Health and Social Care Information Centre

NHS Data Model and Dictionary Service

Type:Patch
Reference:1463
Version No:1.0
Subject:March 2014 Release Patch
Effective Date:Immediate
Reason for Change:Patch
Publication Date:27 March 2014

Background:

This patch updates the NHS Data Model and Dictionary in preparation for the March 2014 Release and includes:

To view a demonstration on "How to Read an NHS Data Model and Dictionary Change Request", visit the NHS Data Model and Dictionary help pages at: http://www.datadictionary.nhs.uk/Flash_Files/changerequest.htm.

Note: if the web page does not open, please copy the link and paste into the web browser.

Summary of changes:

Diagrams
CANCER OUTCOMES AND SERVICES DIAGRAM   Changed Diagram
CARE PROFESSIONAL DIAGRAM   Changed Diagram
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DIAGRAM   Changed Diagram
NATIONAL JOINT REGISTRY DIAGRAM   Changed Diagram
NATIONAL RENAL DIAGRAM   Changed Diagram
RADIOTHERAPY DIAGRAM   Changed Diagram
SYSTEMIC ANTI-CANCER THERAPY DIAGRAM   Changed Diagram
 
Data Set
AMBULANCE SERVICES DATA SET (KA34)   Changed Description
NATIONAL NEONATAL DATA SET - TWO YEAR NEONATAL OUTCOMES ASSESSMENT   Changed Description
NATIONAL RENAL DATA SET - DEMOGRAPHICS   Changed Description
NATIONAL RENAL DATA SET - DIALYSIS   Changed Description
NATIONAL RENAL DATA SET - PAEDIATRICS   Changed Description
NATIONAL RENAL DATA SET - PRESCRIBED ITEMS   Changed Description
NATIONAL RENAL DATA SET - RENAL CARE   Changed Description
NATIONAL RENAL DATA SET - TRANSPLANT   Changed Description
QUARTERLY MONITORING CANCELLED OPERATIONS DATA SET (QMCO)   Changed Description
 
Central Return Forms
KO41(A) 5   Changed Description
KO41(A) 6   Changed Description
 
Supporting Information
ADULT MENTAL HEALTH CARE SPELL   Changed Description
ADULT MENTAL HEALTH CARE TEAM   Changed Description
ADULT MENTAL HEALTH CARE TEAM EPISODE   Changed Description
AMBULANCE SERVICES DATA SET (KA34) OVERVIEW   Changed Description
APPOINTMENT REQUEST   Changed Description
COMMISSIONING DATA SET MANDATED DATA FLOWS   Changed Description
COMMISSIONING DATA SET XML MESSAGE SCHEMA OVERVIEW   Changed Description
DAY CARE SESSION   Changed Description
FIRST CONTACT IN FINANCIAL YEAR   Changed Description
FRACTION   Changed Description
GENITOURINARY CONSULTANT CLINIC ATTENDANCE   Changed Description
MENTAL HEALTH MINIMUM DATA SET OVERVIEW   Changed Description
MENTAL HEALTH RESPONSIBLE CLINICIAN   Changed Description
MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT   Changed Description
NATIONAL INTERIM CLINICAL IMAGING PROCEDURE CODE SET   Changed Description
OPERATING THEATRE SESSION   Changed Description
PRIMARY PROCEDURE DATE   Changed Description
REFERRAL TO TREATMENT CLOCK STOP ADMINISTRATIVE EVENT   Changed Description
REGULAR ATTENDER EPISODE   Changed Description
SPECIALIST COMMUNITY PUBLIC HEALTH NURSE   Changed Description
SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: FAMILY HEALTH NURSE   Changed Description
SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: HEALTH VISITOR   Changed Description
SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: OCCUPATIONAL HEALTH NURSE   Changed Description
SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: SCHOOL NURSE   Changed Description
WHAT'S NEW: MARCH 2014 renamed from WHAT'S NEW: FEBRUARY 2014   Changed Name, Description
 
Class Definitions
ADDRESS IN GEOGRAPHIC AREA (RETIRED)   Changed Relationships
APPOINTMENT   Changed Description
CARE PROFESSIONAL TEAM MEMBER   Changed Attributes
CLINICAL CLASSIFICATION   Changed Description
CLINICAL INTERVENTION   Changed Attributes
CLINICAL INVESTIGATION RESULT ITEM   Changed Attributes
CURRENCY   Changed Relationships
OFFER OF ADMISSION   Changed Description
ORGANISATION REGISTRATION   Changed Description
PATIENT ORGANISATION   Changed Attributes
PERSON IN PROGRAMME   Changed Description
PLANNED SERVICE   Changed Attributes
REFERRAL REQUEST   Changed Attributes
REGISTER   Changed Description
TISSUE   Changed Attributes
TRANSPORT REQUIREMENT   Changed Attributes
WARD OPERATIONAL PLAN   Changed Attributes
 
Attribute Definitions
ACTIVITY GROUP TYPE   Changed Description
DIABETES TYPE   Changed Description
DIRECT ACCESS REFERRAL INDICATOR   Changed Description
PATIENT PROCEDURE CODING SIGNIFICANCE   Changed Description
SERVICE REQUEST RAISED REASON   Changed Description
VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR renamed from VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR   Changed Name
 
Data Elements
ADMITTED PATIENT OTHER EMERGENCY ADMISSIONS TOTAL   Changed Description
AGE GROUP INTENDED   Changed Description
AMBULANCE INCIDENT NUMBER   Changed Description
CDS PRIME RECIPIENT IDENTITY   Changed Description
CDS SENDER IDENTITY   Changed Description
COMMISSIONING SERIAL NUMBER   Changed Description
DFES ESTABLISHMENT NUMBER   Changed Description
EMERGENCY CARE ATTENDANCES TOTAL   Changed Description
EMERGENCY CARE PATIENTS WAITING OVER 4 HOURS TOTAL   Changed Description
EMERGENT PSYCHOSIS DATE   Changed Description
GUARANTEED ADMISSION DATE   Changed Description
INTENDED AGE GROUP   Changed Description
INTENDED CLINICAL CARE INTENSITY   Changed Description
INTENDED CLINICAL CARE INTENSITY CODE   Changed Description
LOCATION CLASS   Changed Description
NHS SERVICE AGREEMENT CHANGE DATE   Changed Description
PRODROME PSYCHOSIS DATE   Changed Description
PROVIDER REFERENCE NUMBER   Changed Description
SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D)   Changed Description
SAMPLE COLLECTION DATE AND TIME   Changed Description
SAMPLE COLLECTION YEAR AND MONTH   Changed Description
SAMPLE TYPE (NATIONAL NEONATAL DATA SET)   Changed Description
SCAN PERFORMED INDICATOR (PET)   Changed Description
SCHEDULE OF GROWING SKILLS (ACTIVE POSTURE) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (HEARING AND LANGUAGE) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (INTERACTIVE SOCIAL) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (LOCOMOTOR) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (MANIPULATIVE) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (PASSIVE POSTURE) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (SELF-CARE SOCIAL) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (SPEECH AND LANGUAGE) SCALE SCORE   Changed Description
SCHEDULE OF GROWING SKILLS (VISUAL) SCALE SCORE   Changed Description
SENTINEL NODE PROCEDURE   Changed Description
SERVICE REQUEST STATUS DATE (MENTAL HEALTH)   Changed Description
SERVICE TYPE REFERRED TO (COMMUNITY CARE)   Changed Description
SERVICE TYPE REQUESTED   Changed Description
SERVICE TYPE REQUESTED CODE   Changed Description
SEX OF PATIENTS   Changed Description
SEX OF PATIENTS CODE   Changed Description
SHORT TERM RECALL RATE FOLLOWING ASSESSMENT (PERCENTAGE OF SCREENED)   Changed Description
SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR   Changed Description
SIGNPOSTING TO SERVICE INDICATOR (PHYSICAL ACTIVITY SERVICE)   Changed Description
SIGNPOSTING TO SERVICE INDICATOR (STOP SMOKING SERVICE)   Changed Description
SIGNPOSTING TO SERVICE INDICATOR (WEIGHT MANAGEMENT SERVICE)   Changed Description
SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)   Changed Description
SITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)   Changed Description
SMILE INDICATION CODE   Changed Description
SOCIAL PHOBIA INVENTORY SCORE   Changed Description
SOCIAL PHOBIA SCORE   Changed Description
SOCIAL SERVICES CLIENT IDENTIFIER   Changed Description
SOCIAL WORKER CARE INDICATOR (HIV)   Changed Description
SOURCE OF REFERRAL FOR A AND E   Changed Description
SPECIAL DIET DESCRIPTION   Changed Description
SPECIFIC PHOBIA SCORE   Changed Description
SPECIMEN TYPE (CHLAMYDIA TESTING)   Changed Description
SPLENOMEGALY INDICATOR   Changed Description
STAFF GROUP CODE (TRAINING ACTIVITY CLASSIFICATION)   Changed Description
STANDARDISED DETECTION RATIO TOTAL   Changed Description
START DATE (SUPERVISED COMMUNITY TREATMENT RECALL)   Changed Description
START DATE (TREATMENT FOR DIALYSIS RELATED INFECTION)   Changed Description
START DATE AND TIME (RENAL DIALYSIS)   Changed Description
STATUS OF FOLIC ACID SUPPLEMENT (MOTHER AT BOOKING)   Changed Description
STATUTORY ASSESSMENT TYPE   Changed Description
STATUTORY SICK PAY INDICATOR   Changed Description
STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR   Changed Description
STEROID TYPE GIVEN TO MOTHER (SNOMED CT DM+D)   Changed Description
SUBJECTIVE GLOBAL ASSESSMENT   Changed Description
SUBSTANCE USE STATUS (MOTHER AT BOOKING)   Changed Description
SUPPORT STATUS (MOTHER AT BOOKING)   Changed Description
SURFACTANT GIVEN INDICATOR (DURING RESUSCITATION)   Changed Description
SURFACTANT GIVEN INDICATOR (ON NEONATAL CRITICAL CARE DAILY CARE DATE)   Changed Description
SURGICAL ACCESS TYPE   Changed Description
SURGICAL ACCESS TYPE (THORACIC)   Changed Description
SURGICAL DEFAULT TECHNIQUE INDICATOR   Changed Description
SURGICAL PALLIATION TYPE   Changed Description
SUSPENSION END DATE   Changed Description
SUSPENSION START DATE   Changed Description
SYSTEMIC ANTI-CANCER THERAPY DRUG ROUTE OF ADMINISTRATION   Changed Description
SYSTOLIC BLOOD PRESSURE (POST HAEMODIALYSIS)   Changed Description
SYSTOLIC BLOOD PRESSURE (PRE-HAEMODIALYSIS)   Changed Description
THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR   Changed Description
TIME BETWEEN DELIVERY AND SPONTANEOUS RESPIRATION CODE   Changed Description
TIME BETWEEN DELIVERY AND UMBILICAL CORD CLAMPING   Changed Description
TOPOGRAPHY (SNOMED)   Changed Description
TOPOGRAPHY (SNOMED CT)   Changed Description
TOTAL PROTEIN CONCENTRATION (DONOR)   Changed Description
TRACHEOSTOMY TUBE IN SITU INDICATOR   Changed Description
TRANS ARTERIAL CHEMOEMBOLISATION PERFORMED INDICATOR   Changed Description
TRANSFUSED UNITS PER PERIOD (ERYTHROPOIETIN)   Changed Description
TRANSPLANT WAITING LIST STATUS (CHANGED DATE)   Changed linked Attribute
TRANSPLANT WAITING LIST STATUS CODE (RENAL)   Changed Description
TRAUMATIC LESION OF GENITAL TRACT   Changed Description
TUBERCULOSIS TREATMENT INDICATOR (HIV)   Changed Description
TUMOUR GRADE (FOR BREAST SCREENING)   Changed Description
TUMOUR REGRESSION INDICATOR   Changed Description
TURP TUMOUR PERCENTAGE   Changed Description
TWO YEAR NEONATAL OUTCOMES ASSESSMENT YEAR AND MONTH   Changed Description
UMBILICAL CORD CLAMPED IMMEDIATELY AFTER BIRTH INDICATOR   Changed Description
UMBILICAL CORD MILKING PERFORMED INDICATOR   Changed Description
URGENT CARE SERVICE ACCESSED TYPE   Changed Description
URINE DIPSTICK TEST (BLOOD)   Changed Description
URINE DIPSTICK TEST (PROTEIN)   Changed Description
URINE OUTPUT LAST 24 HOURS   Changed Description
URINE OUTPUT LAST HOUR   Changed Description
VASCULAR LINE TYPE IN SITU   Changed Description
VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE)   Changed Description
VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE)   Changed Description
VITAMIN K ROUTE OF ADMINISTRATION   Changed Description
WARD DAY PERIOD AVAILABILITY   Changed Description
WARD DAY PERIOD AVAILABILITY CODE   Changed Description
WARD NIGHT PERIOD AVAILABILITY   Changed Description
WARD NIGHT PERIOD AVAILABILITY CODE   Changed Description
WEEKLY ALCOHOL UNITS (MOTHER AT BOOKING)   Changed Description
WEEKLY HOURS WORKED   Changed Description
WILMS TUMOUR STAGE   Changed Description
WOMEN LOST TO FOLLOW-UP TOTAL (AFTER TECHNICALLY INADEQUATE SCREENING MAMMOGRAM)   Changed Description
YEAR AND MONTH OF BIRTH   Changed Description
YEAR AND MONTH OF BIRTH (BABY)   Changed Description
 

Date:27 March 2014
Sponsor:Richard Kavanagh, Head of Data Standards - Interoperability Specifications, Health and Social Care Information Centre

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

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CANCER OUTCOMES AND SERVICES DIAGRAM

Change to Diagram: Changed Diagram

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CARE PROFESSIONAL DIAGRAM

Change to Diagram: Changed Diagram

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IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DIAGRAM

Change to Diagram: Changed Diagram

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NATIONAL JOINT REGISTRY DIAGRAM

Change to Diagram: Changed Diagram

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NATIONAL RENAL DIAGRAM

Change to Diagram: Changed Diagram

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RADIOTHERAPY DIAGRAM

Change to Diagram: Changed Diagram

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SYSTEMIC ANTI-CANCER THERAPY DIAGRAM

Change to Diagram: Changed Diagram

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AMBULANCE SERVICES DATA SET (KA34)

Change to Data Set: Changed Description

This return is out of date therefore the information should not be used.
For the latest version of the guidance, please see the Health and Social Care Information Centre website at: Ambulance Services Collection (KA34).

Ambulance Services Data Set (KA34) Overview

The Ambulance Services Data Set (KA34) carries the data for monitoring key targets and standards on services provided by NHS Trusts. It should be used to record information on Ambulance Services.

Data Set Data Elements
Providing Organisation:
To carry the details of the organisation providing Ambulance Services.
One occurrence of this group is permitted.
ORGANISATION CODE (CODE OF PROVIDER)
REPORTING PERIOD START DATE
REPORTING PERIOD END DATE
Part 1: Emergency and Urgent Calls
To carry the number of emergency and urgent calls and response times.
One occurrence for each RESPONSE CATEGORY is required.
RESPONSE CATEGORY
EMERGENCY CALLS TOTAL
EMERGENCY RESPONSE TOTAL
EMERGENCY RESPONSE WITHIN 8 MINUTES TOTAL
EMERGENCY RESPONSE NO AMBULANCE REQUIRED TOTAL
EMERGENCY RESPONSE AMBULANCE ARRIVED TOTAL
EMERGENCY RESPONSE WITHIN 19 MINUTES TOTAL
EMERGENCY CALLS RESOLVED BY TELEPHONE TOTAL
Part 2: Patient Destinations: Emergency and Urgent 
To carry the number of emergency and urgent patient journeys.
One occurrence for each RESPONSE CATEGORY is required.
RESPONSE CATEGORY
EMERGENCY PATIENT JOURNEYS TYPE 1 AND 2 TOTAL
EMERGENCY PATIENT JOURNEYS OTHER TYPE TOTAL
EMERGENCY PATIENTS TREATED AT SCENE
Part 3: Patient Journeys: Non-urgent
To carry the details of the number of special or planned patient journeys
One occurrence of this group is required.
SPECIAL PATIENT JOURNEYS TOTAL
PLANNED PATIENT JOURNEYS TOTAL

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NATIONAL NEONATAL DATA SET - TWO YEAR NEONATAL OUTCOMES ASSESSMENT

Change to Data Set: Changed Description

National Neonatal Data Set Overview

The National Neonatal Data Set has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 June 2014.

The Mandatory, Required or Optional (M/R/O) column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
  • R = Required: NHS business processes cannot be delivered without this data element
  • O = Optional: the inclusion of this data element is optional as required for local purposes.

Note: items in the M/R/O column which are shown with notation P have not been approved by the Information Standards Board for Health and Social Care, and are included to facilitate piloting and testing of future Neonatal Data Analysis Unit data requirements, prior to formal inclusion in later versions of the data set.  These items have been included in the data set layout in order to provide advance notice to data providers and system suppliers of the intention to require these items at a later date. Unless ORGANISATIONS are engaged in piloting activities relating to these items, they should NOT submit any data item marked P.

TWO YEAR NEONATAL OUTCOMES ASSESSMENT

One of the following Child Demographics Data Group Structures must be used:

Child Demographics (Standard):
To carry the Child's demographic details where anonymisation of the record is NOT required.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RNHS NUMBER
MNHS NUMBER STATUS INDICATOR CODE
RCOMMUNITY HEALTH INDEX NUMBER
RHEALTH AND CARE NUMBER
MBABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)
RDATE TIME OF BIRTH
MSITE CODE (OF ACTUAL PLACE OF DELIVERY)
or
ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)
OGESTATION LENGTH (AT DELIVERY)
OGESTATION LENGTH (REMAINING DAYS AT DELIVERY)
RPERSON PHENOTYPIC SEX
or 
PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)

OR

Child's Demographics (Withheld):
To carry the Child's demographic details where anonymisation of the record IS required.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
MNHS NUMBER STATUS INDICATOR CODE
MBABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)
RYEAR AND MONTH OF BIRTH
MSITE CODE (OF ACTUAL PLACE OF DELIVERY)
or
ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)
OGESTATION LENGTH (AT BIRTH)
OGESTATION LENGTH (REMAINING DAYS AT DELIVERY)
RPERSON PHENOTYPIC SEX
or 
PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)


One of the following Two Year Assessment Administration Data Group Structures must be used:

Two Year Assessment Administration (Standard):
To carry administrative information relating to the Two Year Neonatal Outcomes Assessment where anonymisation of the record is NOT required.  
One occurrence of this group is required
.
M/R/O Data Set Data Elements 
MTWO YEAR NEONATAL OUTCOMES ASSESSMENT DATE
OCARE PROFESSIONAL JOB ROLE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
RPOSTCODE OF USUAL ADDRESS (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
MSITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
or
ORGANISATION CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
RTWO YEAR NEONATAL OUTCOMES ASSESSMENT NOT CARRIED OUT REASON
RPERSON DEATH DATE (POST DISCHARGE FROM NEONATAL CRITICAL CARE)

OR

Two Year Administration (Withheld):
To carry administrative information relating to the Two Year Neonatal Outcomes Assessment where anonymisation of the record IS required.
One occurrence of this group is required
.
M/R/O Data Set Data Elements 
RTWO YEAR NEONATAL OUTCOMES ASSESSMENT YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
OCARE PROFESSIONAL JOB ROLE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
RSITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
or
ORGANISATION CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
RTWO YEAR NEONATAL OUTCOMES ASSESSMENT NOT CARRIED OUT REASON
RPERSON DEATH YEAR AND MONTH (POST DISCHARGE FROM NEONATAL CRITICAL CARE) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)

Two Year TPRG-SEND - Neuromotor:
To carry information relating to TPRG-SEND Neuromotor at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION C)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION D)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION E)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION F)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION G)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROMOTOR QUESTION H)

Two Year TPRG-SEND - Malformations:
To carry information relating to TPRG-SEND Malformations at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (MALFORMATIONS QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (MALFORMATIONS QUESTION B)

Two Year TPRG-SEND - Respiratory and Cardiovascular:
To carry information relating to TPRG-SEND Respiratory and Cardiovascular System at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RESPIRATORY AND CARDIOVASCULAR SYSTEM QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RESPIRATORY AND CARDIOVASCULAR SYSTEM QUESTION B)

Two Year TPRG-SEND - Gastrointestinal Tract:
To carry information relating to TPRG-SEND Gastrointestinal Tract at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION A)
RSPECIAL DIET DESCRIPTION
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION C)

Two Year TPRG-SEND - Renal:
To carry information relating to TPRG-SEND Renal at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (RENAL QUESTION C)

Two Year TPRG-SEND - Neurology:
To carry information relating to TPRG-SEND Neurology at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION C)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROLOGY QUESTION D)

Two Year TPRG-SEND - Growth:
To carry information relating to TPRG-SEND Growth at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RPERSON WEIGHT (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
POBSERVATION DATE (WEIGHT)
or 
OBSERVATION YEAR AND MONTH (WEIGHT)  
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RPERSON HEIGHT IN CENTIMETRES (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
POBSERVATION DATE (HEIGHT)
or
OBSERVATION YEAR AND MONTH (HEIGHT)  
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RHEAD CIRCUMFERENCE IN CENTIMETRES (AT TWO YEAR NEONATAL OUTCOMES ASSESSMENT)
POBSERVATION DATE (HEAD CIRCUMFERENCE)
or 
OBSERVATION YEAR AND MONTH (HEAD CIRCUMFERENCE) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)

Two Year TPRG-SEND - Development:
To carry information relating to TPRG-SEND Development at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT ADDITIONAL QUESTION FOR NATIONAL NEONATAL DATA SET)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION C)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (DEVELOPMENT QUESTION D)
RNEURODEVELOPMENTAL ASSESSMENT ALREADY TAKEN INDICATOR
RNEURODEVELOPMENTAL ASSESSMENT TEST NAME

Two Year TPRG-SEND - Neurosensory:
To carry information relating to TPRG-SEND Neurosensory at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION C)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION D)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION E)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (NEUROSENSORY QUESTION F)

Two Year TPRG-SEND - Communication:
To carry information relating to TPRG-SEND Communication at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION B)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION C)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION D)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (COMMUNICATION QUESTION E)

Two Year TPRG-SEND - Special Questions:
To carry information relating to TPRG-SEND Special Questions at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (SPECIAL QUESTIONS QUESTION A)
RTPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (SPECIAL QUESTIONS QUESTION B)
RCHILD DIFFICULT TO TEST REASON CODE
Multiple occurrences of this item are permitted

Two Year TPRG-SEND - Neurological Diagnosis:
To carry information relating to TPRG-SEND Neurological Diagnosis at the Two Year Neonatal Outcomes Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RPATIENT DIAGNOSIS INDICATOR (CEREBRAL PALSY)
RCEREBRAL PALSY TYPE CODE (NATIONAL NEONATAL DATA SET)
RDIAGNOSIS (ICD NEUROLOGICAL)
Multiple occurrences of this item are permitted

Two Year Bayley III Assessment:
To carry information relating to the Bayley III Assessment.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
PASSESSMENT TOOL COMPLETION DATE
or
ASSESSMENT TOOL COMPLETION YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)

Two Year Bayley III - Cognitive:
To carry information relating to the Bayley III Cognitive sub-scale.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RBAYLEY III COGNITIVE TOTAL RAW SCORE
RBAYLEY III COGNITIVE SCALE SCORE
RBAYLEY III COGNITIVE DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III COGNITIVE COMPOSITE SCORE

Two Year Bayley III - Communication:
To carry information relating to the Bayley III Communication sub-scales.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RBAYLEY III COMMUNICATION (RECEPTIVE COMMUNICATION) TOTAL RAW SCORE
RBAYLEY III COMMUNICATION (RECEPTIVE COMMUNICATION) SCALE SCORE
RBAYLEY III COMMUNICATION (RECEPTIVE COMMUNICATION) DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III COMMUNICATION (RECEPTIVE COMMUNICATION) COMPOSITE SCORE
RBAYLEY III COMMUNICATION (EXPRESSIVE COMMUNICATION) TOTAL RAW SCORE
RBAYLEY III COMMUNICATION (EXPRESSIVE COMMUNICATION) SCALE SCORE
RBAYLEY III COMMUNICATION (EXPRESSIVE COMMUNICATION) DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III COMMUNICATION (EXPRESSIVE COMMUNICATION) COMPOSITE SCORE
RBAYLEY III COMMUNICATION SUM TOTAL RAW SCORE
RBAYLEY III COMMUNICATION SUM TOTAL SCALE SCORE
RBAYLEY III COMMUNICATION SUM TOTAL DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III COMMUNICATION SUM TOTAL COMPOSITE SCORE

Two Year Bayley III - Neuromotor:
To carry information relating to the Bayley III Neuromotor sub-scales.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RBAYLEY III NEUROMOTOR (FINE MOTOR) TOTAL RAW SCORE
RBAYLEY III NEUROMOTOR (FINE MOTOR) SCALE SCORE
RBAYLEY III NEUROMOTOR (FINE MOTOR) DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III NEUROMOTOR (FINE MOTOR) COMPOSITE SCORE
RBAYLEY III NEUROMOTOR (GROSS MOTOR) TOTAL RAW SCORE
RBAYLEY III NEUROMOTOR (GROSS MOTOR) SCALE SCORE
RBAYLEY III NEUROMOTOR (GROSS MOTOR) DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III NEUROMOTOR (GROSS MOTOR) COMPOSITE SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL RAW SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL SCALE SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL COMPOSITE SCORE

Two Year Bayley III - Social-Emotional:
To carry information relating to the Bayley III Social-Emotional sub-scale.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RBAYLEY III SOCIAL-EMOTIONAL TOTAL RAW SCORE
RBAYLEY III SOCIAL-EMOTIONAL SCALE SCORE
RBAYLEY III SOCIAL-EMOTIONAL DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III SOCIAL-EMOTIONAL COMPOSITE SCORE

Two Year Bayley III - Adaptive Behaviour:
To carry information relating to the Bayley III Adaptive Behaviour sub-scales.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
RBAYLEY III ADAPTIVE BEHAVIOUR (COMMUNICATION) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (COMMUNICATION) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (COMMUNITY USE) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (COMMUNITY USE) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (FUNCTIONAL PRE-ACADEMICS) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (FUNCTIONAL PRE-ACADEMICS) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (HOME LIVING) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (HOME LIVING) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (HEALTH AND SAFETY) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (HEALTH AND SAFETY) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (LEISURE) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (LEISURE) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SELF-CARE) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SELF-CARE) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SELF-DIRECTION) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SELF-DIRECTION) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SOCIAL) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (SOCIAL) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (MOTOR) TOTAL RAW SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR (MOTOR) SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR SUM TOTAL RAW SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL SCALE SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III NEUROMOTOR SUM TOTAL COMPOSITE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR SUM TOTAL SCALE SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR SUM TOTAL DEVELOPMENTAL AGE EQUIVALENT SCORE
RBAYLEY III ADAPTIVE BEHAVIOUR SUM TOTAL COMPOSITE SCORE

Two Year Griffiths:
To carry information relating to Griffiths Scale of Infant Development.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
PASSESSMENT TOOL COMPLETION DATE
or
ASSESSMENT TOOL COMPLETION YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RGRIFFITHS LOCOMOTOR SCALE SCORE
RGRIFFITHS PERSONAL-SOCIAL SCALE SCORE
RGRIFFITHS LANGUAGE SCALE SCORE
RGRIFFITHS EYE AND HAND CO-ORDINATION SCALE SCORE
RGRIFFITHS PERFORMANCE SCALE SCORE
RGRIFFITHS PRACTICAL REASONING SCALE SCORE

Two Year Schedule of Growing:
To carry information relating to Schedule of Growing Skills.
One occurrence of this group is permitted
.
M/R/O Data Set Data Elements 
PASSESSMENT TOOL COMPLETION DATE
or
ASSESSMENT TOOL COMPLETION YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RSCHEDULE OF GROWING SKILLS (PASSIVE POSTURE) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (ACTIVE POSTURE) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (LOCOMOTOR) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (MANIPULATIVE) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (VISUAL) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (HEARING AND LANGUAGE) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (SPEECH AND LANGUAGE) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (INTERACTIVE SOCIAL) SCALE SCORE
RSCHEDULE OF GROWING SKILLS (SELF-CARE SOCIAL) SCALE SCORE

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NATIONAL RENAL DATA SET - DEMOGRAPHICS

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

This section contains data items to capture PATIENT identifiers, demographic information and organisational data.

Data Set Data Elements
Person Demographics.
To carry the demographic details of the patient.
NHS NUMBER 
LOCAL PATIENT IDENTIFIER 
PERSON FAMILY NAME 
PERSON GIVEN NAME 
PERSON BIRTH DATE 
PAEDIATRIC PATIENT INDICATOR *
PERSON GENDER CODE CURRENT
ETHNIC CATEGORY 
PATIENT USUAL ADDRESS 
POSTCODE OF USUAL ADDRESS 
PATIENT USUAL ADDRESS (AT CHRONIC KIDNEY DISEASE DIAGNOSIS) 
POSTCODE OF USUAL ADDRESS (AT CHRONIC KIDNEY DISEASE DIAGNOSIS) 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
ORGANISATION CODE (RESPONSIBLE PCT) 
SITE CODE (OF PRIMARY RENAL UNIT PROVIDER) 
RENAL DIALYSIS CENTRE PRIMARY OR SECONDARY INDICATOR 

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NATIONAL RENAL DATA SET - DIALYSIS

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

The data items in this section apply only to PATIENTS receiving kidney Renal Dialysis. The section contains items such as PATIENT observations relevant to their Renal Dialysis treatment and adequacy, complications and procedures to construct access.

Data Set Data Elements
General dialysis details.
To carry the general dialysis details for the patient.
ORGANISATION CODE (DIALYSIS CENTRE) 
RENAL DIALYSIS ACCESS TYPE (FIRST) 
General diagnosis details.
To carry the general diagnosis details for the patient.
DIAGNOSIS DATE (VASCULAR OR PERITONEAL DEFINITIVE ACCESS FAILED)
RENAL CATHETER OR ACCESS LOST INDICATOR *
General dialysis observation details.
To carry the general dialysis observations for the patient.
WHOLE BLOOD MEAN CORPUSCULAR HAEMOGLOBIN (DIALYSIS)
OBSERVATION DATE (WHOLE BLOOD MEAN CORPUSCULAR HAEMOGLOBIN)
WHOLE BLOOD MEAN CELL VOLUME (DIALYSIS)
OBSERVATION DATE (WHOLE BLOOD MEAN CELL VOLUME)
HAEMOGLOBIN CONCENTRATION (PRIOR END STAGE RENAL FAILURE)
NORMALISED PROTEIN CATABOLIC RATE (DIALYSIS)
OBSERVATION DATE (NORMALISED PROTEIN CATABOLIC RATE)
URINE UREA CONCENTRATION
OBSERVATION DATE (URINE UREA CONCENTRATION)
URINE CREATININE CONCENTRATION
OBSERVATION DATE (URINE CREATININE CONCENTRATION) 
URINE Kt/V
OBSERVATION DATE (URINE Kt/V)
URINE VOLUME
OBSERVATION DATE (URINE VOLUME)
Dialysis Access.
To carry the details of dialysis access procedures. Each patient may have zero or more access procedures. All access procedures should be recorded.
REFERRAL REQUEST RECEIVED DATE (DIALYSIS ACCESS CONSTRUCTION) 
PROCEDURE DATE (DIALYSIS ACCESS CONSTRUCTION) 
RENAL DIALYSIS ACCESS TYPE 
PROCEDURE SIDE (DIALYSIS ACCESS CONSTRUCTION) 
PROCEDURE SITE (DIALYSIS ACCESS CONSTRUCTION) 
ANAESTHETIC METHOD TYPE (DIALYSIS ACCESS CONSTRUCTION) 
REMOVAL DATE (DIALYSIS ACCESS) 
REMOVAL REASON TYPE (DIALYSIS ACCESS) 
GRAFT MATERIAL TYPE (ARTERIOVENOUS) 
PERITONEAL DIALYSIS CATHETER TYPE 
PERITONEAL DIALYSIS CATHETER INSERTION TECHNIQUE 
Dialysis Access Surveillance.
Each dialysis access may have many surveillances recorded. Record all surveillance per access.
SURVEILLANCE DATE (DIALYSIS ACCESS) 
SURVEILLANCE TECHNIQUE (DIALYSIS ACCESS) 
Dialysis Access Complication.
Each dialysis access may have many complications recorded. Record all surveillance per access.
COMPLICATION DATE (RENAL DIALYSIS ACCESS) 
COMPLICATION TYPE (RENAL DIALYSIS ACCESS) 
Dialysis Access procedures or repairs.
Each dialysis access may have many access procedures or repairs recorded. Record all surveillance per access.
PROCEDURE DATE (DIALYSIS ACCESS REPAIR OR REVISION) 
PROCEDURE (DIALYSIS ACCESS REPAIR OR REVISION) 
Haemodialysis general details.
To carry the general details of haemodialysis (HD) patients.
One occurrence of this group is permitted.
RENAL DIALYSIS EPISODES PER WEEK 
PRESCRIBED DOSE (HAEMODIALYSIS MINUTES PER EPISODE) 
ACTUAL DOSE (HAEMODIALYSIS MINUTES LAST EPISODE) 
BLOOD FLOW RATE (DIALYSIS)
DIALYSATE FLOW RATE (DIALYSIS)
RENAL DIALYSIS DATE (PRE AND POST RENAL DIALYSIS MEASURES APPLICABLE)
MANUFACTURERS NAME (DIALYSER) 
DIALYSER REUSED INDICATOR *
Haemodialysis observation details.
To carry the observation details for haemodialysis patients.
DOMINANT ARM CODE
PERSON WEIGHT (PRE-DIALYSIS)
PERSON WEIGHT (POST DIALYSIS)
DIASTOLIC BLOOD PRESSURE (PRE-HAEMODIALYSIS)
SYSTOLIC BLOOD PRESSURE (PRE-HAEMODIALYSIS)
OBSERVATION DATE (BLOOD PRESSURE PRE-HAEMODIALYSIS) 
DIASTOLIC BLOOD PRESSURE (POST HAEMODIALYSIS)
SYSTOLIC BLOOD PRESSURE (POST HAEMODIALYSIS)
SERUM CREATININE CONCENTRATION (PRE-DIALYSIS)
HAEMOGLOBIN CONCENTRATION (PRE-DIALYSIS)
SERUM UREA CONCENTRATION (PRE-DIALYSIS)
SERUM UREA CONCENTRATION (POST DIALYSIS)
Peritoneal Dialysis Prescriptions.
To carry the details of the treatment regime for peritoneal dialysis patients.
PERITONEAL DIALYSIS TREATMENT REGIME 
START DATE (PERITONEAL DIALYSIS TREATMENT REGIME) 
PRESCRIBED ITEM (VOLUME OF 1.36% GLUCOSE FLUID)
PRESCRIBED ITEM (VOLUME OF 2.27% GLUCOSE FLUID)
PRESCRIBED ITEM (VOLUME OF 3.86% GLUCOSE FLUID)
PRESCRIBED ITEM (VOLUME OF AMINO ACID DIALYSIS FLUID)
PRESCRIBED ITEM (VOLUME OF ICODEXTRIN DIALYSIS FLUID)
PRESCRIBED ITEM (LOW GLUCOSE DEGRADATION PRODUCT DIALYSIS FLUID) *
PRESCRIBED ITEM (LOW SODIUM GLUCOSE DIALYSIS FLUID) *
PERITONEAL DIALYSIS FLUID MANUFACTURERS NAME 
PRESCRIBED ITEM VOLUME USAGE PER OVERNIGHT (PERITONEAL DIALYSIS FLUID ON AUTOMATED PERITONEAL DIALYSIS) 
PRESCRIBED ITEM SIZE (PERITONEAL BAG) 
SUPPLEMENTARY HAEMODIALYSIS INDICATOR *
Peritoneal dialysis diagnosis details.
To carry the diagnosis details for peritoneal dialysis patients.
DIAGNOSIS PERITONITIS *
DIAGNOSIS DATE (PERITONITIS)
PERITONITIS ORGANISM 1 (READ) 
PERITONITIS ORGANISM 2 (READ) 
START DATE (TREATMENT FOR DIALYSIS RELATED INFECTION) 
END DATE (TREATMENT FOR DIALYSIS RELATED INFECTION) 
Peritoneal dialysis procedure details.
To carry the procedure details for peritoneal dialysis patients.
PROCEDURE (NET DAILY ULTRAFILTRATION) 
OBSERVATION DATE (NET DAILY ULTRAFILTRATION)
Peritoneal dialysis observation details.
To carry the observation details for peritoneal dialysis patients.
PERITONEAL DIALYSIS TOTAL WEEKLY FLUID VOLUME
OBSERVATION DATE (PERITONEAL DIALYSIS TOTAL WEEKLY FLUID VOLUME) 
DIALYSATE 24 HOUR VOLUME
OBSERVATION DATE (DIALYSATE 24 HOUR VOLUME)
DIALYSATE 24 HOUR CREATININE CONCENTRATION
OBSERVATION DATE (DIALYSATE 24 HOUR CREATININE CONCENTRATION)
DIALYSATE 24 HOUR PROTEIN LOSS
OBSERVATION DATE (DIALYSATE 24 HOUR PROTEIN LOSS)
DIALYSATE 24 HOUR UREA CONCENTRATION
OBSERVATION DATE (DIALYSATE 24 HOUR UREA CONCENTRATION)
Peritoneal Equilibration Test.
To carry the details of the observations for Peritoneal Equilibration Tests.
OBSERVATION DATE (PERITONEAL EQUILIBRATION TEST)
DIALYSATE CREATININE PLASMA RATIO (4 HOUR)
DIALYSATE EFFLUENT VOLUME (4 HOUR)
DIALYSATE GLUCOSE START OF DWELL (4 HOUR)
DIALYSATE GLUCOSE END OF DWELL (4 HOUR)
Other peritoneal dialysis observations.
To carry the details of other observations for peritoneal dialysis patients.
COMBINED Kt/V
OBSERVATION DATE (COMBINED Kt/V)
DIALYSATE Kt/V
OBSERVATION DATE (DIALYSATE Kt/V)
NORMALISED WEEKLY PERITONEAL CREATININE CLEARANCE
OBSERVATION DATE (NORMALISED WEEKLY PERITONEAL CREATININE CLEARANCE)
RESIDUAL RENAL CREATININE CLEARANCE
OBSERVATION DATE (RESIDUAL RENAL CREATININE CLEARANCE) 
SERUM CREATININE Kt/V
OBSERVATION DATE (SERUM CREATININE Kt/V)
WHITE BLOOD CELL COUNT (PERITONEAL FLUID)
OBSERVATION DATE (WHITE BLOOD CELL COUNT) 

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NATIONAL RENAL DATA SET - PAEDIATRICS

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

This section specifies items applicable only to paediatric renal PATIENTS.

Data Set Data Elements
Paediatric general details.
To carry the general details for paediatric patients.
REGISTRATION DATE (BRITISH ASSOCIATION FOR PAEDIATRIC NEPHROLOGY) 
PAEDIATRIC NEPHROLOGY REGISTRY STATUS CODE 
RENAL TREATMENT MODALITY AT DAY 90 CODE 
PERSON RELATIONSHIP GENETICALLY RELATED INDICATOR *
SINGLE CARER SUPPORT INDICATOR * 
PROCEDURE INDICATOR (GROWTH HORMONE ADMINISTERED) *
PRESCRIBED DOSE (GROWTH HORMONE) 
PROCEDURE DATE (GROWTH HORMONE ADMINISTRATION) 
Diagnosis details.
To carry the diagnosis details for paediatric patients up to the start of End Stage Renal Failure.
DIAGNOSIS ANTENATAL AT END STAGE RENAL FAILURE (RENAL PAEDIATRIC) *
PROCEDURE INDICATOR (ANTENATAL TREATMENT) *
PROCEDURE DATE (ANTENATAL TREATMENT)
PRETERM INDICATOR (RENAL PAEDIATRIC) *
NUMBER OF WEEKS PRETERM
DIAGNOSIS DIABETES (RENAL PAEDIATRIC) *
DIAGNOSIS MALIGNANCY (RENAL PAEDIATRIC) *
DIAGNOSIS CEREBRAL PALSY (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (CEREBRAL PALSY)
DIAGNOSIS CONGENITAL HEART DISEASE (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (CONGENITAL HEART DISEASE) 
DIAGNOSIS NEURAL TUBE DEFECT (RENAL PAEDIATRIC)  *
DIAGNOSIS DATE (NEURAL TUBE DEFECT)
DIAGNOSIS DEVELOPMENTAL OR EDUCATIONAL HANDICAP (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (DEVELOPMENT OR EDUCATIONAL HANDICAP) 
DIAGNOSIS LIVER DISEASE END STAGE RENAL FAILURE (RENAL PAEDIATRIC) *
DIAGNOSIS DOWNS SYNDROME (RENAL PAEDIATRIC)*
DIAGNOSIS DATE (DOWNS SYNDROME)
DIAGNOSIS OTHER CHROMOSOMAL ABNORMALITIES (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (OTHER CHROMOSOMAL ABNORMALITIES)
DIAGNOSIS CONGENITAL ANOMALY (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (CONGENITAL ABNORMALITY)
DIAGNOSIS OTHER SYNDROMAL DIAGNOSIS (RENAL PAEDIATRIC) *
DIAGNOSIS DATE (OTHER SYNDROMAL DIAGNOSIS) 
DIAGNOSIS PSYCHIATRIC DISORDER (RENAL PAEDIATRIC) *
DIAGNOSIS PSYCHOLOGICAL DISORDER (RENAL PAEDIATRIC) * 
PERSON PROPERTY FAMILY HISTORY (RENAL DISEASE) *
PERSON PROPERTY FAMILY HISTORY (END STAGE RENAL FAILURE) *
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (KIDNEY) *
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (PANCREAS) *
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (LIVER) *
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (HEART) * 
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (LUNGS) * 
ORGAN OR TISSUE RECIPIENT TRANSPLANT INDICATOR (SMALL INTESTINE) * 
RENAL REASON FOR NO TREATMENT CODE 
RENAL TREATMENT MODALITY NO TREATMENT REASON DATE 
IMPAIRMENT CODE (VISUAL HANDICAP) 
IMPAIRMENT CODE (AUDITORY HANDICAP) 
IMPAIRMENT CODE (PHYSICAL HANDICAP) 
IMPAIRMENT CODE (INTELLECTUAL HANDICAP) 
START DATE (RENAL PAEDIATRIC TRANSITION PROGRAMME) 
END DATE (RENAL PAEDIATRIC TRANSITION PROGRAMME) 
Paediatric observation details.
To carry the observation details for paediatric patients.
BONE AGE (RENAL PAEDIATRIC)
OBSERVATION DATE (BONE AGE) 
HEAD CIRCUMFERENCE (RENAL PAEDIATRIC)
OBSERVATION DATE (HEAD CIRCUMFERENCE)
RESIDUAL URINE OUTPUT (RENAL PAEDIATRIC) *
OBSERVATION DATE (RESIDUAL URINE OUTPUT)
NUMBER OF NATIVE KIDNEYS AT TRANSPLANTATION
RENAL TREATMENT MODALITY AT DEATH CODE 
DEATH DETAILS GENERAL COMMENT 
PLATELETS COUNT
OBSERVATION DATE (PLATELETS COUNT)
NUMBER OF DAYS PER WEEK OF PERITONEAL DIALYSIS 

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NATIONAL RENAL DATA SET - PRESCRIBED ITEMS

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

This section captures indicators on the prescription of various medications and items specific to renal care and their dosages.

Data Set Data Elements
Medication Dosages.
To carry the details of medication dosages prescribed for renal patients.
PRESCRIBED DOSE (ANTI-HUMAN T-LYMPHOCYTE GLOBULIN)
PRESCRIPTION DATE (ANTI-HUMAN T-LYMPHOCYTE GLOBULIN)
PRESCRIBED DOSE (ANTITHYMOCYTE GLOBULIN)
PRESCRIPTION DATE (ANTITHYMOCYTE GLOBULIN)
PRESCRIBED DOSE (AZATHIOPRINE)
PRESCRIBED FREQUENCY (AZATHIOPRINE)
PRESCRIBED TOTAL DAILY DOSE (AZATHIOPRINE)
PRESCRIPTION DATE (AZATHIOPRINE)
PRESCRIBED DOSE (CICLOSPORIN)
PRESCRIBED FREQUENCY (CICLOSPORIN)
PRESCRIBED TOTAL DAILY DOSE (CICLOSPORIN)
PRESCRIPTION DATE (CICLOSPORIN)
PRESCRIBED DOSE (MYCOPHENOLATE MOFETIL)
PRESCRIBED FREQUENCY (MYCOPHENOLATE MOFETIL)
PRESCRIBED TOTAL DAILY DOSE (MYCOPHENOLATE MOFETIL)
PRESCRIPTION DATE (MYCOPHENOLATE MOFETIL)
PRESCRIBED DOSE (MYCOPHENOLATE SODIUM)
PRESCRIBED FREQUENCY (MYCOPHENOLATE SODIUM)
PRESCRIBED TOTAL DAILY DOSE (MYCOPHENOLATE SODIUM)
PRESCRIPTION DATE (MYCOPHENOLATE SODIUM)
PRESCRIBED DOSE (MUROMONAB-CD3)
PRESCRIPTION DATE (MUROMONAB-CD3)
PRESCRIBED DOSE (PREDNISOLONE OR PREDNISONE)
PRESCRIBED TOTAL DAILY DOSE (PREDNISOLONE OR PREDNISONE)
PRESCRIPTION DATE (PREDNISOLONE OR PREDNISONE)
PRESCRIBED DOSE (SIROLIMUS)
PRESCRIBED FREQUENCY (SIROLIMUS)
PRESCRIBED TOTAL DAILY DOSE (SIROLIMUS)
PRESCRIPTION DATE (SIROLIMUS)
PRESCRIBED DOSE (TACROLIMUS)
PRESCRIBED FREQUENCY (TACROLIMUS)
PRESCRIBED TOTAL DAILY DOSE (TACROLIMUS)
PRESCRIPTION DATE (TACROLIMUS)
PRESCRIBED MEDICATION (BASILIXIMAB) *
PRESCRIBED DOSE (BASILIXIMAB)
PRESCRIBED TOTAL DAILY DOSE (BASILIXIMAB)
PRESCRIPTION DATE (BASILIXIMAB)
PRESCRIBED MEDICATION (DACLIZUMAB) *
PRESCRIBED DOSE (DACLIZUMAB)
PRESCRIBED TOTAL DAILY DOSE (DACLIZUMAB)
PRESCRIPTION DATE (DACLIZUMAB)
PRESCRIBED MEDICATION (ALEMTUZUMAB) *
PRESCRIBED DOSE (ALEMTUZUMAB)
PRESCRIBED TOTAL DAILY DOSE (ALEMTUZUMAB)
PRESCRIPTION DATE (ALEMTUZUMAB)
Medication Indicators.
To carry the details of the medication indicators prescribed for renal patients.
PRESCRIBED MEDICATION (ANTICOAGULANT) *
PRESCRIPTION DATE (ANTICOAGULANT)
PRESCRIPTION DATE (OTHER MONOCLONAL ANTIBODY)
PRESCRIBED MEDICATION (HEPARIN SUBCUTANEOUS PROPHYLAXIS) *
PRESCRIPTION DATE (HEPARIN SUBCUTANEOUS PROPHYLAXIS)
PRESCRIBED MEDICATION (INSULIN) *
PRESCRIPTION DATE (INSULIN)
PRESCRIBED MEDICATION (INTRAPERITONEAL ANTIBIOTICS) *
PRESCRIPTION DATE (INTRAPERITONEAL ANTIBIOTICS)
PRESCRIBED MEDICATION (INTRAVENOUS ANTIBIOTICS) *
PRESCRIPTION DATE (INTRAVENOUS ANTIBIOTICS)
PRESCRIBED MEDICATION (THROMBOSIS PREVENTION DRUG) *
PRESCRIPTION DATE (THROMBOSIS PREVENTION DRUG)
PRESCRIBED MEDICATION (PHOSPHATE BINDERS) *
PRESCRIPTION DATE (PHOSPHATE BINDERS)
PRESCRIBED MEDICATION (INTRAVENOUS IRON) *
PRESCRIPTION DATE (INTRAVENOUS IRON)
PRESCRIBED MEDICATION (PROTON PUMP INHIBITORS) *
PRESCRIPTION DATE (PROTON PUMP INHIBITORS)
PRESCRIBED MEDICATION (CYTOMEGALOVIRUS TREATMENT) * 
PRESCRIBED MEDICATION (CYTOMEGALOVIRUS MEDICATION TYPE)
PRESCRIPTION DATE (CYTOMEGALOVIRUS TREATMENT)
PRESCRIBED MEDICATION (ANTI-FUNGAL PROPHYLAXIS) *
PRESCRIPTION DATE (ANTI-FUNGAL PROPHYLAXIS)
PRESCRIBED MEDICATION (DEEP VEIN THROMBOSIS PROPHYLAXIS DONOR) *
PRESCRIBED MEDICATION (DEEP VEIN THROMBOSIS PROPHYLAXIS TYPE) *
PRESCRIPTION DATE (DEEP VEIN THROMBOSIS PROPHYLAXIS)
Erythropoietin Stimulating Agents.
To carry the details of the erythropoietin stimulating agent prescribed for renal patients.
PRESCRIBED MEDICATION (ERYTHROPOIETIN) *
START DATE (ERYTHROPOIETIN EPISODE)
END DATE (ERYTHROPOIETIN EPISODE)
PRESCRIBED ITEM (ERYTHROPOIETIN READ CODE) 
DOSE FREQUENCY (ERYTHROPOIETIN STIMULATING AGENTS) 
TRANSFUSED UNITS PER PERIOD (ERYTHROPOIETIN) 
Medication indicators and doses collected on initial transplant forms.
These items are only collected on the initial transplant forms.
PRESCRIBED MEDICATION (ANTI-HUMAN T-LYMPHOCYTE GLOBULIN) *
PRESCRIBED MEDICATION (AZATHIOPRINE) *
PRESCRIBED MEDICATION (CICLOSPORIN) *
PRESCRIBED MEDICATION (MYCOPHENOLATE MOFETIL) *
PRESCRIBED MEDICATION (MYCOPHENOLATE SODIUM) *
PRESCRIBED MEDICATION (MUROMONAB-CD3) *
PRESCRIBED MEDICATION (PREDNISOLONE OR PREDNISONE) *
PRESCRIBED MEDICATION (SIROLIMUS) *
PRESCRIBED MEDICATION (TACROLIMUS) *
PRESCRIBED MEDICATION (OTHER MONOCLONAL ANTIBODY) *
Non-Medicated prescribed items.
This group contains non-medication prescription details as prescribed for renal patients.
PRESCRIBED ITEM (THROMBO EMBOLISM DETERRENT STOCKING) *
PRESCRIPTION DATE (THROMBO EMBOLISM DETERRENT STOCKING)

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NATIONAL RENAL DATA SET - RENAL CARE

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

This is a general nephrology section capturing a wide range of data. It includes a PATIENT’s treatment, procedures, co-morbidities, test results and observations.

Data Set Data Elements
Patient History.
To carry the details of the patient history.
RENAL TREATMENT MODALITY CODE 
START DATE (RENAL TREATMENT MODALITY) 
END DATE (RENAL TREATMENT MODALITY) 
RENAL TREATMENT MODALITY CHANGE REASON CODE 
PROCEDURE DATE (FIRST END STAGE RENAL FAILURE TREATMENT) 
RENAL TREATMENT PRIMARY SUPERVISION CODE 
RENAL DIALYSIS SCHEDULE TYPE 
PERSON DEATH DATE 
DEATH CAUSE CODE (EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION CLASSIFICATION) 
DEATH CAUSE COMMENT 
Patient Diagnosis.
To carry the details of the patient diagnosis. Use European Dialysis and Transplant Association diagnosis scheme to document the primary renal disease.
PRIMARY RENAL DISEASE DIAGNOSIS 
PRIMARY DIAGNOSIS DATE (RENAL DISEASE) 
PRIMARY RENAL DISEASE TEXT 
DIAGNOSIS INDICATOR (END STAGE RENAL FAILURE) * 
Secondary causes of end stage renal failure.
Up to 3 occurrences of secondary renal diagnosis codes are permitted. The diagnosis scheme should be used for this section as declared in the field.
DIAGNOSIS SCHEME IN USE (RENAL) 
SECONDARY CAUSE OF END STAGE RENAL FAILURE 
Patient Co-morbidities.
To carry the details of the co-morbidity diagnosis at the start of renal replacement therapy.
CO-MORBIDITY DIABETES (RENAL CARE) *
DIAGNOSIS DATE (DIABETES)
DIABETES TYPE (RENAL CARE)
CO-MORBIDITY MALIGNANCY (RENAL CARE) *
CO-MORBIDITY ANGINA (RENAL CARE) *
CO-MORBIDITY LIVER DISEASE (RENAL CARE) *
CO-MORBIDITY CEREBROVASCULAR DISEASE (RENAL CARE) *
CO-MORBIDITY CHRONIC OBSTRUCTIVE PULMONARY DISEASE (RENAL CARE) *
CO-MORBIDITY CLAUDICATION (RENAL CARE) *
CO-MORBIDITY ISCHAEMIC OR NEUROPATHIC ULCERS (RENAL CARE) *
CO-MORBIDITY MYOCARDIAL INFARCTION MORE THAN 3 MONTHS AGO (RENAL CARE) *
CO-MORBIDITY MYOCARDIAL INFARCTION WITHIN LAST 3 MONTHS (RENAL CARE) *
CO-MORBIDITY FRACTURE (RENAL CARE) *
Patient Procedures.
To carry the details of the procedures for the patient. This group lists certain procedures where an indicator as to whether the procedure has been carried out on the patient needs to be collected.
PROCEDURE NON-CORONARY ANGIOPLASTY (RENAL CARE) *
PROCEDURE CORONARY ANGIOPLASTY OR CORONARY ARTERY BYPASS GRAFT (RENAL CARE) *
PROCEDURE PARENTERAL IRON (RENAL CARE) *
PROCEDURE PERIPHERAL VASCULAR DISEASE AMPUTATION (RENAL CARE) *
PROCEDURE AMPUTATION (RENAL CARE) *
Patient Observations.
To carry the general observations of the patient.
PERSON HEIGHT IN CENTIMETRES
OBSERVATION DATE (HEIGHT) 
HEIGHT IN CENTIMETRES FIRST VISIT
PERSON WEIGHT (RENAL CARE)
OBSERVATION DATE (WEIGHT)
DIASTOLIC BLOOD PRESSURE
SYSTOLIC BLOOD PRESSURE
OBSERVATION DATE (BLOOD PRESSURE) 
BLOOD GROUP ABO CLASSIFICATION
BLOOD RHESUS CLASSIFICATION
SMOKING STATUS (RENAL CARE) *
OBSERVATION DATE (SMOKING STATUS)
NUMBER OF YEARS SMOKED
CIGARETTES PER DAY
OBSERVATION DATE (STOPPED SMOKING)
ESTIMATED GLOMERULAR FILTRATION RATE
OBSERVATION DATE (ESTIMATED GLOMERULAR FILTRATION RATE)
Calculated Creatinine Clearance details.
To carry the details of creatinine clearance for the patient.
CALCULATED CREATININE CLEARANCE TYPE 
CALCULATED CREATININE CLEARANCE
OBSERVATION DATE (CALCULATED CREATININE CLEARANCE)
MEASURED 24HR CREATININE CLEARANCE
OBSERVATION DATE (MEASURED 24 HOUR CREATININE CLEARANCE)
Measured Glomerular Filtration Rate details.
To carry the details of the Measured Glomerular Filtration Rate for the patient.
MEASURED GLOMERULAR FILTRATION RATE TYPE CODE
MEASURED GLOMERULAR FILTRATION RATE CORRECTED *
MEASURED GLOMERULAR FILTRATION RATE
OBSERVATION DATE (MEASURED GLOMERULAR FILTRATION RATE)
Blood test observations.
To carry the details of blood tests carried out for the patient.
HEPATITIS B ANTIBODY STATUS (RENAL CARE)
OBSERVATION DATE (HEPATITIS B ANTIBODY)
HEPATITIS B ANTIGEN STATUS (RENAL CARE)
OBSERVATION DATE (HEPATITIS B ANTIGEN)
HEPATITIS C ANTIBODY STATUS (RENAL CARE)
OBSERVATION DATE (HEPATITIS C ANTIBODY)
HUMAN IMMUNODEFICIENCY VIRUS STATUS (RENAL CARE)
OBSERVATION DATE (HUMAN IMMUNODEFICIENCY VIRUS)
SERUM CREATININE CONCENTRATION
OBSERVATION DATE (SERUM CREATININE CONCENTRATION)
SERUM CREATININE CONCENTRATION (PRIOR END STAGE RENAL FAILURE)
SERUM ALBUMIN CONCENTRATION
OBSERVATION DATE (SERUM ALBUMIN CONCENTRATION)
SERUM ALUMINIUM CONCENTRATION
OBSERVATION DATE (SERUM ALUMINIUM CONCENTRATION)
SERUM BICARBONATE CONCENTRATION
OBSERVATION DATE (SERUM BICARBONATE CONCENTRATION) 
BLOOD UREA CONCENTRATION
OBSERVATION DATE (BLOOD UREA CONCENTRATION)
SERUM CALCIUM CONCENTRATION
SERUM CALCIUM CONCENTRATION CORRECTION CODE
OBSERVATION DATE (SERUM CALCIUM CONCENTRATION)
SERUM C-REACTIVE PROTEIN CONCENTRATION
OBSERVATION DATE (SERUM C-REACTIVE PROTEIN CONCENTRATION)
HAEMOGLOBIN CONCENTRATION
OBSERVATION DATE (HAEMOGLOBIN CONCENTRATION)
HbA1c CONCENTRATION (DCCT) or
HbA1c CONCENTRATION (IFCC)
OBSERVATION DATE (HbA1c LEVEL)
HbA1c ASSAY MEASUREMENT METHOD
HYPOCHROMIC RED CELLS PERCENTAGE
OBSERVATION DATE (HYPOCHROMIC RED CELLS PERCENTAGE)
SERUM B12 CONCENTRATION
OBSERVATION DATE (SERUM B12 CONCENTRATION)
TRANSFERRIN SATURATION
OBSERVATION DATE (TRANSFERRIN SATURATION)
RED CELL FOLATE CONCENTRATION
OBSERVATION DATE (RED CELL FOLATE CONCENTRATION)
SERUM FERRITIN CONCENTRATION
OBSERVATION DATE (SERUM FERRITIN CONCENTRATION)
CHOLESTEROL HIGH DENSITY LIPOPROTEIN CONCENTRATION
OBSERVATION DATE (HIGH DENSITY LIPOPROTEIN CHOLESTEROL CONCENTRATION)
CHOLESTEROL LOW DENSITY LIPOPROTEIN CONCENTRATION
OBSERVATION DATE (LOW DENSITY LIPOPROTEIN CHOLESTEROL CONCENTRATION)
CHOLESTEROL TOTAL CONCENTRATION
OBSERVATION DATE (TOTAL CHOLESTEROL CONCENTRATION)
SERUM INTACT PARATHYROID HORMOME CONCENTRATION
OBSERVATION DATE (SERUM INTACT PARATHYROID HORMONE CONCENTRATION)
VITAMIN D CONCENTRATION
OBSERVATION DATE (VITAMIN D CONCENTRATION)
ALKALINE PHOSPHATASE CONCENTRATION
OBSERVATION DATE (ALKALINE PHOSPHATASE CONCENTRATION)
PHOSPHATE CONCENTRATION
OBSERVATION DATE (PHOSPHATE CONCENTRATION)
SODIUM CONCENTRATION
OBSERVATION DATE (SODIUM CONCENTRATION)
TRIGLYCERIDES CONCENTRATION
OBSERVATION DATE (TRIGLYCERIDES CONCENTRATION)
SERUM POTASSIUM CONCENTRATION
OBSERVATION DATE (SERUM POTASSIUM CONCENTRATION)
URIC ACID CONCENTRATION
OBSERVATION DATE (URIC ACID CONCENTRATION)
UREA REDUCTION RATIO
SERUM MAGNESIUM CONCENTRATION
OBSERVATION DATE (SERUM MAGNESIUM CONCENTRATION)
GAMMA GLUTAMYL TRANSFERASE CONCENTRATION
OBSERVATION DATE (GAMMA GLUTAMYL TRANSFERASE CONCENTRATION)
BILIRUBIN CONCENTRATION
OBSERVATION DATE (BILIRUBIN CONCENTRATION)
ALANINE AMINOTRANSFERASE CONCENTRATION
OBSERVATION DATE (ALANINE AMINOTRANSFERASE CONCENTRATION)
ASPARTATE AMINOTRANSFERASE CONCENTRATION
OBSERVATION DATE (ASPARTATE AMINOTRANSFERASE CONCENTRATION)
LACTATE DEHYDROGENASE CONCENTRATION
OBSERVATION DATE (LACTATE DEHYDROGENASE CONCENTRATION)

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NATIONAL RENAL DATA SET - TRANSPLANT

Change to Data Set: Changed Description

National Renal Data Set Overview

Items that are marked * are not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.Items that are marked * were not approved by the Information Standards Board for Health and Social Care as they are under review and will be defined at a later version.

There are two distinct areas of this section, data items to be captured for the recipient of a kidney transplant and the data items to be captured for the donor of that transplant.

Data Set Data Elements
General Transplant details.
To carry the general transplant details for the patient.
SITE CODE (OF UK TRANSPLANT CENTRE) 
UK TRANSPLANT NUMBER 
REFERRAL DATE (TRANSPLANT CONSIDERATION) 
ASSESSMENT DATE (FOR TRANSPLANT SUITABILITY) 
TRANSPLANT WAITING LIST STATUS CODE (RENAL) 
TRANSPLANT WAITING LIST STATUS (CHANGED DATE) 
TRANSPLANT TYPE RECIPIENT REQUIRED CODE 
PROCEDURE DATE (TRANSPLANT) 
SITE CODE (OF SURGERY) 
THEATRE CASE START TIME 
DONOR KIDNEY REMOVED FROM ICE DATE AND TIME 
DONOR KIDNEY PERFUSED WITH RECIPIENT BLOOD DATE AND TIME 
COLD ISCHAEMIC TIME 
Recipient details.
To carry the general details of the donor recipient.
One occurrence of this group is allowed.
LOCAL PATIENT IDENTIFIER (UK TRANSPLANT RECIPIENT NUMBER) 
PANCREAS TRANSPLANT LIST ORGAN OR ISLET CODE 
KIDNEY ONLY TRANSPLANT LIST INDICATOR *
REGISTERED FOR OTHER TRANSPLANT INDICATOR *
REGISTERED FOR OTHER TRANSPLANT TYPE *
PREVIOUS GRAFTS RECEIVED (PANCREAS OR KIDNEY) *
SITE CODE (OF RENAL UNIT) 
SITE CODE (OF RECIPIENT FOLLOW-UP CENTRE) 
RENAL TRANSPLANT ORGAN OR TISSUE TRANSPLANTED CODE 
DIAGNOSIS RENAL PRIMARY OR RECURRENT DISEASE (RENAL RECIPIENT) *
DIAGNOSIS DATE (PRIMARY OR RECURRENT RENAL DISEASE) *
DIAGNOSIS MALIGNANCY WITHIN 3 MONTHS POST TRANSPLANT (RENAL RECIPIENT) *
DIAGNOSIS MALIGNANCY WITHIN 12 MONTHS POST TRANSPLANT (RENAL RECIPIENT) *
DIAGNOSIS DIABETES ONSET SINCE TRANSPLANT (RENAL RECIPIENT) *
DIAGNOSIS PREGNANCY (RENAL RECIPIENT) *
RENAL TRANSPLANT FAILED CAUSE CODE
DIAGNOSIS DATE (RENAL TRANSPLANT FAILED)
DIAGNOSIS ACUTE REJECTION (RENAL RECIPIENT) *
DIAGNOSIS DATE (ACUTE REJECTION INDICATOR)
PROCEDURE INDICATOR (BLOOD TRANSFUSION) *
HYPERTENSION TREATMENT EPISODE (CURRENT) *
TRANSPLANT PATIENT LAST CONTACT DATE 
Recipient procedure details.
To carry the details of the procedures carried out for the recipient.
KIDNEY TRANSPLANTED CODE
PROCEDURE (IMMUNOSUPPRESSIVE OTHER THAN FOR TRANSPLANT) *
PROCEDURE (GRAFT NEPHRECTOMY) *
PROCEDURE DATE (GRAFT NEPHRECTOMY)
Recipient observation details.
To carry the details of the observations carried out for the recipient.
OBSERVATION DATE (GRAFT CLINICAL ASSESSMENT)
BLOOD TEST (CYTOMEGALOVIRUS RECIPIENT)
OBSERVATION DATE (CYTOMEGALOVIRUS)
BLOOD TEST (HEPATITIS B ANTIGEN RECIPIENT)
OBSERVATION DATE (HEPATITIS B ANTIGEN)
BLOOD TEST (CORE ANTIBODY RECIPIENT)
OBSERVATION DATE (CORE ANTIBODY) 
BLOOD TEST (HEPATITIS B E ANTIBODY RECIPIENT)
OBSERVATION DATE (HEPATITIS B E ANTIBODY)
BLOOD TEST (EPSTEIN-BARR VIRUS RECIPIENT)
OBSERVATION DATE (EPSTEIN-BARR VIRUS)
BLOOD TEST (VARICELLA-ZOSTER VIRUS RECIPIENT)
OBSERVATION DATE (VARICELLA-ZOSTER)
DIAGNOSIS CYTOMEGALOVIRUS CODE (RENAL RECIPIENT)
OBSERVATION DATE (CYTOMEGALOVIRUS TYPE)
CYTOMEGALOVIRUS POLYMERASE CHAIN REACTION VIRAL LOAD
OBSERVATION DATE (CYTOMEGALOVIRUS POLYMERASE CHAIN REACTION VIRAL LOAD)
DIAGNOSIS CARDIOVASCULAR COMPLICATIONS (RENAL RECIPIENT)
Recipient Tissue Typing details.
To carry the details of the tissue typing for the recipient.
OBSERVATION DATE (TISSUE TYPING RECIPIENT) 
HUMAN LEUKOCYTE ANTIGEN A BROAD SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN A SPLIT SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN A ALLELE 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN A BROAD SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN A SPLIT SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN A ALLELE 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B BROAD SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B SPLIT SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B ALLELE 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B BROAD SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B SPLIT SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B ALLELE 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN B BW4/BW6 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR BROAD SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR SPLIT SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR ALLELE 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR BROAD SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR SPLIT SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR ALLELE 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DR DR51/52/53/53N RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW BROAD SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW SPLIT SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW ALLELE 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW BROAD SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW SPLIT SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN CW ALLELE 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 BROAD SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 SPLIT SPECIFICITY 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 ALLELE 1 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 BROAD SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 SPLIT SPECIFICITY 2 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN DQB1 ALLELE 2 RECIPIENT
ALLELE DRB3 RECIPIENT
ALLELE DRB4 RECIPIENT
ALLELE DRB5 RECIPIENT
HUMAN LEUKOCYTE ANTIGEN-A MISMATCH INDICATOR 
HUMAN LEUKOCYTE ANTIGEN-B MISMATCH INDICATOR 
HUMAN LEUKOCYTE ANTIGEN-DR MISMATCH INDICATOR 
HUMAN LEUKOCYTE ANTIGEN UNACCEPTABLE SPECIFICITY (ANTIBODY DEFINED) 
HUMAN LEUKOCYTE ANTIGEN UNACCEPTABLE SPECIFICITY (OTHER) 
Recipient immunosuppression and anti rejection details.
To carry the details of the recipient's immunosuppression and anti-rejection (post transplant) observations.
CYCLOSPORINE A 12 HOUR TROUGH LEVEL (RECIPIENT)
OBSERVATION DATE (CYCLOSPORINE A 12 HOUR TROUGH LEVEL)
CYCLOSPORINE A 2 HOUR TROUGH LEVEL C2 (RECIPIENT)
OBSERVATION DATE (CYCLOSPORINE A 2 HOUR LEVEL C2) 
TACROLIMUS 12 HOUR TROUGH LEVEL (RECIPIENT)
OBSERVATION DATE (TACROLIMUS 12 HOUR TROUGH LEVEL)
SIROLIMUS TROUGH LEVEL (RECIPIENT)
OBSERVATION DATE (SIROLIMUS TROUGH LEVEL)
MYCOPHENOLIC ACID TROUGH LEVEL (RECIPIENT)
OBSERVATION DATE (MYCOPHENOLIC ACID TROUGH LEVEL)
PROTEIN CREATININE RATIO
OBSERVATION DATE (PROTEIN CREATININE RATIO)
Donor general details.
To carry the general details of the donor.
LOCAL PATIENT IDENTIFIER (UK TRANSPLANT DONOR NUMBER) 
NHS NUMBER (TRANSPLANT DONOR) 
ORGAN DONOR REGISTER CHECKED INDICATOR *
ORGAN OR TISSUE DONOR NOTIFIED TO UK TRANSPLANT DATE AND TIME 
PERSON AGE IN YEARS AND MONTHS (DONOR) 
PERSON GENDER CODE CURRENT (DONOR) 
ETHNIC CATEGORY (DONOR) 
DONOR BLOOD GROUP ABO CLASSIFICATION
DONOR BLOOD RHESUS CLASSIFICATION
START DATE AND TIME (HOSPITAL PROVIDER SPELL)
SITE CODE (OF DONOR HOSPITAL) 
SITE CODE (OF UK TRANSPLANT ORGAN RETRIEVAL CENTRE) 
CARE PROFESSIONAL JOB ROLE (GRADE OF RETRIEVING SURGEON) 
DIAGNOSIS NORMOTENSIVE (RENAL DONOR) *
DIAGNOSIS DATE (NORMOTENSIVE)
DIAGNOSIS HYPERTENSION (RENAL DONOR) *
DIAGNOSIS DATE (HYPERTENSION)
NUMBER OF DIAGNOSES (HYPOTENSION) 
DIAGNOSIS HYPOTENSION (RENAL DONOR) *
DIAGNOSIS DATE (HYPOTENSION)
NUMBER OF DIAGNOSES (HYPOTENSION) 
DIAGNOSIS CARDIOVASCULAR DISEASE (RENAL DONOR) *
DIAGNOSIS DATE (CARDIOVASCULAR DISEASE)
DIAGNOSIS TUMOUR (RENAL DONOR) *
DIAGNOSIS DATE (TUMOUR)
DIAGNOSIS ALCOHOL ABUSE (RENAL DONOR) * 
DIAGNOSIS DRUG MISUSE (RENAL DONOR) *
DIAGNOSIS URINARY TRACT INFECTION (RENAL DONOR) *
DIAGNOSIS DATE (URINARY TRACT INFECTION)
DIAGNOSIS OTHER PAST MEDICAL HISTORY (RENAL DONOR) *
DIAGNOSIS CHEST INFECTION (RENAL DONOR) *
DIAGNOSIS DATE (CHEST INFECTION)
DIAGNOSIS URINE INFECTION (RENAL DONOR) *
DIAGNOSIS DATE (URINE INFECTION)
DIAGNOSIS ASPIRATION INFECTION (RENAL DONOR) *
DIAGNOSIS DATE (ASPIRATION INFECTION) 
ORGAN OR TISSUE DONOR CONTRAINDICATIONS CODE
DIAGNOSIS DIABETES (RENAL DONOR) *
DIAGNOSIS DATE (DIABETES)
DIAGNOSIS LIVER DISEASE (RENAL DONOR) *
DIAGNOSIS DATE (LIVER DISEASE)
Donor procedure details.
To carry the details of procedures carried out for the donor.
PROCEDURE DATE AND TIME (ORGAN OR TISSUE RETRIEVAL)
PROCEDURE DATE AND TIME (PLACED ON ICE LEFT KIDNEY)
PROCEDURE DATE AND TIME (PLACED ON ICE PANCREAS)
PROCEDURE DATE AND TIME (PLACED ON ICE RIGHT KIDNEY)
PROCEDURE DATE AND TIME (VENTILATION STARTED)
PROCEDURE DATE AND TIME (VENTILATION STOPPED)
NUMBER OF DAYS ON VENTILATION
PROCEDURE DATE AND TIME (COLD PERFUSION)
Donor observation details.
To carry the details of observations carried out for the donor.
PERSON HEIGHT IN CENTIMETRES
OBSERVATION DATE (HEIGHT) 
PERSON WEIGHT (RENAL CARE)
OBSERVATION DATE (WEIGHT)
WAIST MEASUREMENT
OBSERVATION DATE (WAIST MEASUREMENT)
BLOOD PRESSURE AVERAGED
OBSERVATION DATE AND TIME (BLOOD PRESSURE AVERAGED)
BLOOD PRESSURE HIGHEST
OBSERVATION DATE AND TIME (BLOOD PRESSURE HIGHEST)
NUMBER OF MINUTES (BLOOD PRESSURE HIGHEST)
BLOOD PRESSURE LOWEST
OBSERVATION DATE AND TIME (BLOOD PRESSURE LOWEST)
NUMBER OF MINUTES (BLOOD PRESSURE LOWEST)
HEART RATE
OBSERVATION DATE AND TIME (HEART RATE)
TEMPERATURE
OBSERVATION DATE AND TIME (TEMPERATURE)
SMOKING STATUS CIGARETTE SMOKER (TRANSPLANT DONOR) *
OBSERVATION DATE (SMOKING STATUS)
SMOKING STATUS CIGAR OR PIPE SMOKER (TRANSPLANT DONOR) *
OBSERVATION DATE (SMOKING STATUS)
CIGARETTES PER DAY
NUMBER OF YEARS STOPPED SMOKING
START DATE (KIDNEY PERFUSION LEFT KIDNEY)
START TIME (KIDNEY PERFUSION LEFT KIDNEY)
START DATE (KIDNEY PERFUSION RIGHT KIDNEY)
START TIME (KIDNEY PERFUSION RIGHT KIDNEY)
KIDNEY PERFUSION FLUID TYPE
KIDNEY MACHINE PERFUSED INDICATOR *
NUMBER OF MINUTES PERFUSED ON MACHINE
KIDNEY PERFUSION QUALITY INDICATOR (LEFT KIDNEY) *
KIDNEY PERFUSION QUALITY INDICATOR (RIGHT KIDNEY) *
KIDNEY DAMAGE CAPSULE STRIPPED (LEFT KIDNEY) *
KIDNEY DAMAGE CAPSULE STRIPPED (RIGHT KIDNEY) *
KIDNEY DAMAGE CAPSULE TORN (LEFT KIDNEY) *
KIDNEY DAMAGE CAPSULE TORN (RIGHT KIDNEY) *
KIDNEY DAMAGE CUT POLAR ARTERY (LEFT KIDNEY) *
KIDNEY DAMAGE CUT POLAR ARTERY (RIGHT KIDNEY) *
KIDNEY DAMAGE CUT RENAL ARTERY (LEFT KIDNEY) *
KIDNEY DAMAGE CUT RENAL ARTERY (RIGHT KIDNEY) *
KIDNEY DAMAGE RENAL VEIN (LEFT KIDNEY) *
KIDNEY DAMAGE RENAL VEIN (RIGHT KIDNEY) *
KIDNEY DAMAGE PATCH EXCLUDING (LEFT KIDNEY) *
KIDNEY DAMAGE PATCH EXCLUDING (RIGHT KIDNEY) *
KIDNEY DAMAGE PATCH REMOVED (LEFT RENAL ARTERY) *
KIDNEY DAMAGE PATCH REMOVED (RIGHT RENAL ARTERY) *
KIDNEY DAMAGE SMALL HAEMATOMAS (LEFT KIDNEY) *
KIDNEY DAMAGE SMALL HAEMATOMAS (RIGHT KIDNEY) *
KIDNEY DAMAGE URETER STRIPPED (LEFT KIDNEY) *
KIDNEY DAMAGE URETER STRIPPED (RIGHT KIDNEY) *
KIDNEY DAMAGE OTHER DAMAGE TO KIDNEY (LEFT KIDNEY) *
KIDNEY DAMAGE OTHER DAMAGE TO KIDNEY (RIGHT KIDNEY) *
OBSERVATION DATE (FULL BLOOD COUNT TEST)
WHITE BLOOD CELL COUNT
PLATELETS COUNT
OBSERVATION DATE (BLOOD GASES TEST)
FRACTION OF INSPIRED OXYGEN PERCENTAGE
POSITIVE END-EXPIRATORY PRESSURE
SATURATION PERCENTAGE
PH LEVEL
PARTIAL PRESSURE CARBON DIOXIDE
PARTIAL PRESSURE OXYGEN
BICARBONATE CONCENTRATION
BASE EXCESS CONCENTRATION
IMAGING OR RADIODIAGNOSTIC X-RAY (CHEST)
OBSERVATION DATE (CHEST X-RAY)
PHYSIOLOGICAL MEASUREMENT (ELECTROCARDIOGRAM)
OBSERVATION DATE (ELECTROCARDIOGRAM) 
BLOOD TEST (HEPATITIS B ANTIGEN DONOR PRE-TRANSFUSION)
BLOOD TEST (HEPATITIS B ANTIGEN DONOR POST TRANSFUSION)
BLOOD TEST (CORE ANTIBODY PRE-TRANSFUSION)
BLOOD TEST (CORE ANTIBODY POST TRANSFUSION)
BLOOD TEST (HEPATITIS C VIRUS DONOR PRE-TRANSFUSION)
BLOOD TEST (HEPATITIS C VIRUS DONOR POST TRANSFUSION)
BLOOD TEST (HUMAN IMMUNODEFICIENCY VIRUS DONOR PRE-TRANSFUSION)
BLOOD TEST (HUMAN IMMUNODEFICIENCY VIRUS DONOR POST TRANSFUSION)
BLOOD TEST (CYTOMEGALOVIRUS PRE-TRANSFUSION)
BLOOD TEST (CYTOMEGALOVIRUS POST TRANSFUSION)
BLOOD TEST (CYTOMEGALOVIRUS DONOR)
BLOOD TEST (EPSTEIN-BARR VIRUS PRE-TRANSFUSION)
BLOOD TEST (EPSTEIN-BARR VIRUS POST TRANSFUSION)
BLOOD TEST (HUMAN T-CELL LYMPHOTROPIC VIRUS 1 PRE-TRANSFUSION)
BLOOD TEST (HUMAN T-CELL LYMPHOTROPIC VIRUS 1 POST TRANSFUSION)
BLOOD TEST (HUMAN T-CELL LYMPHOTROPIC VIRUS 2 PRE-TRANSFUSION)
BLOOD TEST (HUMAN T-CELL LYMPHOTROPIC VIRUS 2 POST TRANSFUSION)
BLOOD TEST (TOXOPLASMOSIS PRE-TRANSFUSION)
BLOOD TEST (TOXOPLASMOSIS POST TRANSFUSION)
BLOOD TEST (TOXOPLASMOSIS DONOR)
BLOOD TEST (SYPHILIS PRE-TRANSFUSION)
BLOOD TEST (SYPHILIS POST TRANSFUSION)
HAEMOGLOBIN CONCENTRATION
HAEMOGLOBIN CONCENTRATION MEASURED INDICATOR *
OBSERVATION DATE (HAEMOGLOBIN CONCENTRATION)
SERUM CREATININE CONCENTRATION
OBSERVATION DATE (SERUM CREATININE CONCENTRATION)
Donor tissue typing details.
To carry the details of the tissue typing for the donor.
OBSERVATION DATE (TISSUE TYPING DONOR) 
HUMAN LEUKOCYTE ANTIGEN A BROAD SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN A SPLIT SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN A ALLELE 1 DONOR
HUMAN LEUKOCYTE ANTIGEN A BROAD SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN A SPLIT SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN A ALLELE 2 DONOR
HUMAN LEUKOCYTE ANTIGEN B BROAD SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN B SPLIT SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN B ALLELE 1 DONOR
HUMAN LEUKOCYTE ANTIGEN B BROAD SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN B SPLIT SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN B ALLELE 2 DONOR
HUMAN LEUKOCYTE ANTIGEN B BW4/BW6 DONOR
HUMAN LEUKOCYTE ANTIGEN DR BROAD SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DR SPLIT SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DR ALLELE 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DR BROAD SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DR SPLIT SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DR ALLELE 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DR DR51/52/53/53N DONOR
HUMAN LEUKOCYTE ANTIGEN CW BROAD SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN CW SPLIT SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN CW ALLELE 1 DONOR
HUMAN LEUKOCYTE ANTIGEN CW BROAD SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN CW SPLIT SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN CW ALLELE 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 BROAD SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 SPLIT SPECIFICITY 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 ALLELE 1 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 BROAD SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 SPLIT SPECIFICITY 2 DONOR
HUMAN LEUKOCYTE ANTIGEN DQB1 ALLELE 2 DONOR
ALLELE DRB3 DONOR
ALLELE DRB4 DONOR
ALLELE DRB5 DONOR
SITE CODE (OF UK TRANSPLANT TISSUE TYPING CENTRE) 
Donor urine output observation details.
To carry the details of the donor's urine output observations.
URINE OUTPUT LAST 24 HOURS
URINE OUTPUT LAST HOUR
OBSERVATION DATE AND TIME (URINE OUTPUT)
Donor Cadaveric details.
To carry the details of the cadaver donor.
ORGAN OR TISSUE DONOR TYPE (CADAVERIC DONOR) 
PERSON DEATH DATE AND TIME (CERTIFICATION) 
DEATH CAUSE CODE (TRANSPLANT DONOR) 
DEATH LOCATION TYPE (TRANSPLANT DONOR) 
DONOR TRAUMA INJURY INDICATOR (ABDOMEN) *
DONOR TRAUMA INJURY INDICATOR (CHEST) *
DONOR TRAUMA INJURY INDICATOR (HEAD) *
DIAGNOSIS CARDIAC ARREST (RENAL DONOR) *
DIAGNOSIS DATE (CARDIAC ARREST DONOR)
DIAGNOSIS TIME (CARDIAC ARREST DONOR)
NUMBER OF MINUTES (CARDIAC ARREST)
DIAGNOSIS RESPIRATORY ARREST (RENAL DONOR) *
DIAGNOSIS DATE (RESPIRATORY ARREST DONOR)
DIAGNOSIS TIME (RESPIRATORY ARREST DONOR)
NUMBER OF MINUTES (RESPIRATORY ARREST)
PROCEDURE (BLOOD TRANSFUSION DONOR) *
BLOOD TRANSFUSION O NEGATIVE INDICATOR (DONOR) *
BLOOD TRANSFUSION UNITS TRANSFUSED (DURING LAST 3 MONTHS)
BLOOD TRANSFUSION UNITS TRANSFUSED (DURING LAST MONTH)
BLOOD TRANSFUSION UNITS TRANSFUSED (DURING LAST WEEK)
BLOOD TEST PRE-BLOOD TRANSFUSION INDICATOR (DONOR) *
ORGAN OR TISSUE DONATION CONSENT (CORONER) *
ORGAN OR TISSUE DONATION CONSENT (TRANSPLANT) *
ORGAN OR TISSUE DONATION CONSENT (CLINICAL AUDIT) *
ORGAN OR TISSUE DONATION CONSENT (NHS ACADEMIC RESEARCH) *
ORGAN OR TISSUE DONATION CONSENT (COMMERCIAL RESEARCH) *
ORGAN OR TISSUE DONATION CONSENT (TRAINING EDUCATION) *
Further cadaveric donor details.
To carry the details of the retrieved kidneys considered untransplantable and sent for research. Only list the untransplantable kidneys (either individually or en-bloc). If this is both kidneys then the distinction between en-bloc kidneys (one row completed), and separated kidneys (two rows completed) is maintained.
ORGAN OR TISSUE UNSUITABLE ORGAN CODE (RENAL TRANSPLANT) 
ORGAN OR TISSUE UNSUITABLE FOR TRANSPLANTATION REASON CODE 
Cadaver donor procedure details.
To carry the details of the cadaveric donor procedures carried out.
PROCEDURE DATE AND TIME (ESTIMATED DONOR RETRIEVAL)
PROCEDURE (ORGAN OR TISSUE RETRIEVED LEFT KIDNEY) *
PROCEDURE (ORGAN OR TISSUE RETRIEVED RIGHT KIDNEY) *
PROCEDURE (ORGAN OR TISSUE RETRIEVED PANCREAS) *
Cadaver donor observation details.
To carry the details of the observations for the cadaver donor.
OBSERVATION DATE AND TIME (FIRST BRAINSTEM DEATH TEST) 
KIDNEY BRANCHES TIED (LEFT KIDNEY) *
KIDNEY BRANCHES TIED (RIGHT KIDNEY) *
NUMBER OF ARTERIES LEFT KIDNEY (DONOR)
NUMBER OF ARTERIES RIGHT KIDNEY (DONOR)
NUMBER OF ARTERIAL PATCHES LEFT KIDNEY (DONOR)
NUMBER OF ARTERIAL PATCHES RIGHT KIDNEY (DONOR)
NUMBER OF ARTERIES ON PATCH LEFT KIDNEY (DONOR)
NUMBER OF ARTERIES ON PATCH RIGHT KIDNEY (DONOR)
NUMBER OF VEINS LEFT KIDNEY (DONOR)
NUMBER OF VEINS RIGHT KIDNEY (DONOR)
NUMBER OF MINUTES (WARM ISCHAEMIC TIME)
CROSS MATCH MATERIAL INDICATOR (LYMPH NODE LEFT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (LYMPH NODE RIGHT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (SPLEEN LEFT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (SPLEEN RIGHT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (BLOOD LEFT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (BLOOD RIGHT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (CELLS LEFT KIDNEY) *
CROSS MATCH MATERIAL INDICATOR (CELLS RIGHT KIDNEY) *
BLOOD UREA CONCENTRATION (DONOR ON ADMISSION)
BLOOD UREA CONCENTRATION (DONOR ON RETRIEVAL)
GLUCOSE CONCENTRATION (DONOR)
POTASSIUM CONCENTRATION (DONOR ON ADMISSION)
POTASSIUM CONCENTRATION (DONOR ON RETRIEVAL)
SERUM CREATININE CONCENTRATION (DONOR ON ADMISSION)
SERUM CREATININE CONCENTRATION (DONOR ON RETRIEVAL)
SODIUM CONCENTRATION (DONOR ON ADMISSION)
SODIUM CONCENTRATION (DONOR ON RETRIEVAL)
TOTAL PROTEIN CONCENTRATION (DONOR)
SERUM ALBUMIN CONCENTRATION (DONOR)
SERUM CALCIUM CONCENTRATION (DONOR)
PHOSPHATE CONCENTRATION (DONOR)
Cadaveric non heart donor beating details.
To carry the details for the cadaver non heating beating donor.
DIAGNOSIS DATE AND TIME (CARDIAC ARREST UNCONTROLLED DONOR) 
DIAGNOSIS DATE AND TIME (CARDIAC ARREST CONTROLLED DONOR) 
DONOR CATEGORY CODE (NON-HEART BEATING) 
PROCEDURE DATE AND TIME (START RESUSCITATION UNCONTROLLED DONOR) 
PROCEDURE DATE AND TIME (CESSATION OF RESUSCITATION UNCONTROLLED DONOR) 
TREATMENT WITHDRAWN DATE AND TIME 
DIAGNOSIS DATE AND TIME (CIRCULATORY ARREST) 
PROCEDURE DATE AND TIME (VENTILATION CEASED) 
Living donor details.
To carry the details of the living donor.
LAST CONTACT DATE (LIVING DONOR) 
FOLLOW-UP INDICATOR (LIVING DONOR) *
LOST TO FOLLOW-UP INDICATOR (LIVING DONOR) * 
TRANSFERRED FOR FOLLOW-UP INDICATOR (LIVING DONOR) *
PERSON BIRTH DATE (LIVING DONOR) 
PERSON FULL NAME (HUMAN LEUKOCYTE ANTIGEN ASSESSOR) 
SITE CODE (OF DONOR FOLLOW-UP CENTRE) 
PERSON RELATIONSHIP TYPE (DONOR TO RECIPIENT) 
PERSON DEATH DATE (LIVING DONOR) 
PROCEDURE DATE (LIVING DONOR ORGAN DONATION) 
DIAGNOSIS WOUND INFECTION (LIVING DONOR) *
DIAGNOSIS DATE (WOUND INFECTION PERI OR POST OPERATIVE) 
DIAGNOSIS DEEP VEIN THROMBOSIS (LIVING DONOR) * 
DIAGNOSIS DATE (DEEP VEIN THROMBOSIS PERI OR POST OPERATIVE)
DIAGNOSIS PNEUMOTHROAX (LIVING DONOR) *
DIAGNOSIS DATE (PNEUMOTHORAX PERI OR POST OPERATIVE)
DIAGNOSIS PNEUMONIA (LIVING DONOR) *
DIAGNOSIS DATE (PNEUMONIA PERI OR POST OPERATIVE)
DIAGNOSIS PULMONARY THROMBO EMBOLISM (LIVING DONOR) *
DIAGNOSIS DATE (PULMONARY THROMBO EMBOLISM PERI OR POST OPERATIVE)
PRESCRIBED MEDICATION INDICATOR (ANTIHYPERTENSION WITHIN LAST 12 MONTHS LIVING DONOR) *
OTHER POST OR PERI OPERATIVE COMPLICATIONS INDICATOR (LIVING DONOR) *
SUBSEQUENT OPERATION INDICATOR (POST OPERATIVE LIVING DONOR) *
NUMBER OF MONTHS TO RETURN TO PREVIOUS GENERAL ACTIVITY LEVEL 
JOB ROLE (OPERATING SURGEON TYPE FOR DONATION) 
JOB ROLE (ANAESTHETIST TYPE FOR DONATION) 
JOB ROLE (MOST SENIOR SCRUBBED SURGEON FOR DONATION) 
Living donor procedure details.
To carry the procedure details for the living donor.
PROCEDURE (NEPHRECTOMY TYPE) 
PROCEDURE INDICATOR (SPLENECTOMY)  *
Living donor observation details.
To carry the observation details for the living donor.
KIDNEY RETRIEVED CODE
BLOOD TEST (HEPATITIS C VIRUS ANTIBODY DONOR)
HUMAN IMMUNODEFICIENCY VIRUS STATUS (DONOR)
BLOOD TEST (HUMAN T-CELL LYMPHOTROPIC VIRUS)
BLOOD TEST (SYPHILIS DONOR)
NUMBER OF RENAL ARTERIES (DONOR)
BLOOD PRESSURE SITTING
OBSERVATION DATE AND TIME (BLOOD PRESSURE)
URINE DIPSTICK TEST (BLOOD)
OBSERVATION DATE (URINE DIPSTICK TEST BLOOD)
URINE DIPSTICK TEST (PROTEIN)
OBSERVATION DATE (URINE DIPSTICK TEST PROTEIN)
PROTEIN CREATININE RATIO
OBSERVATION DATE (PROTEIN CREATININE RATIO)
ESTIMATED GLOMERULAR FILTRATION RATE
OBSERVATION DATE (ESTIMATED GLOMERULAR FILTRATION RATE)
CALCULATED CREATININE CLEARANCE TYPE 
CALCULATED CREATININE CLEARANCE
OBSERVATION DATE (CALCULATED CREATININE CLEARANCE)
MEASURED CREATININE CLEARANCE
OBSERVATION DATE (MEASURED CREATININE CLEARANCE) 
MEASURED GLOMERULAR FILTRATION RATE CORRECTED *
MEASURED GLOMERULAR FILTRATION RATE
OBSERVATION DATE (MEASURED GLOMERULAR FILTRATION RATE)
ISOTOPIC GLOMERULAR FILTRATION RATE (LIVING DONOR)
OBSERVATION DATE AND TIME (ISOTOPIC GLOMERULAR FILTRATION RATE)
ISOTOPIC GLOMERULAR FILTRATION RATE CORRECTED *

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QUARTERLY MONITORING CANCELLED OPERATIONS DATA SET (QMCO)

Change to Data Set: Changed Description

Quarterly Monitoring Cancelled Operations Data Set (QMCO) Overview

The Quarterly Monitoring Cancelled Operations Data Set (QMCO) carries the data for monitoring key targets and standards on services provided by NHS Trusts and Primary Care Trusts. It should be used to record information on operation cancellations.

Data Set Data Elements
Providing Organisation:
To carry the details of the organisation providing Theatre Services.
One occurrence of this group is permitted.
ORGANISATION CODE (CODE OF PROVIDER)
REPORTING PERIOD START DATE
REPORTING PERIOD END DATE
Cancelled Operations
To carry details on theatres and cancelled operations.
One occurrence of this group is permitted.
OPERATING THEATRE TOTAL
OPERATING THEATRES DEDICATED TO DAY CASES TOTAL
LAST MINUTE CANCELLATIONS FOR NON CLINICAL REASONS TOTAL
FAILURE TO TREAT WITHIN 28 DAYS TOTAL

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KO41(A) 5

Change to Central Return Form: Changed Description

Central Return Form Guidance
 

KO41(a) - Hospital and Community Health Services Complaints

This return is currently under review by the developer, therefore the information should not be used.
For the latest version of the form and further details, please see the Health and Social Care Information Centre website.
  
Part 4: Total Written Complaints received during the year ending 31 March by ethnic category of patient
Ethnic Category of Patients
Total Number of Written Complaints Received By Ethnic Category of Patient
  • If the complainant has not stated their ETHNIC CATEGORY i.e. they were asked and they declined (code 'Z') or it is not known i.e. where the complainant was not asked or the complainant was not in a condition to be asked (code '99'), these should both be recorded as 'Z' on the return. (See Data Set Change Notice 21/2004 and Data Set Change Notice 11/2008 for more information).
  • If the complainant has not stated their ETHNIC CATEGORY i.e. they were asked and they declined (code 'Z') or it is not known i.e. where the complainant was not asked or the complainant was not in a condition to be asked (code '99'), these should both be recorded as 'Z' on the return. (See DSCN 21/2004 and DSCN 11/2008 for more information).

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KO41(A) 6

Change to Central Return Form: Changed Description

Central Return Form Guidance
 

KO41(a) - Hospital and Community Health Services Complaints

This return is currently under review by the developer, therefore the information should not be used.
For the latest version of the form and further details, please see the Health and Social Care Information Centre website.
  
Part 5: Total Written Complaints received during the year ending 31 March by ethnic category of staff involved
Ethnic category of staff involved


  • Enter the total number of WRITTEN COMPLAINTS on HCHS received, which were made against EMPLOYEES in each of the ETHNIC CATEGORIES. This is only for complaints made against an individual as opposed to a service or administrative arrangements.

    If the ETHNIC CATEGORY of staff involved is not stated i.e. they were asked but declined (code 'Z') or it is not known i.e. they were not asked or they not in a condition to be asked (code '99'), these should both be recorded as 'Z' on the return. (See Data Set Change Notice 21/2004 and Data Set Change Notice 11/2008 for more information).

    The total number of WRITTEN COMPLAINTS in part 5 will not necessarily equal the total number of WRITTEN COMPLAINTS in part 1. If the complaint is about two or more members of staff or a team, record the ETHNIC CATEGORY of each member of staff or the team.

  • Enter the total number of WRITTEN COMPLAINTS on HCHS received, which were made against EMPLOYEES in each of the ETHNIC CATEGORIES. This is only for complaints made against an individual as opposed to a service or administrative arrangements.

    If the ETHNIC CATEGORY of staff involved is not stated i.e. they were asked but declined (code 'Z') or it is not known i.e. they were not asked or they not in a condition to be asked (code '99'), these should both be recorded as 'Z' on the return. (See DSCN 21/2004 and DSCN 11/2008 for more information).

    The total number of WRITTEN COMPLAINTS in part 5 will not necessarily equal the total number of WRITTEN COMPLAINTS in part 1. If the complaint is about two or more members of staff or a team, record the ETHNIC CATEGORY of each member of staff or the team.

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ADULT MENTAL HEALTH CARE SPELL

Change to Supporting Information: Changed Description

Adult Mental Health Care Spell is a Care Spell, which is an ACTIVITY GROUP.An Adult Mental Health Care Spell is a Care Spell, which is an ACTIVITY GROUP.

A continuous period of care or assessment for an adult (including elderly) PATIENT provided by a Health Care Provider's specialist mental health services.An Adult Mental Health Care Spell is a continuous period of care or assessment for an adult (including elderly) PATIENT provided by a Health Care Provider's specialist mental health services. This includes the care or assessment of adult and elderly PATIENTS with drug or alcohol dependence but excludes child and adolescent psychiatry PATIENTS and PATIENTS whose only mental disorder is a learning disability. The specialist mental health services are delivered by mental health professionals, some of whom may receive referrals directly.

An Adult Mental Health Care Spell is initiated by a referral, or the temporary or permanent transfer of main responsibility for provision of mental health care for the PATIENT from another Health Care Provider, and ends with a DISCHARGE DATE (MENTAL HEALTH SERVICE).

For referrals, the Adult Mental Health Care Spell commences with an initial assessment which will determine whether treatment or care by the Health Care Provider's specialist mental health services is appropriate. If not appropriate, then the Adult Mental Health Care Spell will end.

 

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ADULT MENTAL HEALTH CARE TEAM

Change to Supporting Information: Changed Description

Adult Mental Health Care Team is a CARE PROFESSIONAL TEAM.An Adult Mental Health Care Team is a CARE PROFESSIONAL TEAM.

An Adult Mental Health Care Team is a team of professionals delivering specialist mental health services, including secondary and self-referral services, for adult and elderly PATIENTS. This includes the care or assessment of adult and elderly PATIENTS with drug or alcohol dependence but excludes child and adolescent psychiatry PATIENTS and PATIENTS with Learning Disabilities.

The Adult Mental Health Care Team can be multidisciplinary and may contain members who are employees of the Health Care Provider or be employees of other NHS or non-NHS ORGANISATIONS.

 

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ADULT MENTAL HEALTH CARE TEAM EPISODE

Change to Supporting Information: Changed Description

An Adult Mental Health Care Team Episode is an ACTIVITY GROUP.

A continuous period of care for a PATIENT by one or more Adult Mental Health Care Teams.An Adult Mental Health Care Team Episode is a continuous period of care for a PATIENT by one or more Adult Mental Health Care Teams.

 

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AMBULANCE SERVICES DATA SET (KA34) OVERVIEW

Change to Supporting Information: Changed Description

This return is out of date therefore the information should not be used.
For the latest version of the guidance, please see the Health and Social Care Information Centre website at: Ambulance Services Collection (KA34).

Contextual Overview
  • The Department of Health requires summary details from NHS Health Care Providers on ambulance activity. The Ambulance Services Data Set (KA34) provides performance management measures of response times; these are also required by NHS Trusts for Ambulance Service internal monitoring and for defining service agreements.
  • The information originally monitored 'Your guide to the NHS' targets and the standards introduced following a review of ambulance performance standards in 1996-97. The standards required that all Ambulance Services would be expected to reach 75% of immediately life-threatening calls within 8 minutes irrespective of location and that all incidents that require a fully equipped Ambulance vehicle (car or Ambulances) must have a vehicle, able to transport the PATIENT in a clinically safe manner (Emergency Ambulance), arrive within 19 minutes of the TRANSPORT REQUEST being made in 95% of cases.
  • The information is required to inform strategic policy development, to provide data to the Care Quality Commission for performance and activity assessment, to ensure that Spending Review bids reflect changes to overall demand and to inform the development of Ambulance Service reference costs.
  • Information based on the data set is published annually in the Health and Social Care Information Centre's Statistical Bulletin 'Ambulance services; England'.
Collection and Submission of the Ambulance Services Data Set (KA34)
Synopsis of the Ambulance Services Data Set (KA34)

Part 1

Emergency and Urgent Calls: 
 The following are sub-divided by RESPONSE CATEGORY A, B and C.
01Total number of emergency and urgent calls received;
02The number of TRANSPORT REQUEST INCIDENTS that resulted in an Emergency Response arriving at the scene of the incident. For RESPONSE CATEGORY A calls, the total of lines 04 and 05 should equal this total;
03The number of TRANSPORT REQUEST INCIDENTS that resulted in an Emergency Response arriving at the scene of the incident within 8 minutes (not required for RESPONSE CATEGORIES B or C calls);
04The number of TRANSPORT REQUEST INCIDENTS where, following the arrival of an Emergency Response, the control room subsequently decided that no Emergency Ambulance was required (not required for RESPONSE CATEGORY C calls);
05The number of TRANSPORT REQUEST INCIDENTS that resulted in an Emergency Ambulance able to transport a PATIENT arriving at the scene of the incident (not required for RESPONSE CATEGORY C calls);
06The number of TRANSPORT REQUEST INCIDENTS that resulted in an Emergency Ambulance able to transport a PATIENT arriving at the scene of the incident within 19 minutes (not required for RESPONSE CATEGORY C calls).;
07The number of calls resolved through telephone advice only (not required for RESPONSE CATEGORIES A or B calls).

Part 1 Additional Guidance

Part 2

Patient Destinations: Emergency and Urgent: 
08Total number of emergency and urgent PATIENT TRANSPORT JOURNEYS to ACCIDENT AND EMERGENCY DEPARTMENT TYPES 1 and 2, sub-divided by RESPONSE CATEGORIES A, B and C.
09Total number of emergency and urgent PATIENT TRANSPORT JOURNEYS to ACCIDENT AND EMERGENCY DEPARTMENT TYPES other than types 1 and 2, sub-divided by RESPONSE CATEGORIES A, B and C.
10Total number of PATIENTS treated at the scene only, sub-divided by RESPONSE CATEGORIES A, B and C.

Part 3

Patient Journeys: Non-Urgent: 
11Total number of non-urgent journeys sub-divided into Special Transport Requests and Planned Transport Requests.

Only the first Emergency Ambulance to arrive at the scene of the TRANSPORT REQUEST INCIDENT should be included in lines 05 and 06 where more than one Emergency Ambulance has been despatched.

Timing of Emergency Response Times

In order to calculate the response time, the 'clock starts' at the TRANSPORT REQUEST CALL CONNECT TIME and the 'clock stops' on the TRANSPORT REQUEST FIRST RESPONSE ARRIVAL TIME or the AMBULANCE ARRIVAL TIME at the scene of the TRANSPORT REQUEST INCIDENT.

An Emergency Response within 8 minutes means 8 minutes 0 seconds (i.e. 480 seconds) or less. Similarly, 19 minutes means 19 minutes 0 seconds or less.

Cross-border Transport Requests

A TRANSPORT REQUEST/TRANSPORT REQUEST INCIDENT that crosses more than one Ambulance Service's boundary should be reported by only one Ambulance Service.

Each NHS Ambulance Service is responsible for reporting on the performance of all Emergency Transport Requests for which it receives the initial TRANSPORT REQUEST. This includes TRANSPORT REQUESTS received by an Ambulance Service that relate to TRANSPORT REQUEST INCIDENTS occurring outside its recognised boundary and TRANSPORT REQUESTS relating to TRANSPORT REQUEST INCIDENTS within or outside its boundary that are subsequently transferred to another Ambulance Service for response.

An Ambulance Service should not report, or report on the performance relating to, any TRANSPORT REQUEST INCIDENT where another Ambulance Service received the initial TRANSPORT REQUEST, even if the TRANSPORT REQUEST was transferred to and dealt with by that Ambulance Service. NHS Trusts responsible for dealing with any cross-border TRANSPORT REQUESTS should advise the NHS Trusts who received the initial TRANSPORT REQUEST of all appropriate clock times for performance reporting purposes.

Where an NHS Ambulance Service asks another NHS Ambulance Service to undertake a TRANSPORT REQUEST on its behalf, the responsibility for dealing with the TRANSPORT REQUEST in the most appropriate way passes to the receiving Ambulance Service once it has accepted it.

Air Ambulances

Air Ambulances are managed locally by Ambulance Services and financed through charitable funding. Any PATIENT TRANSPORT JOURNEY provided by air Ambulance should, therefore, not be included in the Ambulance Services Data Set (KA34).

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APPOINTMENT REQUEST

Change to Supporting Information: Changed Description

An Appointment Request is a type of SERVICE REQUEST for an APPOINTMENT.

Each originating request may result in one or more APPOINTMENT OFFERS, the originating request may be from:

Each Appointment Request should be reviewed by the receiving CARE PROFESSIONAL, ORGANISATION or SERVICE to decide whether an offer of an APPOINTMENT should be made. DECISION TO OFFER AN APPOINTMENT DATE records the date the decision was made to offer an APPOINTMENT.

It is on this date it is considered that the PATIENT has been added to the Out-Patient Waiting List for the APPOINTMENT with the expectation that it will take place.

When it is decided that an offer of an APPOINTMENT should be made then one or more APPOINTMENT OFFER should be offered each of which will record a separate and different APPOINTMENT DATE OFFERED and APPOINTMENT TIME OFFERED to the PATIENT.

The APPOINTMENT DATE OFFERED and APPOINTMENT TIME OFFERED of the APPOINTMENT OFFER equate to the allocated APPOINTMENT SLOT.

When more than one date is offered for the same Appointment Request, the PATIENT can choose which date and time to accept. APPOINTMENT ACCEPTED DATE records whether the offer has been accepted. When multiple dates are offered, the PATIENT should only be allowed to select one of them.

The SERVICE REQUEST DATE and SERVICE REQUEST TIME will also be the default created and recorded date and time for each APPOINTMENT OFFER made for the Appointment Request.

 

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COMMISSIONING DATA SET MANDATED DATA FLOWS

Change to Supporting Information: Changed Description

The minimum Commissioning Data Sets information flow requirement to enable Hospital Episode Statistics, 18 Weeks ACTIVITY reporting, and Payment by Results to be supported by the Secondary Uses Service is shown in the table below.

The Secondary Uses Service supports every CDS TYPE but only a subset is mandated to flow.

Commissioning Data Sets may flow to the Secondary Uses Service using either Net Change or Bulk Replacement Commissioning Data Set Submission Protocols.  Many Standard NHS Contracts between Health Care Providers and the commissioners of their SERVICES, now specify weekly submission of initially-coded data sets to the Secondary Uses Service.  The use of Net Change Commissioning Data Set Submission Protocols is recommended for submissions of this frequency.

CDS TYPE

DESCRIPTION

MIN FREQ

 

DIRECTIVE

 

DATA FLOW

CDS
010
Accident And EmergencyMonthlyAccident and Emergency Attendances were mandated to flow nationally from 1st April 2005, see Data Set Change Notice 32/2004All Accident and Emergency Attendances occurring during the time period being reported and defined by the Commissioning Data Set Submission Protocol being used.
CDS
020
Out-Patient

 
MonthlyOut-Patient Attendance Commissioning Data Sets (including Ward Attenders) were mandated to be submitted to the Secondary Uses Service from 1st October 2001, see Data Set Change Notice 05/2001.

Out-Patient Attendance Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009.

NURSE and MIDWIFE attendances and Attendances for nursing care were enabled to be carried in the Out-Patient Attendance Commissioning Data Set from 1 April 2005, Data Set Change Notice 32/2004. Other Care Professional Attendances where an appropriate Treatment Function exists may also be submitted. 

Out-patient records where the activity relates to the Allied Health Professional Referral To Treatment Measurement standard must be submitted to the Secondary Uses Service (in accordance with ISN ISB0092 Amd 06/2011), and must include the PATIENT PATHWAY data group data items.  Note that this is only supported in Commissioning Data Set version 6-2 onwards, with the introduction of data element WAITING TIME MEASUREMENT TYPE.  Users of CDS 6-1-1 must NOT submit the PATIENT PATHWAY data group for these records.
Due to the high volumes involved, these are often submitted on a weekly basis.
CDS
010
Accident And EmergencyMonthlyAccident and Emergency Attendances were mandated to flow nationally from 1st April 2005, see DSCN 32/2004All Accident and Emergency Attendances occurring during the time period being reported and defined by the Commissioning Data Set Submission Protocol being used.
CDS
020
Out-Patient

 
MonthlyOut-Patient Attendance Commissioning Data Sets (including Ward Attenders) were mandated to be submitted to the Secondary Uses Service from 1st October 2001, see DSCN 05/2001.

Out-Patient Attendance Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009.

NURSE and MIDWIFE attendances and Attendances for nursing care were enabled to be carried in the Out-Patient Attendance Commissioning Data Set from 1 April 2005, DSCN 32/2004 Other Care Professional Attendances where an appropriate Treatment Function exists may also be submitted.

Out-patient records where the activity relates to the Allied Health Professional Referral To Treatment Measurement standard must be submitted to the Secondary Uses Service (in accordance with ISN ISB0092 Amd 06/2011, and must include the PATIENT PATHWAY data group data items.  Note that this is only supported in Commissioning Data Set version 6-2 onwards, with the introduction of data element WAITING TIME MEASUREMENT TYPE.  Users of CDS 6-1-1 must NOT submit the PATIENT PATHWAY data group for these records.
Due to the high volumes involved, these are often submitted on a weekly basis.
CDS
021
Future Out-PatientsAs Required for pilotingFrom 01/01/2008, submissions to support local activities and commissioning will be supported for piloting purposes only. 
CDS
030
Elective Admission List
End of Period
(Standard)
Monthly if usedAll Providers should endeavour to support this data flow.

Elective Admission List End of Period Census (Standard) Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009.

All entries where at the end of the time period being reported and defined by the Commissioning Data Set Submission Protocol, the PATIENT remains on the ELECTIVE ADMISSION LIST.
Optionally and by local agreement with commissioners, entries relating to the PATIENTS that have been removed from the ELECTIVE ADMISSION LIST may be included.
CDS
040
Elective Admission List
End of Period
(New)
Monthly if usedOptionalMay be submitted where the Commissioner has been changed during the time period reported.
CDS
050
Elective Admission List
End of Period
(Old)
Monthly if usedOptionalMay be submitted where the Commissioner has been changed during the time period reported.
CDS
060
Elective Admission List
Event During Period
(Add)
Monthly if usedOptional

Elective Admission List Event During Period (Add) Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009. 

May be submitted where an entry has been added to the ELECTIVE ADMISSION LIST during the time period reported.
CDS
070
Elective Admission List
Event During Period
(Remove)
Monthly if usedOptional

Elective Admission List Event During Period (Remove) Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009. 

May be submitted where an entry has been removed from the ELECTIVE ADMISSION LIST during the time period reported.
CDS
080
Elective Admission List
Event During Period
(Offer)
Monthly if usedOptional

Elective Admission List Event During Period (Offer) CDS records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009. 

May be submitted where an offer has been made during the time period reported.
CDS
090
Elective Admission List
Event During Period
(Available / Unavailable)
Monthly if usedOptionalMay be submitted where a patient becomes Available or Unavailable during the time period reported.
CDS
100
Elective Admission List
Event During Period
(Old Service Agreement)
Monthly if usedOptionalMay be submitted where the Commissioner has been changed during the time period reported.
CDS
110
Elective Admission List
Event During Period
(New Service Agreement)
Monthly if usedOptionalMay be submitted where the Commissioner has been changed during the time period reported.
CDS
120
Finished Birth EpisodeMonthlyAll finished Admitted Patient Care data must be submitted "at least monthly" (EL - Dec 1995).
This includes Non-Contract Activity.
All Episodes that have finished relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
130
Finished General EpisodeMonthlyAll finished Admitted Patient Care data must be submitted "at least monthly" (EL - Dec 1995).

This includes Non-Contract Activity.

Finished General Episode Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009. 

All Episodes that have finished relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
140
Finished Delivery EpisodeMonthlyAll finished Admitted Patient Care data must be submitted at least monthly (EL - Dec 1995).
This includes Non-Contract Activity.
All Episodes that have finished relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
150
Other BirthMonthlyThis includes Home Birth.All Episodes that have finished relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
160
Other DeliveryMonthlyThis includes Home Delivery.All Episodes that have finished relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
170
The Detained and/or Long Term Psychiatric CensusAnnuallyRequired by the Health and Social Care Information Centre.

May optionally be sent more regularly, usually monthly.
Reflects data as at the 31st March each year.
All Episodes that are relevant to the time period defined by the Commissioning Data Set Submission Protocol being used.
CDS
180
Unfinished Birth EpisodeAnnuallyThe Annual Census / Unfinished Census. Required by the Health and Social Care Information Centre.

May optionally be sent more regularly, usually monthly.

Data relating to episodes that were unfinished as at midnight on 31st March and have not been included in the Detained and/or Long Term Psychiatric Census, and have not been submitted to the Secondary Uses Service in either Finished or Unfinished Commissioning Data Set data, must be submitted to the Secondary Uses Service.
CDS
190
Unfinished General EpisodeAnnuallyThe Annual Census / Unfinished Census. Required by the Health and Social Care Information Centre

May optionally be sent more regularly, usually monthly.

Unfinished General Episode Commissioning Data Set records where the activity relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement must include the PATIENT PATHWAY data group items, from 1st October 2009.

Data relating to episodes that were unfinished as at midnight on 31st March and have not been included in the Detained and/or Long Term Psychiatric Census, and have not been submitted to the Secondary Uses Service in either Finished or Unfinished Commissioning Data Set data, must be submitted to the Secondary Uses Service.
CDS
200
Unfinished Delivery EpisodeAnnuallyThe Annual Census / Unfinished Census. Required by the Health and Social Care Information Centre

May optionally be sent more regularly, usually monthly.

Data relating to episodes that were unfinished as at midnight on 31st March and have not been included in the Detained and/or Long Term Psychiatric Census, and have not been submitted to the Secondary Uses Service in either Finished or Unfinished Commissioning Data Set data, must be submitted to the Secondary Uses Service.

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COMMISSIONING DATA SET XML MESSAGE SCHEMA OVERVIEW

Change to Supporting Information: Changed Description

The use of XML was mandated by the e-Government Interoperability Framework (e-GIF) programme as the standard to be used for messaging by government organisations and has accordingly been adopted by the NHS.

For the submission of Commissioning Data Set data to the Secondary Uses Service, XML based messaging has been developed replacing all previously published Commissioning Data Set Message formats.

The CDS-XML Message Schema is supported and applied in the Secondary Uses Service front-end software service (the XML Transfer Service - XTS) to enforce a nationally agreed data specification and thus help protect the data quality and integrity of the data submitted to and stored within the Secondary Uses Service.

It should be noted that after accepting the schema instance data, the Secondary Uses Service then applies further logical data validations and may identify and report further data conditions.

For the most part, the schema applies the data specifications as authorised by the NHS and documented in the NHS Data Model and Dictionary. However, as the NHS Data Model and Dictionary is updated on a continuous time basis and schemas are usually less dynamic and by nature updated on a longer time cycle, there may be subtle differences in the data specifications applied in the schema. However, as the NHS Data Model and Dictionary is updated on a continuous time basis and schemas may be less dynamic and updated on a longer time cycle, there may be subtle differences in the data specifications applied in the schema. For example, additional National Codes may be supported in one version of the Commissioning Data Set XML schema but not in earlier versions. Where this is the case, information relating to the supported National Codes can be found on the CDS Version 6-2 XML Schema Constraints page and associated Attribute and Data Elements.

This variation often applies where a schema may contain historic data element values and the NHS Data Model and Dictionary may have been updated with a revised set of values since the schema was last released.Additionally a schema may deliberately retain historic National Codes as well as supporting the new National Codes in order to enable NHS users to be able to process historic data.

Another variation is where a schema deliberately retains historic values as well as supporting the new values in order to enable NHS users to be able to process historic data.

Schema Standards
The overall standards applied and supported by the schema are:

Note:
e-GIF and the Government Data Standards Catalogue have been archived and are available for reference only.

Schema Naming Conventions
These are in CamelCase as accepted best practice. Wherever possible, schema data item names are compliant (or intuitively identifiable) with the NHS Data Model and Dictionary naming conventions.

Schema Documentation
Schema documentation usually consists of several related publications:

  • Information Standards Notices (ISN)  issued for NHS business, process and definition changes; these will usually include the Data Sets, Data Element definitions etc.
  • Information Standards Notices issued to authorise the CDS-XML Schema itself
  • The CDS-XML Schema Release Notice which provides a technical overview of the release (in MS WORD)
  • The XMLSPY©) generated Schema Documentation which is a large collection of HTML files.
Schema Components: Schema RootSchema Components: Schema Root
The schema root is the control section of the schema and is the only entry point and uses the "XML Include" technique to call all schema sub components:
  • The Standard Data Elements
  • The Standard Data Structures
  • All sub-component schemas for CDS TYPES including the Commissioning Data Set Headers and Trailers

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DAY CARE SESSION

Change to Supporting Information: Changed Description

Day Care Session is a SESSION.A Day Care Session is a SESSION.

A Day Care Session under the control of a CARE PROFESSIONAL, run at a Day Care Facility. Sessions will generally last for half a day, an evening or a whole day.A Day Care Session is under the control of a CARE PROFESSIONAL, run at a Day Care Facility.

PATIENTS participating in a Day Care Session will be recorded as Day Care Attendances.Sessions will generally last for half a day, an evening or a whole day.

Information recorded for a Day Care Session includes:PATIENTS participating in a Day Care Session will be recorded as Day Care Attendances.

DAY CARE FUNCTION
SESSION DATE
SESSION TIME
DAY CARE TOTAL PLACE DAYS AVAILABLE
DAY CARE TOTAL PLACE DAYS CANCELLED   O
 

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FIRST CONTACT IN FINANCIAL YEAR

Change to Supporting Information: Changed Description

An indication of whether the face to face contact is the first occasion on which a PATIENT is seen by the particular Professional Staff Group Service, staff group (community) or Sexual and Reproductive Health Service between 1st April and the following 31st March. This contact may also be the Initial Contact.

An Initial Contact is not necessarily the First Contact In Financial Year as the PATIENT may have had another episode which ended earlier in the financial year.

Classification:

a. Yes
b. No
 

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FRACTION

Change to Supporting Information: Changed Description

A Fraction is a CLINICAL INTERVENTION.

A Fraction is a set of exposures delivered or intended to be delivered to a PATIENT in the course of one visit to a Radiotherapy room.

Note: For technical reasons the Radiotherapy MACHINE TYPE actually used for each EXPOSURE may differ from that indicated when the Fraction was planned.

 

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GENITOURINARY CONSULTANT CLINIC ATTENDANCE

Change to Supporting Information: Changed Description

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MENTAL HEALTH MINIMUM DATA SET OVERVIEW

Change to Supporting Information: Changed Description

The Mental Health Minimum Data Set was introduced by Data Set Change Notice 20/19/P13 in April 2000 in response to the lack of national clinical data collection in the mental health arena, in line with the information requirements of the emerging National Service Framework for Mental Health.The Mental Health Minimum Data Set was introduced by DSCN 20/99/P13 in April 2000 in response to the lack of national clinical data collection in the mental health arena, in line with the information requirements of the emerging National Service Framework for Mental Health.

Since April 2003 (Data Set Change Notice 49/2002) it has been a mandatory requirement that all Providers of specialist adult, including elderly, mental health services submit central Mental Health Minimum Data Set returns on a quarterly basis, with an additional annual submission.Since April 2003 (DSCN 49/2002) it has been a mandatory requirement that all Providers of specialist adult, including elderly, mental health services submit central Mental Health Minimum Data Set returns on a quarterly basis, with an additional annual submission. Prior to April 2013 the frequency of the submission will change to a monthly basis.

The Mental Health Minimum Data Set facilitates the collection of person-focussed clinical data and the sharing of such data to underpin the delivery of mental health care. It is structured around the clinical process and includes an outcome assessment (Health of the Nation Outcome Scale (Working Age Adults), or HoNOS (Working Age Adults)). It records the key role played by partner agencies, particularly social services.

The Mental Health Minimum Data Set describes Adult Mental Health Care Spells. These comprise all interventions made for a PATIENT by a specialist Adult Mental Health Care Team from initial REFERRAL REQUEST to final discharge. For some individuals the Adult Mental Health Care Spell will comprise a short Consultant Out-Patient Episode; for others it may extend over many years and include hospital, community, out-patient and day care episodes.

Information is collected relating to various stages in the journey of the PATIENT, including activity such as Hospital Provider Spells, Consultant Out-Patient Episodes, community care, and NHS day care episodes; mental health reviews and assessments including Care Programme Approach (CPA) and Health of the Nation Outcome Scale (Working Age Adults) contacts with mental health professionals such as care co-ordinators, psychiatric NURSES and CONSULTANTS; and also any diagnosis and treatment.

The prime purpose of the Mental Health Minimum Data Set is to provide local clinicians and managers with better quality information for clinical audit, and service planning and management.

Central collection provides improved national information, facilitating feedback to Trusts, and the setting of benchmarks. It will also allow the delivery of the National Service Framework for Mental Health priorities to be monitored.

The Mental Health Minimum Data Set data is collected from NHS funded providers of specialist mental health services and submitted via the Bureau Services Portal provided by the Systems and Services Delivery (SSD) team.  The Bureau Service processes submissions and produces local extracts for provider and commissioner ORGANISATIONS, and a national pseudonymised extract for the Health and Social Care Information Centre, for storage, analysis and reporting. The Bureau Service processes submissions and produces local extracts for provider and commissioner ORGANISATIONS, and a national pseudonymised extract for the Health and Social Care Information Centre, for storage, analysis and reporting.

Please note that the collection of the Mental Health Minimum Data Set does not replace any other collection of mental health data such as the Admitted Patient Care Commissioning Data Set Type Detained and/or Long Term Psychiatric Census, which should continue to be collected.

For further information on the Mental Health Minimum Data Set, please view the following Health and Social Care Information Centre website: http://www.hscic.gov.uk/mhmdsFor further information on the Mental Health Minimum Data Set, please view the Health and Social Care Information Centre website at: Mental Health Minimum Data Set.

Mental Health Minimum Data Set Version History

Version
 
Date Issued
 
Summary of Changes
 
DSCN / ISN
 
Implementation Date
 
1.0November 1999Introduction of Mental Health Minimum Data Set DSCN 20/99/P13April 2000
1.1June 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 27/2002April 2003
1.2September 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 29/2002April 2003
1.3October 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 48/2002April 2003
2.0October 2002Mental Health Minimum Data Set - Mandatory Central returns. This version of the data set incorporates changes defined in Data Set Change Notice 27/2002, 29/2002 and 48/2002.DSCN 49/2002April 2003
2.1November 2007Introduction of Mental Health Minimum Data Set Version 2.1DSCN 37/2007November 2007
3.0February 2008Introduction of Mental Health Minimum Data Set Version 3.0 - incorporating changes required for Mental Health Act 2007 and Public Service Agreement Delivery Agreement 16 (Social Exclusion)DSCN 06/2008April 2008
3.5November 2010Advance notification of changes to the Mental Health Minimum Data Set to meet Payment by Results requirementsISB 0011
Amd 41/2010
01 April 2011
4.0April 2011Introduction of Mental Health Minimum Data Set (Version 4-0) - incorporating changes required for Payment by Results and reduction of burdenAmd 87/201001 April 2012
4.1November 2012Introduction of Mental Health Minimum Data Set (Version 4-1) - incorporating changes required for the collection of commissioner historyAmd 25/201201 April 2013
1.0November 1999Introduction of Mental Health Minimum Data Set DSCN 20/99/P13April 2000
1.1June 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 27/2002April 2003
1.2September 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 29/2002April 2003
1.3October 2002Data Standards - Changes to Mental Health Minimum Data Set (MHMDS)DSCN 48/2002April 2003
2.0October 2002Mental Health Minimum Data Set - Mandatory Central returns. This version of the data set incorporates changes defined in DSCN 27/2002, DSCN 29/2002 and DSCN 48/2002.DSCN 49/2002April 2003
2.1November 2007Introduction of Mental Health Minimum Data Set Version 2.1DSCN 37/2007November 2007
3.0February 2008Introduction of Mental Health Minimum Data Set Version 3.0 - incorporating changes required for Mental Health Act 2007 and Public Service Agreement Delivery Agreement 16 (Social Exclusion)DSCN 06/2008April 2008
3.5November 2010Advance notification of changes to the Mental Health Minimum Data Set to meet Payment by Results requirementsISB 0011 Amd 41/201001 April 2011
4.0April 2011Introduction of Mental Health Minimum Data Set (Version 4-0) - incorporating changes required for Payment by Results and reduction of burdenISB 0011 Amd 87/201001 April 2012
4.1November 2012Introduction of Mental Health Minimum Data Set (Version 4-1) - incorporating changes required for the collection of commissioner historyISB 0011 Amd 25/201201 April 2013

The full list of documentation related to this standard can be found on the Information Standards Board for Health and Social Care webiste at: Standard ISB 0011

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MENTAL HEALTH RESPONSIBLE CLINICIAN

Change to Supporting Information: Changed Description

A CARE PROFESSIONAL, with a MENTAL HEALTH RESPONSIBLE CLINICIAN PROFESSION within a particular TREATMENT FUNCTION, to act as the clinical supervisor for a Mental Health Care Spell.

A Mental Health Responsible Clinician is a CARE PROFESSIONAL.

A Mental Health Responsible Clinician is a CARE PROFESSIONAL, with a MENTAL HEALTH RESPONSIBLE CLINICIAN PROFESSION within a particular TREATMENT FUNCTION, to act as the clinical supervisor for a Mental Health Care Spell.

There will be only one CARE PROFESSIONAL assigned to a PATIENT as the Mental Health Responsible Clinician at any one time. These assignments may change during the course of a Mental Health Care Spell, though not necessarily at the time of a Care Programme Approach Review.

The role of Mental Health Responsible Clinician was introduced in the Mental Health Act 2007 and replaces the role of the Responsible Medical Officer.

Information recorded for a Mental Health Responsible Clinician includes:

START DATE
END DATE   O
CARE PROFESSIONAL IDENTIFIER of the Mental Health Responsible Clinician
TREATMENT FUNCTION CODE under which the Mental Health Responsible Clinician is acting when treating the PATIENT
MENTAL HEALTH RESPONSIBLE CLINICIAN PROFESSION
 

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MENTAL HEALTH RESPONSIBLE CLINICIAN ASSIGNMENT

Change to Supporting Information: Changed Description

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NATIONAL INTERIM CLINICAL IMAGING PROCEDURE CODE SET

Change to Supporting Information: Changed Description

The National Interim Clinical Imaging Procedure Code Set (NICIP Code Set) is a comprehensive national standard set of codes and descriptions for imaging procedures and is maintained by the UK Terminology Centre.  It is intended for use in all Imaging Department information systems.

The NICIP Code Set has been approved by the Information Standards Board for Health and Social Care (ISB) and is mandated for all in-scope use cases.The NICIP Code Set was approved by the Information Standards Board for Health and Social Care (ISB) and is mandated for all in-scope use cases. Further detail about the initial information standard and subsequent amendments can be found on the Information Standards Board for Health and Social Care website at: ISB 0148 "Interim Clinical Imaging Procedure Codes".

The NICIP Code Set is released biannually. The release dates are the 1st of April and the 1st of October each year.

All versions of the NICIP Code Set, both with and without SNOMED CT maps, are only available from the Technology Reference Data Update Distribution Service (TRUD).

Clinicians and system managers working with the Picture Archiving and Communication Systems (PACS) and Radiology Information Systems (RIS) can make requests for additions to the NICIP Code Set. All requests must first be checked for conformance to the Editorial Principles.

Requests for changes to the NICIP Code Set should be made via the Information Standards Service Desk and clearly marked “Diagnostic Imaging."

For further information on the National Interim Clinical Imaging Procedure Code Set, see the UK Terminology website.

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OPERATING THEATRE SESSION

Change to Supporting Information: Changed Description

Operating Theatre Session is a SESSION.An Operating Theatre Session is a SESSION.

A period of OPERATING THEATRE time allocated to one or more consultant firms (CONSULTANT).An Operating Theatre Session is a period of OPERATING THEATRE time allocated to one or more consultant firms (CONSULTANT).

A SESSION is either scheduled or unscheduled.

  • A scheduled session is when the allocation of time is made to one CONSULTANT whose firm is responsible for the utilisation of this session. It does not include time made available for an operation on a particular PATIENT unless the operation is included in a scheduled session as above and performed by a member of a consultant firm of the same TREATMENT FUNCTION CODE as that allocated to the session.
  • An unscheduled session is when an allocation of time is made available for one or more Theatre Cases in any circumstances outside a scheduled session as above. Theatre Cases in unscheduled sessions may be the responsibility of different CONSULTANTS.

A scheduled session is when the allocation of time is made to one CONSULTANT whose firm is responsible for the utilisation of this session. It does not include time made available for an operation on a particular PATIENT unless the operation is included in a scheduled session as above and performed by a member of a consultant firm of the same TREATMENT FUNCTION CODE as that allocated to the session.

An unscheduled session is when an allocation of time is made available for one or more Theatre Cases in any circumstances outside a scheduled session as above. Theatre Cases in unscheduled sessions may be the responsibility of different CONSULTANTS.

An Operating Theatre Session may under/over-run the allocated time. The allocation, i.e. consultant firm, time and/or theatre may change by agreement any time before the session starts.

An Operating Theatre Session should be considered cancelled if the time slot allocation is not used to perform at least one operation.

 

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PRIMARY PROCEDURE DATE

Change to Supporting Information: Changed Description

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REFERRAL TO TREATMENT CLOCK STOP ADMINISTRATIVE EVENT

Change to Supporting Information: Changed Description

Data Set Change Notice 18/2006 published in December 2006, defined essential new data items required to support the measurement of 18 week REFERRAL TO TREATMENT PERIODS (monitoring of DH PSA target 13 - "By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment"). In particular, the Data Set Change Notice 18/2006 introduced the following new data items.DSCN 18/2006 published in December 2006, defined essential new data items required to support the measurement of 18 week REFERRAL TO TREATMENT PERIODS (monitoring of DH PSA target 13 - "By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment").

In particular, DSCN 18/2006 introduced the following new data items.

Strategic reporting of 18 weeks will be undertaken by the Secondary Uses Service using data obtained via the Commissioning Data Sets. The new data items defined in Data Set Change Notice 18/2006 are enabled to flow in Commissioning Data Set versions 6-1 and 6-2, and will continue to flow in subsequent versions. The data items defined in DSCN 18/2006 are enabled to flow in Commissioning Data Set versions 6-1 and 6-2, and will continue to flow in subsequent versions.

However, an event which results in an update to the REFERRAL TO TREATMENT PERIOD STATUS may occur outside the events that are defined in the Commissioning Data Sets (typically Outpatient or Inpatient encounters) and will therefore not flow to the Secondary Uses Service. These types of events have been termed as "administrative events". They can be defined as any communication event between the Health Care Provider and the PATIENT that occurs outside of an outpatient attendance or inpatient admission and that results in the PATIENT's REFERRAL TO TREATMENT PERIOD STATUS being changed to stop the 18 week clock. These events are not face to face consultations and do not necessarily involve clinical staff.

These Referral To Treatment Clock Stop Administrative Events may be carried using the Commissioning Data Set Type 020 Outpatient record type. They are differentiated from PATIENT contact ACTIVITY by the FIRST ATTENDANCE value carried within them. FIRST ATTENDANCE national code 5 "Referral to treatment clock stop administrative event" signifies that an ACTIVITY has taken place which has ended the REFERRAL TO TREATMENT PERIOD and changed the REFERRAL TO TREATMENT PERIOD STATUS to one of the following:

When to Use Referral To Treatment Clock Stop Administrative Events

These events may happen because:

Secondary Uses Service Processing

The Secondary Uses Service currently processes the following Commissioning Data Set record types in order to build Referral To Treatment pathways.

All other types are not currently processed and so if they carry the  REFERRAL TO TREATMENT PERIOD END DATE for a REFERRAL TO TREATMENT PERIOD, a Referral To Treatment Clock Stop Administrative Event must also be sent in order to inform the Secondary Uses Service of the clock stop.

Note that future versions of the Secondary Uses Service will also process:

The dates when ORGANISATIONS submitting REFERRAL TO TREATMENT PERIOD data to the Secondary Uses Service can cease having to also send a Referral To Treatment Clock Stop Administrative Event when a clock stop is carried in one of the Elective Admission List Commissioning Data Set Types, will be notified as part of the Secondary Uses Service release documentation. It is also anticipated that CDS V6-2 Type 021 - Future Outpatient CDS will be processed once piloting is complete and its use is approved by the Information Standards Board for Health and Social Care. A cancelled future APPOINTMENT record could carry a REFERRAL TO TREATMENT PERIOD Clock Stop. Again the timescales will be notified as part of the Secondary Uses Service release documentation.

There are no current plans for the Secondary Uses Service to process the remaining Commissioning Data Set Types:

This is because a Referral To Treatment Clock Stop Administrative Event occurring in the scenarios where these record types are generated, would be rare. However this will be reviewed as part of the ongoing maintenance of the Referral To Treatment Clock Stop Administrative Event, and the requirements for the Secondary Uses Service.

When NOT to Use a Referral To Treatment Clock Stop Administrative Event

The Referral To Treatment Clock Stop Administrative Event should NOT be used to correct previously submitted records where a REFERRAL TO TREATMENT PERIOD END DATE was submitted incorrectly to the Secondary Uses Service.

For example, if an Out-Patient Appointment took place where First Definitive Treatment was started, but the REFERRAL TO TREATMENT PERIOD END DATE was not sent in the corresponding CDS V6-1 Type 020 - Outpatient Commissioning Data Set/ CDS V6-2 Type 020 - Outpatient Commissioning Data Set record as it was not entered on the Patient Administration System until later; then the CDS V6-1 Type 020 - Outpatient Commissioning Data Set/CDS V6-2 Type 020 - Outpatient Commissioning Data Set record should be resubmitted with the correct data. A Referral To Treatment Clock Stop Administrative Event should NOT be used.

Where an ORGANISATION's Patient Administration System supports the submission of cancelled and Did Not Attend appointments in the CDS V6-1 Type 020 - Outpatient Commissioning Data Set/CDS V6-2 Type 020 - Outpatient Commissioning Data Set, the Referral To Treatment Clock Stop Administrative Event should NOT be used when a PATIENT has a booked Out-Patient Appointment, which is then cancelled because, for example, the PATIENT dies. In these cases the CDS V6-1 Type 020 - Outpatient Commissioning Data Set/CDS V6-2 Type 020 - Outpatient Commissioning Data Set can carry the details of a cancelled CARE ACTIVITY, including the REFERRAL TO TREATMENT PERIOD END DATE and update to the REFERRAL TO TREATMENT PERIOD STATUS. (Note - not all Patient Administration Systems provide functionality to create and submit Commissioning Data Set records for cancellations/Did Not Attend's as this is not yet mandated - you should contact your Patient Administration System support team to ascertain whether your Patient Administration System supports this. If not, then it is permissible to send a Referral To Treatment Clock Stop Administrative Event in order to stop the clock in the Secondary Uses Service instead).

Referral To Treatment Clock Stop Administrative Events only require a sub-set of the data elements contained in the CDS V6-1 Type 020 - Outpatient Commissioning Data Set / CDS V6-2 Type 020 - Outpatient Commissioning Data Set record, to be submitted to the Secondary Uses Service. All other data elements not listed should be omitted from the XML submission of the CDS V6-1 Type 020 - Outpatient Commissioning Data Set/CDS V6-2 Type 020 - Outpatient Commissioning Data Set record to the Secondary Uses Service. The submission of a Referral To Treatment Clock Stop Administrative Event is not reliant on the use of the Net Change Commissioning Data Set Submission Protocol to the Secondary Uses Service

The required data elements making up a Referral To Treatment Clock Stop Administrative Event are:

Data Element Required

Notes

UNIQUE BOOKING REFERENCE NUMBER (CONVERTED) or PATIENT PATHWAY IDENTIFIERThe Commissioning Data Set Schema versions 6-1-1 and 6-2 require EITHER the PATIENT PATHWAY IDENTIFIER, or the UNIQUE BOOKING REFERENCE NUMBER (CONVERTED) to be populated.
ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER)If the UNIQUE BOOKING REFERENCE NUMBER (CONVERTED) is used, the ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER) should contain X09 (which relates to the Choose and Book system)
REFERRAL TO TREATMENT STATUS (CDS V6-1) or REFERRAL TO TREATMENT PERIOD STATUS (CDS V6-2)This should contain only one of the following codes to signify that the REFERRAL TO TREATMENT PERIOD has ended:
WAITING TIME MEASUREMENT TYPE (CDS V6-2 only)This item is XML mandatory in the CDS V6-2 schema (but is not present in the CDS V6-1 schema).
REFERRAL TO TREATMENT PERIOD START DATE  
REFERRAL TO TREATMENT PERIOD END DATE  
NHS NUMBER  

NHS NUMBER STATUS INDICATOR (CDS V6-1) or NHS NUMBER STATUS INDICATOR CODE (CDS V6-2)

 
POSTCODE OF USUAL ADDRESS  
ORGANISATION CODE (PCT OF RESIDENCE) (CDS V6-1 only) 
ORGANISATION CODE (RESIDENCE RESPONSIBILITY) (CDS V6-2 only) 
FIRST ATTENDANCE  (CDS V6-1) or FIRST ATTENDANCE CODE (CDS V6-2)This should always hold the National code 5 - "Referral to Treatment Period Clock Stop Administrative Event"
APPOINTMENT DATEThis field is XML mandatory in Commissioning Data Set Schema versions 6-1-1 and 6-2 for Type 020 Outpatients, and for the purposes of the Referral To Treatment Clock Stop Administrative Event, should hold the same date as the REFERRAL TO TREATMENT PERIOD END DATE 
AGE AT CDS ACTIVITY DATE This field is XML mandatory in the Commissioning Data Set Schema versions 6-1-1 and 6-2 for Type 020 Outpatients, and should hold the PATIENTS age at REFERRAL TO TREATMENT PERIOD END DATE
ORGANISATION CODE (CODE OF PROVIDER)This field is not XML mandatory in the Commissioning Data Set version 6-1-1 schema but is required by the Secondary Uses Service for processing of all records.  It is XML mandatory in the CDS V6-2 schema
ORGANISATION CODE (CODE OF COMMISSIONER) This field is not XML mandatory in the Commissioning Data Set version 6-1-1 schema but is required by the Secondary Uses Service for processing of all records.  It is XML mandatory in the CDS V6-2 schema

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REGULAR ATTENDER EPISODE

Change to Supporting Information: Changed Description

Regular Attender Episode is an ACTIVITY GROUP.A Regular Attender Episode is an ACTIVITY GROUP.

This is a period of care for a regular day attender attending one or more Day Care Facilities of a Health Care Provider within a particular day care function. Regular day attenders are PATIENTS attending a Day Care Facility who are not currently using a Hospital Bed or on Home Leave or on Mental Health Leave of Absence for a period of 28 days or less.A Regular Attender Episode is a period of care for a regular day attender attending one or more Day Care Facilities of a Health Care Provider within a particular day care function.

Regular Attender Episodes must be made up of one or more Day Care Attendances.Regular day attenders are PATIENTS attending a Day Care Facility who are not currently using a Hospital Bed or on Home Leave or on Mental Health Leave of Absence for a period of 28 days or less.

Information recorded for a Regular Attender Episode includes:Regular Attender Episodes must be made up of one or more Day Care Attendances.

EPISODE NUMBER
DAY CARE FUNCTION
End Date   O
Start Date
 

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SPECIALIST COMMUNITY PUBLIC HEALTH NURSE

Change to Supporting Information: Changed Description

A Specialist Community Public Health Nurse is a type of CARE PROFESSIONAL.A Specialist Community Public Health Nurse is a CARE PROFESSIONAL.

A PERSON whose name is registered in the Specialist Community Public Health Nurse's part of the Nursing and Midwifery Council Register maintained by the Nursing and Midwifery Council.A Specialist Community Public Health Nurse is a PERSON whose name is registered in the Specialist Community Public Health Nurse's part of the Nursing and Midwifery Council Register maintained by the Nursing and Midwifery Council.

The Specialist Community Public Health Nursing Committee's definition of Specialist Community Public Health Nursing is:

"Specialist Community Public Health Nursing aims to reduce health inequalities by working with individuals, families, and communities promoting health, preventing ill health and in the protection of health. The emphasis is on partnership working that cuts across disciplinary, professional and organisational boundaries that impact on organised social and political policy to influence the determinants of health and promote the health of whole populations". 

For further information on the Specialist Community Public Health Nursing Committee, see the Nursing and Midwifery Council website.

There are currently four types of Specialist Community Public Health Nurses listed on the Nursing and Midwifery Council Register:

 

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SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: FAMILY HEALTH NURSE

Change to Supporting Information: Changed Description

A Specialist Community Public Health Nurse: Family Health Nurse is a CARE PROFESSIONAL.

Since 2001 the World Health Organisation Health Organisation Europe’s Family Specialist Community Public Health Nurse - Family Health Nurse role has been developing in remote and rural areas of Scotland.

In 2003, an independent evaluation identified a need for facilitation of the Specialist Community Public Health Nurse - Family Health Nurse role and family-health orientated approaches with local primary health care teams. The Scottish Executive Health Department appointed three part-time, regionally-based Family Health Practice Development Facilitators (FHPDFs)  in December 2003 to work over an 18-month period. The Scottish government are currently exploring the possibility of rolling out the model across Scotland.

 

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SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: HEALTH VISITOR

Change to Supporting Information: Changed Description

A Specialist Community Public Health Nurse: Health Visitor is a CARE PROFESSIONAL. 

A Specialist Community Public Health Nurse - Health Visitor is a qualified and registered NURSE or MIDWIFE who is specially trained to assess the health needs of individuals, families and the wider community by offering practical help and advice.

The role involves visiting people in their homes, in particular new parents and children under five, as well as working with other sections of the community. Working as a Specialist Community Public Health Nurse - Health Visitor may also include tackling the impact of social inequality on health, and working closely with at-risk or deprived groups.

 

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SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: OCCUPATIONAL HEALTH NURSE

Change to Supporting Information: Changed Description

A Specialist Community Public Health Nurse: Occupational Health Nurse is a CARE PROFESSIONAL.

Specialist Community Public Health Nurse - Occupational Health Nurses work in a variety of settings mainly industry, health services, commerce, and education. They can be employed as independent practitioners or as part of a larger occupational health service team, often attached to a personnel department. Specialist Community Public Health Nurse - Occupational Health Nurses are considered to be leaders in public health in the workplace setting.  

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SPECIALIST COMMUNITY PUBLIC HEALTH NURSE: SCHOOL NURSE

Change to Supporting Information: Changed Description

A Specialist Community Public Health Nurse: School Nurse is a CARE PROFESSIONAL.

Specialist Community Public Health Nurse - School Nurses provide a variety of services such as:

  • providing health and sex education within Schools
  • carrying out developmental screening
  • undertaking health interviews, administering immunisation programmes etc.
Specialist Community Public Health Nurse - School Nurses can be employed either by the Local Health Authority, Primary Care Trust, NHS Trust or sometimes by the School directly. 

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WHAT'S NEW: MARCH 2014  renamed from WHAT'S NEW: FEBRUARY 2014

Change to Supporting Information: Changed Name, Description

Release: March 2014

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1388 (1 April 2014) - ISB 0090 Amd 17/2013 Updates to the Cancer Outcomes and Services Data Set and XML Schema
  • CR1370 (1 April 2014) - ISB 0090 Amd 17/2013 Updates to the Systemic Anti-Cancer Therapy Data Set and XML Schema
  • CR1322 (1 April 2014) - ISB 0090 Amd 17/2013 Changes to the Radiotherapy Data Set
  • CR1387 (1 April 2014) - ISB 0084 Amd 10/2013 Introduction of OPCS-4.7
  • CR1376 (1 April 2014) - ISB 1607 Amd 26/2013 Emergency Care Weekly Situation Report Data Set
  • CR1433 (Immediate) - DDCN 1433/2014 Data Services for Commissioners
  • CR1467 (1 April 2014) - DDCN 1467/2014 Retirement of Standards
  • CR1464 (1 April 2014) - DDCN 1464/2014 Retirement of Standards - Domains and Diagrams
  • CR1458 (1 April 2014) - DDCN 1458/2014 Retirement of Standards - DSCNs - 11/97/P05, 12/97/P06, 15/97/P09, 18/97/P12, 22/96/P19, 32/96/P27, 49/97/P35, 62/95/P51, 07/2007, 08/2009, 17/92, 20/2001, 22/2006 and 38/2002
  • CR1444 (1 April 2014) - DDCN 1444/2014 Retirement of Standards
  • CR1436 (1 April 2014) - DDCN 1436/2014 Retirement of Standards
  • CR1435 (1 April 2014) - DDCN 1435/2014 Retirement of Standards - DSCNs 22/95/P21, 20/91, 21/93, 40/95/P34, 09/94/P04, 93/95/P76, 23/94/A04, 8/92 and 17/93
  • CR1432 (1 April 2014) - DDCN 1432/2014 Retirement of Standards - DSCN 3/92, DSCN 12/96/P11, DSCN 50/94/P36, DSCN 66/96/W09 and DSCN 16/93
  • CR1429 (1 April 2014) - DDCN 1429/2014 Retirement of Standards - DSCN 07/96/P06
  • CR1425 (1 April 2014) - DDCN 1425/2014 Retirement of Standards
  • CR1423 (1 April 2014) - DDCN 1423/2014 Retirement of Standards - DSCNs 37/98/A09, 14/97/P08, 12/2002, 37/2003, 14/2004 and 27/2001
  • CR1419 (1 April 2014) - DDCN 1419/2014 Retirement of Standards - DSCNs 39/98/A11, 09/99/P06, 11/99/P07, 13/2003, 38/2001, 22/2001, 19/98/A02, 40/96/P34, 29/94/P19, 49/94/P35, 34/95/P29, 53/96/P44 and 96/95/P79
  • CR1418 (1 April 2014) - DDCN 1418/2014 Retirement of Standards
  • CR1417 (1 April 2014) - DDCN 1417/2014 Retirement of Standards - DSCNs 13/95/P12, 44/2001, 29/2004, 18/98/W02 and 24/98/F01
  • CR1416 (1 April 2014) - DDCN 1416/2014 Retirement of Standards - KC64 - DSCNs 05/98/P05 and 26/95/W02
  • CR1414 (1 April 2014) - DDCN 1414/2014 Retirement of Standards - DSCNs 03/99/P03, 10/2002, 12/99/A04, 20/98/A03, 30/98/P21, 35/99/P25, 37/97/P24 and 43/97/P29
  • CR1413 (1 April 2014) - DDCN 1413/2014 Retirement of Standards - DSCNs 13/97/P07, 15/96/P14, 17/2001, 20/2004, 21/2001, 21/2003, 28/98/P20, 33/2003 and 43/2002
  • CR1409 (1 April 2014) - DDCN 1409/2014 Retirement of Standards - DSCN's 46/97/P32, 01/2004, 04/2004, 11/2005, 27/2002, 31/2002, 53/2002 and 54/2002

Release: February 2014

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1460 (Immediate) - DDCN 1460/2014 NHS Dental Services Update
  • CR1459 (Immediate) - DDCN 1459/2014 General Medical Practitioner (Specified), Doctor Index Number and General Medical Practitioner PPD Code Update
  • CR 1446 (Immediate) - DDCN 1446/2014 Health and Social Care Information Centre Update
  • CR1404 (Immediate) - DDCN 1404/2014 Retirement of e-Gif definitions
  • CR1395 (28 February 2014) - ISB 0090 Amd 17/2013 Organisation Data Service – NHS Postcode Directory

Release: January 2014

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1386 (31 January 2014) - ISB 0090 Amd 9/2013 Special Health Authority (SpHA) Code Structure Change
  • CR1443 (Immediate) - DDCN 1443/2014 Change of name of the National Institute for Health and Clinical Excellence
  • CR1441 (Immediate) - DDCN 1441/2014 Retirement of Review of Central Returns (ROCR) - Central Return Form KH03A
  • CR1440 (Immediate) - DDCN 1440/2014 Retirement of Review of Central Returns (ROCR) - Genitourinary Medicine Access Monthly Monitoring Data Set
  • CR1439 (Immediate) - DDCN 1439/2013 Retirement of Review of Central Returns (ROCR) Returns
  • CR1405 (Immediate) - DDCN 1405/2013 Overseas Visitors
  • CR1393 (Immediate) - DDCN 1393/2013 Amendment to Inter-Provider Transfer Administrative Minimum Data Set Overview
  • CR1392 (Immediate) - DDCN 1392/2013 Review of Central Returns (ROCR) Discontinuations - Referral to Treatment Performance Sharing Data Set
  • CR1391 (Immediate) - DDCN 1391/2013 Review of Central Returns (ROCR) Discontinuations - Referral to Treatment (RTT) Summary Patient Tracking List Data Set

The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 June 2014:

Release: November 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1424 (Immediate) - DDCN 1424/2013 Application Identifier (GS1)
  • CR1367 (29 November 2013) - ISB 0090 Amd 5/2013 Organisation Data Service - Introduction of New Sub Type Identifier for Private Dental Practices
  • CR1359 (29 November 2013) - ISB 0090 Amd 47/2012 Organisation Data Service - Identification Codes for Local Authorities
  • CR1407 (Immediate) - DDCN 1407/2013 Clinical Investigations
  • CR1415 (Immediate) - DDCN 1415/2013 Area Teams
  • CR1411 (Immediate) - DDCN 1411/2013 Update to Supporting Information: SNOMED CT®

Release: September 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1348 (1 October 2013) - ISB 1597 Amd 35/2012 Breast Screening Programmes Data Set (KC63 and KC62)
  • CR1403 (Immediate) - DDCN 1403/2013 Religious or Other Belief System Affiliation
  • CR1384 (Immediate) - DDCN 1384/2013 Health and Social Care Information Centre Rebranding of XML Schemas
  • CR1397 (Immediate) - DDCN 1397/2013 Retired Main Specialty Codes

Release: July 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1377 (Immediate) - ISB 0105 Retirement of Accident and Emergency Quarterly Monitoring Data Set (QMAE)

Release: May 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: April 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1372 (Immediate) - DDCN 1372/2013 Organisation Update: April 2013
  • CR1369 (Immediate) - DDCN 1369/2013 Organisation Codes and Organisation Types
  • CR1347 (1 April 2013) - ISB 1521 Amd 40/2012 Updates to the Cancer Outcomes and Services Data Set and XML Schema

Release: March 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: February 2013

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1336 (Immediate) - DDCN 1336/2013 XML Schema Constraint Pages
  • CR1362 (Immediate) - DDCN 1362/2013 Update to Organisations in the NHS Data Model and Dictionary
  • CR1246 (Immediate) - DDCN 1246/2013 Guidance for Merging Organisations
  • CR1345 (Immediate) - DDCN 1345/2013 e-Government Interoperability Framework (e-GIF) and Government Data Standards Catalogue
  • CR1354 (Immediate) - DDCN 1354/2013 Treatment Function Code - Well Babies

Release: December 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1155 (Immediate) - ISB 1567 Amd 12/2011 National Joint Registry Data Set Version 5
  • CR1324 (1 December 2012) - ISB 1067 Amd 23/2012 Workforce Data Set Version 2.5
  • CR1196, CR1287 and CR1195 (1 January 2013) - ISB 1521 Amd 64/2010 Cancer Outcomes and Services Data Set, Cancer Outcomes and Services Data Set Message and Retirement of Cancer Registration Data Set and National Cancer Data Set

The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2013:

  • CR1337 (1 April 2013) - ISB 1072 Amd 30/2012 Update to Child and Adolescent Mental Health Services Secondary Uses Data Set

Release: November 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1166, CR1167 and CR1306 (1 November 2012) - ISB 0092 Amd-16-2010 Commissioning Data Set Version 6-2, Commissioning Data Set XML Message Version 6-2 and Retirement of CDS 6-0
  • CR1305 (1 April 2013) - ISB 0092 Amd 06/2011 Allied Health Professions Referral to Treatment (AHP RTT) Update - CDS 6-2
  • CR1286 (1 November 2012) - ISB 0028 Amd 17/2012 Treatment Function Codes Update
  • CR1343 (Immediate) - DDCN 1343/2012 Change of name for NHS Commissioning Board Authority
  • CR1342 (Immediate) - DDCN 1342/2012 Overseas Visitors Update
  • CR1341 (Immediate) - DDCN 1341/2012 Discharge Default Code Descriptions
  • CR1323 (Immediate) - National Cancer Waiting Times Monitoring Data Set Update for "Delay Reason To Treatment For Cancer"

CR1323 is a corrigendum to CR1258 (1 July 2012) - ISB 0147 Amd 23/2011 Changes to the National Cancer Waiting Times Monitoring Data Set published in the June 2012 release

The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2013:

  • CR1231 and CR1288 (1 April 2013) - ISB 1570 Amd 164/2010 HIV and AIDS Reporting Data Set and HIV and AIDS Related Data Set Message

Release: September 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1103 (Immediate) - ISB 0066 Amd 43/2010 Renal Data Set - Data Item Addition, Changes and Deletions
  • CR1334 (Immediate) - DDCN 1334/2012 Psychology Definitions
  • CR1331 (Immediate) - DDCN 1331/2012 Activity Date Time Type
  • CR1329 (Immediate) - DDCN 1329/2012 Change of name for "Health and Social Care Information Centre"

Release: August 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1326 (Immediate) - DDCN 1326/2012 Health and Care Professions Council
  • CR1241 (Immediate) - DDCN 1241/2012 NHS dictionary of medicines and devices
  • CR1292 (Immediate) - ISB 1549 Amd 4/2011 and DDCN 1292/2012 Deprecation and withdrawal of version 3.2 of the Acute Myocardial Infarction Data Set and subsequent retiring of the Data Set from the NHS Data Model and Dictionary

Release: June 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1314 (Immediate) - DDCN 1314/2012 Reasonable Offer Update
  • CR1282 (29 June 2012) - ISB 0090 Amd 36/2011 Independent Sector Healthcare Provider (ISHP) Codes extended for ISHPs and Sites
  • CR1258 (1 July 2012) - ISB 0147 Amd 23/2011 Changes to the National Cancer Waiting Times Monitoring Data Set

Release: May 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1215 (1 June 2012) - ISB 1067 Amd 30/2011 National Workforce Data Set

    The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2013:

  • CR1028 (1 April 2013) - ISB 1069 Amd 14/2012 Children and Young People's Health Services Data Set
  • CR1029 (1 April 2013) - ISB 1072 Amd 12/2012 Child and Adolescent Mental Health Services (CAMHS) Data Set
  • CR1104 (1 April 2013) - ISB 1513 Amd 13/2012 Maternity Secondary Uses Data Set

Release: March 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: January 2012

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: November 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1264 (Immediate) - ISB 1077 Amd 3/2012 Automatic Identification and Data Capture (AIDC) for Patient Identification Data Set
  • CR1274 (Immediate) - DDCN 1274/2011 CDS Prime Recipient Identity Update

    The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012:

  • CR1265 (1 April 2012) - ISB 1520 Amd 29/2011 Changes to the Improving Access to Psychological Therapies Data Set

Release: October 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1271 (Immediate) - DDCN 1271/2011 Commissioning Data Set Addressing Grid Update
  • CR1268 (Immediate) - DDCN 1268/2011 Sexual Orientation Code
  • The following has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012:

  • CR1158 and CR1260 (1 April 2012) - ISB 1533 Amd 63/2010 Systemic Anti-Cancer Therapy Data Set and Systemic Anti-Cancer Therapy Data Set Message Schema

    The following have been incorporated early to allow users to see the changes, but please note that the implementation date is 1 July 2012:

  • CR1270 (1 July 2012) - ISB 1080 Amd 25/2011 Amendments to NHS Health Check Data Set
  • CR1250 (1 July 2012) - ISB 1080 Amd 25/2011 NHS Health Checks Data Set Message Schema Version 2.0.0

Release: August 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1232 (Immediate) - ISB 0034 Amd 26/2006 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) - NHS Data Model and Dictionary Overview
  • CR1222 (1 April 2012) - ISB 0021 Amd 86/2010 Introduction of the International Classification of Diseases Tenth Revision 4th Edition
  • CR1190 (1 September 2011) - ISB 1538 Amd 131/2010 Chlamydia Testing Activity Data Set
  • CR1188 (Immediate) - Amd 85/2010 Genitourinary Medicine Clinic Activity Data Set (GUMCAD) Extension to include Enhanced Sexual Health Services (ESHS)

The following data set is initially being introduced for local use only. A future Information Standards Notice will be published to notify providers and system suppliers of the requirement to flow the data set nationally:

Release: July 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1249 (Immediate) - DDCN 1249/2011 General Pharmaceutical Council Registration Changes

The following has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 July 2012:

Release: June 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1256 (Immediate) - DDCN 1256/2011 School Definitions
  • CR1117 (26 August 2011) - ISB 0090 Amd 94/2010 Organisation Data Service Identification Codes for Local Authorities in England and Wales
  • CR1251 (Immediate) - DDCN 1251/2011 Change to the Format/Length of Weekly Hours Worked
  • CR1243 (Immediate) - DDCN 1243/2011 National Interim Clinical Imaging Procedure (NICIP) Code Set

Release: April 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1154 (1 April 2011) - ISB 0011 Amd 87/2010 Mental Health Minimum Data Set Version 4.0
  • CR1234 (Immediate) - DDCN 1234/2011 Technology Reference Data Update Distribution Service (TRUD)
  • CR1168 (Immediate) - ISB 0097 Amd 140/2010 Genitourinary Medicine Access Monthly Monitoring Data Set Amendments - Removal of Human Immunodeficiency Virus data

The following has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012:

Release: March 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: January 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1116 (1 April 2010) - ISB 0003 Amd 79/2010 Immunisation Programmes Activity Data Set (KC50)
  • CR1112 (1 April 2010) - ISB 1511 Amd 26/2010 NHS Continuing Healthcare and NHS Funded Nursing Care
  • CR1068 (Immediate) - ISB 0133 Amd 161/2010 Change To Central Return: Human Papillomavirus (HPV) Immunisation Programme - Vaccine Monitoring Minimum Data Set
  • CR1211 (Immediate) - DDCN 1211/2010 Commissioning Data Set Addressing Grid / Organisation Code (Code of Commissioner) Update

Release: December 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

Release: November 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1119 (Immediate) - DDCN 1119/2010 Organisation Codes Update 
  • CR1192 (Immediate) - DDCN 1192/2010 Change of name for "Health Solution Wales"
  • CR1199 (Immediate) - DDCN 1199/2010 General Pharmaceutical Council and Royal Pharmaceutical Society of Great Britain Update
  • CR1189 (Immediate) - DDCN 1189/2010 National Institute for Health and Clinical Excellence
  • CR1187 (Immediate) - DDCN 1187/2010 Introduction of the Department for Education

Release: September 2010

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1128 (Immediate) - DDCN 1128/2010 Changes to reporting procedures for Overseas Visitors from the European Economic Area and Switzerland
  • CR1173 (Immediate) - DDCN 1173/2010 Care Quality Commission Update
  • CR1143 (Immediate) - DDCN 1143/2010 General Pharmaceutical Council
  • CR1061 (1 October 2010) - ISB 0092/2010 CDS Type 20: Out-patient: Retirement of Default Codes for Out-patient Procedures
  • CR1133 (Immediate) - ISB 00289/2010 National Specialty List

Release: August 2010

  • The August 2010 Release introduces the NHS Data Model and Dictionary Help Pages.

Release: July 2010

Information Standards Notices and Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

Release: May 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

Release: March 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1123 (1 April 2010) - DSCN 18/2010 Information Standards Notice (ISN)
  • CR1139 (Immediate) - DSCN 16/2010 Person Weight
  • CR1130 (Immediate) - DSCN 15/2010 Change of name for "The NHS Information Centre for health and social care"
  • CR1013 (April 2010) - DSCN 14/2010 Sexual and Reproductive Health Activity Dataset (SRHAD)
  • CR1125 (Immediate) - DSCN 13/2010 NHS Data Model and Dictionary Maintenance Update - Policy Definitions
  • CR1122 (Immediate) - DSCN 11/2010 Changes to Family Planning References

Release: January 2010

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1115 (Immediate) - DSCN 10/2010 Data Standards: Updating of e-Government Interoperability Framework and Government Data Standards Catalogue References

Release: December 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1100 (Immediate) - DSCN 25/2009 NHS Prescription Services Update
  • CR1045 (1 December 2009) - DSCN 17/2009 Referral to Treatment Clock Stop Administrative Event
  • CR1003 (1 December 2009) - DSCN 16/2009 Commissioning Data Sets: Mandation of 18 Week Referral To Treatment Data Items

Release: November 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1113 (Immediate) - DSCN 24/2009 Information Standards Board for Health and Social Care Update
  • CR1087 (Immediate) - DSCN 23/2009 Health Professions Council Update
  • CR1081 (Immediate) - DSCN 22/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
  • CR1019 (27 November 2009) - DSCN 21/2009 Data Standards: Organisation Data Service (ODS) - Optical Sites and Optical Headquarters
  • CR1034 (27 November 2009) - DSCN 20/2009 Data Standards: Organisation Data Service (ODS) - Care Homes in England and Wales and their Headquarters

Release: September 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1065 (1 October 2009) - DSCN 15/2009 Data Standards: Organisation Data Service, Local Health Boards

Release: June 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1014 (1 June 2009) - DSCN 13/2009 Religious and Other Belief System Affiliation
  • CR1074 (Immediate) - DSCN 12/2009 Data Standards: Care Quality Commission
  • CR1056 (Immediate) - DSCN 11/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
  • CR1072 (1 December 2009) - DSCN 10/2009 Data Standards: National Radiotherapy Data Set
  • CR1073 (Immediate) - DSCN 09/2009 Central Returns: Diagnostic Waiting Times and Activity Data Set
  • CR1066 (Immediate) - DSCN 08/2009 Data Standards: NHS Prescription Services and NHS Dental Services
  • CR1047 (1 April 2011) - DSCN 07/2009 Data Standards: Diabetic Retinopathy Screening Dataset v3.6 
  • CR1059 (Immediate) - DSCN 06/2009 Data Standard: National Workforce Data Set v2.1
  • CR914 (April 2008 (Retrospective)) - DSCN 05/2009 NHS Stop Smoking Services Quarterly Monitoring Return
  • CR899 (Immediate) - DSCN 02/2009 NHS Data Model and Dictionary Maintenance Update

Release: March 2009

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1001 (1 April 2009) - DSCN 03/2009 Introduction of Commissioning Data Set Schema Version 6-1 (2008-04-01) and update to Commissioning Data Set Schema Version 6-0 (2008-01-14)
  • CR976 (31 March 2009) - DSCN 26/2008 Subject: KP90 - Admissions, Changes in Status and Detentions under the Mental Health Act
  • CR1017 (1 April 2009) - DSCN 25/2008 Critical Care Minimum Data Set
  • CR1002 (1 April 2009) - DSCN 24/2008 Data Standards: Introduction of Commissioning Dataset Version 6.1
  • CR1016 (Immediate) - DSCN 23/2008 4 Byte Version of the Read Codes - Withdrawal

Release: December 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1022 (1 January 2009) - DSCN 29/2008 Data Standards: 18 Weeks Referral to Treatment (RTT) Time, Performance Sharing
  • CR901 (Immediate) - DSCN 28/2008 Removal of references to EDIFACT and the NHS Wide Clearing Service (NWCS) 
  • CR843 (1 April 2009) - DSCN 22/2008 Data Standards: National Radiotherapy Data Set
  • CR1011 (1 January 2009) - DSCN 20/2008 Data Standards: National Cancer Waiting Times Minimum Data Set 

Release: November 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1026 (3 November 2008) - DSCN 21/2008 Information Standard: Mental Health Act 2007 Mental Category

Release: August 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR1018 (Immediate) - DSCN 19/2008 Data Standards: Change of Name for National Administrative Code Services (NACS) to Organisation Data Service (ODS)
  • CR956 (1 September 2008) - DSCN 18/2008 Central Return: Human Papillomavirus (HPV) Immunisation Programme, Vaccine Monitoring Minimum Dataset
  • CR861 (Immediate) - DSCN 16/2008 Central Return:  Hospital and Community Services Complaints and General Practice (including Dental) Complaints - KO41(a) and KO 41(b)
  • CR964 (Immediate) - DSCN 14/2008 Central Return: 18 Weeks ‘Adjusted’ Referral to Treatment (RTT) Dataset
  • CR965 (Immediate) - DSCN 13/2008 Data Standards: Organisation Data Service (ODS) - Change to the Default Codes Set to Support Changes to GMS Contract
  • CR879 (Immediate) - DSCN 12/2008 Data Standards: Quarterly Monitoring: Cancelled Operations Data Set (QMCO)

Release: May 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR502 (Immediate) - DSCN 10/2008 Data Standards: National Workforce Data Definitions (v2.0)
  • CR910 (1 April 2008) - DSCN 08/2008 Data Standards: National Direct Access Audiology Patient Tracking List (PTL) and Waiting Times (WT) data sets
  • CR900 (Immediate) - DSCN 07/2008 Data Standards: Inter-Provider Transfer Administrative Minimum Data Set
  • CR934 (1 April 2008) - DSCN 06/2008 Data Standards: Mental Health Minimum Data Set (version 3.0)
  • CR935 (Immediate) - DSCN 05/2008 Data Standards: 18 Weeks Rules Suite
  • CR925 (1 September 2008) - DSCN 04/2008 Genitourinary Medicine Clinic Activity Data Set Change to an Information Standard
  • CR942 (1 June 2008) - DSCN 03/2008 General Practice and General Medical Practitioner (GMP) - changes resulting from the introduction of the General Medical Services (GMS) Contract

Release: February 2008

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR812 (Immediate) - DSCN 01/2008 Central Return: Diagnostics Waiting Times Census Data Set
  • CR881 (31 December 2007) - DSCN 42/2007 Central Return: Referral To Treatment Summary Patient Tracking List
  • CR904 (Immediate) - DSCN 41/2007 Data Standards: Admission Intended Procedure Update
  • CR824 (1 February 2008) - DSCN 39/2007 Data Standards: 48 Hour Genitourinary Medicine Access Monthly Monitoring (GUMAMM)

Release: November 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR919 (Immediate) - DSCN 38/2007 Data Standards: Mental Health Minimum Data Set Schema
  • CR814 (1 April 2008) - DSCN 37/2007 Data Standards: Introduction of Mental Health Minimum Data Set version 2.1
  • CR930 (31 December 2007) - DSCN 35/2007 Data Standards: A correction to the version 6 Commissioning Data Set schema
  • CR834 (Immediate) - DSCN 34/2007 Data Standards: Referral Request Received Date
  • CR875 (Immediate) - DSCN 33/2007 Data Standards: National Administrative Codes Service: Introduction of codes for the new Pan SHAs
  • CR880 (Immediate) - DSCN 29/2007 Data Standards: Amendments to Doctor Index Number (DIN) Description

Release: August 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR845 (Immediate) - DSCN 28/2007 Data Standards: Treatment Function Code (Referral to Treatment Period)
  • CR831 (1 October 2007) - DSCN 27/2007 Data Standards: Update to Commissioning Data Set XML Schema v5
  • CR825 (1 October 2007) - DSCN 16/2007 Data Standards: Source of Referral for Outpatients (18 Weeks)

Release: June 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR799 (31 December 2007) - DSCN 18/2007 Data Standards: Introduction of Commissioning Data Set Version 6
  • CR833 (Immediate) - DSCN 17/2007 Data Standards: Introduction of Commissioning Data Set validation table
  • CR801 (Immediate) - DSCN 15/2007 Data Standards: Cover of Vaccination Evaluated Rapidly (COVER) Return

Release: May 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR800 (31 December 2007) - DSCN 14/2007 Commissioning Data Set Schema Version 6-0
  • CR856 (1 October 2007) - DSCN 13/2007 Data Standards: Discharge Ready Date
  • CR869 (Immediate) - DSCN 12/2007 Data Standards: Update to Clinical Coding Introduction
  • CR827 (1 October 2007) - DSCN 09/2007 Data Standards: Earliest Reasonable Offer Date
  • CR817 (1 October 2007) - DSCN 08/2007 Data Standards: Introduction of Age into Commissioning Data Sets
  • CR849 (May 2007) - DSCN 07/2007 National Administrative Codes Service: Introduction of new identification codes for Dental Consultants
  • CR822 (Immediate) - DSCN 06/2007 Data Standards: Update to Organisation Codes
  • CR850 (Immediate) - DSCN 05/2007 National Administrative Codes Service: Amendments to Default Codes
  • CR786 (1 April 2007) - DSCN 04/2007 Quarterly Monitoring Accident and Emergency Services (QMAE) Central Return

Release: February 2007

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR811 (Immediate) - DSCN 03/2007 Diagnostic Waiting Times and Activity
  • CR826 (1 October 2007) - DSCN 02/2007 Extension of Treatment Function to Support the Measurement of 18 Week Referral to Treatment Periods
  • CR813 (1 April 2007) - DSCN 01/2007 Paediatric Critical Care Minimum Data Set
  • CR768 (1 January 2007) - DSCN 18/2006 Changes to the NHS Data Dictionary to support the measurement of 18 week referral to treatment periods
  • CR798 (6 November 2006) - DSCN 19/2006 Commissioning Data Set (CDS) Version 5 XML Message Schema
  • CR776 (1 October 2006) - DSCN 05/2006 Data Standards: Accident and Emergency Enhancements to Investigation and Treatment Codes

Release: September 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR795 (31 October 2006) - DSCN 22/2006 Organisation Codes / Organisation Site Codes
  • CR792 (1 April 2007) - DSCN 15/2006 Neonatal Critical Care
  • CR719 (1 April 2006) - DSCN 09/2006 Measuring and Recording of Waiting Times
  • CR791 (1 April 2007) - DSCN 13/2006 Priority Type
  • CR774 (1 September 2006) - DSCN 12/2006 Person Marital Status

Release: May 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR764 (1 April 2006) - DSCN 08/2006 Diagnostics waiting times and activity
  • Correction to menu structure to include Critical Care Minimum Data Set

Release: April 2006

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR608 (1 October 2006) - DSCN 07/2006 Introduction of Commissioning Data Set Version 5 and its associated XML schema into the NHS Data Dictionary.
  • CR756 (1 September 2005) - DSCN 19/2005 PbR Commissioning for Out of Area Treatments (OATs) and Charge-Exempt Overseas Visitors
  • CR724 (1 April 2006) - DSCN 13/2005 Critical Care Minimum Data Set
  • CR754 (1 April 2006) - DSCN 17/2005 Treatment Function and Main Specialty Code Revisions
  • CR763 (1 April 2006) - DSCN 20/2005 New Treatment Functions for therapy services and anticoagulant service
  • CR767 (Immediate) - DSCN 02/2006 Referral Request Received Date
  • CR690 (1 September 2005) - DSCN 16/2005 Marital Status

Release: August 2005

Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

  • CR555 (1 April 2005) - DSCN 11/2005 Data Standards: COVER - Hepatitis B immunisation for babies
  • CR715 (Immediate) - DSCN 10/2005 Data Standards: Treatment Function Codes - correction and clarification of names and descriptions
  • CR706 (1 April 2005) - DSCN 09/2005 Data Standards: Cancer Registration Data Set
  • CR691 (1 July 2005) - DSCN 06/2005 Data Standards: NSCAG Commissioner Code

For all Information Standards Notices and Data Set Change Notices, see the Information Standards Board for Health and Social Care Website.

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ADDRESS IN GEOGRAPHIC AREA (RETIRED)

Change to Class: Changed Relationships

Each ADDRESS IN GEOGRAPHIC AREA (retired)
Kmust be for one and only one ADDRESS

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APPOINTMENT

Change to Class: Changed Description

An arrangement for a PATIENT to be seen by or be in contact with one or more CARE PROFESSIONALS.An arrangement for a PATIENT to be seen by or be in contact with one or more CARE PROFESSIONALS, following an Appointment Request.

An APPOINTMENT becomes an entry on the APPOINTMENT WAITING LIST when it is decided that an offer of an APPOINTMENT should be made following a SERVICE REQUEST for an out-patient APPOINTMENT being received. The offer of an APPOINTMENT is made by one or more APPOINTMENT OFFERS.

APPOINTMENTS include:

APPOINTMENTS are also made for Screening Tests and Day Care Attendances.

When a PATIENT accepts an APPOINTMENT OFFER the APPOINTMENT DATE OFFERED and APPOINTMENT TIME OFFERED of the offer become the APPOINTMENT DATE and APPOINTMENT TIME of the accepted APPOINTMENT.

Where more than one APPOINTMENT OFFER has been made for an APPOINTMENT and one has been accepted all the others for the same APPOINTMENT should be refused.

The APPOINTMENT should be removed from the APPOINTMENT WAITING LIST when the APPOINTMENT has taken place.

A series of APPOINTMENTS should relate to the same SERVICE REQUEST which initiated the series within the ORGANISATION. The SERVICE REQUEST may be related to a previous SERVICE REQUEST either from within the same or another ORGANISATION and be related to subsequent SERVICE REQUEST to the same or another ORGANISATION.

 

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CARE PROFESSIONAL TEAM MEMBER

Change to Class: Changed Attributes

Attributes of this Class are:
KCARE PROFESSIONAL TEAM MEMBER START DATE
CARE PROFESSIONAL TEAM MEMBER END DATE

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CLINICAL CLASSIFICATION

Change to Class: Changed Description

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CLINICAL INTERVENTION

Change to Class: Changed Attributes

Attributes of this Class are:
ABDOMINAL XRAY PERFORMED REASON
ABDOMINAL XRAY PERFORMED TO INVESTIGATE ABDOMINAL SIGNS INDICATOR
ABLATIVE THERAPY TYPE
ACCIDENT AND EMERGENCY INVESTIGATION
ACCIDENT AND EMERGENCY TREATMENT
ANAESTHESIA TYPE IN LABOUR AND DELIVERY
ANAESTHETIC METHOD TYPE FOR DIALYSIS ACCESS CONSTRUCTION
ANAESTHETIC TYPE FOR JOINT REPLACEMENT
ANTI CANCER REGIMEN NUMBER
ARTERIOVENOUS GRAFT MATERIAL TYPE
ARTIFICIAL RUPTURE OF MEMBRANES REASON CODE
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE
ASSOCIATED PROCEDURE TYPE FOR ANKLE REPLACEMENT
BILIARY STENT INSERTION REASON
BIOLOGICAL RESURFACING TYPE
BLOOD FLOW RATE
BLOOD TRANSFUSION PRODUCT TYPE
BLOOD TRANSFUSION TYPE
BLOOD TRANSFUSION UNITS TRANSFUSED
BONEGRAFT INDICATOR FOR JOINT REPLACEMENT
BONEGRAFT INDICATOR FOR REVISION ANKLE REPLACEMENT
BONEGRAFT TYPE FOR JOINT REPLACEMENT
BRACHYTHERAPY TYPE
BREAST ASSESSMENT OUTCOME
BREAST SCREENING TEST OUTCOME
CANCER IMAGING MODALITY
CANCER TREATMENT MODALITY
CHEMICAL THROMBO PROPHYLAXIS REGIME TYPE
CHEMO RADIATION INDICATOR
CHEMOTHERAPY ACTUAL DOSE
CHEST DRAIN IN SITU INDICATOR
CLINICAL INTERVENTION TYPE
CLINICAL INVESTIGATION NOT PERFORMED REASON CODE FOR MATERNITY
CO MORBIDITY ADJUSTMENT INDICATOR
COMPLICATION TYPE FOR RENAL DIALYSIS ACCESS
COMPONENT REMOVAL INDICATOR
CONTINUOUS INFUSION OF PULMONARY VASODILATOR RECEIVED INDICATOR
CONTINUOUS POSITIVE AIRWAY PRESSURE DELIVERY MODE
CONTRACEPTION METHOD STATUS
CYTOLOGY SCREENING ACTION TYPE
DELIVERED IN WATER INDICATOR
DELIVERY INSTRUMENT TYPE
DELIVERY OF PLACENTA METHOD
DRUG ADMINISTRATION DURATION
DRUG ADMINISTRATION STATUS
DRUG DAYS SUPPLY
DRUG DOSAGE AND ADMIN SPECIFICATION
DRUG IDENTIFICATION
DRUG INFORMATION COMMENT
DRUG INFORMATION TYPE
DRUG QUANTITY SUPPLIED
DRUG REGIMEN ACRONYM
DRUG TREATMENT INTENT
ENDOSCOPIC OR RADIOLOGICAL COMPLICATION TYPE
ENDOSCOPIC PROCEDURE TYPE
ENTERAL FEEDING METHOD
ENTERAL FEED TYPE GIVEN
EPISIOTOMY PERFORMED REASON CODE
EXCISION TYPE
FETAL ORDER
FIRST DEFINITIVE TREATMENT PROVIDED
FIRST DIAGNOSTIC TEST
FIXATION TYPE FOR ELBOW OR SHOULDER REPLACEMENT
FORMULA MILK OR MILK FORTIFIER TYPE
FRACTION NUMBER
HIP SURGERY PATIENT POSITION
IMAGE GUIDED SURGERY INDICATOR
IMAGING ANATOMICAL SITE
IMAGING INTERVENTION INDICATOR
IMAGING MODALITY
IMAGING OR RADIODIAGNOSTIC EVENT INDICATION CODE FOR RENAL CARE
IMMUNITY TEST RESULT
INFECTION CULTURE TEST INDICATOR
INTERVENTION SESSION TYPE
INTRAPARTUM ANTIBIOTICS GIVEN INDICATOR
JOINT REPLACEMENT REVISION REASON CODE FOR ANKLE
JOINT REPLACEMENT REVISION REASON CODE FOR ELBOW
JOINT REPLACEMENT REVISION REASON CODE FOR HIP
JOINT REPLACEMENT REVISION REASON CODE FOR KNEE
JOINT REPLACEMENT REVISION REASON CODE FOR SHOULDER
KIDNEY TRANSPLANTED CODE
LABOUR FIRST STAGE LENGTH
LABOUR OR DELIVERY ONSET METHOD
LABOUR SECOND STAGE LENGTH
LAPAROTOMY FOR NECROTISING ENTEROCOLITIS INDICATION CODE
LONG HEAD BICEPS TENOTOMY INDICATOR
MARGIN INVOLVED INDICATION CODE
MATERNAL CRITICAL INCIDENT TYPE CODE
MECHANICAL THROMBO PROPHYLAXIS REGIME TYPE
MINIMALLY INVASIVE SURGERY INDICATOR
MORE THAN THREE RECTAL WASHOUTS RECEIVED INDICATOR
NEOADJUVANT THERAPY INDICATOR
NEONATAL CRITICAL INCIDENT TYPE CODE
NEONATAL RESUSCITATION METHOD
NEONATAL RESUSCITATION METHOD FOR NATIONAL NEONATAL DATA SET
NEPHRECTOMY TYPE
NEURODEVELOPMENTAL ASSESSMENT ALREADY TAKEN INDICATOR
NEWBORN HEARING INCOMPLETE REASON CODE
NEWBORN HEARING SCREENING TEST TYPE
NITRIC OXIDE GIVEN INDICATOR
NUMBER OF TELETHERAPY FIELDS
OPPORTUNISTIC SCREENING TYPE
PAIN RELIEF TYPE IN LABOUR AND DELIVERY
PARENTAL CONSENT TO ADMINISTER VITAMIN K INDICATOR
PARENTAL CONSENT TO POST MORTEM INDICATOR
PARENTERAL NUTRITION RECEIVED INDICATOR
PATHOLOGY INVESTIGATION PRIORITY
PATHOLOGY RESULT REPORTED DATE
PATIENT PROCEDURE PERFORMED INDICATOR
PATIENT PROCEDURE TYPE FOR PRIMARY ANKLE REPLACEMENT
PATIENT PROCEDURE TYPE FOR PRIMARY ELBOW REPLACEMENT
PATIENT PROCEDURE TYPE FOR PRIMARY HIP REPLACEMENT
PATIENT PROCEDURE TYPE FOR PRIMARY KNEE REPLACEMENT
PATIENT PROCEDURE TYPE FOR PRIMARY SHOULDER REPLACEMENT
PATIENT PROCEDURE TYPE FOR REVISION ANKLE REPLACEMENT
PATIENT PROCEDURE TYPE FOR REVISION ELBOW REPLACEMENT
PATIENT PROCEDURE TYPE FOR REVISION HIP REPLACEMENT
PATIENT PROCEDURE TYPE FOR REVISION KNEE REPLACEMENT
PATIENT PROCEDURE TYPE FOR REVISION SHOULDER REPLACEMENT
PERFORATIONS OR SEROSAL INVOLVEMENT INDICATION CODE
PERITONEAL DIALYSIS CATHETER INSERTION TECHNIQUE
PERITONEAL DIALYSIS CATHETER TYPE
PLANE OF SURGICAL EXCISION TYPE
PLANNED TREATMENT CHANGE REASON
POST MORTEM CARRIED OUT INDICATOR
POST MORTEM CONFIRMED NECROTISING ENTEROCOLITIS DIAGNOSIS INDICATOR
POST MORTEM TYPE
PREVIOUS BONY INFECTION INDICATOR OF TIBIA OR HINDFOOT
PREVIOUS FRACTURE INDICATOR FOR ANKLE REPLACEMENT
PREVIOUS SURGERY TYPE FOR ANKLE JOINT
PREVIOUS SURGERY TYPE FOR SHOULDER REPLACEMENT
PRINCIPAL DIAGNOSTIC IMAGING TYPE
PROCEDURE RENAL DIALYSIS ACCESS REPAIR OR REVISION TYPE
PROCEDURE SIDE RENAL DIALYSIS ACCESS CONSTRUCTION CODE
PROCEDURE SITE RENAL DIALYSIS ACCESS CONSTRUCTION CODE
RADIOISOTOPE
RADIOLOGICAL PROCEDURE TYPE
RADIOTHERAPY ACTUAL DOSE
RADIOTHERAPY BEAM TYPE
RADIOTHERAPY PRESCRIBED DOSE
RADIOTHERAPY TREATMENT MODALITY
REMOVAL REASON TYPE FOR DIALYSIS ACCESS
RENAL DIALYSIS ACCESS TYPE
RENAL TRANSPLANT FAILURE CAUSE CODE
REPLOGLE TUBE IN SITU INDICATOR
RESPIRATORY SUPPORT DEVICE TYPE FOR NATIONAL NEONATAL DATA SET
RESPIRATORY SUPPORT MODE FOR NATIONAL NEONATAL DATA SET
RESULT SENT DIRECT
RETINOPATHY OF PREMATURITY SCREENING OUTCOME STATUS CODE
REVISION PROCEDURE TYPE FOR ANKLE OR KNEE REPLACEMENT
REVISION PROCEDURE TYPE FOR ELBOW OR SHOULDER REPLACEMENT
REVISION PROCEDURE TYPE FOR HIP REPLACEMENT
ROTATOR CUFF CONDITION
RUPTURE OF MEMBRANES METHOD
SARCOMA SURGICAL MARGIN
SENTINEL LYMPH NODE BIOPSY TYPE
SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR
STEM CELL INFUSION DONOR TYPE
STEM CELL INFUSION SOURCE CODE
STENT DEPLOYED SUCCESS INDICATOR
STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR
STOMA PRESENT INDICATOR
SURGICAL ACCESS TYPE
SURGICAL ACCESS TYPE FOR THORACIC
SURGICAL APPROACH FOR PRIMARY HIP REPLACEMENT
SURGICAL APPROACH FOR PRIMARY KNEE REPLACEMENT
SURGICAL APPROACH FOR PRIMARY OR REVISION ANKLE REPLACEMENT
SURGICAL APPROACH FOR PRIMARY OR REVISION SHOULDER REPLACEMENT
SURGICAL APPROACH FOR REVISION HIP REPLACEMENT
SURGICAL APPROACH FOR REVISION KNEE REPLACEMENT
SURGICAL COMPLICATION TYPE
SURGICAL DEFAULT TECHNIQUE INDICATOR
SURGICAL PALLIATION TYPE
SURGICAL VOICE RESTORATION PERMANENT VALVE REMOVAL REASON
SYSTEMIC ANTI CANCER THERAPY DRUG ROUTE OF ADMINISTRATION
SYSTEMIC ANTI CANCER THERAPY PROGRAMME NUMBER
SYSTEMIC ANTI CANCER THERAPY REGIMEN MODIFICATION INDICATOR
TELETHERAPY BEAM TYPE
TELETHERAPY ELECTRON ENERGY
TELETHERAPY PHOTON ENERGY
TRACHEOSTOMY TUBE IN SITU INDICATOR
TREATMENT TYPE FOR NECROTISING ENTEROCOLITIS
TREATMENT TYPE FOR PATENT DUCTUS ARTERIOSUS
UNPLANNED OPERATION INDICATOR
UNTOWARD INTRAOPERATIVE EVENT CODE FOR ANKLE REPLACEMENT
UNTOWARD INTRAOPERATIVE EVENT CODE FOR ELBOW REPLACEMENT
UNTOWARD INTRAOPERATIVE EVENT CODE FOR HIP REPLACEMENT
UNTOWARD INTRAOPERATIVE EVENT CODE FOR KNEE REPLACEMENT
UNTOWARD INTRAOPERATIVE EVENT CODE FOR SHOULDER REPLACEMENT
VASCULAR LINE TYPE IN SITU
VISUAL INSPECTION CONFIRMED NECROTISING ENTEROCOLITIS DURING LAPAROTOMY INDICATOR
VITAMIN K ADMINISTERED INDICATOR
VITAMIN K ROUTE OF ADMINISTRATION

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CLINICAL INVESTIGATION RESULT ITEM

Change to Class: Changed Attributes

Attributes of this Class are:
KINVESTIGATION RESULT DATE
KINVESTIGATION RESULT TIME
ABNORMALITY DETECTED INDICATOR
ALBUMINURIA STAGE
ALK 1 STATUS
ANKLE DORSIFLEXION CODE
ANKLE PLANTARFLEXION CODE
ARITHMETIC COMPARATOR
BIOPSY REFERRAL OUTCOME
BREAST BIOPSY REFERRAL OUTCOME
BREAST CANCER HISTOLOGICAL TYPE
BREAST SCREENING MAMMOGRAPHY OUTCOME CODE
CANCER VASCULAR OR LYMPHATIC INVASION
CENTRAL TONE STATUS
CERVICAL GLANDULAR INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE
CERVICAL NODE STATUS
CERVICAL SMEAR EXAMINED DATE
CHLAMYDIA TEST RESULT
CLINICAL ASSESSMENT RESULT CODE FOR BREAST CANCER
CLINICAL INVESTIGATION ITEM TYPE
CLINICAL INVESTIGATION ITEM UNIT OF MEASURE
CLINICAL INVESTIGATION RESULT CODE FOR RENAL CARE
CLINICAL INVESTIGATION RESULT CODE FOR RENAL TRANSPLANT
CLINICAL INVESTIGATION RESULT VALUE
CONDITION SEEN IN ABDOMEN DURING XRAY
CYSTIC PERIVENTRICULAR LEUKOMALACIA OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR
CYTOGENETIC ANALYSIS CODE
CYTOGENETIC PRESENCE TYPE FOR RHABDOMYOSARCOMA
CYTOGENETIC RISK CODE
CYTOLOGY RESULT TYPE
CYTOLOGY SMEAR REASON
DEGREES OF FIXED FLEXION DEFORMITY
DEGREES OF FLEXION RANGE
DETRUSOR MUSCLE PRESENCE INDICATION CODE
DEVIATING RESULT INDICATOR
DIPSTICK TEST RESULT CODE
EPIDERMAL GROWTH FACTOR RECEPTOR MUTATIONAL STATUS
EXCISION MARGIN
GENETIC CONFIRMATION INDICATOR
GRADE OF DIFFERENTIATION
HAEMOGLOBINOPATHY INVESTIGATION RESULT CODE FOR NATIONAL NEONATAL DATA SET
HbA1C ASSAY MEASUREMENT METHOD
HEPATOMEGALY INDICATOR
HORMONE EXPRESSION TYPE
INTRAVENTRICULAR HAEMORRHAGE GRADE
INVASIVE CANCER SPECIAL TYPE INDICATOR
INVESTIGATION EXAMINATION RESULT CODE
INVESTIGATION HAEMOGLOBINOPATHY RESULT CODE
INVESTIGATION RESULT STATUS CODE
INVESTIGATION RESULT TEXT
INVESTIGATION RISK RATIO RESULT CODE
INVESTIGATION RUBELLA RESULT INDICATOR
INVESTIGATION SENSITISED RESULT INDICATOR
KARYOTYPE TEST OUTCOME
LACTATE DEHYDROGENASE LEVEL
LYMPH NODE STATUS
MAMMOGRAM RESULT CODE
METASTASIS EXTENT CODE
NEWBORN BLOOD SPOT TEST OUTCOME STATUS CODE
NEWBORN HEARING SCREENING OUTCOME
NUMBER OF FETUSES
NUMERICAL VALUE
PATHOLOGICAL RISK CLASSIFICATION CODE AFTER NEPHRECTOMY
PATHOLOGICAL RISK CLASSIFICATION CODE AFTER PREOPERATIVE CHEMOTHERAPY
PERSON BLOOD GROUP
PERSON RHESUS FACTOR
PORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR
PREOPERATIVE THERAPY RESPONSE TYPE
RADIOLOGICAL RESULT VERIFIED DATE
RADIOLOGICAL RESULT VERIFIED TIME
RESULT ITEM STATUS
RETINOPATHY OF PREMATURITY CLOCK HOURS MAXIMUM STAGE
RETINOPATHY OF PREMATURITY MAXIMUM ZONE
RETINOPATHY OF PREMATURITY PLUS DISEASE STATUS
RETINOPATHY OF PREMATURITY STAGE
S CATEGORY CODE
SERUM CALCIUM CONCENTRATION CORRECTION CODE
SPECIMEN NATURE
SPLEEN BELOW COSTAL MARGIN
SPLENOMEGALY INDICATOR
SUBTALAR JOINT MOVEMENT CODE
TIBIA HINDFOOT ALIGNMENT CODE
TUMOUR NECROSIS
ULTRASOUND RESULT CODE FOR BREAST CANCER
VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR

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CURRENCY

Change to Class: Changed Relationships

Each CURRENCY
Kmay be used for one or more SERVICE FINANCIAL ALLOCATION
may be relate to one or more GMP CLAIM FOR PAYMENT OR REIMBURSEMENT (retired)

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OFFER OF ADMISSION

Change to Class: Changed Description

This records each OFFER OF ADMISSION made to a PATIENT on the ELECTIVE ADMISSION LIST.

When a PATIENT is given a set of more than one OFFERED FOR ADMISSION DATES, each OFFER OF ADMISSION in the set should record the same OFFER OF ADMISSION GROUP IDENTIFIER.When the PATIENT accepts an OFFERED FOR ADMISSION DATE, it is this offered date that the PATIENT is expected to attend and be admitted.

When the PATIENT accepts an OFFERED FOR ADMISSION DATE, it is this offered date that the PATIENT is expected to attend and be admitted. ADMISSION OFFER OUTCOME records whether or not the PATIENT was admitted and the circumstances that applied.ADMISSION OFFER OUTCOME records whether or not the PATIENT was admitted and the circumstances that applied.

 

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ORGANISATION REGISTRATION

Change to Class: Changed Description

A registration of an ORGANISATION SITE of an ORGANISATION.

This could be with, for example, Care Quality Commission, Ofsted etc.

This may be a Care Home, Children's Home, a residential or nursing home, private and voluntary hospital or clinic, residential family centre, domiciliary care agency, nurses agency, an adoption agency or other establishment registration.

A residential family centre is an establishment at which;

-accommodation is provided for children and their parents
-the parents' capacity to respond to the children's needs and to safeguard their welfare is monitored or assessed, and
-the parents are given such advice, guidance or counselling as is considered necessary.

A domiciliary care agency is an undertaking which consists of or includes arranging the provision of personal care in their own homes for PERSONS who by reason of illness, infirmity or disability are unable to provide it for themselves without assistance.

A fostering agency is an undertaking which discharges functions of Local Authorities in connection with the placing of children with foster parents or a voluntary organisation which places children with foster parents under section 59(1) of the Children Act 1989.

A nurses agency is an employment agency or employment business which supplies, or provides services for the purpose of supplying, NURSES.

 

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PATIENT ORGANISATION

Change to Class: Changed Attributes

Attributes of this Class are:
KPATIENT ORGANISATION START DATE
DISTANCE UNITS
DISTANCE UNITS ADDITIONAL
LOCAL PATIENT IDENTIFIER
RENAL DIALYSIS CENTRE PRIMARY OR SECONDARY INDICATOR
SOCIAL SERVICES CLIENT IDENTIFIER

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PERSON IN PROGRAMME

Change to Class: Changed Description

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PLANNED SERVICE

Change to Class: Changed Attributes

Attributes of this Class are:
KPLANNED SERVICE START DATE
NUMBER OF PLACE DAYS INTENDED AVAILABLE

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REFERRAL REQUEST

Change to Class: Changed Attributes

Attributes of this Class are:
BENIGN THERAPEUTIC OPERATION INDICATOR
COLPOSCOPY REFERRAL INDICATION
COMMISSIONER REFERENCE NUMBER
REASON FOR REFERRAL TO COMMUNITY CARE
REFERRAL CLOSURE REASON FOR COMMUNITY CARE
REFERRAL REQUEST ACCEPTANCE INDICATOR
REFERRAL REQUEST RECEIVED TIME
REFERRAL REQUEST SERVICE TYPE FOR NHS HEALTH CHECK
REFERRAL REQUEST TYPE
REFERRAL STATUS
SCREENING REFERRAL SOURCE
SERVICE TYPE REQUESTED
SERVICE TYPE REQUESTED FOR CHILD AND ADOLESCENT MENTAL HEALTH
SOURCE OF REFERRAL FOR A and E
SOURCE OF REFERRAL FOR COMMUNITY
SOURCE OF REFERRAL FOR MENTAL HEALTH
SOURCE OF REFERRAL FOR OUT-PATIENTS
SOURCE OF REFERRAL FOR PROF STAFF GROUP
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE

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REGISTER

Change to Class: Changed Description

A REGISTER maintained by an ORGANISATION.

REGISTER REGISTRATION TYPE CODE identifies the type of registration being made to the REGISTER.

 

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TISSUE

Change to Class: Changed Attributes

Attributes of this Class are:
KTISSUE IDENTIFIER
KTISSUE TYPE AT NEAREST MARGIN
TISSUE TYPE AT NEAREST MARGIN

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TRANSPORT REQUIREMENT

Change to Class: Changed Attributes

Attributes of this Class are:
KTRANSPORT REQUIREMENT NUMBER
TRANSPORT ARRANGED INDICATOR
TRANSPORT ARRANGEMENT DATE
TRANSPORT ARRANGEMENT RESPONSIBILITY
TRANSPORT ARRANGEMENT TIME
TRANSPORT NEED
TRANSPORT REQUIREMENT DESCRIPTION

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WARD OPERATIONAL PLAN

Change to Class: Changed Attributes

Attributes of this Class are:
KWARD OPERATIONAL PLAN START DATE
AGE GROUP INTENDED
AUGMENTED CARE LOCATION CODE
CLINICAL CARE INTENSITY
IC OR HD BEDS INDICATOR
SEX OF PATIENTS
WARD AVAILABLE BED
WARD DAY NIGHT INDICATOR
WARD DAY PERIOD AVAILABILITY
WARD NIGHT PERIOD AVAILABILITY
WARD OPERATIONAL PLAN END DATE

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ACTIVITY GROUP TYPE

Change to Attribute: Changed Description

The type of ACTIVITY GROUP.

National Codes:

01Accident and Emergency Episode 
02Acute Myocardial Infarction Care Spell (Retired July 2012)
03Augmented Care Period (Retired 1 April 2006) 
04Breast Cancer Care Spell 
05Cancer Care Spell 
06Care Home Stay (Consultant Care) 
07Care Home Stay (Midwife Care) 
08Care Home Stay (Nursing Care) 
09Care Home Stay (Residential) 
10Care Programme Approach Episode 
11Colorectal Cancer Care Spell 
12Community Episode 
13Mental Health Care Professional Episode (Acute Home-Based) 
14Consultant Episode (Hospital Provider) 
15Consultant Out-Patient Episode 
16Dental Episode (Retired 01 April 2014)
17Drug Misuse Episode 
18Sexual Health And HIV Episode 
19Head and Neck Cancer Care Spell 
20Home Dialysis Episode 
21Hospital Provider Spell 
22Lung Cancer Care Spell 
23Adult Mental Health Care Spell 
24Midwife Episode 
25Neonatal Level Of Care Period 
26Nursing Episode 
27Palliative Care Episode 
28Person Stop Smoking Episode 
29Pregnancy Episode 
30Professional Staff Group Episode 
31Regular Attender Episode 
32Road Traffic Accident Treatment (Retired 01 April 2014)
33Sarcoma Care Spell 
34Skin Cancer Care Spell 
35Supervised Discharge Episode (Retired 01 April 2014)
36Supervision Register Episode (Retired 01 April 2014)
37Upper Gastrointestinal Cancer Care Spell 
38Urological Cancer Care Spell 
39Ward Stay 
40Hospital Stay 
41Care Spell 
42CRITICAL CARE PERIOD 
43PATIENT PATHWAY 
44REFERRAL TO TREATMENT PERIOD 
45Active Monitoring 
46Supervised Community Treatment Recall 
47Supervised Community Treatment 
48Mental Health Care Without Patient Consent 
49Cancer Treatment Period 
50Gynaecological Cancer Care Spell 
51Mental Health Care Spell 
52Improving Access to Psychological Therapies Care Spell 
53Adult Mental Health Care Team Episode 
54Mental Health NHS Day Care Episode 
55Mental Health Delayed Discharge Period 
56Mental Health Care Cluster Assignment Period 
57Mental Health Care Coordinator Assignment 
58Child and Adolescent Mental Health Clinical Intervention Episode 
59Child and Adolescent Mental Health Care Spell 
60Maternity Episode
61HIV Episode
62Central Nervous System Cancer Care Spell
63Children Teenagers and Young Adults Cancer Care Spell
64Haematology Cancer Care Spell
65Lung Cancer Care Spell
66Commissioner Assignment Period
67Breast Screening Episode
68High Risk Breast Screening Episode
69Open Breast Screening Episode
70Neonatal Critical Care Spell
71Radiotherapy Episode
72Healthy Person Stay
73Mental Health Responsible Clinician Assignment

Note:
The list is not in alphabetical order.

 

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DIABETES TYPE

Change to Attribute: Changed Description

Classifies the type of diabetes experienced by the PATIENT.

National Codes:

01Type 1
02Type 2
06MODY
08Other Specified
99Not specified

'99 - Not Specified' should only be used in the short term and refined to one of the alternative options as soon as possible.

 

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DIRECT ACCESS REFERRAL INDICATOR

Change to Attribute: Changed Description

An indication of whether a PATIENT was referred to a Direct Access Service

National Codes:

YReferred to a Direct Access Service
NNot referred to a Direct Access Service
YReferred to a Direct Access Service
NNot referred to a Direct Access Service
 

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PATIENT PROCEDURE CODING SIGNIFICANCE

Change to Attribute: Changed Description

A classification of each INTERVENTION CLASSIFICATION ASSOCIATION for Patient Procedure within each Consultant Episode (Hospital Provider) or Out-Patient Attendance Consultant.A classification of each Patient Procedure within each Consultant Episode (Hospital Provider) or Out-Patient Attendance Consultant.

Classification:

a.Primary
b.First secondary
c.Second secondary
d.Third secondary
e.Other
 

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SERVICE REQUEST RAISED REASON

Change to Attribute: Changed Description

The reason a SERVICE REQUEST has been raised.

National Codes:

01Transfer of Clinical Responsibility
02Opinion Only
03Diagnostic Test
96Other
98Not Applicable
99Not Known
01Transfer of Clinical Responsibility
02Opinion Only
03Diagnostic Test
96Other
98Not Applicable
99Not Known
 

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VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR  renamed from VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR

Change to Attribute: Changed Name

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ADMITTED PATIENT OTHER EMERGENCY ADMISSIONS TOTAL

Change to Data Element: Changed Description

Format/Length:max n6
HES Item: 
National Codes: 
Default Codes: 

Notes: 
ADMITTED PATIENT OTHER EMERGENCY ADMISSIONS TOTAL is the total number of PATIENTS admitted to a Hospital Provider Spell within the REPORTING PERIOD where the ADMISSION METHOD is 'Emergency Admission, where admission is unpredictable and at short notice because of clinical need', National Codes:

 

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ADMITTED PATIENT OTHER EMERGENCY ADMISSIONS TOTAL

Change to Data Element: Changed Description

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AGE GROUP INTENDED

Change to Data Element: Changed Description

Format/Length:n1
HES Item: 
National Codes: 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component AGE GROUPS INTENDED is required to be separately recorded.

Based on the classifications of attribute AGE GROUP INTENDED, with the addition of Home Leave:   

Permitted National Codes:

1Neonates
2Children and /or adolescents
3Elderly
8Any age
9Home Leave

AGE GROUP INTENDED will be replaced with INTENDED AGE GROUP, which should be used for all new and developing data sets and for XML messages.

 

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AMBULANCE INCIDENT NUMBER

Change to Data Element: Changed Description

Format/Length:max an20
HES Item: 
National Codes:See PATIENT JOURNEY NUMBER
Default Codes: 

Notes: 
AMBULANCE INCIDENT NUMBER is the same as attribute PATIENT JOURNEY NUMBER.

From Commissioning Data Set version 6-2, this data element may be submitted where the PATIENT arrived at hospital by Ambulance, and an Accident and Emergency Attendance or Hospital Provider Spell related to this PATIENT TRANSPORT JOURNEY was recorded.From Commissioning Data Set version 6-2, this data element may be submitted where the PATIENT arrived at hospital by Ambulance, and an Accident and Emergency Attendance or Hospital Provider Spell related to this PATIENT TRANSPORT JOURNEY was recorded.

 

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CDS PRIME RECIPIENT IDENTITY

Change to Data Element: Changed Description

Format/Length:an3 or an5
HES Item: 
National Codes:See ORGANISATION CODE 
National Codes: 
ODS Default Codes:TDH00 - Overseas Visitor exempt from charges

Notes: 
CDS PRIME RECIPIENT IDENTITY is the mandatory NHS ORGANISATION CODE (or valid Organisation Data Service Default Code) representing the ORGANISATION determined to be the Commissioning Data Set Prime Recipient of the Commissioning Data Set Message as indicated in the Commissioning Data Set Addressing Grid.

Usage:
The CDS PRIME RECIPIENT IDENTITY must be allocated on the first creation and submission of a CDS TYPE for a PATIENT and must not change even if the ADDRESS or Primary Care Trust of the PATIENT changes during the lifetime of the Commissioning Data Set record otherwise duplicate Commissioning Data Set data may be lodged in the Secondary Uses Service database.

CDS PRIME RECIPIENT IDENTITY is a mandatory data item crucial for the correct indexing of the database and must not be changed during the life of the associated Commissioning Data Set. It does not identify the first or most important recipient of data, i.e. there is no inference of primacy of one recipient over another.

Organisation Data Service Default Codes for CDS PRIME RECIPIENT IDENTITIES are detailed in the Commissioning Data Set Addressing Grid

Please note that the following Organisation Data Service Default Codes must not be used in the Commissioning Data Set (CDS) header because they are not default Commissioner codes:

 

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CDS SENDER IDENTITY

Change to Data Element: Changed Description

Format/length:an3 or an5
HES item: 
National Codes:See ORGANISATION CODE 
National Codes: 
Default Codes: 

Notes: 
CDS SENDER IDENTITY is the mandatory NHS ORGANISATION CODE of the ORGANISATION acting as the physical Sender of Commissioning Data Set submissions.

Usage:
The Commissioning Data Set sender must make sure that the Commissioning Data Set extraction and submission facilities and processes differentiate correctly between:

Once associated with the a Commissioning Data Set record and submitted to the Secondary Uses Service, the CDS SENDER IDENTITY should not be changed unless great care is taken to delete the original Commissioning Data Set records before any resubmission is undertaken.

Usually, the CDS SENDER IDENTITY is never altered once assigned. 

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COMMISSIONING SERIAL NUMBER

Change to Data Element: Changed Description

Format/Length:an6
HES Item:CSNUM
National Codes: 
Default Codes: 

Notes: 
COMMISSIONING SERIAL NUMBER is the same as attribute NHS SERVICE AGREEMENT NUMBER.

From 01/04/2001 this data item will be used to identify PATIENTS treated under Non-Contract Activities. NHS Trusts are required to insert the letters 'OAT' (mandated input as capitals) in the first three characters of the COMMISSIONING SERIAL NUMBER field of the Admitted Patient Care Commissioning Data Set. The remaining three characters will continue to be defined locally, see Data Set Change Notice 17/2000. The remaining three characters will continue to be defined locally, see DSCN 17/2000.

From 01/04/2005 an '=' (equals) as the last significant character in this six character field will indicate an episode that should be excluded from the Payment by Results tariff. The position of the last character depends on any preceding characters eg 1st character if field is otherwise blank, 4th character if following 'OAT', up to a maximum of 6th position. This provides a general exclusion facility for unusual circumstances or where more specific rules regarding coding in other fields cannot be implemented due to local software restrictions.

 

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DFES ESTABLISHMENT NUMBER

Change to Data Element: Changed Description

Format/Length:an6
HES Item: 
National Codes:See DFES ESTABLISHMENT NUMBER
National Codes: 
Default Codes: 

Notes: 
DFES ESTABLISHMENT NUMBER is the same as attribute DFES ESTABLISHMENT NUMBER

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EMERGENCY CARE ATTENDANCES TOTAL

Change to Data Element: Changed Description

Format/length:max n6
HES item: 
Format/Length:max n6
HES Item: 
National Codes: 
Default Codes: 

Notes: 
EMERGENCY CARE ATTENDANCES TOTAL is the total number of  Accident and Emergency Attendances to the same EMERGENCY CARE FACILTY TYPE, where the A AND E ATTENDANCE CATEGORY is: 

EMERGENCY CARE ATTENDANCES TOTAL excludes attendances at a Consultant Clinic.

 

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EMERGENCY CARE PATIENTS WAITING OVER 4 HOURS TOTAL

Change to Data Element: Changed Description

Format/Length:max n6
HES Item: 
National Codes: 
Default Codes: 

Notes: 
EMERGENCY CARE PATIENTS WAITING OVER 4 HOURS TOTAL is the total number of PATIENTS who have a total time in an Emergency Care Department over 4 hours.

EMERGENCY CARE PATIENTS WAITING OVER 4 HOURS TOTAL is the period of time derived from the  ARRIVAL TIME AT ACCIDENT AND EMERGENCY DEPARTMENT and the A and E DEPARTURE TIME.

 

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EMERGENT PSYCHOSIS DATE

Change to Data Element: Changed Description

Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 


Notes: 
This is the date at which there was first clear evidence of a positive psychotic symptom for the PATIENT (i.e. delusion, hallucination, or thought disorder), regardless of its duration.

EMERGENT PSYCHOSIS DATE is the date at which there was first clear evidence of a positive psychotic symptom for the PATIENT (i.e. delusion, hallucination, or thought disorder), regardless of its duration. 

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GUARANTEED ADMISSION DATE

Change to Data Element: Changed Description

Format/length:see DATE 
HES item: 
Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 

Notes: 
This has been included to assist commissioners and providers to manage and monitor elective admission lists; the guaranteed date may be the admission date guaranteed by the Patient's Charter or a locally determined guaranteed admission date offering a shorter waiting time.GUARANTEED ADMISSION DATE is the same as attribute GUARANTEED ADMISSION DATE. 

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INTENDED AGE GROUP

Change to Data Element: Changed Description

Format/length:an1
HES item: 
National Codes:See AGE GROUP INTENDED 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component AGE GROUPS INTENDED is required to be separately recorded.

Based on the classifications of attribute AGE GROUP INTENDED, with the addition of Home Leave:   

Permitted National Codes:

1Neonates
2Children and /or adolescents
3Elderly
8Any age
9Home Leave *

* Note - National Code 9 is not valid for the Mental Health Minimum Data Set (Version 4-1).

INTENDED AGE GROUP replaces AGE GROUP INTENDED and should be used for all new and developing data sets and for XML messages.

 

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INTENDED CLINICAL CARE INTENSITY

Change to Data Element: Changed Description

Format/Length:n2
HES Item: 
National Codes:See CLINICAL CARE INTENSITY 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component INTENDED CLINICAL CARE INTENSITY is required to be separately recorded.

INTENDED CLINICAL CARE INTENSITY is the same as attribute CLINICAL CARE INTENSITY, and the values recorded within the Commissioning Data Set messages are the National Codes contained within the definition of CLINICAL CARE INTENSITY, including additions:

 For PATIENTS with mental illness
51for intensive care: specially designated ward for PATIENTS needing containment and more intensive management. This is not to be confused with intensive nursing where PATIENTS may require one to one nursing while on a standard WARD 
52for short stay: PATIENTS intended to stay less than a year
53for long stay: PATIENTS intended to stay a year or more
 For PATIENTS with Learning Disabilities 
61designated or interim secure unit
62PATIENTS intending to stay less than a year
63PATIENTS intending to stay a year or more
 For maternity PATIENTS 
41only for PATIENTS looked after by CONSULTANTS 
43only for PATIENTS looked after by GENERAL MEDICAL PRACTITIONERS 
42for joint use by CONSULTANTS & GENERAL MEDICAL PRACTITIONERS 
 For neonates
33maternity: associated with the maternity WARD in that cots are in the maternity WARD nursery or in the WARD itself
32non-maternity: not associated with the maternity WARD and without designated cots for intensive care
31not associated with the maternity WARD and in which there are some designated cots for intensive care
 For the younger physically disabled
21spinal units, only those units which are nationally recognised
22other units
 For terminally ill/Palliative Care 
81terminally ill/Palliative Care 
 For general PATIENTS 
11for intensive therapy, including high dependency care
12for normal therapy: where resources permit the admission of PATIENTS who might need all but intensive or high dependency therapy
13for limited therapy: where nursing care rather than continuous medical care is provided. Such WARDS can be used only for PATIENTS carefully selected and restricted to a narrow range in terms of the extent and nature of disease
 additional codes
71Home Leave, non-psychiatric
72Home Leave, psychiatric

INTENDED CLINICAL CARE INTENSITY will be replaced with INTENDED CLINICAL CARE INTENSITY CODE, which should be used for all new and developing data sets and for XML messages.

 

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INTENDED CLINICAL CARE INTENSITY CODE

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See CLINICAL CARE INTENSITY 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component INTENDED CLINICAL CARE INTENSITY CODE is required to be separately recorded.

INTENDED CLINICAL CARE INTENSITY CODE is the same as attribute CLINICAL CARE INTENSITY and the values recorded are the National Codes contained within the definition of CLINICAL CARE INTENSITY, including additions:

 For PATIENTS with mental illness
51for intensive care: specially designated ward for PATIENTS needing containment and more intensive management. This is not to be confused with intensive nursing where PATIENTS may require one to one nursing while on a standard WARD 
52for short stay: PATIENTS intended to stay less than a year
53for long stay: PATIENTS intended to stay a year or more
 For PATIENTS with Learning Disabilities 
61designated or interim secure unit
62PATIENTS intending to stay less than a year
63PATIENTS intending to stay a year or more
 For maternity PATIENTS 
41only for PATIENTS looked after by CONSULTANTS 
43only for PATIENTS looked after by GENERAL MEDICAL PRACTITIONERS 
42for joint use by CONSULTANTS & GENERAL MEDICAL PRACTITIONERS 
 For neonates
33maternity: associated with the maternity WARD in that cots are in the maternity WARD nursery or in the WARD itself
32non-maternity: not associated with the maternity WARD and without designated cots for intensive care
31not associated with the maternity WARD and in which there are some designated cots for intensive care
 For the younger physically disabled
21spinal units, only those units which are nationally recognised
22other units
 For terminally ill/Palliative Care 
81terminally ill/Palliative Care 
 For general PATIENTS 
11for intensive therapy, including high dependency care
12for normal therapy: where resources permit the admission of PATIENTS who might need all but intensive or high dependency therapy
13for limited therapy: where nursing care rather than continuous medical care is provided. Such WARDS can be used only for PATIENTS carefully selected and restricted to a narrow range in terms of the extent and nature of disease
 additional codes
71Home Leave, non-psychiatric
72Home Leave, psychiatric

INTENDED CLINICAL CARE INTENSITY CODE replaces INTENDED CLINICAL CARE INTENSITY and should be used for all new and developing data sets and for XML messages.

 

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LOCATION CLASS

Change to Data Element: Changed Description

Format/length:an2
HES item: 
Format/Length:an2
HES Item: 
National Codes: 
Default Codes: 

Notes: 
A classification for use within Commissioning Data Set messages of the physical location within which the recorded patient event occurs.LOCATION CLASS is a classification for use within Commissioning Data Set messages of the physical location within which the recorded PATIENT event occurs.

Permitted National Codes:

01Health Site (General Occurrence)
02Home
03Delivery Place
04Health site at the start of Health Care Activity
05Health site at the end of Health Care Activity
01Health Site (General Occurrence)
02Home
03Delivery Place
04Health site at the start of Health Care Activity
05Health site at the end of Health Care Activity

CDS-XML Message:

The codes as specified above must be used in CDS-XML messages. 

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NHS SERVICE AGREEMENT CHANGE DATE

Change to Data Element: Changed Description

Format/length:see DATE 
HES item: 
Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 
 Notes: 
NHS SERVICE AGREEMENT CHANGE DATE is the same as attribute NHS SERVICE AGREEMENT CHANGE DATE. 

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PRODROME PSYCHOSIS DATE

Change to Data Element: Changed Description

Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 


Notes: 
This is the date at which first noticeable change in behaviour or mental state of the PATIENT occurred, prior to emergence of full-blown psychosis.PRODROME PSYCHOSIS DATE is the date at which first noticeable change in behaviour or mental state of the PATIENT occurred, prior to emergence of full-blown psychosis.  There should be clear deterioration in functioning from previous levels.

 

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PROVIDER REFERENCE NUMBER

Change to Data Element: Changed Description

Format/length:an17
HES item: 
Format/Length:an17
HES Item: 
National Codes: 
Default Codes: 

Notes: 
A convention agreed locally between a provider and Commissioner for use within a Commissioning Data Set message.PROVIDER REFERENCE NUMBER is a number convention agreed locally between a provider and Commissioner for use within a Commissioning Data Set message. 

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SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D)

Change to Data Element: Changed Description

Format/Length:max n18
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D) is the same as attribute CLINICAL CLASSIFICATION CODE.

SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D) is the SNOMED CT concept ID from the NHS Dictionary of Medicines and Devices which is used to identify the antibiotics to which a culture SAMPLE is sensitive (i.e. which antibiotics are most likely to successfully treat a bacterial infection).

Further details of the permitted SNOMED CT codes from the NHS Dictionary of Medicines and Devices can be found on the Neonatal Data Analysis Unit website.

 

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SAMPLE COLLECTION DATE AND TIME

Change to Data Element: Changed Description

Format/Length:See DATE AND TIME
HES Item: 
National Codes: 
Default Codes: 

NotesNotes: 
SAMPLE COLLECTION DATE AND TIME is the same as data element DATE AND TIME.

SAMPLE COLLECTION DATE AND TIME is the SAMPLE COLLECTION DATE and SAMPLE COLLECTION TIME.

 

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SAMPLE COLLECTION YEAR AND MONTH

Change to Data Element: Changed Description

Format/Length:See YEAR AND MONTH
HES Item: 
National Codes: 
Default Codes: 

NotesNotes: 
SAMPLE COLLECTION YEAR AND MONTH is the YEAR AND MONTH of the recorded SAMPLE COLLECTION DATE AND TIME when a SAMPLE was collected.

For the National Neonatal Data Set - Episodic and Daily Care, SAMPLE COLLECTION YEAR AND MONTH is submitted instead of SAMPLE COLLECTION DATE AND TIME, where the data set record is anonymised.

 

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SAMPLE TYPE (NATIONAL NEONATAL DATA SET)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SAMPLE TYPE FOR NATIONAL NEONATAL DATA SET
Default Codes: 

Notes: 
SAMPLE TYPE (NATIONAL NEONATAL DATA SET) is the same as attribute SAMPLE TYPE FOR NATIONAL NEONATAL DATA SET

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SCAN PERFORMED INDICATOR (PET)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes:9 - Not Known (Not Recorded)

Notes: Notes: 
SCAN PERFORMED INDICATOR (PET) is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate if a PET Scan has been performed on a PATIENT.SCAN PERFORMED INDICATOR (PET) is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate if a PET Scan has been performed on a PATIENT. 

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SCHEDULE OF GROWING SKILLS (ACTIVE POSTURE) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (ACTIVE POSTURE) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Active Posture) Scale Score

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SCHEDULE OF GROWING SKILLS (HEARING AND LANGUAGE) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (HEARING AND LANGUAGE) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Hearing and Language) Scale Score

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SCHEDULE OF GROWING SKILLS (INTERACTIVE SOCIAL) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (INTERACTIVE SOCIAL) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Interactive Social) Scale Score

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SCHEDULE OF GROWING SKILLS (LOCOMOTOR) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (LOCOMOTOR) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Locomotor) Scale Score

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SCHEDULE OF GROWING SKILLS (MANIPULATIVE) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (MANIPULATIVE) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Manipulative) Scale Score

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SCHEDULE OF GROWING SKILLS (PASSIVE POSTURE) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (PASSIVE POSTURE) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Passive Posture) Scale Score

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SCHEDULE OF GROWING SKILLS (SELF-CARE SOCIAL) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (SELF-CARE SOCIAL) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Self-Care Social) Scale Score

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SCHEDULE OF GROWING SKILLS (SPEECH AND LANGUAGE) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (SPEECH AND LANGUAGE) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Speech and Language) Scale Score

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SCHEDULE OF GROWING SKILLS (VISUAL) SCALE SCORE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SCHEDULE OF GROWING SKILLS (VISUAL) SCALE SCORE is the PERSON SCORE for the Schedule of Growing Skills (Visual) Scale Score

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SENTINEL NODE PROCEDURE

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:SENTINEL LYMPH NODE BIOPSY TYPE
Default Codes: 

Notes: 
SENTINEL NODE PROCEDURE is the same as attribute SENTINEL LYMPH NODE BIOPSY TYPE

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SERVICE REQUEST STATUS DATE (MENTAL HEALTH)

Change to Data Element: Changed Description

Format/Length:See DATE 
HES item: 
National Codes: 
Default Codes: 


Notes: 
SERVICE REQUEST STATUS DATE (MENTAL HEALTH) is the date when the STATUS OF SERVICE REQUEST FOR MENTAL HEALTH was first recorded, or changed as a result of a change of status of the SERVICE REQUEST.

 

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SERVICE TYPE REFERRED TO (COMMUNITY CARE)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See SERVICE TYPE REFERRED TO FOR COMMUNITY CARE
Default Codes: 


Notes: 
SERVICE TYPE REFERRED TO (COMMUNITY CARE) is the same as attribute SERVICE TYPE REFERRED TO FOR COMMUNITY CARE.

 

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SERVICE TYPE REQUESTED

Change to Data Element: Changed Description

Format/length:n1
HES item: 
National Codes:See SERVICE TYPE REQUESTED
Default Codes: 


Notes: 
SERVICE TYPE REQUESTED is the same as attribute SERVICE TYPE REQUESTED.

SERVICE TYPE REQUESTED will be replaced with SERVICE TYPE REQUESTED CODE, which should be used for all new and developing data sets and for XML messages.

 

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SERVICE TYPE REQUESTED CODE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SERVICE TYPE REQUESTED
Default Codes: 


Notes: 
SERVICE TYPE REQUESTED CODE is the same as attribute SERVICE TYPE REQUESTED.

SERVICE TYPE REQUESTED CODE replaces SERVICE TYPE REQUESTED and should be used for all new and developing data sets and for XML messages.

 

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SEX OF PATIENTS

Change to Data Element: Changed Description

Format/length:n1
HES item: 
National Codes: 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component SEX OF PATIENTS is required to be separately recorded. The classifications for SEX OF PATIENTS are not the same as the National Codes contained within the definition of PERSON GENDER.

Based on the classifications of attribute SEX OF PATIENTS, with the addition of Home Leave: 

Permitted National Codes:

1Male
2Female
8Not specified
9Home Leave

SEX OF PATIENTS will be replaced with SEX OF PATIENTS CODE, which should be used for all new and developing data sets and for XML messages.

 

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SEX OF PATIENTS CODE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes: 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component SEX OF PATIENTS CODE is required to be separately recorded. The classifications for SEX OF PATIENTS CODE are not the same as the National Codes contained within the definition of PERSON GENDER.

Based on the classifications of attribute SEX OF PATIENTS, with the addition of Home Leave:

Permitted National Codes:

1Male
2Female
8Not specified
9Home Leave *

* Note - National Code 9 is not valid for the Mental Health Minimum Data Set (Version 4-1).

SEX OF PATIENTS CODE replaces SEX OF PATIENTS and should be used for all new and developing data sets and for XML messages.

 

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SHORT TERM RECALL RATE FOLLOWING ASSESSMENT (PERCENTAGE OF SCREENED)

Change to Data Element: Changed Description

Format/Length:max n3.n1
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SHORT TERM RECALL RATE FOLLOWING ASSESSMENT (PERCENTAGE OF SCREENED) is the percentage of women with a BREAST ASSESSMENT OUTCOME recorded as National Code 'Short term recall'.

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SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR
Default Codes:9 - Unknown if there was significant maternal pyrexia

Notes: 
SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR  is the same as attribute SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR

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SIGNPOSTING TO SERVICE INDICATOR (PHYSICAL ACTIVITY SERVICE)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SIGNPOSTING TO SERVICE INDICATOR
Default Codes: 


Notes: 
SIGNPOSTING TO SERVICE INDICATOR (PHYSICAL ACTIVITY SERVICE) is the same as attribute SIGNPOSTING TO SERVICE INDICATOR.

For the NHS Health Checks Data Set this is an indication of whether Signposting was provided to a PATIENT, where the SIGNPOSTING TO SERVICE TYPE FOR NHS HEALTH CHECK is National Code 'Physical Activity Service', during an NHS Health Check Assessment.

 

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SIGNPOSTING TO SERVICE INDICATOR (STOP SMOKING SERVICE)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SIGNPOSTING TO SERVICE INDICATOR
Default Codes: 


Notes: 
SIGNPOSTING TO SERVICE INDICATOR (STOP SMOKING SERVICE) is the same as attribute SIGNPOSTING TO SERVICE INDICATOR.

For the NHS Health Checks Data Set this is an indication of whether Signposting was provided to a PATIENT, where the SIGNPOSTING TO SERVICE TYPE FOR NHS HEALTH CHECK is National Code 'Stop Smoking Service', during an NHS Health Check Assessment.

 

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SIGNPOSTING TO SERVICE INDICATOR (WEIGHT MANAGEMENT SERVICE)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SIGNPOSTING TO SERVICE INDICATOR
Default Codes: 


Notes: 
SIGNPOSTING TO SERVICE INDICATOR (WEIGHT MANAGEMENT SERVICE) is the same as attribute SIGNPOSTING TO SERVICE INDICATOR.

For the NHS Health Checks Data Set this is an indication of whether Signposting was provided to a PATIENT, where the SIGNPOSTING TO SERVICE TYPE FOR NHS HEALTH CHECK is National Code 'Weight Management Service', during an NHS Health Check Assessment.

 

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SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT)

Change to Data Element: Changed Description

Format/Length:See ORGANISATION SITE CODE 
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) is the same as the attribute ORGANISATION SITE CODE.

SITE CODE (OF TWO YEAR NEONATAL OUTCOMES ASSESSMENT) is the ORGANISATION SITE CODE of the ORGANISATION where a Two Year Neonatal Outcomes Assessment takes place.

 

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SITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)

Change to Data Element: Changed Description

Format/Length:See ORGANISATION SITE CODE 
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY) is the same as the attribute ORGANISATION SITE CODE.

SITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY) is the ORGANISATION SITE CODE of the ORGANISATION that is responsible for undertaking the Two Year Neonatal Outcomes Assessment.

 

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SMILE INDICATION CODE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SMILE INDICATION CODE
Default Codes: 

Notes: 
SMILE INDICATION CODE is the same as attribute SMILE INDICATION CODE

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SOCIAL PHOBIA INVENTORY SCORE

Change to Data Element: Changed Description

Format/Length:max n2
HES Item: 
National Codes: 
Default Codes: 


Notes: 
SOCIAL PHOBIA INVENTORY SCORE is the PERSON SCORE for an APPOINTMENT where the ASSESSMENT TOOL TYPE is 'Social Phobia Inventory Questionnaire'.

The score will be between 0 and 68.

 

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SOCIAL PHOBIA SCORE

Change to Data Element: Changed Description

Format/Length:n1
HES Item: 
National Codes: 
Default Codes: 


Notes: 
SOCIAL PHOBIA SCORE is the PERSON SCORE for an APPOINTMENT where the ASSESSMENT TOOL TYPE is 'Social Phobia Questionnaire'.

The score will be between 0 and 8.

 

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SOCIAL SERVICES CLIENT IDENTIFIER

Change to Data Element: Changed Description

Format/length:an20
HES item: 
Format/Length:an20
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SOCIAL SERVICES CLIENT IDENTIFIER is the same as attribute SOCIAL SERVICES CLIENT IDENTIFIER.

Notes:  SOCIAL SERVICES CLIENT IDENTIFIER is the same as attribute SOCIAL SERVICES CLIENT IDENTIFIER. 

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SOCIAL WORKER CARE INDICATOR (HIV)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SOCIAL WORKER CARE INDICATOR FOR HIV
Default Codes: 

Notes: 
SOCIAL WORKER CARE INDICATOR (HIV) is the same as attribute SOCIAL WORKER CARE INDICATOR FOR HIV

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SOURCE OF REFERRAL FOR A AND E

Change to Data Element: Changed Description

Format/length:an2
HES item: 
Format/Length:an2
HES Item: 
National Codes:See SOURCE OF REFERRAL FOR A and E
Default Codes: 


Notes: 
SOURCE OF REFERRAL FOR A and E is the same as attribute SOURCE OF REFERRAL FOR A and E.

 

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SPECIAL DIET DESCRIPTION

Change to Data Element: Changed Description

Format/Length:max an250
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SPECIAL DIET DESCRIPTION is the same as attribute PERSON OBSERVATION TEXT STRING.

SPECIAL DIET DESCRIPTION is a text description of a special diet regime followed by a PATIENT

For the National Neonatal Data Set - Two Year Neonatal Outcomes Assessment, SPECIAL DIET DESCRIPTION should be completed where the TPRG-SEND TWO YEAR CORRECTED AGE OUTCOME ASSESSMENT SCORE (GASTRO-INTESTINAL TRACT QUESTION A) response is 'Yes'. 

 

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SPECIFIC PHOBIA SCORE

Change to Data Element: Changed Description

Format/Length:n1
HES Item: 
National Codes: 
Default Codes: 


Notes: 
This is the PERSON SCORE for an APPOINTMENT where the ASSESSMENT TOOL TYPE is "Specific Phobia Questionnaire".

SPECIFIC PHOBIA SCORE is the PERSON SCORE for an APPOINTMENT where the ASSESSMENT TOOL TYPE is "Specific Phobia Questionnaire".

The score will be between 0 and 8.

 

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SPECIMEN TYPE (CHLAMYDIA TESTING)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See SPECIMEN TYPE FOR CHLAMYDIA TESTING
Default Codes: 


Notes: 
SPECIMEN TYPE (CHLAMYDIA TESTING) is the same as attribute SPECIMEN TYPE FOR CHLAMYDIA TESTING.

Any conjunctival specimens should be excluded from the Chlamydia Testing Activity Data Set.

 

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SPLENOMEGALY INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SPLENOMEGALY INDICATOR
Default Codes: 

Notes: 
SPLENOMEGALY INDICATOR is the same as attribute SPLENOMEGALY INDICATOR

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STAFF GROUP CODE (TRAINING ACTIVITY CLASSIFICATION)

Change to Data Element: Changed Description

Format/Length:an2
NWDS ID:ETAC
ESR Field Name:Category Type (Training Classification)
National Codes:See STAFF GROUP CODE
Default Codes: 


Notes: 
STAFF GROUP CODE (TRAINING ACTIVITY CLASSIFICATION) is the same as attribute STAFF GROUP CODE.

STAFF GROUP CODE (TRAINING ACTIVITY CLASSIFICATION) is the STAFF GROUP CODE which classifies the staff group for which the TRAINING ACTIVITY is targeted.

 

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STANDARDISED DETECTION RATIO TOTAL

Change to Data Element: Changed Description

Format/Length:n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
STANDARDISED DETECTION RATIO TOTAL is derived from INVASIVE BREAST CANCER TOTAL OBSERVED and INVASIVE BREAST CANCER TOTAL EXPECTED.

STANDARDISED DETECTION RATIO TOTAL should only be reported in Table A, B and C1, in the NHS Breast Screening Programme Central Return Data Set (KC62).

 

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START DATE (SUPERVISED COMMUNITY TREATMENT RECALL)

Change to Data Element: Changed Description

Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 

Notes: 
START DATE (SUPERVISED COMMUNITY TREATMENT RECALL) is the same as attribute ACTIVITY DATE where the ACTIVITY DATE TYPE is National Code 'Start Date' of the Supervised Community Treatment Recall

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START DATE (TREATMENT FOR DIALYSIS RELATED INFECTION)

Change to Data Element: Changed Description

Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 

Notes: 
START DATE (TREATMENT FOR DIALYSIS RELATED INFECTION) is the same as attribute ACTIVITY DATE where the ACTIVITY DATE TYPE is 'Start Date' for the start of a course of treatment for an infection caused by a prior CARE ACTIVITY for peritoneal dialysis. 

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START DATE AND TIME (RENAL DIALYSIS)

Change to Data Element: Changed Description

Format/Length:See DATE AND TIME
HES Item: 
National Codes: 
Default Codes: 

Notes: 
START DATE AND TIME (RENAL DIALYSIS) is the same as data element DATE AND TIME of the start of Renal Dialysis

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STATUS OF FOLIC ACID SUPPLEMENT (MOTHER AT BOOKING)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See FOLIC ACID SUPPLEMENT STATUS CODE
Default Codes: 

Notes: 
STATUS OF FOLIC ACID SUPPLEMENT (MOTHER AT BOOKING) is the same as attribute FOLIC ACID SUPPLEMENT STATUS CODE, reported by the mother at APPOINTMENT DATE (FORMAL ANTENATAL BOOKING)

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STATUTORY ASSESSMENT TYPE

Change to Data Element: Changed Description

Format/Length:a3
HES Item: 
National Codes:See STATUTORY ASSESSMENT TYPE
Default Codes: 


Notes: 
STATUTORY ASSESSMENT TYPE is the same as attribute STATUTORY ASSESSMENT TYPE.

 

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STATUTORY SICK PAY INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See STATUTORY SICK PAY INDICATOR
Default Codes: 


Notes: 
STATUTORY SICK PAY INDICATOR is the same as attribute STATUTORY SICK PAY INDICATOR.

For the Improving Access to Psychological Therapies Data Set, this is taken from the PATIENT's completed Employment Status Questionnaire during the current Improving Access to Psychological Therapies Care Spell.

 

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STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR
Default Codes:9 - Not known if steroids given

Notes: 
STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR is the same as attribute STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR

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STEROID TYPE GIVEN TO MOTHER (SNOMED CT DM+D)

Change to Data Element: Changed Description

Format/Length:max n18
HES Item: 
National Codes: 
Default Codes: 

Notes: 
STEROID TYPE GIVEN TO MOTHER (SNOMED CT DM+D) is the same as attribute CLINICAL CLASSIFICATION CODE.

STEROID TYPE GIVEN TO MOTHER (SNOMED CT DM+D) is the SNOMED CT concept ID from the NHS Dictionary of Medicines and Devices which is used to identify the type of steroid given to the mother during a Pregnancy Episode in order to mature the fetal lungs.

Further details of the permitted SNOMED CT codes from the NHS Dictionary of Medicines and Devices can be found at the Neonatal Data Analysis Unit website.

 

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SUBJECTIVE GLOBAL ASSESSMENT

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SUBJECTIVE GLOBAL ASSESSMENT 
Default Codes: 

Notes: 
SUBJECTIVE GLOBAL ASSESSMENT is the same as attribute SUBJECTIVE GLOBAL ASSESSMENT

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SUBSTANCE USE STATUS (MOTHER AT BOOKING)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See SUBSTANCE MISUSED STATUS
Default Codes: 


Notes: 
SUBSTANCE USE STATUS (MOTHER AT BOOKING) is the SUBSTANCE MISUSED STATUS reported by the mother, for a SUBSTANCE MISUSED other than alcohol or tobacco, at the APPOINTMENT DATE (FORMAL ANTENATAL BOOKING).

 

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SUPPORT STATUS (MOTHER AT BOOKING)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SUPPORT STATUS INDICATOR
Default Codes: 

Notes: 
SUPPORT STATUS (MOTHER AT BOOKING) is the SUPPORT STATUS INDICATOR reported by the mother at the APPOINTMENT DATE (FORMAL ANTENATAL BOOKING)

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SURFACTANT GIVEN INDICATOR (DURING RESUSCITATION)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SURFACTANT GIVEN INDICATOR
Default Codes:9 - Not known if surfactant was given during resuscitation

Notes: 
SURFACTANT GIVEN INDICATOR (DURING RESUSCITATION) is the same as attribute SURFACTANT GIVEN INDICATOR, where this takes place during resuscitation of the PATIENT

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SURFACTANT GIVEN INDICATOR (ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SURFACTANT GIVEN INDICATOR
Default Codes:9 - Not known if surfactant was given during resuscitation

Notes: 
SURFACTANT GIVEN INDICATOR (ON NEONATAL CRITICAL CARE DAILY CARE DATE) is the same as attribute SURFACTANT GIVEN INDICATOR, where this takes place on a NEONATAL CRITICAL CARE DAILY CARE DATE but not during resuscitation of the PATIENT

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SURGICAL ACCESS TYPE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SURGICAL ACCESS TYPE
Default Codes: 

Notes: 
SURGICAL ACCESS TYPE is the same as attribute SURGICAL ACCESS TYPE

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SURGICAL ACCESS TYPE (THORACIC)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See SURGICAL ACCESS TYPE FOR THORACIC
Default Codes:NA - Not Applicable

Notes: 
SURGICAL ACCESS TYPE (THORACIC) is the same as attribute SURGICAL ACCESS TYPE FOR THORACIC

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SURGICAL DEFAULT TECHNIQUE INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SURGICAL DEFAULT TECHNIQUE INDICATOR
Default Codes: 

Notes:Notes: 
SURGICAL DEFAULT TECHNIQUE INDICATOR is the same as attribute SURGICAL DEFAULT TECHNIQUE INDICATOR

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SURGICAL PALLIATION TYPE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See SURGICAL PALLIATION TYPE
Default Codes:9 - Not Known (Not Recorded)

Notes: 
SURGICAL PALLIATION TYPE is the same as attribute SURGICAL PALLIATION TYPE

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SUSPENSION END DATE

Change to Data Element: Changed Description

Format/length:see DATE 
HES item: 
Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 


Notes: 
SUSPENSION END DATE is the same as the attribute LIST SUSPENSION END DATE.

 

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SUSPENSION START DATE

Change to Data Element: Changed Description

Format/length:see DATE 
HES item: 
Format/Length:See DATE 
HES Item: 
National Codes: 
Default Codes: 


Notes: 
SUSPENSION START DATE is the same as the attribute LIST SUSPENSION START DATE.

 

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SYSTEMIC ANTI-CANCER THERAPY DRUG ROUTE OF ADMINISTRATION

Change to Data Element: Changed Description

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SYSTOLIC BLOOD PRESSURE (POST HAEMODIALYSIS)

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SYSTOLIC BLOOD PRESSURE (POST HAEMODIALYSIS) is the same as data element SYSTOLIC BLOOD PRESSURE where this is recorded after a Renal Dialysis session. 

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SYSTOLIC BLOOD PRESSURE (PRE-HAEMODIALYSIS)

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
SYSTOLIC BLOOD PRESSURE (PRE-HAEMODIALYSIS) is the same as data element SYSTOLIC BLOOD PRESSURE where this is recorded before a Renal Dialysis session. 

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THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes: 

Notes: 
THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate whether Therapeutic Hypothermia was induced for a PATIENT.

For the National Neonatal Data Set - Episodic and Daily Care, THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR indicates whether Therapeutic Hypothermia was induced in the baby on the NEONATAL CRITICAL CARE DAILY CARE DATE.

 

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TIME BETWEEN DELIVERY AND SPONTANEOUS RESPIRATION CODE

Change to Data Element: Changed Description

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TIME BETWEEN DELIVERY AND UMBILICAL CORD CLAMPING

Change to Data Element: Changed Description

Format/Length:max n4
HES Item: 
National Codes: 
Default Codes:9999 - Time between delivery and the clamping of the umbilical cord not known

Notes: 
TIME BETWEEN DELIVERY AND UMBILICAL CORD CLAMPING is the amount of time in seconds between the delivery of a baby and the Patient Procedure to clamp the umbilical cord.

For the National Neonatal Data Set - Episodic and Daily Care, this is measured in seconds.  The value is in the range of 0 - 3600.

 

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TOPOGRAPHY (SNOMED)

Change to Data Element: Changed Description

Format/Length:max an18
HES Item: 
National Codes: 
Default Codes: 

Notes: 
TOPOGRAPHY (SNOMED) is the same as attribute CLINICAL CLASSIFICATION CODE.

TOPOGRAPHY (SNOMED) is the topographical site of the Tumour using the SNOMED® (Systematised Nomenclature of Medicine) code as part of a Cancer Care Spell.

 

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TOPOGRAPHY (SNOMED CT)

Change to Data Element: Changed Description

Format/Length:max n18
HES Item: 
National Codes: 
Default Codes: 

Notes: 
TOPOGRAPHY (SNOMED CT) is the same as attribute CLINICAL CLASSIFICATION CODE.

TOPOGRAPHY (SNOMED CT) is the SNOMED CT concept ID which is used to identify a topographical site.

For the Cancer Outcomes and Services Data Set, TOPOGRAPHY (SNOMED CT) is used to identify the topographical site of the Tumour, recorded as part of a Cancer Care Spell.

 

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TOTAL PROTEIN CONCENTRATION (DONOR)

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
TOTAL PROTEIN CONCENTRATION (DONOR) is the result of the Clinical Investigation which measures the ORGAN OR TISSUE DONOR's total protein concentration in 'g/L'

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TRACHEOSTOMY TUBE IN SITU INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See TRACHEOSTOMY TUBE IN SITU INDICATOR
Default Codes: 

Notes: 
TRACHEOSTOMY TUBE IN SITU INDICATOR is the same as attribute TRACHEOSTOMY TUBE IN SITU INDICATOR.

For the National Neonatal Data Set - Episodic and Daily Care, TRACHEOSTOMY TUBE IN SITU INDICATOR indicates whether the baby had a tracheostomy tube in situ on the NEONATAL CRITICAL CARE DAILY CARE DATE

 

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TRANS ARTERIAL CHEMOEMBOLISATION PERFORMED INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes:9 - Not Known (Not Recorded)

Notes: 
TRANS ARTERIAL CHEMOEMBOLISATION PERFORMED INDICATOR is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate if Trans Arterial Chemoembolisation (administration of chemotherapeutic agents) was performed on a PATIENT

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TRANSFUSED UNITS PER PERIOD (ERYTHROPOIETIN)

Change to Data Element: Changed Description

Format/Length:max n5
HES Item: 
National Codes: 
Default Codes: 

Notes: 
TRANSFUSED UNITS PER PERIOD (ERYTHROPOIETIN) is the total amount of a Erythropoietin Stimulating Agents administered to a PATIENT during the period.
This is recorded in 'iu/week' or 'µg/week' dependant on the type of Erythropoietin Stimulating Agent prescribed.

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TRANSPLANT WAITING LIST STATUS (CHANGED DATE)

Change to Data Element: Changed linked Attribute

TRANSPLANT WAITING LIST STATUS (CHANGED DATE)
 
Attribute:
ACTIVITY DATE
TRANSPLANT WAITING LIST STATUS CODE CHANGED DATE

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TRANSPLANT WAITING LIST STATUS CODE (RENAL)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See TRANSPLANT WAITING LIST STATUS CODE 
Default Codes: 

Notes: 
TRANSPLANT WAITING LIST STATUS CODE (RENAL) is the same as attribute TRANSPLANT WAITING LIST STATUS CODE

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TRAUMATIC LESION OF GENITAL TRACT

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See TRAUMATIC LESION OF GENITAL TRACT TYPE CODE
Default Codes: 

Notes: 
TRAUMATIC LESION OF GENITAL TRACT is the same as attribute TRAUMATIC LESION OF GENITAL TRACT TYPE CODE

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TUBERCULOSIS TREATMENT INDICATOR (HIV)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes: 

Notes: 
TUBERCULOSIS TREATMENT INDICATOR (HIV) is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate if the PATIENT is receiving anti-tuberculosis treatment, as recorded at the HIV Clinic Attendance

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TUMOUR GRADE (FOR BREAST SCREENING)

Change to Data Element: Changed Description

Format/Length:max an2
HES Item: 
National Codes: 
Default Codes:NA - Grade not applicable

Notes: 
TUMOUR GRADE (FOR BREAST SCREENING) is based on the National Codes in attributes BREAST INVASIVE GRADE and DUCTAL CARCINOMA IN SITU GRADE as below:

Permitted National Codes:

CODEDESCRIPTION
1Brest Invasive Grade 1 - Well differentiated (Best prognosis)
2Brest Invasive Grade 2 - Moderately differentiated (Medium prognosis)
3Brest Invasive Grade 3 - Poorly differentiated (Worst prognosis)
XBrest Invasive Grade not known or not assessable
HDCIS Grade High
IDCIS Grade Intermediate
LDCIS Grade Low
NDDCIS Grade not known or not assessable

 

 

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TUMOUR REGRESSION INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See TUMOUR REGRESSION INDICATOR
Default Codes: 

Notes: 
TUMOUR REGRESSION INDICATOR is the same as attribute TUMOUR REGRESSION INDICATOR

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TURP TUMOUR PERCENTAGE

Change to Data Element: Changed Description

Format/Length:max n3
HES Item: 
National Codes: 
Default Codes: 

Notes: 
TURP TUMOUR PERCENTAGE is the result of the Clinical Investigation which measures the percentage of the Tumour if clinically unsuspected for Transurethral resection of the prostate (TURP) only. 

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TWO YEAR NEONATAL OUTCOMES ASSESSMENT YEAR AND MONTH

Change to Data Element: Changed Description

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UMBILICAL CORD CLAMPED IMMEDIATELY AFTER BIRTH INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes: 

Notes: 
UMBILICAL CORD CLAMPED IMMEDIATELY AFTER BIRTH INDICATOR is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate whether the umbilical cord was clamped immediately after the birth of the baby. 

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UMBILICAL CORD MILKING PERFORMED INDICATOR

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See PATIENT PROCEDURE PERFORMED INDICATOR
Default Codes:9 - Not known if umbilical cord milking performed

Notes: 
UMBILICAL CORD MILKING PERFORMED INDICATOR is the same as attribute PATIENT PROCEDURE PERFORMED INDICATOR, to indicate whether the umbilical cord was milked of blood before clamping, to enhance placental-infant transfusion at birth. 

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URGENT CARE SERVICE ACCESSED TYPE

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See URGENT CARE SERVICE ACCESSED TYPE
Default Codes: 

Notes: 
URGENT CARE SERVICE ACCESSED TYPE is the same as attribute URGENT CARE SERVICE ACCESSED TYPE

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URINE DIPSTICK TEST (BLOOD)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See DIPSTICK TEST RESULT CODE
Default Codes: 

Notes: 
URINE DIPSTICK TEST (BLOOD) is the same as attribute DIPSTICK TEST RESULT CODE for a PERSON's urine dipstick test for blood. 

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URINE DIPSTICK TEST (PROTEIN)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See DIPSTICK TEST RESULT CODE
Default Codes: 

Notes: 
URINE DIPSTICK TEST (PROTEIN) is the same as attribute DIPSTICK TEST RESULT CODE for a PERSON's urine dipstick test for protein. 

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URINE OUTPUT LAST 24 HOURS

Change to Data Element: Changed Description

Format/Length:max n5
HES Item: 
National Codes: 
Default Codes: 

Notes: 
URINE OUTPUT LAST 24 HOURS is the result of the Clinical Investigation which measures the PATIENT's Urine Output in the last 24 hours, where the UNIT OF MEASUREMENT is 'Millilitres (ml)'

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URINE OUTPUT LAST HOUR

Change to Data Element: Changed Description

Format/Length:max n4
HES Item: 
National Codes: 
Default Codes: 

Notes: 
URINE OUTPUT LAST HOUR is the result of the Clinical Investigation which measures the PATIENT's Urine Output in the last hour, where the UNIT OF MEASUREMENT is 'Millilitres (ml)'

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VASCULAR LINE TYPE IN SITU

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See VASCULAR LINE TYPE IN SITU
Default Codes:9 - Not applicable (no vascular lines in situ)

Notes: 
VASCULAR LINE TYPE IN SITU is the same as attribute VASCULAR LINE TYPE IN SITU.

For the National Neonatal Data Set - Episodic and Daily Care, VASCULAR LINE TYPE IN SITU indicates the type of vascular line in situ on the NEONATAL CRITICAL CARE DAILY CARE DATE.

 

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VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE)

Change to Data Element: Changed Description

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VENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE)

Change to Data Element: Changed Description

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VITAMIN K ROUTE OF ADMINISTRATION

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See VITAMIN K ROUTE OF ADMINISTRATION
Default Codes:9 - Route of administration unknown

Notes: 
VITAMIN K ROUTE OF ADMINISTRATION  is the same as attribute VITAMIN K ROUTE OF ADMINISTRATION

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WARD DAY PERIOD AVAILABILITY

Change to Data Element: Changed Description

Format/Length:n1
HES Item: 
National Codes: 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For CDS message purposes therefore the constituent component WARD DAY PERIOD AVAILABILITY is required to be separately recorded.

The value for the number of days open only during the day is as recorded by attribute WARD DAY PERIOD AVAILABILITY, but with the addition of Home Leave:

Permitted National Codes:

0Zero days
1One day
2Two days
3Three days
4Four days
5Five days
6Six days
7Seven days
9Home Leave

WARD DAY PERIOD AVAILABILITY will be replaced with WARD DAY PERIOD AVAILABILITY CODE, which should be used for all new and developing data sets and for XML messages.

 

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WARD DAY PERIOD AVAILABILITY CODE

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See WARD DAY PERIOD AVAILABILITY
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component WARD DAY PERIOD AVAILABILITY is required to be separately recorded.

The value for the number of days open only during the day is as recorded by attribute WARD DAY PERIOD AVAILABILITY, but with the addition of Home Leave:

Permitted National Codes:

0Zero days
1One day
2Two days
3Three days
4Four days
5Five days
6Six days
7Seven days
9Home Leave

WARD DAY PERIOD AVAILABILITY CODE replaces WARD DAY PERIOD AVAILABILITY and should be used for all new and developing data sets and for XML messages.

 

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WARD NIGHT PERIOD AVAILABILITY

Change to Data Element: Changed Description

Format/Length:n1
HES Item: 
National Codes: 
Default Codes: 

Notes: 
Data Set Change Notice 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components.DSCN 07/2000 implemented a change to replace the composite data items WARD TYPE AT PSYCHIATRIC CENSUS DATE and WARD TYPE AT START OF EPISODE within Commissioning Data Set by their constituent components. For Commissioning Data Set message purposes therefore the constituent component WARD NIGHT PERIOD AVAILABILITY is required to be separately recorded.

The value for the number of days open only during the night is as recorded by attribute WARD NIGHT PERIOD AVAILABILITY, but with the addition of Home Leave:

Permitted National Codes:

0Zero nights
1One night
2Two nights
3Three nights
4Four nights
5Five nights
6Six nights
7Seven nights
9Home Leave

WARD NIGHT PERIOD AVAILABILITY will be replaced with WARD NIGHT PERIOD AVAILABILITY CODE, which should be used for all new and developing data sets and for XML messages.

 

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WARD NIGHT PERIOD AVAILABILITY CODE