Health and Social Care Information Centre

NHS Data Model and Dictionary Service

Type:Patch
Reference:1472
Version No:1.0
Subject:May 2014 Release Patch
Effective Date:Immediate
Reason for Change:Patch
Publication Date:29 May 2014

Background:

This patch updates the NHS Data Model and Dictionary in preparation for the May 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.

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Summary of changes:

Data Set
NATIONAL NEONATAL DATA SET - EPISODIC AND DAILY CARE   Changed Description
NATIONAL NEONATAL DATA SET - TWO YEAR NEONATAL OUTCOMES ASSESSMENT   Changed Description
 
Supporting Information
ACTIVITY DIAGRAM OVERVIEW   Changed Description
ADDRESS DIAGRAM OVERVIEW   Changed Description
APPOINTMENT DIAGRAM OVERVIEW   Changed Description
CARE PROGRAMME APPROACH EPISODE   Changed Description
CARE PROGRAMME APPROACH REVIEW   Changed Description
CARE PROGRAMME APPROACH REVIEW DATE   Changed Description
COMMISSIONING DATA SET MANDATED DATA FLOWS   Changed Description
HOSPITAL PROVIDER SPELL   Changed Description
MAIN MENU   Changed Description
MENTAL HEALTH CARE CLUSTER   Changed Description
MENTAL HEALTH CARE CLUSTER ASSIGNMENT PERIOD   Changed Description
MENTAL HEALTH CARE CLUSTER SUPER CLASS   Changed Description
MENTAL HEALTH CARE SPELL SUSPENSION   Changed Description
MENTAL HEALTH CLUSTERING TOOL   Changed Description
MENTAL HEALTH MINIMUM DATA SET OVERVIEW   Changed Description
ORGANISATION DIAGRAM OVERVIEW   Changed Description
PATIENT PATHWAY DIAGRAM OVERVIEW   Changed Description
WHAT'S NEW: MAY 2014 renamed from WHAT'S NEW: APRIL 2014   Changed Name, Description
 
Attribute Definitions
GENERAL MEDICAL PRACTITIONER PPD CODE   Changed Description
 
Data Elements
DFES ESTABLISHMENT NUMBER   Changed Description
HEALTH PROGRAMME STAGE NUMBER (HUMAN PAPILLOMAVIRUS VACCINE)   Changed Description
INVASIVE BREAST CANCER DETECTION RATE (PER 1,000 SCREENED)   Changed Description
INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 10MM (PER 1,000 SCREENED)   Changed Description
INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 15MM (PER 1,000 SCREENED)   Changed Description
INVASIVE BREAST CANCER GRADE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)   Changed Description
INVASIVE BREAST CANCER LYMPH NODE STATUS NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)   Changed Description
INVASIVE BREAST CANCER SIZE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)   Changed Description
INVASIVE BREAST CANCER SPECIAL TYPE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)   Changed Description
INVASIVE TUMOUR SIZE   Changed Description
INVESTIGATION RESULT (MOTHER RHESUS ANTIBODIES BOOKING)   Changed Description
INVESTIGATION RESULT (SCREENING MOTHER HAEMOGLOBINOPATHY)   Changed Description
INVESTIGATION RESULT (SCREENING MOTHER HEPATITIS B)   Changed Description
INVESTIGATION RESULT (SCREENING MOTHER HUMAN IMMUNODEFICIENCY VIRUS)   Changed Description
INVESTIGATION RESULT (SCREENING MOTHER RUBELLA SUSCEPTIBILITY)   Changed Description
INVESTIGATION RESULT (SCREENING MOTHER SYPHILIS)   Changed Description
INVESTIGATION RESULT (ULTRASOUND FETAL ANOMALY SCREENING)   Changed Description
INVESTIGATION RESULT DATE   Changed Description
INVESTIGATION RISK RATIO RESULT (SCREENING DOWNS SYNDROME)   Changed Description
 

Date:29 May 2014
Sponsor:Richard Kavanagh, Head of Data Standards - Interoperability Specifications, Information Standards Delivery, 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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NATIONAL NEONATAL DATA SET - EPISODIC AND DAILY CARE

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.

DEMOGRAPHICS AND BIRTH INFORMATION (BABY)

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

Baby Demographics (Standard):
To carry the Baby'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 (BABY)
MNHS NUMBER STATUS INDICATOR CODE (BABY)
RCOMMUNITY HEALTH INDEX NUMBER (BABY)
RHEALTH AND CARE NUMBER (BABY)
MBABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)
RDATE TIME OF BIRTH (BABY)
MSITE CODE (OF ACTUAL PLACE OF DELIVERY)
or
ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)
RBIRTH WEIGHT
OBIRTH LENGTH
OBIRTH HEAD CIRCUMFERENCE
OGESTATION LENGTH (AT DELIVERY)
OGESTATION LENGTH (REMAINING DAYS AT DELIVERY)
RPERSON PHENOTYPIC SEX
PPERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)
OBLOOD GROUP (BABY)
ORHESUS GROUP (BABY)
RBASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH)

OR

Baby Demographics (Withheld):
To carry the Baby'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 (BABY)
MBABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)
RYEAR AND MONTH OF BIRTH (BABY)
MSITE CODE (OF ACTUAL PLACE OF DELIVERY)
or
ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)
RBIRTH WEIGHT
OBIRTH LENGTH
OBIRTH HEAD CIRCUMFERENCE
OGESTATION LENGTH (AT DELIVERY)
OGESTATION LENGTH (REMAINING DAYS AT DELIVERY)
RPERSON PHENOTYPIC SEX
PPERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)
OBLOOD GROUP (BABY)
ORHESUS GROUP (BABY)
RBASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH)

PARENTS

One of the following Parent's Demographics Data Group Structures should be used:

Parents Demographics (Standard):
To carry the Parent's demographic details where anonymisation of the record is NOT required.
One occurrence of this group is permitted.
 
RNHS NUMBER (MOTHER)
MNHS NUMBER STATUS INDICATOR CODE (MOTHER)
RCOMMUNITY HEALTH INDEX NUMBER (MOTHER)
RHEALTH AND CARE NUMBER (MOTHER)
RYEAR OF BIRTH (MOTHER)
MPOSTCODE OF USUAL ADDRESS (MOTHER)
PQUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET)
OOCCUPATION MOTHER (SNOMED CT)
RETHNIC CATEGORY (MOTHER)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER))
RYEAR OF BIRTH (FATHER)
RETHNIC CATEGORY (FATHER)
RPARENTS CONSANGUINEOUS INDICATOR

OR

Parents Demographics (Withheld):
To carry the Parent's demographic details where anonymisation of the record IS required.
One occurrence of this group is permitted.
 
MNHS NUMBER STATUS INDICATOR CODE (MOTHER)
RYEAR OF BIRTH (MOTHER)
PQUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET)
OOCCUPATION MOTHER (SNOMED CT)
RETHNIC CATEGORY (MOTHER)
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER))
RYEAR OF BIRTH (FATHER)
RETHNIC CATEGORY (FATHER)
RPARENTS CONSANGUINEOUS INDICATOR

ANTENATAL

Pregnancy Details:
To carry details of the pregnancy.
One occurrence of this group is required
M/R/O Data Set Data Elements 
PMOTHER ANTENATALLY BOOKED INDICATOR
MSITE CODE (OF INTENDED PLACE OF DELIVERY)
or
ORGANISATION CODE (OF INTENDED PLACE OF DELIVERY)
RPREGNANCY TOTAL PREVIOUS PREGNANCIES
RMATERNITY COMPLICATING MEDICAL DIAGNOSIS TYPE (NATIONAL NEONATAL DATA SET)
Multiple occurrences of this item are permitted
PMATERNITY OBSTETRIC DIAGNOSIS TYPE (CURRENT PREGNANCY)
Multiple occurrences of this item are permitted
RMATERNITY MEDICAL DIAGNOSIS TYPE (CURRENT PREGNANCY)
Multiple occurrences of this item are permitted
RBLOOD GROUP (MOTHER)
RRHESUS GROUP (MOTHER)
OHAEMOGLOBINOPATHY INVESTIGATION RESULT CODE FOR NATIONAL NEONATAL DATA SET (MOTHER)
RMOTHER CURRENT SMOKER AT BOOKING INDICATOR
OCIGARETTES PER DAY (MOTHER AT BOOKING)
RSTEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR
RANTENATAL STEROID COURSE COMPLETION STATUS
OSTEROID TYPE GIVEN TO MOTHER (SNOMED CT DM+D)
OINVESTIGATION RESULT CODE (MOTHER RUBELLA SCREENING)
RLAST MENSTRUAL PERIOD DATE
or
LAST MENSTRUAL PERIOD YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)
MESTIMATED DATE OF DELIVERY (AGREED)
or
ESTIMATED DATE OF DELIVERY (AGREED) YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RESTIMATED DATE OF DELIVERY METHOD (AGREED)

LABOUR AND DELIVERY

Labour and Delivery Details:
To carry details of the labour and delivery.
One occurrence of this group is required
M/R/O Data Set Data Elements 
RLABOUR OR DELIVERY ONSET METHOD CODE (NATIONAL NEONATAL DATA SET)
OMECONIUM PRESENT IN LIQUOR INDICATOR
OMEDICATION GIVEN DURING LABOUR (SNOMED CT DM+D)
Multiple occurrences of this item are permitted
RRUPTURE OF MEMBRANES DATE TIME
or
RUPTURE OF MEMBRANES YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)
OSIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR
OINTRAPARTUM ANTIBIOTICS GIVEN INDICATOR
RPRESENTATION AT DELIVERY
MMODE OF DELIVERY
PIN LABOUR BEFORE CAESARIAN SECTION INDICATOR
PDELIVERY INSTRUMENT TYPE
Multiple occurrences of this item are permitted
RBIRTH ORDER (MATERNITY SERVICES)
RNUMBER OF FETUSES (NOTED DURING PREGNANCY EPISODE)
OTIME BETWEEN DELIVERY AND SPONTANEOUS RESPIRATION CODE
RAPGAR SCORE (1 MINUTE)
RAPGAR SCORE (5 MINUTES)
RAPGAR SCORE (10 MINUTES)
RNEONATAL RESUSCITATION METHOD (NATIONAL NEONATAL DATA SET)
ONEONATAL RESUSCITATION DRUG (SNOMED CT DM+D)
Multiple occurrences of this item are permitted
PUMBILICAL CORD CLAMPED IMMEDIATELY AFTER BIRTH INDICATOR
PTIME BETWEEN DELIVERY AND UMBILICAL CORD CLAMPING
PUMBILICAL CORD MILKING PERFORMED INDICATOR
OUMBILICAL CORD BLOOD PH LEVEL (ARTERIAL)
OUMBILICAL CORD BLOOD PH LEVEL (VENOUS)
OUMBILICAL CORD BLOOD PARTIAL PRESSURE CARBON DIOXIDE (ARTERIAL)
OUMBILICAL CORD BLOOD PARTIAL PRESSURE CARBON DIOXIDE (VENOUS)
OUMBILICAL CORD BLOOD LACTATE LEVEL
RUMBILICAL CORD BLOOD BASE EXCESS CONCENTRATION (ARTERIAL)
RUMBILICAL CORD BLOOD BASE EXCESS CONCENTRATION (VENOUS)
RSURFACTANT GIVEN INDICATOR (DURING RESUSCITATION)

ADMISSION TO NEONATAL CRITICAL CARE

Admission Details:
To carry details of the admission to Neonatal Critical Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
MCRITICAL CARE START DATE AND TIME
or
CRITICAL CARE START YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)
MSITE CODE (OF ADMITTING NEONATAL UNIT)
or
ORGANISATION CODE (OF ADMITTING NEONATAL UNIT)
REPISODE NUMBER (NEONATAL CRITICAL CARE SPELL)
RSITE CODE (ADMITTED FROM TO NEONATAL UNIT)
or
ORGANISATION CODE (ADMITTED FROM TO NEONATAL UNIT)
OLOCATION IN HOSPITAL TYPE (BABY ADMITTED FROM)
RPRIMARY CATEGORY OF CARE REQUIRED ON ADMISSION TO NEONATAL CRITICAL CARE
MTEMPERATURE RECORDED AFTER ADMISSION TO NEONATAL CRITICAL CARE INDICATOR
MTEMPERATURE (ON ADMISSION TO NEONATAL CRITICAL CARE)
ROBSERVATION DATE AND TIME (TEMPERATURE)
or
OBSERVATION YEAR AND MONTH (TEMPERATURE)
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RMEAN ARTERIAL BLOOD PRESSURE (ON ADMISSION TO NEONATAL CRITICAL CARE)
RHEART RATE (ON ADMISSION TO NEONATAL CRITICAL CARE)
ORESPIRATORY RATE (ON ADMISSION TO NEONATAL CRITICAL CARE)
OOXYGEN SATURATION (ON ADMISSION TO NEONATAL CRITICAL CARE)
OBLOOD GLUCOSE CONCENTRATION (ON ADMISSION TO NEONATAL CRITICAL CARE)
RDIAGNOSIS (ICD ON ADMISSION TO NEONATAL CRITICAL CARE)
Multiple occurrences of this item are permitted
and/or
DIAGNOSIS (SNOMED CT ON ADMISSION TO NEONATAL CRITICAL CARE)
Multiple occurrences of this item are permitted
OPARENTAL CONSENT TO ADMINISTER VITAMIN K INDICATOR
OVITAMIN K ADMINISTERED INDICATOR
OVITAMIN K ROUTE OF ADMINISTRATION
OCARE PROFESSIONAL JOB ROLE CODE (COMPLETING NEONATAL INTENSIVE CARE UNIT ADMISSION FORM)
MPARENTS SEEN BY SENIOR STAFF MEMBER WITHIN 24 HOURS OF ADMISSION INDICATOR
MPARENTS SEEN BY SENIOR STAFF MEMBER DATE AND TIME
or
PARENTS SEEN BY SENIOR STAFF MEMBER YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)

DISCHARGE FROM NEONATAL CRITICAL CARE UNIT

Discharge Details:
To carry details of the discharge from the Neonatal Intensive Care Unit.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
MCRITICAL CARE DISCHARGE DATE AND TIME
or
CRITICAL CARE DISCHARGE YEAR AND MONTH
and
NUMBER OF MINUTES (BIRTH TO EVENT)
MDESTINATION ON DISCHARGE FROM NEONATAL CRITICAL CARE
RTRANSFERRED FOR FURTHER CARE TYPE (NATIONAL NEONATAL DATA SET)
OWARD TYPE DISCHARGED TO (NATIONAL NEONATAL DATA SET)
RSITE CODE (RECEIVING)
or
ORGANISATION CODE (RECEIVING)
RPERSON DEATH DATE AND TIME (DURING NEONATAL CRITICAL CARE PERIOD)
or
PERSON DEATH YEAR AND MONTH (DURING NEONATAL CRITICAL CARE PERIOD)
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RDEATH CAUSE ICD CODE (DURING NEONATAL CRITICAL CARE PERIOD)
Multiple occurrences of this item are permitted
OPOST MORTEM CARRIED OUT INDICATOR
OPARENTAL CONSENT TO POST MORTEM INDICATOR
OPOST MORTEM CONFIRMED NECROTISING ENTEROCOLITIS DIAGNOSIS INDICATOR
ORECEIVING OXYGEN THERAPY ON DISCHARGE INDICATOR
OSITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)
or
ORGANISATION CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)
RDIAGNOSIS (ICD RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)
Multiple occurrences of this item are permitted
and/or
DIAGNOSIS (SNOMED CT RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)
Multiple occurrences of this item are permitted

Procedures Recorded At Discharge:
To carry details of procedures recorded at discharge.
Multiple occurrences of this group are permitted.
M/R/O Data Set Data Elements 
RPROCEDURE (OPCS RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)
and/or 
PROCEDURE (SNOMED CT RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)
RPROCEDURE DATE AND TIME (DURING NEONATAL CRITICAL CARE PERIOD)
or
PROCEDURE YEAR AND MONTH (DURING NEONATAL CRITICAL CARE PERIOD) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)

CLINICAL TRIALS (EPISODIC)
 
Clinical Trials Details:
To carry details of Clinical Trial enrolment at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
M/R/O Data Set Data Elements 
OCLINICAL TRIAL NAME
OCLINICAL TRIAL MEDICATION ADMINISTERED NAME
Multiple occurrences of this item are permitted

INFECTION CULTURES (EPISODIC)

Infection Culture Indicators:
To carry indicators relating to Infection Cultures undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
PINFECTION CULTURE TEST INDICATOR (BLOOD)
PINFECTION CULTURE TEST INDICATOR (CEREBROSPINAL FLUID)
PINFECTION CULTURE TEST INDICATOR (URINE)

Infection Cultures:
To carry information relating to Infection Cultures at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
 
M/R/O Data Set Data Elements 
RSAMPLE COLLECTION DATE AND TIME
or
SAMPLE COLLECTION YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RSAMPLE TYPE (NATIONAL NEONATAL DATA SET)
RCLINICAL SIGN OBSERVED AT SAMPLE COLLECTION
Multiple occurrences of this item are permitted
RSAMPLE TEST RESULT ORGANISM TYPE (SNOMED CT)
Multiple occurrences of this item are permitted
OSAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D)
Multiple occurrences of this item are permitted

ABDOMINAL X-RAYS (EPISODIC)

Abdominal X-Ray Indicator:
To carry an indicator relating to Abdominal X-Rays undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
PABDOMINAL X-RAY PERFORMED INDICATOR

Abdominal X-Rays:
To carry information relating to Abdominal X-Rays at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
 
M/R/O Data Set Data Elements 
RPROCEDURE DATE AND TIME (ABDOMINAL X-RAY)
or
PROCEDURE YEAR AND MONTH (ABDOMINAL X-RAY) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RABDOMINAL X-RAY PERFORMED TO INVESTIGATE ABDOMINAL SIGNS INDICATOR
RCONDITION SEEN IN ABDOMEN DURING X-RAY
Multiple occurrences of this item are permitted
RABDOMINAL X-RAY PERFORMED REASON
Multiple occurrences of this item are permitted
RTRANSFERRED FROM NEONATAL INTENSIVE CARE UNIT FOR NECROTISING ENTEROCOLITIS MANAGEMENT INDICATOR
RLAPAROTOMY FOR NECROTISING ENTEROCOLITIS INDICATION CODE
RVISUAL INSPECTION CONFIRMED NECROTISING ENTEROCOLITIS DURING LAPAROTOMY INDICATOR
RHISTOLOGY CONFIRMED NECROTISING ENTEROCOLITIS FOLLOWING LAPAROTOMY INDICATOR
RPERITONEAL DRAIN INSERTED FOLLOWING ABDOMINAL X-RAY INDICATOR

RETINOPATHY OF PREMATURITY SCREENING (EPISODIC)

Retinopathy of Prematurity Screening Indicator:
To carry an indicator relating to Retinopathy of Prematurity Screening undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
MRETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR

Retinopathy of Prematurity Screening:
To carry information relating to Retinopathy of Prematurity Screening at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
M/R/O Data Set Data Elements 
RPROCEDURE DATE AND TIME (RETINOPATHY OF PREMATURITY SCREENING)
or
PROCEDURE YEAR AND MONTH (RETINOPATHY OF PREMATURITY SCREENING) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RSITE CODE (OF RETINOPATHY OF PREMATURITY SCREENING)
or 
ORGANISATION CODE (OF RETINOPATHY OF PREMATURITY SCREENING)
RRETINOPATHY OF PREMATURITY STAGE (LEFT EYE)
RRETINOPATHY OF PREMATURITY STAGE (RIGHT EYE)
RRETINOPATHY OF PREMATURITY CLOCK HOURS MAXIMUM STAGE (LEFT EYE)
RRETINOPATHY OF PREMATURITY CLOCK HOURS MAXIMUM STAGE (RIGHT EYE)
RRETINOPATHY OF PREMATURITY MAXIMUM ZONE (LEFT EYE)
RRETINOPATHY OF PREMATURITY MAXIMUM ZONE (RIGHT EYE)
RRETINOPATHY OF PREMATURITY PLUS DISEASE STATUS (LEFT EYE)
RRETINOPATHY OF PREMATURITY PLUS DISEASE STATUS (RIGHT EYE)
RRETINOPATHY OF PREMATURITY SCREENING OUTCOME STATUS CODE

CRANIAL ULTRASOUND SCANS (EPISODIC)

Cranial Ultrasound Scan Indicator:
To carry an indicator relating to Cranial Ultrasound Scans undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
PCRANIAL ULTRASOUND SCAN PERFORMED INDICATOR

Cranial Ultrasound Scan:
To carry information relating to Cranial Ultrasound Scans at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
M/R/O Data Set Data Elements 
RPROCEDURE DATE AND TIME (CRANIAL ULTRASOUND SCAN)
or
PROCEDURE YEAR AND MONTH (CRANIAL ULTRASOUND SCAN) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
OINTRAVENTRICULAR HAEMORRHAGE GRADE (LEFT SIDE)
OPORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE)
OVENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE)
OINTRAVENTRICULAR HAEMORRHAGE GRADE (RIGHT SIDE)
OPORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE)
OVENTRICULAR DILATION DIAGNOSED DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE)
OCYSTIC PERIVENTRICULAR LEUKOMALACIA OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR
OPOST HAEMORRHAGIC HYDROCEPHALUS OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR

NEWBORN BLOOD SPOT BIOCHEMICAL SCREENING (EPISODIC)

Newborn Blood Spot Test Indicator:
To carry an indicator relating to Newborn Blood Spot Tests undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
MNEWBORN BLOOD SPOT TEST PERFORMED INDICATOR

Newborn Blood Spot Screening:
To carry details of Newborn Blood Spot Biochemical Screening undertaken at any time in the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
 
M/R/O Data Set Data Elements 
RBLOOD SPOT CARD COMPLETION DATE
or
BLOOD SPOT CARD COMPLETION YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)

NEWBORN HEARING SCREENING (EPISODIC)

Newborn Hearing Screening Indicator:
To carry an indicator relating to Newborn Hearing Screening undertaken at any time during the Neonatal Critical Care Period.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
PNEWBORN HEARING SCREENING PERFORMED INDICATOR

Newborn Hearing Screening:
To carry information relating to Newborn Hearing Screening at any time during the Neonatal Critical Care Period.
Multiple occurrences of this group are permitted.
M/R/O Data Set Data Elements 
RPROCEDURE DATE AND TIME (NEWBORN HEARING SCREENING)
or
PROCEDURE YEAR AND MONTH (NEWBORN HEARING SCREENING) 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
ONEWBORN HEARING SCREENING OUTCOME LEFT EAR (NATIONAL NEONATAL DATA SET)
ONEWBORN HEARING SCREENING OUTCOME RIGHT EAR (NATIONAL NEONATAL DATA SET)
ONEWBORN HEARING SCREENING TEST TYPE

DAILY CARE INFORMATION

Daily Care General Information:
To carry General Information relating to Daily Care.
Multiple occurrences of this group are permitted (at least one occurrence is required).
M/R/O Data Set Data Elements 
MNEONATAL CRITICAL CARE DAILY CARE DATE
or
NEONATAL CRITICAL CARE DAILY CARE YEAR AND MONTH 
and
NUMBER OF MINUTES (BIRTH TO EVENT)
RPERSON WEIGHT IN GRAMS
OHEAD CIRCUMFERENCE IN CENTIMETRES
OPERSON LENGTH IN CENTIMETRES
RLOCATION OF HIGHEST LEVEL OF CARE
RPATIENT RECEIVING ONE TO ONE NURSING CARE INDICATOR
RCARER RESIDENT INDICATION CODE (NATIONAL NEONATAL DATA SET)
RDIAGNOSIS (ICD ON NEONATAL CRITICAL CARE DAILY CARE DATE)
Multiple occurrences of this item are permitted
and/or
DIAGNOSIS (SNOMED CT ON NEONATAL CRITICAL CARE DAILY CARE DATE)
Multiple occurrences of this item are permitted
RPROCEDURE (OPCS ON NEONATAL CRITICAL CARE DAILY CARE DATE)
Multiple occurrences of this item are permitted
and/or 
PROCEDURE (SNOMED CT ON NEONATAL CRITICAL CARE DAILY CARE DATE)
Multiple occurrences of this item are permitted
RPERSON ACCOMPANYING TRANSPORTED PATIENT
Multiple occurrences of this item are permitted

Daily Care Respiratory:
To carry Respiratory information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
PRESPIRATORY SUPPORT DEVICE TYPE (NATIONAL NEONATAL DATA SET)
Multiple occurrences of this item are permitted
PRESPIRATORY SUPPORT MODE (NATIONAL NEONATAL DATA SET)
Multiple occurrences of this item are permitted
RNITRIC OXIDE GIVEN INDICATOR
RCHEST DRAIN IN SITU INDICATOR
RTRACHEOSTOMY TUBE IN SITU INDICATOR
RREPLOGLE TUBE IN SITU INDICATOR
RSURFACTANT GIVEN INDICATOR (ON NEONATAL CRITICAL CARE DAILY CARE DATE)
PFRACTION OF INSPIRED OXYGEN PERCENTAGE

Daily Care Cardiovascular:
To carry Cardiovascular information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RCONTINUOUS INFUSION OF PULMONARY VASODILATOR RECEIVED INDICATOR
RINOTROPE INFUSION RECEIVED INDICATOR
RPROSTAGLANDIN INFUSION RECEIVED INDICATOR
RTREATMENT TYPE FOR PATENT DUCTUS ARTERIOSUS
Multiple occurrences of this item are permitted

Daily Care Gastrointestinal:
To carry Gastrointestinal information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RPERITONEAL DIALYSIS RECEIVED INDICATOR
RHAEMOFILTRATION RECEIVED INDICATOR
RTREATMENT TYPE FOR NECROTISING ENTEROCOLITIS
RMORE THAN THREE RECTAL WASHOUTS RECEIVED INDICATOR
RSTOMA PRESENT INDICATOR

Daily Care Blood Transfusion:
To carry Blood Transfusion information relating to Daily Care.
Multiple occurrences of this group are permitted.
 
M/R/O Data Set Data Elements 
RBLOOD TRANSFUSION TYPE
RBLOOD TRANSFUSION PRODUCT TYPE
Multiple occurrences of this item are permitted

Daily Care Neurology:
To carry Neurology information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RCENTRAL TONE STATUS
RNEONATAL CONSCIOUSNESS STATUS
RSEIZURE OCCURRED INDICATOR
RNEONATAL ABSTINENCE SYNDROME OBSERVED INDICATOR
RBRAIN ACTIVITY SCAN PERFORMED INDICATOR
RTHERAPEUTIC HYPOTHERMIA INDUCED INDICATOR
RHYPOXIC ISCHEMIC ENCEPHALOPATHY GRADE (HIGHEST ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Daily Care Retinopathy of Prematurity Screening:
To carry Retinopathy of Prematurity information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RRETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR

Daily Care Fluids and Feeding:
To carry Fluids and Feeding information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RVASCULAR LINE TYPE IN SITU
Multiple occurrences of this item are permitted
RPARENTERAL NUTRITION RECEIVED INDICATOR
RINTRAVENOUS INFUSION OF GLUCOSE AND ELECTROLYTE SOLUTION RECEIVED INDICATOR
RENTERAL FEED TYPE GIVEN
Multiple occurrences of this item are permitted
RFORMULA MILK OR MILK FORTIFIER TYPE
Multiple occurrences of this item are permitted
or
FORMULA MILK OR MILK FORTIFIER TYPE (SNOMED CT DM+D)
Multiple occurrences of this item are permitted
RTOTAL VOLUME OF MILK RECEIVED
OENTERAL FEEDING METHOD
Multiple occurrences of this item are permitted

Daily Care Infections:
To carry Infection information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RSEPSIS SUSPECTED INDICATOR

Daily Care Jaundice:
To carry Jaundice information relating to Daily Care.
One occurrence of this group is required.
 
M/R/O Data Set Data Elements 
RPHOTOTHERAPY RECEIVED INDICATOR

Daily Care Medication:
To carry Medication Administered information relating to Daily Care.
One occurrence of this group is permitted.
 
M/R/O Data Set Data Elements 
RMEDICATION GIVEN DURING NEONATAL CRITICAL CARE DAILY CARE DATE (SNOMED CT DM+D)
Multiple occurrences of this item are permitted

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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 DELIVERY)
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) TOTAL RAW 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 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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ACTIVITY DIAGRAM OVERVIEW

Change to Supporting Information: Changed Description

The Activity Diagram demonstrates how the ACTIVITY class encompasses all the spells, episodes, stays, contacts and interventions which may be provided for a PATIENT.The Activity Diagram demonstrates how an ACTIVITY encompasses all the spells, episodes, stays, contacts and interventions which may be provided for a PATIENT. It also shows the CARE PROFESSIONALS and ORGANISATIONS involved.

Related diagrams include:

USING THE DIAGRAM

By clicking on a Class on the diagram opposite, the selected Class definition will be displayed. By clicking on an Attribute name displayed within the Class, the selected Attribute definition will be displayed.

Note that not all attributes for a class will be visible. The full list of attributes for a class can be viewed in the class definition, by selecting the 'Attribute' tab.

To view the diagram in full, select the 'Print Window' option, this will open a new window that will display only the diagram. You can also use this view to print the diagram, by right clicking on the diagram and selecting 'Print Picture'.

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ADDRESS DIAGRAM OVERVIEW

Change to Supporting Information: Changed Description

The Address Diagram demonstrates how the class ADDRESS may be utilised by a PERSON or an ORGANISATION.The Address Diagram demonstrates how an ADDRESS may be utilised by a PERSON or an ORGANISATION.

Related diagrams include:

USING THE DIAGRAM

By clicking on a Class on the diagram opposite, the selected Class definition will be displayed. By clicking on an Attribute name displayed within the Class, the selected Attribute definition will be displayed.

Note that not all attributes for a class will be visible. The full list of attributes for a class can be viewed in the class definition, by selecting the 'Attribute' tab.

To view the diagram in full, select the 'Print Window' option, this will open a new window that will display only the diagram. You can also use this view to print the diagram, by right clicking on the diagram and selecting 'Print Picture'.

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APPOINTMENT DIAGRAM OVERVIEW

Change to Supporting Information: Changed Description

The Appointment Diagram demonstrates how the APPOINTMENT class is related to the delivery of an ACTIVITY.The Appointment Diagram demonstrates how an APPOINTMENT is related to the delivery of an ACTIVITY.

Related diagrams include:

USING THE DIAGRAM

By clicking on a Class on the diagram opposite, the selected Class definition will be displayed. By clicking on an Attribute name displayed within the Class, the selected Attribute definition will be displayed.

Note that not all attributes for a class will be visible. The full list of attributes for a class can be viewed in the class definition, by selecting the 'Attribute' tab.

To view the diagram in full, select the 'Print Window' option, this will open a new window that will display only the diagram. You can also use this view to print the diagram, by right clicking on the diagram and selecting 'Print Picture'.

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CARE PROGRAMME APPROACH EPISODE

Change to Supporting Information: Changed Description

Care Programme Approach Episode is an ACTIVITY GROUP.A Care Programme Approach Episode is an ACTIVITY GROUP.

A period of care provided as part of the care programme approach for an adult (including elderly) PATIENT.A Care Programme Approach Episode is a period of care provided as part of the care programme approach for an adult (including elderly) PATIENT. The Care Programme Approach Episode forms part of a Adult Mental Health Care Spell.

The first Care Programme Approach Episode starts when the Adult Mental Health Care Spell initial assessment of the PATIENT determines that a plan of care or treatment is required which will be delivered under the care programme approach.

The Care Programme Approach Episode ends when one of the following occurs:

  • a review determines that no further care need be provided
  • a different level of care programme approach is required
  • a PATIENT transfers to another Health Care Provider with main responsibility for provision of mental health care also being transferred
  • death of the PATIENT

A Care Programme Approach Episode must involve all of the following key elements:

a. An assessment of the PATIENT's health and social care needs
b. A written care plan to meet the assessed needs, the PATIENT being involved in drawing up the care plan
c. Regular reviews of the PATIENT's care plan
d. A named mental health worker, called a care coordinator, who is responsible for the PATIENT care under the care programme approach

Each Care Programme Approach Episode must be subject to at least one Care Programme Approach Review and at least one Care Programme Approach Care Co-ordinator Allocation.

 

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CARE PROGRAMME APPROACH REVIEW

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Care Programme Approach Review is a CARE CONTACT.A Care Programme Approach Review is a CARE CONTACT.

A clinical review of the health and social needs of a PATIENT who is the subject of a Care Programme Approach Episode. The review may take the form of a single meeting of interested parties, usually including the allocated care coordinator and the PATIENT or it may comprise a series of meetings and discussions over a number of days. The Care Programme Approach Review ends when a definite outcome is established and recorded.A Care Programme Approach Review is a clinical review of the health and social needs of a PATIENT who is the subject of a Care Programme Approach Episode.

The review may take the form of a single meeting of interested parties, usually including the allocated care coordinator and the PATIENT or it may comprise a series of meetings and discussions over a number of days.

The Care Programme Approach Review ends when a definite outcome is established and recorded. The date when this is recorded will be taken as the Care Programme Approach Review Date. The outcome will determine whether the Care Programme Approach Episode continues or is ended.

The review will also include the assessment and recording of the Health of the Nation Outcome Scale and the assessment or re-assessment of the need for a Supervision Register Episode. 

 

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CARE PROGRAMME APPROACH REVIEW DATE

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COMMISSIONING DATA SET MANDATED DATA FLOWS

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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 TYPE

DESCRIPTION

MIN FREQUENCY

 

DIRECTIVE

 

DATA FLOW

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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HOSPITAL PROVIDER SPELL

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Hospital Provider Spell is an ACTIVITY GROUP.A Hospital Provider Spell is an ACTIVITY GROUP.

The total continuous stay of a PATIENT using a Hospital Bed on premises controlled by a Health Care Provider during which medical care is the responsibility of one or more CONSULTANTS, or the PATIENT is receiving care under one or more Nursing Episodes or Midwife Episodes in a WARD.A Hospital Provider Spell is the total continuous stay of a PATIENT using a Hospital Bed on premises controlled by a Health Care Provider during which medical care is the responsibility of one or more CONSULTANTS, or the PATIENT is receiving care under one or more Nursing Episodes or Midwife Episodes in a WARD. During Nursing Episodes and Midwife Episodes general medical care is the responsibility of their own GENERAL MEDICAL PRACTITIONER, who is not acting as a CONSULTANT. The Hospital Provider Spell may be as a result of an ELECTIVE ADMISSION LIST ENTRY.

During the Hospital Provider Spell, the PATIENT may be subject to more than one ADMINISTRATIVE CATEGORY PERIODS. The PATIENT may be subject to one or more CRITICAL CARE PERIODS.

The Hospital Provider Spell starts when a CONSULTANT, NURSE or MIDWIFE assumes responsibility for care following the DECISION TO ADMIT the PATIENT. This may be before formal admission procedures have been completed and the PATIENT transferred to a WARD. For example, if a PATIENT is brought into hospital as an emergency and dies in the OPERATING THEATRE before being transferred to a WARD, the PATIENT would have started a Hospital Provider Spell.

In some circumstances a PATIENT may take Home Leave, or Mental Health Leave of Absence for a period of 28 days or less, or have a current period of Mental Health Absence Without Leave of 28 days or less, which does not interrupt the Hospital Provider Spell, Consultant Episode (Hospital Provider), Nursing Episode, Midwife Episode or Hospital Stay.

Each admission as part of a series of regular day/night admissions generates a separate Hospital Provider Spell and Consultant Episode (Hospital Provider). An admission is the start of the PATIENT's Hospital Provider Spell and the first Consultant Episodes (Hospital Provider), Midwife Episode or Nursing Episode within the spell. If the PATIENT is on a Hospital Site the admission will also start the first Hospital Stay and, unless the PATIENT has to spend time as a LODGED PATIENT, the admission will also start the first Ward Stay within that Hospital Provider Spell. If the PATIENT is in a Care Home the admission will start the first Care Home Stay (Consultant Care) within the Hospital Provider Spell. Any admission of a PERSON liable to be detained under the Mental Health Act 1983 cannot be in a Care Home and must be a Hospital Provider Spell.

A discharge will be the end of the last Consultant Episode (Hospital Provider), Midwife Episode or Nursing Episode, and the end of the last Care Home Stay (Consultant Care) or Hospital Stay and Ward Stay within that Hospital Provider Spell.

If there is any time spent as a LODGED PATIENT before transfer to a WARD this is included in the Hospital Provider Spell.

A Hospital Provider Spell starts with a Hospital Provider admission and ends with a Hospital Provider discharge.

There may be one or more Mental Health Delayed Discharge Periods recorded for any Consultant Episode (Hospital Provider) within the Hospital Provider Spell.

 

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MAIN MENU

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MENTAL HEALTH CARE CLUSTER

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A Mental Health Care Cluster is a MENTAL HEALTH CARE CLUSTER which is a type of CATEGORY VALUED PERSON OBSERVATION.

A Mental Health Care Cluster is part of a currency developed to support Payment by Results for Mental Health Services.  Mental Health Care Clusters are 21 groupings of Mental Health PATIENTS based on their characteristics, and are a way of classifying individuals utilising Mental Health Services that forms the basis for payment.

A Mental Health Care Cluster is assigned using a decision tree or algorithm based on the PERSON SCORE from the Mental Health Clustering Tool undertaken by a CARE PROFESSIONAL for the PATIENT.

This is done by first assigning the PATIENT to one of three Mental Health Care Cluster Super Classes, to narrow down the number of possible Mental Health Care Clusters which are applicable to the PATIENTS condition.  The PATIENT is then assigned to the most appropriate of this sub-set of Mental Health Care Clusters. The PATIENT is then assigned to the most appropriate of this sub-set of Mental Health Care Clusters.

The Mental Health Care Clusters into which the presenting needs of the PATIENT may fall are:

Care Cluster 0:  Variance - Despite careful consideration of all the other Mental Health Care Clusters, this group of PATIENTS are not adequately described by any of their descriptions.  PATIENTS who cannot be initially assigned to a Mental Health Care Cluster Super Class during the clustering process will be automatically assigned to this Mental Health Care Cluster. PATIENTS who cannot be initially assigned to a Mental Health Care Cluster Super Class during the clustering process will be automatically assigned to this Mental Health Care Cluster.

Care Cluster 1:  Common Mental Health Problems (Low Severity) - This group of PATIENTS has definite but minor problems of depressed mood, anxiety or other disorder, but they do not present with any psychotic symptoms

Care Cluster 2:  Common Mental Health Problems (Low Severity with Greater Need) - This group of PATIENTS has definite but minor problems of depressed mood, anxiety or other disorder, but not with any psychotic symptoms.  They may have already received care associated with Care Cluster 1 and require more specific intervention, or previously been successfully treated at a higher level but are re-presenting with low level symptoms They may have already received care associated with Care Cluster 1 and require more specific intervention, or previously been successfully treated at a higher level but are re-presenting with low level symptoms

Care Cluster 3:  Non-Psychotic (Moderate Severity) - This group of PATIENTS have moderate problems involving depressed mood, anxiety or other disorder (not including psychosis)

Care Cluster 4:  Non-Psychotic (Severe) - This group of PATIENTS is characterised by severe depression and/or anxiety and/or other disorders, and increasing complexity of needs.  They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks. They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks.

Care Cluster 5:  Non-Psychotic Disorders (Very Severe) - This group of PATIENTS will be severely depressed and/or anxious and/or other.  They will not present with hallucinations or delusions but may have some unreasonable beliefs.  They may often be at high risk for suicide and they may present safeguarding issues and have severe disruption to everyday living. They will not present with hallucinations or delusions but may have some unreasonable beliefs. They may often be at high risk for suicide and they may present safeguarding issues and have severe disruption to everyday living.

Care Cluster 6:  Non-Psychotic Disorder of Over-Valued Ideas - This group of PATIENTS suffer from moderate to very severe disorders that are difficult to treat.  This may include treatment resistant eating disorders, Obsessive Compulsive Disorder etc, where extreme beliefs are strongly held, some personality disorders, and enduring depression. This may include treatment resistant eating disorders, Obsessive Compulsive Disorder etc, where extreme beliefs are strongly held, some personality disorders, and enduring depression.

Care Cluster 7:  Enduring Non-Psychotic Disorders (High Disability) - This group of PATIENTS suffer from moderate to severe disorders that are very disabling.  They will have received treatment for a number of years and although they may have an improvement in positive symptoms, considerable disability remains that is likely to affect role functioning in many ways.

Care Cluster 8:  Non-Psychotic Chaotic and Challenging Disorders - This group of PATIENTS will have a wide range of symptoms and chaotic and challenging lifestyles.  They are characterised by moderate to very severe repeat deliberate self-harm and/or other impulsive behaviour and chaotic, over-dependant engagement, and are often hostile with services. They are characterised by moderate to very severe repeat deliberate self-harm and/or other impulsive behaviour and chaotic, over-dependant engagement, and are often hostile with services.

Care Cluster 9:  Cluster Under Review - Note: This Mental Health Care Cluster is under review by the Department of Health and should not be used.

Care Cluster 10:  First Episode Psychosis - This group of PATIENTS will be presenting to the Mental Health service for the first time with mild to severe psychotic phenomena.  They may also have depressed mood and/or anxiety and/or other behaviours.  Drinking or drug taking may be present but will not be the only problem. They may also have depressed mood and/or anxiety and/or other behaviours. Drinking or drug taking may be present but will not be the only problem.

Care Cluster 11:  Ongoing Recurrent Psychosis (Low Symptoms) - This group of PATIENTS have a history of psychotic symptoms that are currently controlled and causing minor problems if any at all.  They are currently experiencing a period of recovery where they are capable of full or near functioning. They are currently experiencing a period of recovery where they are capable of full or near functioning.  However, there may be impairment in self-esteem and efficacy and vulnerability to life.

Care Cluster 12:  Ongoing or Recurrent Psychosis (High Disability) - This group of PATIENTS have a history of psychotic symptoms with a significant disability with major impact on role functioning.  They are likely to be vulnerable to abuse or exploitation. They are likely to be vulnerable to abuse or exploitation.

Care Cluster 13:  Ongoing or Recurrent Psychosis (High Symptoms and Disability) - This group of PATIENTS will have a history of psychotic symptoms which are not controlled.  They will present with moderate to severe psychotic symptoms and some anxiety or depression.  They have a significant disability with major impact on role functioning. They will present with moderate to severe psychotic symptoms and some anxiety or depression. They have a significant disability with major impact on role functioning.

Care Cluster 14:  Psychotic Crisis - This group of PATIENTS will be experiencing an acute psychotic episode with severe symptoms that cause severe disruption to role functioning.  They may present as vulnerable and a risk to others or themselves. They may present as vulnerable and a risk to others or themselves.

Care Cluster 15:  Severe Psychotic Depression - This group of PATIENTS will be suffering from an acute episode of moderate to severe depressive symptoms.  Hallucinations and delusions will be present.  It is likely that this group will present a risk of suicide and have disruption in many areas of their lives. Hallucinations and delusions will be present. It is likely that this group will present a risk of suicide and have disruption in many areas of their lives.

Care Cluster 16:  Dual Diagnosis - This group of PATIENTS have enduring, moderate to severe psychotic of affective symptoms with unstable, chaotic lifestyles and co-existing substance misuse.  They may present a risk to self and others and engage poorly with services.  Role functioning is often globally impaired. They may present a risk to self and others and engage poorly with services. Role functioning is often globally impaired.

Care Cluster 17:  Psychosis and Affective Disorder (Difficult to Engage) - This group of PATIENTS have moderate to severe psychotic symptoms with unstable, chaotic lifestyles.  There may be some problems with drugs or alcohol not severe enough to warrant dual diagnosis care.  This group have a history of non-concordance, are vulnerable, and engage poorly with services. There may be some problems with drugs or alcohol not severe enough to warrant dual diagnosis care. This group have a history of non-concordance, are vulnerable, and engage poorly with services.

Care Cluster 18:  Cognitive Impairment (Low Need) - People who may be in the early stages of dementia (or who may have an organic brain disorder affecting their cognitive function) who have some memory problems, or other low level cognitive impairment, but who are still managing to cope reasonably well.  Underlying reversible physical causes have been ruled out. Underlying reversible physical causes have been ruled out.

Care Cluster 19:  Cognitive Impairment or Dementia Complicated (Moderate Need) - People who have problems with their memory, and/or other aspects of cognitive functioning resulting in moderate problems looking after themselves and maintaining social relationships.  Probable risk of self-neglect or harm to others and may be experiencing some anxiety or depression. Probable risk of self-neglect or harm to others and may be experiencing some anxiety or depression.

Care Cluster 20:  Cognitive Impairment or Dementia (High Need) - People with dementia who are having significant problems in looking after themselves and whose behaviour may challenge their carers or services.  They may have high levels of anxiety or depression, psychotic symptoms, or significant problems such as aggression or agitation.  They may not be aware of their problems.  They are likely to be at high risk of self-neglect or harm to others, and there may be a significant risk of their care arrangements breaking down. They may have high levels of anxiety or depression, psychotic symptoms, or significant problems such as aggression or agitation. They may not be aware of their problems. They are likely to be at high risk of self-neglect or harm to others, and there may be a significant risk of their care arrangements breaking down.

Care Cluster 21:  Cognitive Impairment or Dementia (High Physical or Engagement) - People with cognitive impairment or dementia who are having significant problems in looking after themselves, and whose physical condition is becoming increasingly frail.  They may not be aware of their problems and there may be a significant risk of their care arrangements breaking down. They may not be aware of their problems and there may be a significant risk of their care arrangements breaking down.

Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Department of Health Developing Payment By Results for Mental Health website.Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Monitor website at: National Tariff document and annexes: Annex 7C - Mental health clustering tool booklet.

 

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MENTAL HEALTH CARE CLUSTER ASSIGNMENT PERIOD

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MENTAL HEALTH CARE CLUSTER SUPER CLASS

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A Mental Health Care Cluster Super Class is identified during the process of assigning a Mental Health Care Cluster to a PATIENT.  It enables the number of applicable Mental Health Care Clusters to be narrowed down, by deciding if the origin of the presenting condition is primarily:

  • non-psychotic
  • psychotic or
  • organic

If the PATIENT cannot be assigned to a Mental Health Care Cluster, MENTAL HEALTH CARE CLUSTER SUPER CLASS CODE is recorded as National Code Z 'Unable to assign PATIENT to Mental Health Care Cluster', and the PATIENT will automatically be assigned to Mental Health Care Cluster 0 (Variance).

Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Department of Health Developing Payment By Results for Mental Health website.Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Monitor website at: National Tariff document and annexes: Annex 7C - Mental health clustering tool booklet.

 

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MENTAL HEALTH CARE SPELL SUSPENSION

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Mental Health Care Spell Suspension is an ACTIVITY SUSPENSION.A Mental Health Care Spell Suspension is an ACTIVITY SUSPENSION.

A period of time during which the main responsibility for provision of mental health care for a PATIENT is transferred to another Health Care Provider on a temporary basis, with the expectation that responsibility will be transferred back at some time in the future.A Mental Health Care Spell Suspension is a period of time during which the main responsibility for provision of mental health care for a PATIENT is transferred to another Health Care Provider on a temporary basis, with the expectation that responsibility will be transferred back at some time in the future. This will end the current Care Programme Approach Episode and suspend the Adult Mental Health Care Spell.

If responsibility for the mental health care for the PATIENT is not transferred back within one year of the suspension starting, it will be considered that the transfer is permanent and the Adult Mental Health Care Spell will be ended. In this eventuality the end date of the Adult Mental Health Care Spell should be taken as the start date of the Mental Health Care Spell Suspension.

 

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MENTAL HEALTH CLUSTERING TOOL

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The Mental Health Clustering Tool is a type of ASSESSMENT TOOL.

The Mental Health Clustering Tool is a needs assessment tool designed to rate the care needs of a PATIENT, based upon a series of 18 rating scales.

The first 12 of these rating scales are the same as the Health of the Nation Outcome Scale (Working Age Adults) rating scales, originally developed by the Royal College of Psychiatrists. These 12 rating scales are numbered 1 - 12 under 'Current Ratings' in the Mental Health Clustering Tool.

One additional 'current' rating and a new section relating to historical ratings have also been added, to form the Mental Health Clustering ToolThese items are referred to as the Summary Assessment of Characteristics (SAC) items. These items are referred to as the Summary Assessment of Characteristics (SAC) items.

Part 1:  Current Ratings

These ratings relate to the most severe occurrence in the two weeks prior to the Mental Health Clustering Tool ASSESSMENT TOOL COMPLETION DATE.

  1. Overactive, aggressive, disruptive or agitated behaviour (current)
  2. Non-accidental self injury (current)
  3. Problem drinking or drug taking (current)
  4. Cognitive problems (current)
  5. Physical illness or disability problems (current)
  6. Problems associated with hallucinations and delusions (current)
  7. Problems with depressed mood (current)
  8. Other mental and behavioural problems (current), qualified by specific disorders: and the alphabetical list of headings from the glossary:
  •             A  Phobic
  •             B  Anxiety
  •             C  Obsessive-compulsive
  •             D  Stress
  •             E  Dissociative
  •             F  Somatoform
  •             G  Eating
  •             H  Sleep
  •             I  Sexual
  •             J  Other
   9.  Problems with relationships (current)
 10.  Problems with activities of daily living (current)
 11.  Problems with living conditions (current)
 12.  Problems with occupation and activities (current)
 13.  Strong unreasonable beliefs occurring in non-psychotic disorders only (current)

Part 2:  Historical Ratings

These ratings relate to problems that occur in an episodic or unpredictable way, from a more 'historical' perspective.  Whilst there may not be any direct observation or report of a manifestation during the two weeks prior to the Mental Health Clustering Tool ASSESSMENT TOOL COMPLETION DATE, the evidence and clinical judgement would suggest that there is still a cause for concern that cannot be disregarded.  In these circumstances, any event that remains relevant to the current CARE PLAN should be included. Whilst there may not be any direct observation or report of a manifestation during the two weeks prior to the Mental Health Clustering Tool ASSESSMENT TOOL COMPLETION DATE, the evidence and clinical judgement would suggest that there is still a cause for concern that cannot be disregarded. In these circumstances, any event that remains relevant to the current CARE PLAN should be included.

     A.  Agitated behaviour / expansive mood (historical)
     B.  Repeat self-harm (historical)
     C.  Safeguarding children and vulnerable dependant adults (historical)
     D.  Engagement (historical)
     E.  Vulnerability (historical)

The allowed responses to each of the 18 items in the Mental Health Clustering Tool are:

  • 0 - No problem
  • 1 - Minor problem requiring no action
  • 2 - Mild problem but definitely present
  • 3 - Moderately severe problem
  • 4 - Severe to very severe problem
  • 9 - Not known

The PERSON SCORE from the Mental Health Clustering Tool is used to allocate the PATIENT to the most appropriate Mental Health Care Cluster.

Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Department of Health Developing Payment By Results for Mental Health website.Further information relating to the Mental Health Clustering Tool and Mental Health Care Clusters is available from the Monitor website at: National Tariff document and annexes: Annex 7C - Mental health clustering tool booklet.

 

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MENTAL HEALTH MINIMUM DATA SET OVERVIEW

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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 (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.

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

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ORGANISATION DIAGRAM OVERVIEW

Change to Supporting Information: Changed Description

The Organisation Diagram details relationships for the ORGANISATION class, with respect to the management of CARE PROFESSIONALS and the delivery of ACTIVITIES.The Organisation Diagram details relationships for an ORGANISATION, with respect to the management of CARE PROFESSIONALS and the delivery of ACTIVITIES.

Related diagrams include:

USING THE DIAGRAM

By clicking on a Class on the diagram opposite, the selected Class definition will be displayed. By clicking on an Attribute name displayed within the Class, the selected Attribute definition will be displayed.

Note that not all attributes for a class will be visible. The full list of attributes for a class can be viewed in the class definition, by selecting the 'Attribute' tab.

To view the diagram in full, select the 'Print Window' option, this will open a new window that will display only the diagram. You can also use this view to print the diagram, by right clicking on the diagram and selecting 'Print Picture'.

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PATIENT PATHWAY DIAGRAM OVERVIEW

Change to Supporting Information: Changed Description

The Patient Pathway Diagram demonstrates how the PATIENT PATHWAY class is related to the delivery of an ACTIVITY by an ORGANISATION, in order to achieve the 18 week referral to treatment target.The Patient Pathway Diagram demonstrates how a PATIENT PATHWAY is related to the delivery of an ACTIVITY by an ORGANISATION, in order to achieve the 18 week referral to treatment target.

Related diagrams include:

USING THE DIAGRAM

By clicking on a Class on the diagram opposite, the selected Class definition will be displayed. By clicking on an Attribute name displayed within the Class, the selected Attribute definition will be displayed.

Note that not all attributes for a class will be visible. The full list of attributes for a class can be viewed in the class definition, by selecting the 'Attribute' tab.

To view the diagram in full, select the 'Print Window' option, this will open a new window that will display only the diagram. You can also use this view to print the diagram, by right clicking on the diagram and selecting 'Print Picture'.

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WHAT'S NEW: MAY 2014  renamed from WHAT'S NEW: APRIL 2014

Change to Supporting Information: Changed Name, Description

Release: May 2014

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

Release: April 2014

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

Release: March 2014

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1388 (1 April 2014) - ISB 1521 Amd 23/2013 Updates to the Cancer Outcomes and Services Data Set and XML Schema
  • CR1370 (1 April 2014) - ISB 1533 Amd 24/2013 Updates to the Systemic Anti-Cancer Therapy Data Set and XML Schema
  • CR1322 (1 April 2014) - ISB 0111 Amd 26/2012 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
  • CR1446 (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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GENERAL MEDICAL PRACTITIONER PPD CODE

Change to Attribute: Changed Description

This is the NHS Prescription Services code to identify a GENERAL MEDICAL PRACTITIONER.

The DOCTOR INDEX NUMBER is passed to the NHS Prescription Services, which adds a leading character and a check digit to create the GENERAL MEDICAL PRACTITIONER PPD CODENHS Prescription Services use this for the issue of prescription pads etc.

For England and Wales, in addition to a GENERAL MEDICAL PRACTITIONER PPD CODE, a GENERAL MEDICAL PRACTITIONER may have one or more spurious GENERAL MEDICAL PRACTITIONER Code(s). These are allocated if a GENERAL MEDICAL PRACTITIONER works in additional General Medical Practitioner Practice. The spurious GENERAL MEDICAL PRACTITIONER Codes are not derived from the DOCTOR INDEX NUMBER, but do follow the same format as the GENERAL MEDICAL PRACTITIONER PPD CODE, and are allocated by the NHS Prescription Services. All spurious GENERAL MEDICAL PRACTITIONER Codes begin with either 'G6' or 'G7'.

England and Wales General Medical Practitioner Code format

Practitioner
Code Type

Character Position

Allocated
By
Allocated
To
Known
As
Notes

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 
GENERAL MEDICAL PRACTITIONER PPD CODEG0-90-90-90-90-90-90-9NHS Prescription ServicesPrescribing GMPs in England & WalesGMPDerived from DOCTOR INDEX NUMBER - NHS Prescription Services add leading G and a check digit. Associated with practice
GENERAL MEDICAL PRACTITIONER PPD CODEG0-90-90-90-90-90-90-9NHS Prescription ServicesPrescribing GMPs in England & WalesGMPDerived from DOCTOR INDEX NUMBER - NHS Prescription Services add leading G and a check digit. Associated with practice.

Scottish General Medical Practitioner Code format

Practitioner
Code Type

Character Position

Allocated
By
Allocated
To
Known
As
Notes

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 
Scottish General Medical Practitioner CodeS0-90-90-90-90-90-90-9Information Standards Division (Scotland)GMPs in ScotlandGMP 

Northern Ireland General Medical Practitioner Code format

Practitioner
Code Type

Character Position

Allocated
By
Allocated
To
Known
As
Notes

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 
Northern Ireland General Medical Practitioner CodeZE, N, S, W0-90-90-90-90-90Northern Ireland Dept of Health, Social Services and Public SafetyGMPs in Northern IrelandGMP 
 

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DFES ESTABLISHMENT NUMBER

Change to Data Element: Changed Description

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

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

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HEALTH PROGRAMME STAGE NUMBER (HUMAN PAPILLOMAVIRUS VACCINE)

Change to Data Element: Changed Description

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

Notes:
HEALTH PROGRAMME STAGE NUMBER (HUMAN PAPILLOMAVIRUS VACCINE) is the STAGE NUMBER for a TARGET POPULATION for the Immunisation Programme for the Human Papillomavirus Vaccine of either 'routine' or 'catch up'.

For further information and advise please see Department of Health Key Vaccine InformationFor further information and advise please see the Public Health England part of the gov.uk webiste at: Human papillomavirus (HPV).

 

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INVASIVE BREAST CANCER DETECTION RATE (PER 1,000 SCREENED)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER DETECTION RATE (PER 1,000 SCREENED) is the rate of invasive breast cancers detected, per 1,000 screened. 

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INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 10MM (PER 1,000 SCREENED)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 10mm (PER 1,000 SCREENED) is the rate of invasive breast cancers smaller than 10mm detected, per 1,000 screened. 

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INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 15MM (PER 1,000 SCREENED)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER DETECTION RATE INVASIVE SIZE LESS THAN 15mm (PER 1,000 SCREENED) is the rate of invasive breast cancers smaller than 15mm detected, per 1,000 screened. 

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INVASIVE BREAST CANCER GRADE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER GRADE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS) is the percentage of women diagnosed with invasive breast cancer, where the BREAST BIOPSY REFERRAL OUTCOME is recorded as National Code 'Positive; i.e. cancer detected - invasive size not known - grade not known' or 'Positive; i.e. cancer detected - invasive size known - grade not known'. 

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INVASIVE BREAST CANCER LYMPH NODE STATUS NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER LYMPH NODE STATUS NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS) is the percentage of women diagnosed with invasive breast cancer, where the LYMPH NODE STATUS is recorded as National Code 'Not known' and the BREAST BIOPSY REFERRAL OUTCOME is recorded as National Code 'Positive; i.e. cancer detected - invasive size known' or 'Positive; i.e. cancer detected - invasive size not known'

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INVASIVE BREAST CANCER SIZE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER SIZE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS) is the percentage of invasive breast cancers diagnosed by cytology or histology, where the size is not recorded. 

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INVASIVE BREAST CANCER SPECIAL TYPE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS)

Change to Data Element: Changed Description

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

Notes:
INVASIVE BREAST CANCER SPECIAL TYPE NOT KNOWN (PERCENTAGE OF INVASIVE BREAST CANCERS) is the percentage of women diagnosed with invasive breast cancer, where the INVASIVE CANCER SPECIAL TYPE INDICATOR has not been recorded and where the BIOPSY REFERRAL OUTCOME is recorded as National Code 'Positive; i.e. cancer detected - invasive size known' or 'Positive; i.e. cancer detected - invasive size not known'. 

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INVASIVE TUMOUR SIZE

Change to Data Element: Changed Description

Format/Length:max an2
HES Item: 
National Codes: 
Default Codes:NK - Invasive size not known
NA - Size not applicable (non-invasive or micro-invasive cancer only)

Notes:
INVASIVE TUMOUR SIZE is the same as attribute TUMOUR SIZE.

INVASIVE TUMOUR SIZE is the size of the Tumour, where the UNIT OF MEASUREMENT is 'Millimetres (mm)' and is only applicable where the cancer detected was invasive.

 

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INVESTIGATION RESULT (MOTHER RHESUS ANTIBODIES BOOKING)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National Codes:See INVESTIGATION SENSITISED RESULT INDICATOR
Default Codes: 


Notes:
INVESTIGATION RESULT (MOTHER RHESUS ANTIBODIES BOOKING) is the INVESTIGATION SENSITISED RESULT INDICATOR of a Clinical Investigation for a blood test for Rhesus Antibodies, performed at early pregnancy (usually at the APPOINTMENT DATE (FORMAL ANTENATAL BOOKING)).

 

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INVESTIGATION RESULT (SCREENING MOTHER HAEMOGLOBINOPATHY)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See INVESTIGATION HAEMOGLOBINOPATHY RESULT CODE
Default Codes: 


Notes:
INVESTIGATION RESULT (SCREENING MOTHER HAEMOGLOBINOPATHY) is the INVESTIGATION HAEMOGLOBINOPATHY RESULT CODE of a Clinical Investigation for a blood test for Haemoglobinopathy Screening to detect inherited disorders such as sickle cell disease and thalassaemia.

 

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INVESTIGATION RESULT (SCREENING MOTHER HEPATITIS B)

Change to Data Element: Changed Description

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


Notes:
INVESTIGATION RESULT (SCREENING MOTHER HEPATITIS B) is the result of the Clinical Investigation for a blood test for Hepatitis B antibody, this presented as either:

01Negative result
02Positive result
03Test process incomplete
PNTest not required - prior diagnosis
Z0Test not taken - decline
 

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INVESTIGATION RESULT (SCREENING MOTHER HUMAN IMMUNODEFICIENCY VIRUS)

Change to Data Element: Changed Description

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


Notes:
INVESTIGATION RESULT (SCREENING MOTHER HUMAN IMMUNODEFICIENCY VIRUS) is the result of the Clinical Investigation for a blood test for Human Immunodeficiency Virus (HIV) antibodies, this presented as either:

01Negative result
02Positive result
03Test process incomplete
PNTest not required - prior diagnosis
Z0Test not taken - decline
 

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INVESTIGATION RESULT (SCREENING MOTHER RUBELLA SUSCEPTIBILITY)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See INVESTIGATION RUBELLA RESULT INDICATOR 
Default Codes: 


Notes:
INVESTIGATION RESULT (SCREENING MOTHER RUBELLA SUSCEPTIBILITY) is the INVESTIGATION RUBELLA RESULT INDICATOR of a Clinical Investigation for a blood test for Rubella Antibodies.

 

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INVESTIGATION RESULT (SCREENING MOTHER SYPHILIS)

Change to Data Element: Changed Description

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


Notes:
INVESTIGATION RESULT (SCREENING MOTHER SYPHILIS) is the result of a Clinical Investigation for a blood test for Syphilis antibodies, this presented as either:

01Negative result
02Positive result
03Test process incomplete
Z0Test not taken - decline
 

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INVESTIGATION RESULT (ULTRASOUND FETAL ANOMALY SCREENING)

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:see FETAL ANOMALY DIAGNOSIS
Default Codes:NA - No abnormality detected


Notes:
INVESTIGATION RESULT (ULTRASOUND FETAL ANOMALY SCREENING) is the same as  attribute FETAL ANOMALY DIAGNOSIS, for a Fetal Anomaly Ultrasound Scan for the mother during the Maternity Episode.

 

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INVESTIGATION RESULT DATE

Change to Data Element: Changed Description

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

Notes:
INVESTIGATION RESULT DATE is the same as INVESTIGATION RESULT DATE

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INVESTIGATION RISK RATIO RESULT (SCREENING DOWNS SYNDROME)

Change to Data Element: Changed Description

Format/Length:max an7
HES Item: 
National Codes: 
Default Codes: 


Notes:
INVESTIGATION RISK RATIO RESULT (SCREENING DOWNS SYNDROME) is the INVESTIGATION RISK RATIO RESULT CODE of a Clinical Investigation for Downs Syndrome Screening.

 

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For enquiries about this Change Request, please email information.standards@hscic.gov.uk