1
      2
      Guidance/advice only- written
      - verbal
      1
      2
      Anaesthesia- general anaesthetic
      - local anaesthetic
      - regional block
      - entonox
      - sedation
      - other
      1
      2
      3
      4
      5
      6
      Tetanus- immune
      - tetanus toxoid course
      - tetanus toxoid booster
      - human immunoglobulin
      - combined tetanus/diphtheria course
      - combined tetanus/diphtheria booster
      1
      2
      3
      4
      5
      6
      Parenteral thrombolysis- streptokinase parenteral thrombolysis
      - recombinant - plasminogen activator
      1

      2
      Other Parenteral drugs- intravenous drug, e.g. stat/bolus
      - intravenous infusion
      1
      2
      Medication administered- oral
      - intra-muscular
      - subcutaneous
      - per rectum
      - sublingual
      - intra-nasal
      - eye drops
      - ear drops
      - topical skin cream
      1
      2
      3
      4
      5
      6
      7
      8
      9
      Occupational Therapy- OT functional assessment
      - OT activities of daily living equipment provision
      1
      2
      Eye- orthoptic exercises
      - laser of retina/iris or posterior capsule
      - retrobulbar injection
      - epilation of lashes
      - subconjunctival injection
      1
      2

      3
      4
      5
    TreatmentCode
    Dressing*01
    Bandage/support02
    Sutures*03
    Wound closure (excluding sutures)*04
    Plaster of Paris*05
    Splint06
    Prescription - Retired 2006-04-0107
    Removal foreign body08
    Physiotherapy*09
    Manipulation*10
    Incision & drainage11
    Intravenous cannula12
    Central line13
    Lavage/emesis/charcoal/eye irrigation14
    Intubation & Endotracheal tubes/laryngeal mask airways/rapid sequence induction15
    Chest drain16
    Urinary catheter/suprapubic17
    Defibrillation/pacing*18
    Resuscitation/cardiopulmonary resuscitation19
    Minor surgery20
    Observation/electrocardiogram, pulse oximetry/head injury/trends21
    Guidance/advice only*22
    Anaesthesia*23
    Tetanus*24
    Nebuliser/spacer25
    Parenteral thrombolysis*28
    Other Parenteral drugs*29
    Recording vital signs30
    Burns review31
    Recall/x-ray review32
    Fracture review33
    Wound cleaning34
    Dressing/wound review35
    Sling/collar cuff/broad arm sling36
    Epistaxis control37
    Nasal airway38
    Oral airway39
    Supplemental oxygen40
    Continuous positive airways pressure/nasal intermittent positive pressure ventilation/bag valve mask41
    Arterial line42
    Infusion fluids43
    Blood product transfusion44
    Pericardiocentesis45
    Lumbar puncture46
    Joint aspiration47
    Minor plastic procedure/split skin graft48
    Active rewarming of the hypothermic patient49
    Cooling - control body temperature50
    Medication administered*51
    Occupational Therapy*52
    Loan of walking aid (crutches)53
    Social work intervention54
    Eye*55
    Dental treatment56
    Prescriptionmedicines prepared to take away57
    Other (consider alternatives)27
    None (consider guidance/advice option)99

    Items sub-analysed in Table below

    Accident and Emergency Treatment - Sub-analysis

    Sub-analysis Treatment Code
    Dressing- dressing minor wound/burn/eye
    - dressing major wound/burn
    1
    2
    Sutures- primary sutures
    - secondary/complex suture
    - removal of sutures/clips
    1
    2
    3
    Wound closure (excluding sutures)- steristrips
    - wound glue
    - other (e.g. clips)
    1
    2
    3
    Plaster of Paris- application Plaster of Paris
    - removal Plaster of Paris
    1
    2
    Physiotherapy-strapping, ultra sound treatment, short wave diathermy, manipulation
    - gait re-education, falls prevention
    1


    2
    Manipulation- manipulation of upper limb fracture
    - manipulation of lower limb fracture
    - manipulation of dislocation
    1
    2
    3
    Defibrillation/pacing- defibrillation
    - external pacing
    1
    2
    Guidance/advice only- written
    - verbal
    1
    2
    Anaesthesia- general anaesthetic
    - local anaesthetic
    - regional block
    - entonox
    - sedation
    - other
    1
    2
    3
    4
    5
    6
    Tetanus- immune
    - tetanus toxoid course
    - tetanus toxoid booster
    - human immunoglobulin
    - combined tetanus/diphtheria course
    - combined tetanus/diphtheria booster
    1
    2
    3
    4
    5
    6
    Parenteral thrombolysis- streptokinase parenteral thrombolysis
    - recombinant - plasminogen activator
    1

    2
    Other Parenteral drugs- intravenous drug, e.g. stat/bolus
    - intravenous infusion
    1
    2
    Medication administered- oral
    - intra-muscular
    - subcutaneous
    - per rectum
    - sublingual
    - intra-nasal
    - eye drops
    - ear drops
    - topical skin cream
    1
    2
    3
    4
    5
    6
    7
    8
    9
    Occupational Therapy- OT functional assessment
    - OT activities of daily living equipment provision
    1
    2
    Eye- orthoptic exercises
    - laser of retina/iris or posterior capsule
    - retrobulbar injection
    - epilation of lashes
    - subconjunctival injection
    1
    2

    3
    4
    5

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    ADMINISTRATIVE CODES AND CLASSIFICATIONS  renamed from ADMINISTRATIVE CODES & CLASSIFICATIONS

    Change to Supporting Information: Changed Name

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    ADMINISTRATIVE DATA SETS INTRODUCTION

    Change to Supporting Information: Changed Description

    Introduction


    An administrative data set is a data set which is essential for the safe management of care.

    Administrative data sets are exchanged between Health Care Providers or between DEPARTMENTS or CARE PROFESSIONAL TEAMS in Health Care Providers.

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    CENTRAL RETURN DATA SETS INTRODUCTION

    Change to Supporting Information: Changed Description

    Introduction


    The development of data sets supports:
    • information requirements of national and local performance management, planning and clinical governance
    • assurance of the quality of health and social care services
    • the monitoring of National Service Frameworks (NSFs)

    The information in the Central Return Data Sets is transmitted at aggregate level.Some of these Central Return Data Sets are transmitted to Unify2.
    Unify2 is the data collection system used by the Knowledge and Intelligence team in the Department of Health to collect a wide range of performance information.The Unify2 homepage can be found at the following address:
    http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx  

    Note: access to this address requires a Unify2 account and password. Any queries about the site can be addressed to the Unify2 helpdesk by emailing STEIS-Helpdesk@dh.gsi.gov.uk or calling 0113 254 5278

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    CENTRAL RETURN FORMS INTRODUCTION

    Change to Supporting Information: Changed Description

    Introduction and Overview

    The Department of Health uses the information gathered from Central Return Forms to monitor service provision at a high level and to support trend analysis for health service activity and health needs assessment.The Department of Health uses the information gathered from Central Returns to monitor service provision at a high level and to support trend analysis for health service activity and health needs assessment. In addition, the returns support the monitoring of progress in the achievement of overall objectives for the NHS and contribute towards the development of policy and the process of funding allocation.

    Each Central Return Form contained within this publication has an image of the Central Return Form itself and provides guidance on its content and completion. The guidance also describes how data items held in the NHS Data Model and Dictionary are used to derive the information required for Central Return Forms.Each Central Return contained within this publication has an image of the Central Return form itself and provides guidance on its content and completion. The guidance also describes how data items held in the NHS Data Dictionary are used to derive the information required for Central Returns. Physical definitions of data items, such as the code values, are included.

    Important Notes
    1. Some of the Central Return Forms covered in this publication are under review. Changes arising from these reviews are not covered in this publication as they were not available in time for publishing. Users should therefore use this publication in conjunction with relevant change notifications as they are published. These were issued as Data Set Change Notices (DSCNs) at time of writing, but the Information Standards Board for Health and Social Care may use a different notification system.

    2. Not all mandated Central Return Forms are contained within this publication. For those returns not yet covered, please consult the Notes for Completion provided with the form for detailed information requirements.

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    CLINICAL CODING MENU  renamed from CLINICAL CODING

    Change to Supporting Information: Changed Name, Description

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    CRITICAL CARE PERIOD (RETIRED)

    Change to Supporting Information: Changed Description

    Critical Care Period is an ACTIVITY GROUP.

    A period of time within a Hospital Provider Spell during which a PATIENT receives care in a designated critical care bed.

    Excluded from this is care provided to neonates, which is recorded elsewhere. Outreach activity and resuscitation conducted outside designated critical care areas should not be recorded as a Critical Care Period. Also excluded from this is care provided on general wards (except as an occasional non-standard location), A&E, Radiology Departments, labour wards and special care baby units.

    A new Critical Care Period starts when the PATIENT is admitted to a critical care location regardless of CRITICAL CARE LEVEL. Repeated admissions to the same unit, transfers to a different critical care location and transfers from a non-standard location to a critical care unit within the same Hospital Provider Spell trigger a new Critical Care Period. A change of Consultant Episode (Hospital Provider) or brief transfers for investigation or treatment do not end the Critical Care Period.

    A Critical Care Period ends when the PATIENT is discharged from the critical care location or dies.

    Critical care locations are described by CRITICAL CARE UNIT FUNCTION and UNIT BED CONFIGURATION. Critical Care beds may include occasional non-standard locations using a ward area or operating department when conventional critical care beds are not available. Non standard locations may only be recorded if the CRITICAL CARE LEVEL is National Code 02 'Level 2' or 03 'Level 3' and the delivery of care is greater than four hours.

    The type of ORGAN SYSTEM SUPPORTED is recorded and the duration of each organ system support is calculated from the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE. The ORGAN SUPPORT MAXIMUM is the maximum number of different ORGAN SYSTEMS SUPPORTED on any one day in the Critical Care Period. Each organ system can only be counted once on any calendar day. Both basic and advanced categories cannot be counted at the same time. The range of values for ORGAN SUPPORT MAXIMUM is from 0 to 7.

    CRITICAL CARE DISCHARGE READY DATE and CRITICAL CARE DISCHARGE READY TIME are recorded to identify and quantify significant problems in discharging patients from critical care units.

    A subset of the BAD_REFERENCE is used to derive Adult Critical Care HRGs.A subset of the Critical Care Minimum Data Set is used to derive Adult Critical Care HRGs. The subset is sent in the following Commissioning Data Set messages:
    ADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODEADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODE
    ADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODEADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODE
    ADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODEADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODE

    A Critical Care Period does not include the following:
    a. Surgical and anaesthetic intra-operative care
    b. Post-operative care within an operating department except where level 2 or level 3 care are provided for more than 4 hours
    c. Cardiac (coronary) Care
    d. Imaging procedures
    e. Endoscopy procedures

    Information recorded for a Critical Care Period includes:

    CRITICAL CARE ADMISSION SOURCE
    CRITICAL CARE ADMISSION TYPE
    CRITICAL CARE DISCHARGE DESTINATION   O
    CRITICAL CARE DISCHARGE LOCATION   O
    CRITICAL CARE DISCHARGE STATUS   O
    CRITICAL CARE SOURCE LOCATION

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    DEFAULT CODES SUMMARY TABLE

    Change to Supporting Information: Changed Description

    DEFAULT CODES SUMMARY


    Default (or pseudo) codes may be used:

    • to indicate an ORGANISATION TYPE, such as Commissioner Code for Ministry of Defence (MoD) Healthcare;
    • to indicate that the code value is not known;
    • to indicate that a code cannot be supplied (e.g. no referring doctor or dentist).
    Person Default CodesCode
    CONSULTANT: GENERAL MEDICAL COUNCIL (GMC) NUMBER not knownC9999998
    Dental CONSULTANT: GENERAL MEDICAL COUNCIL (GMC) NUMBER/ GENERAL DENTAL COUNCIL NUMBER not knownCD999998
    Dentist code not applicable (dentist does not have Dental Practice Board number)D9999981
    Dentist, Dental Practice Board (DPB) number not knownD9999998
    GENERAL MEDICAL PRACTITIONER PPD CODE not knownG9999998
    Locum refersCode of GP for whom locum is acting
    MIDWIFE M9999998
    Ministry of Defence DoctorA9999998
    GENERAL MEDICAL PRACTITIONER PPD CODE not applicableG9999981
    NURSE N9999998
    Other health care professionalH9999998
    Overseas visitor exempt from chargesTDH00
    Private PATIENTS/Overseas visitor liable for chargesVPP00
    REFERRER CODE not applicable, e.g. PATIENT has self-presented or not knownX9999998
    Referrer other than GENERAL MEDICAL PRACTITIONER, GENERAL DENTAL PRACTITIONER or CONSULTANT R9999981
    Organisation Default CodesCode
    Commissioner Code for Ministry of Defence (MoD) HealthcareXMD00
    No Registered GP Practice V81997
    ORGANISATION CODE (CODE OF PROVIDER) - non-NHS UK provider where no ORGANISATION CODE has been issued89999
    ORGANISATION CODE (CODE OF PROVIDER) - non-UK provider where no ORGANISATION CODE has been issued89997
    GP Practice Code not applicableV81998
    GP Practice Code not knownV81999
    Primary Care Trust code not applicable (e.g. overseas visitors, Wales, Scotland or Northern Ireland).
    Note: this code must not be used in the Commissioning Data Set (CDS) header. It is not a default Commissioner code.
    X98
    Primary Care Trust of residence not known
    Note: This code must not be used in the Commissioning Data Set header. It is not a default commissioner code.
    Q99
    Referring ORGANISATION CODE not applicableX99998
    Referring ORGANISATION CODE not knownX99999
    Strategic Health Authority of residence not knownQ99
    Organisation Site Default CodesCode
    SITE CODE (OF TREATMENT) - not a hospital site (for use on Out-Patient Commissioning Data Set)R9998
    SITE CODE (OF TREATMENT) - non-NHS UK Provider where no ORGANISATION SITE CODE has been issued89999
    SITE CODE (OF TREATMENT) - non-UK Provider where no ORGANISATION SITE CODE has been issued89997

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    DEFINITIONS INTRODUCTION

    Change to Supporting Information: Changed Description

    DEFINITIONS INTRODUCTION



    Class Definitions

    All the classes that appear within the NHS data standards logical data model. Each class contains its nationally agreed definition, all of its attributes and all the relationships it has with other classes.

    Attribute Definitions

    All the attributes of the classes that appear within the NHS data standards logical data model. Each attribute contains its nationally agreed definition which may also include its agreed National Codes or classifications and a clickable 'data' tab, if a data element also exists for it.

    Data Elements

    Data elements which may be supported by an attribute definition i.e. the data element has the same name as an attribute, be a derived item which is derivable from attributes or only exists as a data element.

    Where a data element is supported by an attribute definition, such as the national codes to be used in that data element exist in an attribute, then there will be a link to that attribute through a 'definition' tab.

    Data elements are used in the completion of Datasets, CDS, Hospital Episode Statistics and Central Returns. The data element information comprises format and field length, Hospital Episode Statistics name if applicable, National Codes or classifications and useful notes clarifying the selected data element.

    NHS Business Definitions

    These contain the business rules for recording NHS activity and will be of particular relevance to NHS Information Professionals.

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    DIAGNOSTICS WAITING TIMES CENSUS DATA SET OVERVIEW

    Change to Supporting Information: Changed Description


    The data set provides definitions to support the national census on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment. This is a census reporting the diagnostic test waiting times.

    The data set provides definitions to support the national data collections on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment.The Diagnostics Waiting Times Census Data Set provides definitions to support the national data collections on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment. This is a census of DIAGNOSTIC TEST waiting times.

    This data set is for the census covering 4 main areas of DIAGNOSTIC TESTS as below:

    Part 1 - Endoscopy

    Part 2 - Imaging

    Part 3 - Pathology

    Parts 4 to 11 - Physiological Measurement

    Patient level information

    Information is to be submitted onto the Unify2 database that has been developed and maintained by the Department of Health.Information is to be submitted onto the Unify2 database that has been developed and maintained by the Department of Health. All PATIENTS waiting for a DIAGNOSTIC TEST/procedure funded by the NHS should be included. This includes all referral routes (i.e. whether the PATIENT was referred by a GENERAL PRACTITIONER or by a hospital-based clinician or other route) and also all settings (i.e. Out-Patient Clinic, WARD, Imaging Department, GP Practice, one-stop centres etc.). It is recognised that there will be some overlap between PATIENTS reported on this census and PATIENTS reported in the inpatient and outpatient waiting times returns.

    How the data set is transmitted

    Full guidance on Unify2 can be found at the following address:
    Unify2 Guidance

    Further guidance

    Guidance on extracting the data sets, including OPCS Classification of Interventions and Procedures, can be found at:Guidance on extracting the data sets, including OPCS Classification of Interventions and Procedures, can be found at:
    Department of Health - Monthly and Biannual Diagnostics statistics - Definitions

    and

    NHS 18 weeks - Guidance on Diagnostic Data Collections.NHS 18 weeks - Guidance on Diagnostic Data Collections.

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    DISCLAIMER

    Change to Supporting Information: Changed Description

    Disclaimer


    Copyright

    Content on this website is copyright unless otherwise stated. Where copyright applies, visitors can download material for private research, study or in-house use only. Visitors must not copy, distribute, or publish any material from this website.

    Computer Viruses

    Every reasonable effort has been made to ensure that the information and data that is held on this web site is free from computer viruses or other contamination. However, it is recommended that content downloaded from this site, is additionally checked by your own anti-virus checking system prior to use.

    NHS Connecting for Health cannot accept liability for any damage, however caused to computer systems and/or data contained therein by any programs, including viruses, in content downloaded from any NHS Connecting for Health site.

    Links

    All links are provided for information and convenience only. We cannot accept responsibility for the sites linked to, or the information found there. A link does not imply an endorsement of a site; likewise, not linking to a particular site does not imply lack of endorsement.

    Availability

    We cannot guarantee uninterrupted access to this website, or the sites to which it links. We accept no responsibility for any damages arising from the loss of use of this information.

    Accuracy

    While we have taken every care to compile accurate information and to keep it up-to-date, we cannot guarantee its correctness and completeness. The information provided on this site does not constitute business, medical or other professional advice, and is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information. If you believe that there are errors, or inaccuracies please contact the webmaster.

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    GENITOURINARY MEDICINE ACCESS MONTHLY MONITORING DATA SET OVERVIEW

    Change to Supporting Information: Changed Description


    Contextual Overview

    The Department of Health requires this dataset from NHS providers of specialised services, where the primary function of the specialist clinical multidisciplinary team is concerned with the provision of screening, diagnosis and management of sexually transmissible infections and related genital medical conditions.The Department of Health requires this data set from NHS providers of specialised services, where the primary function of the specialist clinical multidisciplinary team is concerned with the provision of screening, diagnosis and management of sexually transmissible infections and related genital medical conditions. In line with the national strategy for sexual health, Human Immunodeficiency Virus (HIV), genitourinary medicine services are represented as level three providers. This information is collected via the Genitourinary Medicine Access Monthly Monitoring Data Set. This information is collected via the Genitourinary Medicine Access Monthly Monitoring Data Set.

    The Genitourinary Medicine Access Monthly Monitoring Data Set provides essential information for :-The Genitourinary Medicine Access Monthly Monitoring Data Set provides essential information for:

    • monitoring the 48 hour access target
    • assurance of validity and veracity of the achievement of the target
    • support for local service modernisation, performance management and commissioning required to assure 48 hour access on an on-going basis
  • support for local service modernisation, performance management and commissioning required to assure 48 hour access on an on-going basis
  • Collection and Submission of the Genitourinary Medicine Access Monthly Monitoring Data SetCollection and Submission of the Genitourinary Medicine Access Monthly Monitoring Data Set

    Synopsis of the Genitourinary Medicine Access Monthly Monitoring Data SetSynopsis of the Genitourinary Medicine Access Monthly Monitoring Data Set
    1. REPORTING PERIOD, ORGANISATION CODE (CODE OF PROVIDER), ORGANISATION CODE (CODE OF COMMISSIONER) and SITE CODE (OF TREATMENT)
    2. Attendances
    3. First APPOINTMENTS Missed
    4. First APPOINTMENTS offered within 2 days (excludes bank holidays & weekends)
    5. PATIENTS reporting symptoms
    6. FIRST ATTENDANCES seen after 2 days (excludes bank holidays & weekends)
    7. Human immunodeficiency virus (HIV) clinic attendances
    8. PATIENT perspective
    9. PATIENTS registered but not seen

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    GLOSSARY OF TERMS

    Change to Supporting Information: Changed Description

    GLOSSARY OF TERMS


    The Glossary lists commonly used terms in alphabetical order. These terms are not defined and therefore do not have a class or attribute. Each entry in the Glossary is shown with its related class and attribute where appropriate.

    For example 'Booked Admission' is shown as relating to the class ELECTIVE ADMISSION LIST ENTRY. ELECTIVE ADMISSION LIST ENTRY has an attribute ELECTIVE ADMISSION TYPE and reference to the attribute definition will identify that 'Booked Admission' is one of the national code classifications of ELECTIVE ADMISSION TYPES.

    ClassAttribute
    Admission
    Hospital Provider Spell ACTIVITY DATE of the ACTIVITY DATE TIME TYPE Start Date
    Annual Census
    Hospital Provider Spell ACTIVITY DATE of the ACTIVITY DATE TIME TYPE Start Date
    OPERATIVE PROCEDURE  
    Legal Status MENTAL CATEGORY 
    Hospital Provider Spell ACTIVITY DATE of the ACTIVITY DATE TIME TYPE Discharge Date
    PATIENT DIAGNOSIS  
    Bed
    WARD OPERATIONAL PLAN  
    Booked Admission
    ELECTIVE ADMISSION LIST ENTRY ELECTIVE ADMISSION TYPE 
    Code of General Practitioner
    GENERAL MEDICAL PRACTITIONER GENERAL MEDICAL PRACTITIONER PPD CODE 
    GENERAL DENTAL PRACTITIONER GENERAL DENTAL PRACTITIONER CODE 
    Consultant Code
    CONSULTANT CONSULTANT CODE 
    Consultant Name
    PERSON NAME  
    Day Case Admission
    Hospital Provider Spell PATIENT CLASSIFICATION 
    Diagnostic Services
    Pathology Department  
    Radiology Department  
    Isotope Procedure Department  
    Physiological Measurement Department  
    Discharge
    Hospital Provider Spell ACTIVITY DATE of the ACTIVITY DATE TIME TYPE Discharge Date
    Drop-In Clinic
    REFERRAL REQUEST OUT-PATIENT CLINIC REFERRING INDICATOR 
    Emergency Admission
    Hospital Provider Spell ADMISSION METHOD 
    Emergency Journey
    Emergency Transport Request  
     
    General Practitioner Name
    PERSON NAME  
    GMC or GDC Number
    CARE PROFESSIONAL CARE PROFESSIONAL IDENTIFIER 
    Local Patient Identifier
    PATIENT ORGANISATION LOCAL PATIENT IDENTIFIER 
    Maternity Admission
    Hospital Provider Spell ADMISSION METHOD 
    Neonate
    PATIENT  
    Nurse Identifier
    CARE PROFESSIONAL CARE PROFESSIONAL IDENTIFIER 
    Nurse Name
    PERSON NAME  
    Ordinary Admission
    Hospital Provider Spell PATIENT CLASSIFICATION 
    Organisation Postcode
    ADDRESS POSTCODE 
    ADDRESS ASSOCIATION  
    Organisation Address
    ADDRESS ASSOCIATION ADDRESS ASSOCIATION TYPE 
    Patient Name
    PERSON NAME  
    Patients Usual Address
    ADDRESS ASSOCIATION ADDRESS ASSOCIATION TYPE 
    Planned Admission
    ELECTIVE ADMISSION LIST ENTRY ELECTIVE ADMISSION TYPE 
    Postcode of Usual Address
    ADDRESS POSTCODE 
    Regular Day Admission
    Hospital Provider Spell PATIENT CLASSIFICATION 
    Sex
    PERSON GENDER PERSON GENDER CODE 
    PERSON GENDER CURRENT  
    PERSON GENDER AT REGISTRATION  
    Special/Planned Journey
    Special Transport Request  
    Planned Transport Request  
    Telephone Number
    COMMUNICATION CONTACT INFORMATION COMMUNICATION CONTACT METHOD 
    COMMUNICATION CONTACT STRING 
    Two Man/One Man Crew
    TRANSPORT REQUIREMENT TRANSPORT NEED 
    TCI (To Come In Date)
    OFFER OF ADMISSION OFFERED FOR ADMISSION DATE 
    Urgent Journey
    Urgent Transport Request  
    Waiting List Admission
    ELECTIVE ADMISSION LIST ENTRY ELECTIVE ADMISSION TYPE 
    Ward Transfer
    Ward Stay ACTIVITY DATE of the ACTIVITY DATE TIME TYPE End Date
    WARD STAY TERMINATION REASON 

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    HEALTH AND SOCIAL CARE INFORMATION CENTRE

    Change to Supporting Information: Changed Description

    The Health and Social Care Information Centre is an NHS Special Health Authority that collects, analyses and distributes national statistics on health and social care.

    It also underpins regulation, health research, education and training. Health, social care, government and education bodies trust information from the Health and Social Care Information Centre, which is reliable, up-to-date, independent and trustworthy.

    The Health and Social Care Information Centre collection systems make it quick and easy for frontline staff to provide data with minimum impact on the delivery of care.

    NHS frontline management, clinicians, information and care professionals, policy makers, patients and the media rely on the Health and Social Care Information Centre for their information needs.

    The Health and Social Care Information Centre is also referred to as the Information Centre for health and social care or the Information Centre (IC).

    Further information on the Health and Social Care Information Centre can be found on their website.Further information on the Health and Social Care Information Centre can be found on their website.

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    INFORMATION STANDARDS BOARD FOR HEALTH AND SOCIAL CARE

    Change to Supporting Information: Changed Description

    The purpose of the Information Standards Board for Health and Social Care (ISB HaSC) is to provide assurance and approval that information standards, when implemented in the NHS and Social Care, are implementable, interoperable, fit for purpose (as described in the standard's scope and purpose) and safe.

    Specifically, the role of the Information Standards Board for Health and Social Care is to:

    • Approve standards based on the recommendations of independent Appraisal Panels, and decide on their approval status for implementation in the NHS and Social Care.
    • Communicate details of its activities to the wider NHS, Social Care, system suppliers, and other partner organisations.
    • Commission, manage, and respond to reviews of existing NHS and Social Care Information Standards and make recommendations on any action needed.
    • With other parties, identify gaps and contribute to policy and strategy around information standards and make recommendations on the action needed.

    For further information on the Information Standards Board for Health and Social Care, see the Information Standards Board for Health and Social Care website.For further information on the Information Standards Board for Health and Social Care, see the Information Standards Board for Health and Social Care website.

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    LOCATION TYPE CODES

    Change to Supporting Information: Changed Aliases, Description

    LOCATION TYPE CODES

    1. The codes enable the classification of LOCATION TYPE. This is the type of physical location where PATIENTS are seen or where services are provided or from which requests for services are sent.


      • The codes enable the classification of LOCATION TYPE. This is the type of physical location where PATIENTS are seen or where services are provided or from which requests for services are sent.

      • Each LOCATION must be classified by one, and only one, LOCATION TYPE, i.e. once a building (or department or unit within that building) has been allocated a specific LOCATION TYPE, that LOCATION TYPE should be used by all users regardless of the type of activity, specialty or client group involved. The LOCATION TYPE should only be altered if there is a complete change in use.

      • Note that the term Professional Staff Group refers to health professional staff and covers Chiropody, Clinical Psychology, Dietetics, Occupational Therapy, Physiotherapy and Speech and Language Therapy.

      • Please note that the following Central Return forms have been discontinued with effect from the 1st April 2004:
        KC56 - Patient Care in the Community: District Nursing
        KC57 - Patient Care in the Community: Community Psychiatric Nursing
        KC58 - Patient Care in the Community: Learning Disability Nursing

      • Tables 1 to 3 gives the groupings used on the following Central Returns:

        KC56: Patient Care in the Community: District Nursing
        KC57: Patient Care in the Community: Community Psychiatric Nursing
        KC58: Patient Care in the Community: Learning Disability Nursing

      • Note that the leading zero of Location Type Code should be omitted for use with the cdstab/CDS.

        Location Type Codes

        CodeDescription
        001Client's or Patient's Home
        002Health Centre
        003GP Practice premises other than Health Centre
        004Ward on NHS Hospital Site
        006Hospice
        007Other Voluntary or Private Hospital or Nursing Home
        008Group Home managed by the NHS
        009Group Home managed by Local Authority
        010Group Home managed by Voluntary or Private Agents
        011Other Residential Care Homes managed by Local Authority
        012Other Residential Care Homes managed by Voluntary or Private Agents
        013NHS Day Care Facility on NHS Hospital Site
        014NHS Day Care Facility on Other Sites
        015Day Centre managed by Local Authority
        016Day Centre managed by Voluntary or Private Agents
        017NHS Consultant Clinic Premises on a NHS Hospital site
        018NHS Consultant Clinic Premises off a NHS Hospital site
        019Health Clinic managed by the NHS
        020Health Clinic managed by Voluntary or Private Agents
        021Resource Centre on NHS Hospital Site
        022Resource Centre managed by the NHS off NHS Hospital Site
        023Resource Centre managed by Local Authority
        024Resource Centre managed by Voluntary or Private Agents
        025Professional Staff Group Department on NHS Hospital Site
        026Professional Staff Group Department managed by the NHS off NHS Hospital Site
        027Professional Staff Group Department managed by Local Authority
        028Professional Staff Group Department managed by Voluntary or Private Agents
        029Educational Establishment Premises managed by Local Authority or Grant Maintained
        030Educational Establishment Premises managed by Voluntary or Private Agents
        031Other Health or Local Authority Facility on NHS Hospital Site
        032Other Health or Local Authority Site managed by the NHS off NHS Hospital Site
        033Other Health or Local Authority Site managed by Local Authority
        034Other Health or Local Authority Site managed by Voluntary or Private Agents
        035Prison Department Establishments
        036Public Place or Street, or Police Station
        037Other locations not classified elsewhere
        038NHS Nursing Home
        039Other Residential Care Homes managed by the NHS

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    LOCATION TYPE CODES

    Change to Supporting Information: Changed Aliases, Description


    MAIN SPECIALTY AND TREATMENT FUNCTION CODES

    Change to Supporting Information: Changed Description


    TREATMENT FUNCTION, rather than the Royal College or Faculty specialty, is required on most activity returns and in the Commissioning Data Sets (CDS). It is based on specialty, but also includes approved sub-specialties and treatment specialties used by lead CARE PROFESSIONALS including hospital CONSULTANTS.

    The appropriate TREATMENT FUNCTION CODE can be used by any lead CARE PROFESSIONAL eg Intermediate Care as the TREATMENT FUNCTION CODE for a Nursing Episode.

    A full list of TREATMENT FUNCTION CODES (Table 2) follows the MAIN SPECIALTY CODES (Table 1).

    MAIN SPECIALTY CODES are aligned with the specialties recognised in the European Specialist Medical Qualifications Order 1995 and European Primary and Specialist Dental Qualifications Regulations 1998. Pseudo codes should be used in Commissioning Data Set (CDS) messages for lead CARE PROFESSIONALS other than hospital CONSULTANTS eg Nursing Episode.

    For further information, contact the NHS Data Model and Dictionary Service; see Contact Details.For further information, contact the NHS Data Model and Dictionary Service; see Contact Details.

    Table 1 Main Specialty codes

     CodeMain Specialty Title
      Surgical Specialties
     100GENERAL SURGERY
     101UROLOGY
     110TRAUMA & ORTHOPAEDICS
     120ENT
     130OPHTHALMOLOGY
     140ORAL SURGERY
     141RESTORATIVE DENTISTRY
     142PAEDIATRIC DENTISTRY
     143ORTHODONTICS
     145ORAL & MAXILLO FACIAL SURGERY
     146ENDODONTICS
     147PERIODONTICS
     148PROSTHODONTICS
     149SURGICAL DENTISTRY
     150NEUROSURGERY
     160PLASTIC SURGERY
     170CARDIOTHORACIC SURGERY
     171PAEDIATRIC SURGERY
     180ACCIDENT & EMERGENCY
     190ANAESTHETICS
     191no longer in use
     192CRITICAL CARE MEDICINE
      Medical Specialties
     300GENERAL MEDICINE
     301GASTROENTEROLOGY
     302ENDOCRINOLOGY
     303CLINICAL HAEMATOLOGY
     304CLINICAL PHYSIOLOGY
     305CLINICAL PHARMACOLOGY
     310AUDIOLOGICAL MEDICINE
     311CLINICAL GENETICS
     312CLINICAL CYTOGENETICS and MOLECULAR GENETICS
     313CLINICAL IMMUNOLOGY and ALLERGY
     314REHABILITATION
     315PALLIATIVE MEDICINE
     320CARDIOLOGY
     321PAEDIATRIC CARDIOLOGY
     330DERMATOLOGY
     340RESPIRATORY MEDICINE (also known as thoracic medicine)
     350INFECTIOUS DISEASES
     352TROPICAL MEDICINE
     360GENITOURINARY MEDICINE
     361NEPHROLOGY
     370MEDICAL ONCOLOGY
     371NUCLEAR MEDICINE
     400NEUROLOGY
     401CLINICAL NEURO-PHYSIOLOGY
     410RHEUMATOLOGY
     420PAEDIATRICS
     421PAEDIATRIC NEUROLOGY
     430GERIATRIC MEDICINE
     450DENTAL MEDICINE SPECIALTIES
     460MEDICAL OPHTHALMOLOGY
    500OBSTETRICS and GYNAECOLOGY
     501OBSTETRICS
     502GYNAECOLOGY
     510no longer in use
     520no longer in use
     560MIDWIFE EPISODE
     600GENERAL MEDICAL PRACTICE
     601GENERAL DENTAL PRACTICE
     610no longer in use
     620no longer in use
      Psychiatry
     700LEARNING DISABILITY
     710ADULT MENTAL ILLNESS
     711CHILD and ADOLESCENT PSYCHIATRY
     712FORENSIC PSYCHIATRY
     713PSYCHOTHERAPY
     715OLD AGE PSYCHIATRY
      Radiology
     800CLINICAL ONCOLOGY (previously RADIOTHERAPY)
     810RADIOLOGY
      Pathology
     820GENERAL PATHOLOGY
     821BLOOD TRANSFUSION
     822CHEMICAL PATHOLOGY
     823HAEMATOLOGY
     824HISTOPATHOLOGY
     830IMMUNOPATHOLOGY
     831MEDICAL MICROBIOLOGY
     832no longer in use
      Other
     900COMMUNITY MEDICINE
     901OCCUPATIONAL MEDICINE
     902COMMUNITY HEALTH SERVICES DENTAL
     903PUBLIC HEALTH MEDICINE
     904PUBLIC HEALTH DENTAL
     950NURSING EPISODE
     960ALLIED HEALTH PROFESSIONAL EPISODE
     990no longer in use
      
     Code 500 is not acceptable for Central Returns including HES
      Pseudo Main Specialty codes should be used in CDS messages for lead CARE PROFESSIONALS other than CONSULTANT medical and dental staff eg 560, 950 and 960.
      The Main Specialty for GPs is General Medical Practice or General Dental Practice
      Joint Consultant Clinic activity should be recorded against the MAIN SPECIALTY CODE of the CONSULTANT managing the clinic
    Table 2 Treatment Function codes
    CodeTreatment Function TitleComments
     Surgical Specialties 
    100GENERAL SURGERYIncludes sub-categories not elsewhere listed eg endocrine surgery.
    101UROLOGY 
    102TRANSPLANTATION SURGERYIncludes pre- and post-operative care for major organ transplants except heart and lung (see Cardiothoracic Transplantation). Excludes corneal grafts.
    103BREAST SURGERYIncludes treatment for cancer, suspected neoplasms, cysts and post-cancer reconstructive surgery. Excludes cosmetic surgery.
    104COLORECTAL SURGERYSurgical treatment of disorders of the lower intestine (colon, anus and rectum)
    105HEPATOBILIARY & PANCREATIC SURGERYIncludes liver surgery, but liver transplantation should be recorded in 102 Transplantation Surgery
    106UPPER GASTROINTESTINAL SURGERY 
    107VASCULAR SURGERY 
    110TRAUMA & ORTHOPAEDICS 
    120ENTEar, nose and throat
    130OPHTHALMOLOGY 
    140ORAL SURGERY 
    141RESTORATIVE DENTISTRYEndodontics, Periodontics and Prosthodontics are all part of Restorative Dentistry
    142PAEDIATRIC DENTISTRY 
    143ORTHODONTICS 
    144MAXILLO-FACIAL SURGERYMouth, jaw and face related surgery.
    150NEUROSURGERY 
    160PLASTIC SURGERY 
    161BURNS CARETo be used by recognised specialist units and associated outreach services only
    170CARDIOTHORACIC SURGERYShould only be used where there are no separate services for Cardiac Surgery and Thoracic Surgery
    171PAEDIATRIC SURGERYThis is paediatric general surgery
    172CARDIAC SURGERY 
    173THORACIC SURGERY 
    174CARDIOTHORACIC TRANSPLANTATIONTo be used by recognised specialist units and associated outreach services only. Includes pre- and post-operative services.
    180ACCIDENT & EMERGENCY 
    190ANAESTHETICSThis can be used in out-patients only. Pain Management should be recorded in 191.
    191PAIN MANAGEMENTComplex pain disorders requiring diagnosis and treatment by a specialist multi-professional team
    192CRITICAL CARE MEDICINEalso known as Intensive Care Medicine
     Other Children's Specialties 
    211PAEDIATRIC UROLOGYDedicated services to children with appropriate facilities and support staff
    212PAEDIATRIC TRANSPLANTATION SURGERYDedicated services to children with appropriate facilities and support staff
    213PAEDIATRIC GASTROINTESTINAL SURGERYDedicated services to children with appropriate facilities and support staff. Includes Upper Gastrointestinal Surgery and Colorectal Surgery.
    214PAEDIATRIC TRAUMA AND ORTHOPAEDICSDedicated services to children with appropriate facilities and support staff.
    215PAEDIATRIC EAR NOSE AND THROATDedicated services to children with appropriate facilities and support staff
    216PAEDIATRIC OPHTHALMOLOGYDedicated services to children with appropriate facilities and support staff
    217PAEDIATRIC MAXILLO-FACIAL SURGERYDedicated services to children with appropriate facilities and support staff
    218PAEDIATRIC NEUROSURGERYDedicated services to children with appropriate facilities and support staff
    219PAEDIATRIC PLASTIC SURGERYDedicated services to children with appropriate facilities and support staff
    220PAEDIATRIC BURNS CAREDedicated services to children with appropriate facilities and support staff
    221PAEDIATRIC CARDIAC SURGERYDedicated services to children with appropriate facilities and support staff
    222PAEDIATRIC THORACIC SURGERYDedicated services to children with appropriate facilities and support staff
    241PAEDIATRIC PAIN MANAGEMENTDedicated services to children with appropriate facilities and support staff
    242PAEDIATRIC INTENSIVE CAREOnly to be used by designated Paediatric Intensive Care Units
    251PAEDIATRIC GASTROENTEROLOGYDedicated services to children with appropriate facilities and support staff
    252PAEDIATRIC ENDOCRINOLOGYDedicated services to children with appropriate facilities and support staff
    253PAEDIATRIC CLINICAL HAEMATOLOGYDedicated services to children with appropriate facilities and support staff
    254PAEDIATRIC AUDIOLOGICAL MEDICINEDedicated services to children with appropriate facilities and support staff
    255PAEDIATRIC CLINICAL IMMUNOLOGY AND ALLERGYDedicated services to children with appropriate facilities and support staff
    256PAEDIATRIC INFECTIOUS DISEASESDedicated services to children with appropriate facilities and support staff
    257PAEDIATRIC DERMATOLOGYDedicated services to children with appropriate facilities and support staff
    258PAEDIATRIC RESPIRATORY MEDICINEDedicated services to children with appropriate facilities and support staff
    259PAEDIATRIC NEPHROLOGYDedicated services to children with appropriate facilities and support staff
    260PAEDIATRIC MEDICAL ONCOLOGYDedicated services to children with appropriate facilities and support staff
    261PAEDIATRIC METABOLIC DISEASEDedicated services to children with appropriate facilities and support staff
    262PAEDIATRIC RHEUMATOLOGYDedicated services to children with appropriate facilities and support staff
    280PAEDIATRIC INTERVENTIONAL RADIOLOGYDedicated services to children with appropriate facilities and support staff
    290COMMUNITY PAEDIATRICSIncludes routine health surveillance, health promotion, behavioural paediatrics and looked-after children. Excludes Paediatric Neuro-Disability.
    291PAEDIATRIC NEURO-DISABILITYDedicated services for children with Cerebral Palsy and non-progressive handicapping neurological conditions, with or without learning disability.
     Medical Specialties 
    300GENERAL MEDICINEIncludes sub-categories not elsewhere listed eg metabolic medicine.
    301GASTROENTEROLOGY 
    302ENDOCRINOLOGY 
    303CLINICAL HAEMATOLOGYExcludes ANTICOAGULANT SERVICE see 324
    304CLINICAL PHYSIOLOGYPhysiological measurement including ECG (e.g. exercise testing, stress testing), gastrointestinal physiology, cardiac physiology, vascular technology, urodynamics, and ophthalmic and vision science. Does not include Clinical Neurophysiology, Audiology or Respiratory Physiology.
    305CLINICAL PHARMACOLOGY 
    306HEPATOLOGYAlso known as liver medicine
    307DIABETIC MEDICINE 
    308BLOOD AND MARROW TRANSPLANTATIONPreviously in Clinical Haematology. Includes haemopoietic stem cell transplantation.
    309HAEMOPHILIAPreviously in Clinical Haematology
    310AUDIOLOGICAL MEDICINEThe medical specialty concerned with the investigation, diagnosis and management of patients with disorders of balance, hearing, tinnitus and auditory communication. Excludes audiology and hearing tests.
    311CLINICAL GENETICSTo be used by recognised specialist units and associated outreach services only.
    312not a Treatment Function 
    313CLINICAL IMMUNOLOGY and ALLERGYShould only be used where there are no separate services for Clinical Immunology and Allergy
    314REHABILITATION 
    315PALLIATIVE MEDICINE 
    316CLINICAL IMMUNOLOGY 
    317ALLERGYThe diagnosis and management of allergic disease (abnormal immune responses to external substances) and the exclusion of allergic causes in other conditions.
    318INTERMEDIATE CAREIntermediate care encompasses a range of multi-disciplinary services designed to safeguard independence by maximising rehabilitation and recovery after illness or injury
    319RESPITE CARE 
    320CARDIOLOGY 
    321PAEDIATRIC CARDIOLOGY 
    322CLINICAL MICROBIOLOGY 
    323SPINAL INJURIESTo be used by recognised specialist units and associated outreach services only.
    324ANTICOAGULANT SERVICEThe monitoring and control of anticoagulant therapy including the initiation and/or supervision of oral anticoagulant therapy and the determination of anticoagulant dosage. This can be used in out-patients only.
    330DERMATOLOGY 
    340RESPIRATORY MEDICINEalso known as Thoracic Medicine
    341RESPIRATORY PHYSIOLOGYPhysiological measurement of the function of the respiratory system. Includes Sleep Studies (the diagnosis and treatment of sleep disordered breathing, including upper airway resistance syndrome and sleep apnoea).
    350INFECTIOUS DISEASES 
    352TROPICAL MEDICINE 
    360GENITOURINARY MEDICINE 
    361NEPHROLOGY 
    370MEDICAL ONCOLOGYThe diagnosis and treatment, typically with chemotherapy, of patients with cancer.
    371NUCLEAR MEDICINE 
    400NEUROLOGY 
    401CLINICAL NEUROPHYSIOLOGYThe study of the central and peripheral nervous systems through the recording of bioelectrical activity. Includes EEG.
    410RHEUMATOLOGY 
    420PAEDIATRICS 
    421PAEDIATRIC NEUROLOGY 
    422NEONATOLOGYSpecial Care, High Dependency and Intensive Care.
    424WELL BABIESCare given by the mother/substitute with medical and neonatal nursing advice if needed
    430GERIATRIC MEDICINE 
    450DENTAL MEDICINE SPECIALTIESIncludes oral medicine.
    460MEDICAL OPHTHALMOLOGY 
    500not a Treatment Function 
    501OBSTETRICSThe management of pregnancy and childbirth including miscarriages but excluding planned terminations.
    502GYNAECOLOGYDisorders of the female reproductive system. Includes planned terminations.
    503GYNAECOLOGICAL ONCOLOGY 
    510no longer in useRecord as Obstetrics, antenatal clinic can be used as a local sub-specialty if required
    520no longer in useRecord as Obstetrics, postnatal clinic can be used as a local sub-specialty if required
    560MIDWIFE EPISODE 
    600not a Treatment Function 
    610no longer in useRecord as Obstetrics
    620no longer in useUse the appropriate function under which the patient is treated
     Therapies 
    650PHYSIOTHERAPYThe treatment of human function and movement to help people to achieve their full physical potential. The use of physical approaches to promote, maintain and restore wellbeing.
    651OCCUPATIONAL THERAPYThe use of specific activities to limit the effects of disability and promote independence in all aspects of daily life.
    652SPEECH AND LANGUAGE THERAPYThe assessment, treatment and help to prevent speech, language and swallowing difficulties.
    653PODIATRYAlso known as Chiropody. The diagnosis and treatment of disorders, diseases and deformities of the feet.
    654DIETETICSThe application of the science of nutrition to devise eating plans for patients to treat medical conditions. The promotion of good health by helping to facilitate a positive change in food choices amongst individuals, groups and communities.
    655ORTHOPTICSThe diagnosis and treatment of visual problems involving eye movement and alignment.
    656CLINICAL PSYCHOLOGYThe diagnosis and treatment of emotional and behavioural disorders.
     Psychiatry 
    700LEARNING DISABILITY 
    710ADULT MENTAL ILLNESS 
    711CHILD and ADOLESCENT PSYCHIATRY 
    712FORENSIC PSYCHIATRY 
    713PSYCHOTHERAPY 
    715OLD AGE PSYCHIATRY 
    720EATING DISORDERSA specialist psychiatric service for the diagnosis and treatment of eating disorders including anorexia, bulimia and compulsive overeating.
    721ADDICTION SERVICESThe psychiatric prevention and treatment of substance misuse including drugs and alcohol
    722LIAISON PSYCHIATRYThe provision of psychiatric treatment to patients attending general hospitals including out-patient clinics, accident and emergency departments and admission to wards. Deals with the interface between physical and psychological health.
    723PSYCHIATRIC INTENSIVE CAREThe provision of psychiatric services to vulnerable individuals who are admitted to Psychiatric Intensive Care Units from open acute wards and forensic settings.
    724PERINATAL PSYCHIATRYA specialist psychiatric service for the diagnosis and treatment of post-natal psychiatric problems.
     Radiology 
    800CLINICAL ONCOLOGY (previously RADIOTHERAPY)The diagnosis and treatment, typically with radiotherapy, of patients with cancer.
    810not a Treatment Function 
    811INTERVENTIONAL RADIOLOGYNot to be used for diagnostic imaging.
    812DIAGNOSTIC IMAGINGThe production and interpretation of high quality images of the body to diagnose injuries and disease, e.g. x-rays, ultrasound, MRI, PET or CT scans.
     Pathology 
    820not a Treatment Function 
    821not a Treatment Function 
    822CHEMICAL PATHOLOGYTo be used for clinical management only.
    823not a Treatment FunctionSee Clinical Haematology
    824not a Treatment Function 
    830not a Treatment Functionsee Clinical Immunology
    831not a Treatment FunctionSee Clinical Microbiology
    832no longer in use 
    840AUDIOLOGYPhysiological measurement and diagnosis of hearing disorders, and the rehabilitation of patients with hearing loss.
     Other 
    900not a Treatment Function 
    901not a Treatment Function 
    950not a Treatment FunctionUse the appropriate function under which the patient is treated
    960not a Treatment FunctionUse the appropriate function under which the patient is treated
    990no longer in use 
      Treatment Function Codes should be used for all aggregate central returns unless otherwise stated eg Workforce returns use Main Specialty Codes
      GP, Nurse and Allied Health Professional/Biomedical Scientist/Clinical Scientist activity should be recorded against the Treatment Function under which the patient is treated
      Joint Consultant Clinic activity should be recorded against the Treatment Function which best describes the specialised service

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    MENTAL HEALTH ACT TABLE

    Change to Supporting Information: Changed Description

    MENTAL HEALTH ACT


    The following table is effective from 3rd November 2008 onwards after the relevant section of the Mental Health Act 2007 comes into force, and sets out the relationship between Parts and Sections of the Mental Health Act 1983 (amended by the Crime (Sentences) Act 1997 and the Mental Health Act 2007), and specifies how the codes in Category of Patient, LEGAL STATUS CLASSIFICATION CODE, Status Of Patient Included in the Psychiatric Census and MENTAL HEALTH ACT 2007 MENTAL CATEGORY interrelate.

    The underlying LEGAL STATUS CLASSIFICATION CODE of a Mental Health Care Spell will be carried through a period of Supervised Community Treatment although the LEGAL STATUS CLASSIFICATION will be suspended during that period.

    PARTSECTIONSLEGAL STATUS CLASSIFICATION CODE Status of Patient In Psychiatric CensusMENTAL CATEGORY 
    Part II2 - 3402 - 061 or 3A, B, 9
    Part III35 - 5507 - 18, 341 or 3A, B, 9
    Part IV56 - 64Not listed, not relevant
    Part V65 - 79Not listed, not relevant
    Part VI80 - 92Not listed, not relevant
    Part VII93 - 113Not listed, not relevant
    Part VIII114 - 125Not listed, not relevant
    Part IX126 - 130Not listed, not relevant
    Part X131 - 14919 - 201 or 3A, B, 9
    Previous legislation
    (other acts)
    30 - 321 or 3A, B, 9
    Not detained01, 33, 35, 3628

    The following table is effective prior to 3rd November 2008 when the relevant section of the Mental Health Act 2007 comes into force, and sets out the relationship between Parts and Sections of the Mental Health Act 1983 (amended by the Crime (Sentences) Act 1997), and specifies how the codes in Category of Patient, LEGAL STATUS CLASSIFICATION CODE, Status Of Patient Included in the Psychiatric Census and MENTAL CATEGORY interrelate.

    PARTSECTIONSLEGAL STATUS CLASSIFICATION CODE Status of Patient In Psychiatric CensusMENTAL CATEGORY 
    Part II2 - 3402 - 061 or 31 - 5, 9
    Part III35 - 5507 - 18, 341 or 31 - 5, 9
    Part IV56 - 64Not listed, not relevant
    Part V65 - 79Not listed, not relevant
    Part VI80 - 92Not listed, not relevant
    Part VII93 - 113Not listed, not relevant
    Part VIII114 - 125Not listed, not relevant
    Part IX126 - 130Not listed, not relevant
    Part X131 - 14919 - 201 or 31 - 5, 9
    Previous legislation
    (other acts)
    30 - 321 or 31 - 5, 9
    Not detained/
    Supervised Discharge
    under Section 25
    01, 33, 35, 3628

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    MESSAGES MENU (RETIRED)  renamed from MESSAGES MENU

    Change to Supporting Information: Changed Name, status to Retired

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    METADATA FILES

    Change to Supporting Information: Changed Description


    Files Available
    • The following pages give the record layouts and data content for Country Pseudo Postcode metadata files.

    Country Pseudo Postcode File Data Content
    • This file contains about 130 records. The usual country of residence for short term overseas visitors is derived from the country pseudo postcode. The codes are  available in electronic format on the NHS Postcode Directory ("Gridlink version").

      For the Organisation Data Service contact details, see Contact Details.

    • This file contains about 130 records. The usual country of residence for short term overseas visitors is derived from the country pseudo postcode. The codes are  available in electronic format on the NHS Postcode Directory ("Gridlink version").

      For the Organisation Data Service contact details, see Contact Details.

    • The expanded area code field contains the country of birth code in characters 1-4 (a repeat of the characters 3-6 in the pseudo postcode). The remainder of the expanded area code is blank except for codes 993C (UK nos) and 993V (no fixed abode) where characters 5-7 are 9space9.

      COUNTRY PSEUDO FILE RECORD LAYOUT

      Start PosSizeData TypeField Description
      111Xselection indicators
      126X6 digit postcode (POSTSIX)
      181A7th digit
      196Xfiller
      2550Xname of country
      755Xfiller
      8019Xarea details
      99154Xfiller

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    META MODEL MENU  renamed from META MODEL

    Change to Supporting Information: Changed Name

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    NATIONAL DIRECT ACCESS AUDIOLOGY PATIENT TRACKING LIST DATA SET OVERVIEW

    Change to Supporting Information: Changed Description

    The National Direct Access Audiology Patient Tracking List Data Set collects performance information on a weekly basis, on the Referral To Treatment pathways of PATIENTS who are receiving NHS funded audiology treatment in England, who are not already included in the Referral to Treatment Summary Patient Tracking List Data Set.The National Direct Access Audiology Patient Tracking List Data Set collects performance information on a weekly basis, on the Referral To Treatment pathways of PATIENTS who are receiving NHS funded audiology treatment in England, who are not already included in the Referral to Treatment Summary Patient Tracking List Data Set. This includes:

    • both analogue and digital hearing aid fittings
    • services provided directly by NHS Healthcare Providers and also NHS funded PATIENTS treated via the Independent Sector and third sector providers (collected directly or via Primary Care Trusts)
    • both new and existing PATIENTS
    • any other PATIENTS attending Audiology services directly

    For the purposes of the National Direct Access Audiology Patient Tracking List Data Set, "Direct Access" means PATIENTS who are not referred via Ear, Nose and Throat (ENT) or other hospital CONSULTANT.For the purposes of the National Direct Access Audiology Patient Tracking List Data Set, "Direct Access" means PATIENTS who are not referred via Ear, Nose and Throat (ENT) or other hospital CONSULTANT. Any pathways that are subject to the 18 weeks waiting time target for Referral to Treatment are out of scope. For this reason PATIENTS on Ear, Nose and Throat pathways (or pathways from other specialties) are excluded from this central return data set - information on these PATIENTS is available via the Referral To Treatment Summary Patient Tracking List Data Set data collection. For this reason PATIENTS on Ear, Nose and Throat pathways (or pathways from other specialties) are excluded from this central return data set - information on these PATIENTS is available via the Referral to Treatment Summary Patient Tracking List Data Set data collection.

    The National Direct Access Audiology Patient Tracking List Data Set is in two parts, as follows:The National Direct Access Audiology Patient Tracking List Data Set is in two parts, as follows:

    Parts 1A and 1B: Untreated Patients

    Part 1A should be completed for PATIENTS who have not had an ACTIVITY which ends their REFERRAL TO TREATMENT PERIOD (such as first definitive treatment, or a decision not to treat)

    AND

    who do not have a future APPOINTMENT for an ACTIVITY with an anticipated REFERRAL TO TREATMENT PERIOD STATUS of 30 before the REFERRAL TO TREATMENT PERIOD EXCEEDS 18 WEEKS DATE.

    Part 1B should be completed for PATIENTS who have not had an ACTIVITY which ends their REFERRAL TO TREATMENT PERIOD (such as first definitive treatment, or a decision not to treat)

    AND

    whose REFERRAL TO TREATMENT PERIOD EXCEEDS 18 WEEKS DATE has passed.

    Part 2 should be completed for PATIENTS who have a REFERRAL TO TREATMENT PERIOD END DATE within the last 7 days

    Full guidance on the completion and submission of the National Direct Access Audiology Waiting Times Data Set is available from the Department of Health website.Full guidance on the completion and submission of the National Direct Access Audiology Waiting Times Data Set is available from the Department of Health website.

    The Department of Health document 'Improving Access to Audiology Service in England' can be found at the "Direct Access Audiology Waiting Times and PTL collections section" of the Department of Health website.

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    NAVIGATION

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    Navigating the NHS Data Model and Dictionary


    The NHS Data Model and Dictionary has been developed as a web based publication, for presentation compatible with browsers upwards from Internet Explorer version 4.0 and Netscape Navigator version 4.0. The standard navigation buttons of both these browsers are active and work as normal.

    Text which is displayed in blue indicates a clickable and active link.

    Please note that for easy access to all of the contents of the NHS Data Model and Dictionary, we have created a new 'All Items Index', which lists alphabetically the whole contents of the dictionary.

    In addition to the standard browser navigation buttons, certain screens will display with their own tabs. If these are used they will navigate you within the publication rather than the overall browser. For example, click on the relationships tab within a class window and this will display the relationship list for that class (if one is present). Click on the 'description' tab to navigate back to the class definition.

    Recommended Screen Display Settings

    If you use a 14 or 15 inch monitor the recommended display setting to view this web publication is 800 x 600. If you use a 17 monitor, or above, the recommended screen setting is 1024 x 768.

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    NHS DATA MODEL AND DICTIONARY ELEMENTS  renamed from THE NHS DATA MODEL & DICTIONARY ELEMENTS

    Change to Supporting Information: Changed Name, Aliases, Description

    The NHS Data Dictionary and the NHS Data Manual were originally published separately. The elements of both these publications have been consolidated into one browsable integrated publication called the NHS Data Model and Dictionary.

    NHS Data Standards

    The NHS Data Model and Dictionary gives common definitions and guidance to support the sharing, exchange and comparison of information across the NHS. The common definitions, known as data standards, are used in commissioning and make up the base currency of Commissioning Data Sets. On the monitoring side, they support comparative data analysis, preparation of performance tables, and data returned to the Department of Health. NHS data standards also support clinical messages, such as those used for pathology and radiology. NHS data standards are presented as a logical data model, ensuring that the standards are consistent and integrated across all NHS business areas.

    NHS data standards should not just be seen as supporting the collection of data on a consistent basis throughout the NHS. They also have an important role in supporting the flow and quality of information used in different parts of the NHS so that health care professionals are presented with the relevant information where and when it is required. An example of this is the linking of all records about a patient collected in different parts of the NHS, to be available to a health care professional wherever the patient attends to be seen for treatment, thus facilitating the Electronic Patient Record. Changes to NHS data standards are still being published as Data Set Change Notices at the time of publication. The Information Standards Board for Health and Social Care may eventually use a different form of change notification, but the principles of regulated changes will still apply.

    See the Information Standards Board for Health and Social Care.

    The NHS Data Model and Dictionary Elements
    Class Definitions All the classes that appear within the NHS data standards logical data model. Each class contains its nationally agreed definition, all of its attributes, all relationships it has with other classes.
    Class Definitions Introduction 
    Attribute Definitions All the attributes of the classes that appear within the NHS data standards logical data model. Each attribute contains its nationally agreed definition which may also include its agreed National Codes or classifications and a clickable 'data' tab if a data element also exists for it.
    Attribute Definitions Introduction 
    Data Elements Data elements which may be supported by an attribute definition i.e. the data element has the same name as an attribute, be a derived item which is derivable from attributes or only exists as a data element.

    Where a data element is supported by an attribute definition, such as the national codes to be used in that data element exist in an attribute, then there will be a link to that attribute through a 'definition' tab.

    Data elements are used in the completion of Data Sets, Commissioning Data Sets, Hospital Episode Statistics and Central Returns. The data element information comprises format and field length, Hospital Episode Statistics name if applicable, National Codes or classifications and useful notes clarifying the selected data element.

    Data Elements Introduction
    NHS Business Definitions These contain the business rules for recording NHS activity and will be of particular relevance to NHS Information Professionals.
    NHS Business Definitions Introduction 
    CDS and HES Hospital Episode Statistics is now extracted automatically from the Secondary Uses Service.
    Data Sets The primary purpose of national data sets is to enable the same health information to be generated across the country independent of the organisation or system that captures it.
    Data Sets Contextual Overview 
    Central Return Forms Guidance on completion of Central Returns for hospital activity, complaints management process, cervical and breast screening activity, patient transport and some community activity.
    Central Return Forms Introduction 
    Diagrams The new generic dictionary is based on a small set of rationalised diagrams.
    Diagrams Introduction 
    Supporting Information Supporting information such as clinical coding etc, is provided to help users understand the Commissioning Data Set and Central Returns.
    Supporting Information Introduction 
    Data Sets The primary purpose of national data sets is to enable the same health information to be generated across the country independent of the organisation or system that captures it.
    Data Sets Contextual Overview 
    Central Return Forms Guidance on completion of Central Returns for hospital activity, complaints management process, cervical and breast screening activity, patient transport and some community activity.
    Central Return Forms Introduction 
    Diagrams The new generic dictionary is based on a small set of rationalised diagrams.
    Diagrams Introduction 
    Supporting Information Supporting information such as clinical coding etc, is provided to help users understand the Commissioning Data Set and Central Returns.
    Supporting Information Introduction 

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    NHS DATA MODEL AND DICTIONARY ELEMENTS  renamed from THE NHS DATA MODEL & DICTIONARY ELEMENTS

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    NHS TRUST MERGERS

    Change to Supporting Information: Changed Description

    GUIDANCE ON NHS TRUST MERGERS AND THE CONCLUSION OF HOSPITAL PROVIDER SPELLS


    Introduction
    1. This guidance explains the circumstances under which Hospital Provider Spells should close and reopen as a result of a merger or demerger, in terms of NHS data standards. It specifies which codes should be used for those Hospital Provider Spells which must be closed and reopened,

      Note that the NHS-wide Clearing Service (NWCS) has also issued Guidance Note NWCS/GN-003 which explains the use of NWCS Exchange Protocols when NHS Trusts merge.

    When Hospital Provider Spells Should be Closed and Reopened
    1. A Hospital Provider Spell is provided by one ORGANISATION acting as a Health Care Provider. This means that the spell is linked to the ORGANISATION CODE of the provider. If the ORGANISATION CODE changes, the spell must end and another begin with the new ORGANISATION CODE. If the spell does end, the Consultant Episode (Hospital Provider) within the spell must also end.

      The following scenarios explain what this means in terms of NHS Trust mergers or demergers. Note that these assume that nothing changes other than the fact that the NHS Trusts merge or demerge, e.g. the CONSULTANT stays the same, etc.

    Mergers
    1. Trust A merges with Trust B to produce Trust C, which has a new ORGANISATION CODE. The ORGANISATION CODE will change for both Trust A and B. Therefore Hospital Provider Spells in both Trust A and B should close, and new spells should be opened using the new ORGANISATION CODE for Trust C.
    2. Trust A merges with Trust B to produce an ORGANISATION which uses Trust A's ORGANISATION CODE. For those Hospital Provider Spells in Trust A, the ORGANISATION CODE will not change. Therefore Trust A's Hospital Provider Spells should not be closed just as a result of the merger. However, for Trust B the ORGANISATION CODE will change. Therefore Hospital Provider Spells in Trust B should close, and new spells should be opened using the new ORGANISATION CODE for Trust A.
    Demergers
    1. Trust A splits into Trust B and Trust C, both of which have a new ORGANISATION CODE. The ORGANISATION CODE will change for both Trust B and C. Therefore all Hospital Provider Spells in Trust A should close, and new spells should be opened in Trust B and C using the new ORGANISATION CODES for each.
    2. Trust A splits into Trust B and C. Trust B retains Trust A's ORGANISATION CODE and Trust C is issued with a new one. The ORGANISATION CODE for Hospital Provider Spells in Trust A which are taken over by Trust B will not change. Therefore they should not be closed just as a result of the merger. However, Trust A's Hospital Provider Spells which are taken over by Trust C should close, and new spells should be opened using the new ORGANISATION CODE for Trust C.
    The Codes Used when Hospital Provider Spells are Closed and Reopened
    1. If Hospital Provider Spells are to be closed and reopened only as a result of NHS Trust mergers or demergers, for most cases the codes below should be used.
    The CLOSED Hospital Provider Spell

    DISCHARGE DESTINATIONS

    This depends on the type of WARD the PATIENT is in, but will be either:

    51     NHS Hospital Provider - WARD for general PATIENTS or the younger physically disabled

    52     NHS Hospital Provider - WARD for maternity PATIENTS or neonates

    53     NHS Hospital Provider - WARD for PATIENTS who are mentally ill or have learning disabilities

    DISCHARGE METHOD

    1     PATIENT discharged on clinical advice or with clinical consent

    The REOPENED Hospital Provider Spell

    ADMISSION METHOD

    81     Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency

    Note that this ADMISSION METHOD is classed under "Other Admission". It is not elective and the PATIENT does therefore not have an entry on an Elective Admission List.
    SOURCE OF ADMISSION

    Again, this depends on the type of WARD the PATIENT is in, but will be either:

    51     NHS Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Accident And Emergency Department

    52     NHS Hospital Provider - WARD for maternity PATIENTS or neonates

    53     NHS Hospital Provider - WARD for PATIENTS who are mentally ill or have learning disabilities

    REFERRER CODE

    This will be the referrer to the Hospital Provider Spell within which the PATIENT was receiving care before the merger, i.e. the "original" Hospital Provider Spell.

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    OPCS CLASSIFICATION OF INTERVENTIONS AND PROCEDURES

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    Introduction

    The OPCS Classification of Interventions and Procedures (OPCS-4) is a Fundamental Information Standard.The OPCS Classification of Interventions and Procedures (OPCS-4) is a Fundamental Information Standard.  The classification is used by Health Care Providers and Strategic Health Authorities.

     OPCS-4 is used to support operational and strategic planning, resource utilisation, performance management, reimbursement, research and epidemiology. OPCS-4 is used to support operational and strategic planning, resource utilisation, performance management, reimbursement, research and epidemiology.  It is used by NHS suppliers to build/update software to support NHS business functions and interoperability.

    The OPCS-4 is subject to annual review and potential update to ensure that modern clinical practice is represented appropriately.The OPCS-4 is subject to annual review and potential update to ensure that modern clinical practice is represented appropriately.  This will be continued until further notice as shown below:

    YearVersion of OPCS-4*
    Up to 31 March 2006OPCS-4.2
    01-Apr-2006 – 31-Mar-2007OPCS-4.3
    01-Apr-2007 – 31-Mar-2008
    01-Apr-2008 – 31-Mar-2009
    OPCS-4.4
    01-Apr-2009 – until further notificationOPCS-4.5
    01-Apr-2006 to 31-Mar-2007OPCS-4.3
    01-Apr-2007 to 31-Mar-2008
    01-Apr-2008 to 31-Mar-2009
    OPCS-4.4
    01-Apr-2009 until further notificationOPCS-4.5


    *Tables of Coding Equivalences are issued for mapping back to previous versions found at https://www.uktcregistration.nss.cfh.nhs.uk/trud/

    The NHS Data Model and Dictionary contains a number of data collections that require OPCS-4 codes, such as Central Returns and Commissioning Data Sets.  All data collections should use the latest version of the  OPCS-4 classification as specified in the table above.The NHS Data Model and Dictionary contains a number of data collections that require OPCS-4 codes, such as Central Returns and Commissioning Data Sets.  All data collections should use the latest version of the  OPCS-4 classification as specified in the table above.

    Background

    The classification of Surgical Operations and Procedures was originally issued by the Office of Population Censuses and Surveys (OPCS). The 4th revision was first implemented in hospital information systems in 1987. This was subject to a significant number of amendments and a consolidated version was reproduced in 1990.

    The OPCS Classification of Surgical Operations and Procedures (OPCS-4.2) was substantially enhanced to ensure that modern clinical practice was represented appropriately within the classification and a new version was implemented in 2006 titled OPCS Classification of Interventions and Procedures (OPCS-4.3) with a commitment to undertake annual review and potential update. The classification comprises a list of alphanumeric codes with mainly anatomically based chapters, most of which relate to the whole or part of a body system. Each chapter is designated alphabetically e.g. Chapter A covers the nervous system and Chapter K is assigned to the heart. The alphabetic character for each chapter forms the prefix of the 3 and 4 digit codes within it. The strict link between chapters and body systems with specific procedures being listed for individual organs was breached in OPCS-4.3 because of limited capacity.

    There are instances where an existing category needs extension because all the available codes have been allocated. In such cases an extended category is created within the Tabular List chapter. These categories are referred to as principal category or extended category and identified by an accompanying note to ease navigation.

    Chapters that have reached capacity are extended using alphanumeric categories which are assigned using the free alpha O. This has occurred within three chapters (Chapters L, W and Z). Codes created in this way still form part of an existing chapter even though they have a different alpha prefix to the rest of that chapter. Such new codes will, therefore, logically sit at the end of the body system chapter and are readily identified within the alphabetical index. There is an additional chapter (Chapter X) for operations on multiple systems using miscellaneous procedures.

    The classification is published in two volumes. The Tabular List and Alphabetical Index are available from The Stationary office at www.tsoshop.co.uk

    OPCS-4 Requests Portal

    The OPCS-4 Requests Portal allows stakeholders to submit change requests to the NHS Classification Service all year round.The OPCS-4 Requests Portal allows stakeholders to submit change requests to the NHS Classification Service all year round. A cut-off date is necessary to support the annual review of requests and business case to proceed with an update to the classification.

    More information about this classification and access to the OPCS-4 Requests Portal can be found at:
    http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/44submissions

    High Cost Drugs and Chemotherapy Regimens

    The listings of High Cost Drugs and Chemotherapy Regimens which are mapped to OPCS-4 codes are provided as look-up tables downloadable either from:

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    ORGANISATIONS MENU

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    PUBLICATION DETAIL

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    PUBLICATION FEEDBACK

    Change to Supporting Information: Changed Aliases


    PUBLICATION INFORMATION CONTACT DETAILS

    Change to Supporting Information: Changed Description

    CONTACT DETAILS


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    PUBLICATION VERSION

    Change to Supporting Information: Changed Description

    PUBLICATION VERSION


    The version number is held at the individual element level, which means that a Change Log can be held for each attribute, data element, central return form, CDS message etc.The version number is held at the individual element level, which means that a Change Log can be held for each Attribute, Data Element, Central Return Form, Commissioning Data Set message etc.

    Classes have been treated slightly differently as they have been broken down into three separate sections, one each for its description, attribute and relationship list, and each will have its own Change Log and version number.

    Version Number Structure

    Each version number is composed of 3 numbers, e.g. Version 3.5.1.

    The first number reflects the version number of the publication as a whole (currently version 3), and will only change when there is a major new release of whole Data Dictionary.The first number reflects the version number of the publication as a whole (currently version 3), and will only change when there is a major new release of whole NHS Data Model and Dictionary.

    The second number changes whenever the individual element has been affected by a nationally approved change, currently published in DSCNs. In this example the element has been changed by three DSCNs, each of which will be listed in the Change Log.

    The third number is incremented whenever a minor patch change is made to the element, for instance to make a simple typographical change to the text, which would not normally need to go through the usual standards approval mechanism. These minor changes will not appear in the Change Log.

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    QUARTERLY MONITORING CANCELLED OPERATIONS DATA SET (QMCO) OVERVIEW

    Change to Supporting Information: Changed Description

    Contextual Overview

    The data set provides essential information for monitoring key targets and standards in the Cancelled Operations Guarantee.TheQuarterly Monitoring Cancelled Operations Data Set (QMCO) provides essential information for monitoring key targets and standards in the Cancelled Operations Guarantee.

    The Department of Health requires information on services provided by Health Care Providers of Theatre services and this information is collected by the Department of Health via the Quarterly Monitoring Cancelled Operations Data Set (QMCO).The Department of Health requires information on services provided by Health Care Providers of Theatre services and this information is collected by the Department of Health via the Quarterly Monitoring Cancelled Operations Data Set (QMCO).

    Reporting

    The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a quarterly return with the first quarter starting on 1 April and the last quarter ending on 31 March.The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a quarterly return with the first quarter starting on 1 April and the last quarter ending on 31 March.

    Any ACTIVITY where the outcome is not yet known should be reported in the following quarter. That is any ACTIVITY where it not known the outcome of subsequent OFFERS OF ADMISSION within the 28 day limit.

    Data sets must be submitted by 15 working days after the end of the quarter.

    The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a provider based return.The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a provider based return.

    The data is entered via Unify2, an online data collection system. NHS providers enter their data onto Unify2 either directly or by uploading a spreadsheet.

    Quarterly Monitoring Cancelled Operations Data Set (QMCO)Quarterly Monitoring Cancelled Operations Data Set (QMCO)

    The Quarterly Monitoring Cancelled Operations Data Set (QMCO) requires the following for each ORGANISATION CODE (CODE OF PROVIDER), REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE:The Quarterly Monitoring Cancelled Operations Data Set (QMCO) requires the following for each ORGANISATION CODE (CODE OF PROVIDER), REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE:

    Cancellation at 'the last minute' or 'short notice' means on or after the day that the PATIENT was due to arrive in hospital.

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    SUMMARISED ACTIVITY FLOWS DATA SET OVERVIEW

    Change to Supporting Information: Changed Description


    Contextual Overview

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    SUMMARISED STOCKS DATA SET OVERVIEW

    Change to Supporting Information: Changed Description

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    SUPPORTING INFORMATION INTRODUCTION

    Change to Supporting Information: Changed Description

    SUPPORTING INFORMATION INTRODUCTION


    Supporting information such as Clinical Coding, Meta Data etc, is provided to help users understand the Commissioning Data Sets (CDS), Data Sets (National Cancer Data Set, etc) and Central Return forms.

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    SUPPORTING INFORMATION MENU

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    TOP INDEX LEFT PANE

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    WARD ATTENDER

    Change to Supporting Information: Changed Description

    Ward Attender provides further guidance for attendance of a PATIENT in a WARD.Ward Attendance provides further guidance for attendance of a PATIENT in a WARD.

    Ward attenders are PATIENTS who come into a WARD to receive nursing care, but have not been admitted to hospital and do not stay in the WARD.Ward Attenders are PATIENTS who come into a WARD to receive nursing care, but have not been admitted to hospital and do not stay in the WARD. They may need care because of diseases or injuries or other factors such as pregnancy that can affect their health. You need to record details about these PATIENTS since they use WARD resources, such as staff time and other facilities. Details about these PATIENTS need to be recorded as they use WARD resources, such as staff time and other facilities.

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    HEALTH PROGRAMME POPULATION

    Change to Class: Changed Attributes

    Attributes of this Class are:
    KCENSUS DATE
    BREAST CANCER TARGET AGE GROUP
    CERVICAL CYTOLOGY AGE GROUP
    HEALTH PROGRAMME TYPE
    HEALTH PROMOTION TARGET GROUP
    HEALTH PROMOTION TARGET GROUP SIZE
    SCREENING PROGRAMME TOTAL WOMEN
    TARGET POPULATION

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    ADMISSION METHOD

    Change to Attribute: Changed Description

    The method of admission to a Hospital Provider Spell. A detailed definition of elective admission is given in ELECTIVE ADMISSION TYPE. A detailed definition of Elective Admission is given in ELECTIVE ADMISSION TYPE.

    National Codes:

    Elective admission, when the DECISION TO ADMIT could be separated in time from the actual admission:
    Elective Admission, when the DECISION TO ADMIT could be separated in time from the actual admission:
    11Waiting list
    12Booked
    13Planned
    Note that this does not include a transfer from another Hospital Provider (see 81 below).

    Emergency admission, when admission is unpredictable and at short notice because of clinical need:
    21Accident and emergency or dental casualty department of the Health Care Provider
    22General practitioner: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy
    Note that this does not include a transfer from another Hospital Provider (see 81 below).

    Emergency admission, when admission is unpredictable and at short notice because of clinical need:
    21Accident and emergency or dental casualty department of the Health Care Provider
    22GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy
    23Bed bureau
    24Consultant clinic, of this or another Health Care Provider
    28Other means, examples are:

    - admitted from the Accident And Emergency Department of another provider where they had not been admitted
    - transfer of an admitted PATIENT from another Hospital Provider in an emergency
    - baby born at home as intended

     

    Maternity admission, of a pregnant or recently pregnant woman to a maternity ward (including delivery facilities) except when the intention is to terminate the pregnancy
    24Consultant Clinic, of this or another Health Care Provider
    28Other means, examples are:

    - admitted from the Accident And Emergency Department of another provider where they had not been admitted
    - transfer of an admitted PATIENT from another Hospital Provider in an emergency
    - baby born at home as intended


    Maternity admission, of a pregnant or recently pregnant woman to a maternity ward (including delivery facilities) except when the intention is to terminate the pregnancy
    31Admitted ante-partum
    32Admitted post-partum

    Other admission not specified above
    82The birth of a baby in this Health Care Provider
    83Baby born outside the Health Care Provider except when born at home as intended.
    81Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency

    Other admission not specified above
    82The birth of a baby in this Health Care Provider
    83Baby born outside the Health Care Provider except when born at home as intended.
    81Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency
     

    Note: The classification has been listed in logical sequence rather than alphanumeric order.

     

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    ETHNIC GROUP

    Change to Data Element: Changed Description

    Format/length:an2
    HES item: 
    National Codes:Click on the attribute tab to display the attribute that contains the National Codes.
    National Codes: 
    Default Codes:9 - Not given

    Notes:
    ETHNIC GROUP is the old classification of ethnicity replaced by ETHNIC CATEGORY CODE.

    New ethnic categories defined in the 2001 census have become the national mandatory standard for the collection of ethnicity. These new ethnic categories have replaced the existing categories of ethnic data as classified by ETHNIC GROUP but there will be a period where both may need to co-exist at the same time.

    Note: ETHNIC CATEGORY CODE should be used when classifying people from 01/04/2001 and in the Commissioning Data Sets.

    ETHNIC GROUP classifies the ethnicity of a PERSON, as specified by the PERSON.ETHNIC GROUP classifies the ethnicity of a PERSON, as specified by the PERSON. The classification was used in the 1991 census, and will exist in parallel with ETHNIC CATEGORY CODE for some time.


    National Codes:
    0White
    1Black - Caribbean
    2Black - African
    3Black - Other
    4Indian
    5Pakistani
    6Bangladeshi
    7Chinese
    8Any other ethnic group

    When recording Ethnic Group in a 2-digit field, the national code should be entered as the left digit. In order to avoid coding errors, providers collecting ethnic group to the national standard with no further detail are advised to add 0 (zero) after the national code.

    Code 8 does not carry the standard default meaning of Not applicable.

     

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    HEALTHCARE RESOURCE GROUP CODE

    Change to Data Element: Changed Description

    Format/length:an3
    HES item:HRGNHS
    National Codes: 
    Default Codes: 

    Notes:
    The National Schedule of Reference Costs, developed by the Department of Health, uses Healthcare Resource Groups as the basis for costing inpatient and daycase services.

    Healthcare Resource Groups for Admitted Patient Care are derived from existing Commissioning Data Set data items.

    Healthcare Resource Groups for Out-Patient Attendances are directly assigned and cannot be derived from the Out-Patient Attendance Commissioning Data Set data items.

    HEALTHCARE RESOURCE GROUP CODES identify the HRGs.

    DSCN 08/2000 includes HEALTHCARE RESOURCE GROUP CODES in the Commissioning Data Set to standardise the handling of this data item within the Commissioning Data Set and thus stored by the Secondary Uses Service.DSCN 08/2000 includes HEALTHCARE RESOURCE GROUP CODES in the Commissioning Data Set to standardise the handling of this data item within the Commissioning Data Set and thus stored by the Secondary Uses Service. It is mandatory from 01/10/2001.

     

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    HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER

    Change to Data Element: Changed Description

    Format/length:an3
    HES item:HRGNHSVN
    National Codes:OP (applies to out-patient HRGs only)
    Default Codes: 

    Notes:
    The version number should be 'OP' when designating an out-patient Healthcare Resource Group code, rather than a numeric value.The version number should be 'OP' when designating an out-patient HEALTHCARE RESOURCE GROUP CODE, rather than a numeric value.

    The National Schedule of Reference Costs, developed by the Department of Health, uses Healthcare Resource Groups as the basis for costing inpatient and day case services.

    Healthcare Resource Groups are derived for Admitted Patient Care from existing Commissioning Data Set data items.

    Healthcare Resource Groups for Out-Patient Attendances are directly assigned and cannot be derived from the Out-Patient Attendance Commissioning Data Set data items.

    HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBERS identify which version of the Healthcare Resource Group has been used to identify the Healthcare Resource Group.


    This will facilitate the management of regular Healthcare Resource Group updates issued by the Health and Social Care Information Centre

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    LOCATION TYPE

    Change to Data Element: Changed Description

    Format/length:n2
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    LOCATION TYPE is the same as attribute LOCATION TYPE CODE.

    See supporting information Location Type Codes for coding and usage.See Location Type Codes for coding and usage.

    The codes used for this element are under review.The codes used for this Data Element are under review.

    Use in the Future Outpatient CDS:
    If the Location Type where treatment is intended to take place is not yet known, this data element should be omitted.If the LOCATION TYPE where treatment is intended to take place is not yet known, this Data Element should be omitted.

    Please note that the following Central Return forms have been discontinued with effect from 1st April 2004:
    KC56: Patient Care in the Community: District Nursing
    KC57: Patient Care in the Community: Community Psychiatric Nursing
    KC58: Patient Care in the Community: Learning Disability Nursing

     

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    LOCATION TYPE (HUMAN PAPILLOMAVIRUS VACCINE)

    Change to Data Element: Changed Description

    Format/length:n3
    HES item: 
    National Codes: 
    Default Codes:096 - Other

    Notes:
    The LOCATION TYPE where the Human Papillomavirus vaccine was administered.

    The codes to be used are as follows:

    003GP Practice Premises other than Health Centre
    070Health Clinic/Community Clinic. This is derived from Location Type Codes 002 'Health Centre', 019 'Health Clinic managed by the NHS' and 020 'Health Clinic managed by Voluntary or Private Agents'
    080Educational Establishment Premises. This is derived from Location Type Codes 029 'Educational Establishment Premises managed by Local Authority or Grant Maintained' and 030 'Educational Establishment Premises managed by Voluntary or Private Agents'
    070Health Clinic/Community Clinic. This is derived from Location Type Code 002 'Health Centre', 019 'Health Clinic managed by the NHS' and 020 'Health Clinic managed by Voluntary or Private Agents'
    080Educational Establishment Premises. This is derived from Location Type Code 029 'Educational Establishment Premises managed by Local Authority or Grant Maintained' and 030 'Educational Establishment Premises managed by Voluntary or Private Agents'
    096Other

    Note: If a GP Practice is also based at a Health Centre, those vaccinations administered by the GP Practice should be recorded under 003 'GP Practice Premises other than Health Centre'.

     

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    AMBULANCE TOP INDEX

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    CENTRAL RETURN FORMS  renamed from CENTRAL RETURNS

    Change to Package: Changed Name

    • Changed Name from Data_Dictionary.Messages.Central_Returns to Data_Dictionary.Messages.Central_Return_Forms

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    CLINICAL CODING

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    COMMISSIONING DATA SET V5  renamed from COMMISSIONING DATA SET

    Change to Package: Changed Name

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