Change Request

 

DSCN 34/2003

 

NHS Information Authority

Data Standards Programme

Reference: Change Request 347
Version No:1.39
Subject:Data Standards: Updates to Specialty Function Codes
Type of Change:Changes to Specialty Function and Consultant Specialty Function and revision of Specialty Function codes
Effective Date:1 April 2004
Reason for Change:The current national specialty list, first developed in the 1980s, is out of date and unable to support the proper and meaningful recording of patient activity aligned to clinical practice that is required under the quality agenda.

Background:

DSCN 26/2003 was issued to update the National Specialties List. This DSCN identifies the changes to the NHS Data Dictionary required to support the new codes. The name Health Care Professional has been changed to Care Professional and Care Episodes have been introduced to accommodate changes in care provision.

The Specialty Function Codes have been put into two tables named Main Specialty codes and Treatment Function codes. The list of Treatment Function Codes has been updated to include sub-specialties and widened to cover the activity of other lead Care Professionals.

Main Specialty is the specialty in which the consultant is contracted or recognised. Main Specialty only refers to Medical and Dental specialties and the individual specialties can only be attributed to consultant medical and dental staff (default codes are used in the Commissioning Data Set (CDS) message to identify the work of non consultant lead professionals eg Midwife and Nurse). Main specialties have been aligned to the European Specialist Medical Qualifications Order 1995 and European Primary & Specialist Dental Qualifications Regulations 1998.

Treatment Function describes the specialised service within which the patient is treated. Treatment Function codes can be used by all Care Professionals who are responsible for patient care. The list of codes has been updated to include new treatment functions and to exclude non-treatment specialties.

These are some examples of how Main Specialty and Treatment Function are used:
Main Specialty - General Surgery; Treatment Function - Breast Surgery
Main Specialty - Nursing Episode; Treatment Function - Intermediate Care
Main Specialty - Trauma & Orthopaedics; Treatment Function - Pain Management
Main Specialty - General Medical Practice; Treatment Function - Obstetrics

Treatment Function should be used for all aggregate Central Returns. Until the aggregate return forms are updated with the new Treatment Functions Trusts will have to use the existing specialties.

There is an ongoing process for the identification and approval of new Treatment Functions.

Summary of changes:
 
Class Definitions
ACCIDENT AND EMERGENCY ATTENDANCE   Change to Description
ACCIDENT AND EMERGENCY EPISODE   Change to Description
AUGMENTED CARE PERIOD   Change to Description
AUGMENTED CARE PERIOD   Change to Relationships
CARE EPISODE   New Class
CLINICAL INTERVENTION   Change to Relationships
CLINICAL INVESTIGATION SERVICE PROVIDER   Change to Relationships
CLINIC ATTENDANCE NURSE   Change to Description
CONSULTANT   Change to Super Type
CONSULTANT   Change to Relationships
CONSULTANT CLINIC   Change to Super Type
CONSULTANT EPISODE (ACUTE HOME-BASED)   Change to Relationships
CONSULTANT EPISODE (HOSPITAL PROVIDER)   Change to Super Type
CONSULTANT EPISODE (HOSPITAL PROVIDER)   Change to Attributes
CONSULTANT EPISODE (HOSPITAL PROVIDER)   Change to Relationships
CONSULTANT OUT-PATIENT EPISODE   Change to Relationships
CONSULTANT SPECIALTY FUNCTION   Change to Name
CONSULTANT SPECIALTY FUNCTION renamed CONSULTANT SPECIALTY FUNCTION   Change to Aliases
CONSULTANT SPECIALTY FUNCTION   Change to Relationships
DAY CARE ATTENDANCE   Change to Description
DAY CARE ATTENDANCE   Change to Relationships
DAY CARE SESSION   Change to Relationships
DISPENSED ITEM   Change to Relationships
DRUG TREATMENT   Change to Relationships
ELECTIVE ADMISSION LIST   Change to Relationships
ELECTIVE ADMISSION LIST ENTRY   Change to Relationships
FACE TO FACE CONTACT OPTICAL   Change to Description
GENERAL MEDICAL PRACTITIONER REGISTRAR   Change to Description
GENERAL PRACTITIONER   Change to Description
GMP PRACTICE CONSULTATION   Change to Description
GMP PRACTICE CONSULTATION   Change to Relationships
HEALTH CARE PROFESSIONAL   Change to Name
HEALTH CARE PROFESSIONAL renamed CARE PROFESSIONAL   Change to Aliases
HEALTH CARE PROFESSIONAL   Change to Relationships
HEALTH CARE PROFESSIONAL INVOLVEMENT   Change to Name
HEALTH CARE PROFESSIONAL INVOLVEMENT renamed CARE PROFESSIONAL INVOLVEMENT   Change to Aliases
HEALTH CARE PROFESSIONAL INVOLVEMENT   Change to Relationships
HONOS SCORE FOR PERSON   Change to Description
HONOS SCORE FOR PERSON   Change to Relationships
HOSPITAL PROVIDER SPELL   Change to Relationships
INDEPENDENT HEALTH CARE REGISTRATION   Change to Description
ITEM OF SERVICE DELIVERY ROLE   Change to Description
ITEM OF SERVICE DELIVERY ROLE   Change to Relationships
JOINT LEAD CARE PROFESSIONAL   New Class
LOCAL SUB-SPECIALTY   Change to Description
MEDICAL AND DENTAL POST   Change to Relationships
MEDICAL AND DENTAL POST BY SPECIALTY   Change to Description
MEDICAL AND DENTAL POST BY SPECIALTY   Change to Relationships
MEDICAL AND DENTAL SPECIALTY INTEREST   Change to Description
MEDICAL AND DENTAL SPECIALTY INTEREST   Change to Relationships
MHCS SPECIALTY ASSOCIATION   Change to Description
MHCS SPECIALTY ASSOCIATION   Change to Relationships
MIDWIFE   Change to Description
MIDWIFE EPISODE   Change to Description
MIDWIFE EPISODE   Change to Relationships
NURSE   Change to Description
NURSING EPISODE   Change to Description
NURSING EPISODE   Change to Relationships
OPERATING THEATRE INTENDED SPECIALTY   Change to Description
OPERATING THEATRE INTENDED SPECIALTY   Change to Relationships
OPERATING THEATRE SESSION   Change to Description
OPERATING THEATRE SESSION   Change to Relationships
OPHTHALMIC MEDICAL PRACTITIONER   Change to Description
OPHTHALMIC OPTICIAN   Change to Description
OPHTHALMOLOGY SERVICE   Change to Description
OPHTHALMOLOGY SERVICE   Change to Relationships
OPTICIAN SITE   Change to Description
OUT-PATIENT ATTENDANCE CONSULTANT   Change to Description
PATIENT   Change to Relationships
PATIENT DIAGNOSIS   Change to Relationships
PATIENT PROCEDURE   Change to Relationships
PERSON OBSERVATION   Change to Description
PERSON OBSERVATION   Change to Relationships
PRESCRIPTION   Change to Relationships
PROFESSIONAL STAFF GROUP CONTACT   Change to Description
PROFESSIONAL STAFF GROUP EPISODE   Change to Relationships
RADIOLOGY DEPARTMENT   Change to Description
RADIOLOGY INVESTIGATION PLAN   Change to Relationships
REFERRAL REQUEST   Change to Relationships
REGULAR ATTENDER EPISODE   Change to Relationships
REQUEST FOR DIAGNOSTIC TEST   Change to Description
REQUEST FOR DIAGNOSTIC TEST   Change to Relationships
RESPONSIBLE MEDICAL OFFICER ASSIGNMENT   Change to Description
RESPONSIBLE MEDICAL OFFICER ASSIGNMENT   Change to Relationships
RIGHT OF ADMISSION   Change to Relationships
ROAD TRAFFIC ACCIDENT TREATMENT   Change to Relationships
ROTATIONAL ARRANGEMENT   Change to Description
SERVICE PROVIDED   Change to Relationships
SERVICE REPORT COPY   Change to Relationships
SERVICE REPORT HEADER   Change to Relationships
SHARED CARE CONSULTANT   Change to Relationships
SHARED CLINIC CONSULTANT   Change to Description
SIGHT TEST   Change to Description
SPECIALTY   Change to Name
SPECIALTY renamed MAIN SPECIALTY   Change to Aliases
SPECIALTY   Change to Attributes
SPECIALTY renamed MAIN SPECIALTY   Change to Relationships
SPECIALTY FUNCTION   Change to Name
SPECIALTY FUNCTION renamed TREATMENT FUNCTION   Change to Description
SPECIALTY FUNCTION   Change to Attributes
SPECIALTY FUNCTION   Change to Relationships
THEATRE CASE   Change to Relationships
WARD INTENDED BED USE   Change to Description
WARD INTENDED BED USE   Change to Relationships
WARD OPERATIONAL PLAN   Change to Description
 
Attribute Definitions
CLAIMING GMP RELATIONSHIP   Change to Description
DEPARTMENT TYPE   Change to Description
ELECTIVE ADMISSION LIST NUMBER   Change to Description
GYNAECOLOGICAL ONCOLOGY ACCREDITATION   Change to Description
HONOS SCORE DATE   Change to Description
MEDICAL AND DENTAL POST SPECIALTY GROUP   Change to Description
PRESCRIPTION DATE   Change to Description
REQUEST FOR APPOINTMENT DATE   Change to Description
REQUEST FOR APPOINTMENT TIME   Change to Description
SESSION IDENTIFIER   Change to Description
SPECIALIST HIV SKILLS AVAILABLE   Change to Description
SPECIALIST REGISTRAR FLAG   Change to Description
SPECIALTY CODE   Change to Name
SPECIALTY CODE renamed MAIN SPECIALTY CODE   Change to Aliases
SPECIALTY FUNCTION CODE   Change to Name
SPECIALTY FUNCTION CODE renamed TREATMENT FUNCTION CODE   Change to Aliases
 
Data Elements
ADMISSIONS (MENTAL HEALTH)   Change to Description
BED DAYS (MENTAL HEALTH)   Change to Description
BED DAYS (MENTAL HEALTH INTENSIVE)   Change to Description
BED DAYS (MENTAL HEALTH MEDIUM SECURE)   Change to Description
CARE PROFESSIONAL CODE (REQUESTED BY)   Change to Description
CARE PROFESSIONAL CODE (REQUESTED BY)   Change to Description
CODE OF RESPONSIBLE HCP (OPCS)   Change to Name
CODE OF RESPONSIBLE HCP (OPCS) renamed RESPONSIBLE CARE PROFESSIONAL CODE (OPCS)   Change to Aliases
COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH)   Change to Description
CONSULTANT CODE   Change to Description
CONSULTANT SPECIALTY FUNCTION CODE   Change to Name
CONSULTANT SPECIALTY FUNCTION CODE renamed TREATMENT FUNCTION CODE   Change to Description
CONTACTS (CONSULTANT PSYCHOTHERAPY)   Change to Description
DISCHARGES (MENTAL HEALTH)   Change to Description
ELECTIVE ADMISSION LIST   Change to Description
FIRST CONTACT TIMES LIST (MENTAL HEALTH)   Change to Description
HOSPITAL STAYS LIST (MENTAL HEALTH)   Change to Description
ORGANISATION CODE (REQUESTED BY)   Change to Description
OUT-PATIENT ATTENDANCE CONSULTANT   Change to Description
OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH)   Change to Description
PSYCHIATRIC PATIENT   Change to Description
REFERRER CODE   Change to Description
SPECIALTY FUNCTION CODE   Change to Name
SPECIALTY FUNCTION CODE renamed MAIN SPECIALTY CODE   Change to Description
SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD)   Change to Name
SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) renamed MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD)   Change to Aliases
SPECIALTY FUNCTION CODE (MENTAL HEALTH)   Change to Name
SPECIALTY FUNCTION CODE (MENTAL HEALTH) renamed MAIN SPECIALTY CODE (MENTAL HEALTH)   Change to Description
 
Data Sets (CDS, CMDS, HES)
ADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODE   Change to Table
ADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODE   Change to Table
ADMITTED PATIENT CARE CDS TYPE - DETAINED AND - OR LONG TERM PSYCHIATRIC CENSUS   Change to Table
ADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODE   Change to Table
ELECTIVE ADMISSION LIST CMDS-END OF PERIOD CENSUS   Change to Table
ELECTIVE ADMISSION LIST CMDS-EVENT DURING PERIOD   Change to Table
GP REFERRAL LETTER CMDS   Change to Table
HES - CDS DATA ITEMS CROSS REFERENCED BY HES ITEM - TABLE 2   Change to Table
HES - CDS DATA ITEMS CROSS REFERENCED BY HES NAME - TABLE 1   Change to Table
MENTAL HEALTH MINIMUM DATA SET   Change to Table
OUT-PATIENT ATTENDANCE CDS TYPE   Change to Table
 
Central Return Forms
KC61 1   Change to Guidance Text
KH06 1   Change to Guidance Text
KH06 2   Change to Guidance Text
KH06 3   Change to Guidance Text
KH06 4   Change to Guidance Text
KH06 5   Change to Guidance Text
KH06R 1   Change to Guidance Text
KH06R 2   Change to Guidance Text
KH06R 3   Change to Guidance Text
KH06R 4   Change to Guidance Text
KH06R 5   Change to Guidance Text
KH07 1   Change to Guidance Text
KH07 2   Change to Guidance Text
KH07 3   Change to Guidance Text
KH07 4   Change to Guidance Text
KH07 5   Change to Guidance Text
KH07 6   Change to Guidance Text
KH07 7   Change to Guidance Text
KH07A 1   Change to Guidance Text
KH07A 2   Change to Guidance Text
KH07A 3   Change to Guidance Text
KH07AR 1   Change to Guidance Text
KH07AR 2   Change to Guidance Text
KH07AR 3   Change to Guidance Text
KH09 1   Change to Guidance Text
KH09 2   Change to Guidance Text
KH09 3   Change to Guidance Text
QF01 1   Change to Guidance Text
QF01 2   Change to Guidance Text
QF01 3   Change to Guidance Text
QF01 4   Change to Guidance Text
QF01 5   Change to Guidance Text
QF01 6   Change to Guidance Text
QF01 7   Change to Guidance Text
QM08 1   Change to Guidance Text
QM08 2   Change to Guidance Text
QM08 3   Change to Guidance Text
QM08 4   Change to Guidance Text
QM08R 1   Change to Guidance Text
QM08R 2   Change to Guidance Text
QM08R 3   Change to Guidance Text
QM08R 4   Change to Guidance Text
 
Diagrams
AD010 CORE ADMINISTRATIVE DATA - PERSON DETAILS   Change to Diagram Contents
AD020 CORE ADMINISTRATIVE DATA - ORGANISATION DETAILS   Change to Diagram Contents
CC010 PAEDIATRIC OPERATIONS AND INTERVENTIONS   Change to Diagram Contents
CDS020 PATIENT DETAILS - ALL CDS TYPES   Change to Diagram Contents
CDS030 REFERRAL DETAILS - ALL CDS TYPES   Change to Diagram Contents
CDS050 CONSULTANT EPISODE DETAILS - ALL ADMITTED PATIENT CARE CDS TYPES   Change to Diagram Contents
CDS070 PREGNANCY AND DELIVERY DETAILS   Change to Diagram Contents
CDS080 AUGMENTED CARE PERIOD DETAILS   Change to Diagram Contents
CDS090 EPISODE AND ATTENDANCE DETAILS - OUT-PATIENT AND WARD ATTENDERS CDS TYPES   Change to Diagram Contents
CEN1ETC CEN1, CEN2, CEN4 AND CEN5 ASSISTANTS, REGISTRARS, SALARIED DOCTORS AND RETAINERS   Change to Diagram Contents
CEN3 GMP ADDITIONAL DATA   Change to Diagram Contents
CL010 PERSON OBSERVATIONS AND CHARACTERISTICS   Change to Diagram Contents
CL020 CLINICAL INTERVENTIONS   Change to Diagram Contents
CM110 COMMUNITY - NURSING CARE IN THE COMMUNITY   Change to Diagram Contents
CMDS020 ELECTIVE ADMISSION LIST, SUSPENSION, OFFER OF ADMISSION AND REMOVAL DETAILS - ELECTIVE ADMISSION LIST CMDS   Change to Diagram Contents
CMDS030 GP REFERRAL LETTERS CMDS   Change to Diagram Contents
DIT DOCTORS IN TRAINING - HOURS OF DUTY   Change to Diagram Contents
EDS1 EMERGENCY DENTAL SESSIONS   Change to Diagram Contents
GN020 ORGANISATION STRUCTURE   Change to Diagram Contents
GN080 MAIN SPECIALTY AND TREATMENT FUNCTION   New Diagram
HA48 LIST OF OPHTHALMIC PRACTITIONERS   Change to Diagram Contents
HES01 HOSPITAL EPISODE STATISTICS: ADMINISTRATIVE PATIENT DATA   Change to Diagram Contents
HES05 HOSPITAL EPISODE STATISTICS: DETENTION DETAILS   Change to Diagram Contents
HP010 REFERRAL REQUESTS   Change to Diagram Contents
HP020 CLINICS   Change to Diagram Contents
HP030 CONSULTANT CLINICS   Change to Diagram Contents
HP040 OUT-PATIENT ATTENDANCES   Change to Diagram Contents
HP050 ELECTIVE ADMISSION LISTS   Change to Diagram Contents
HP060 ADMISSION RIGHTS   Change to Diagram Contents
HP070 CONSULTANT EPISODES (HOSPITAL PROVIDER)   Change to Diagram Contents
HP080 AUGMENTED CARE PERIODS   Change to Diagram Contents
HP090 ADMITTED PATIENT CONSULTANT CARE   Change to Diagram Contents
HP100 ADMITTED PATIENT NURSING CARE   Change to Diagram Contents
HP110 ADMITTED PATIENT STAYS   Change to Diagram Contents
HP120 WARDS   Change to Diagram Contents
HP150 REGISTRABLE BIRTHS   Change to Diagram Contents
HP170 HOSPITAL BEDS - PLANNING INTENT   Change to Diagram Contents
HP180 OPERATING THEATRES   Change to Diagram Contents
HP200 PATHOLOGY SERVICES - DIAGNOSTIC TEST REQUESTS   Change to Diagram Contents
HP210 PATHOLOGY SERVICES   Change to Diagram Contents
HP220 PATHOLOGY SERVICE REQUESTS - GP HOSPITAL COMMUNICATIONS   Change to Diagram Contents
HP230 RADIOLOGY DEPARTMENTS   Change to Diagram Contents
HP240 RADIOLOGY SERVICE REQUESTS - GP HOSPITAL COMMUNICATIONS   Change to Diagram Contents
HP250 ISOTOPE PROCEDURES   Change to Diagram Contents
HP260 PHYSIOLOGICAL MEASUREMENT   Change to Diagram Contents
HP270 PROFESSIONAL STAFF GROUP SERVICES AND DEPARTMENTS   Change to Diagram Contents
HP300 NURSING EPISODES   Change to Diagram Contents
HP310 MIDWIFE EPISODES   Change to Diagram Contents
HP320 LEGAL STATUS FOR PATIENT   Change to Diagram Contents
HP340 HOSPITAL EYE SERVICE   Change to Diagram Contents
HP350 NHS DAY CARE FACILITIES   Change to Diagram Contents
HP360 PSYCHIATRIC HEALTH OF THE NATION OUTCOME SCALES (HONOS)   Change to Diagram Contents
JDH JUNIOR DOCTORS HOURS   Change to Diagram Contents
KH06 DEMAND FOR ELECTIVE ADMISSION: EVENTS OCCURRING DURING THE QUARTER, PROVIDER BASED   Change to Diagram Contents
KH06R DEMAND FOR ELECTIVE ADMISSION: POSITION AT THE END OF THE QUARTER, RESPONSIBLE POPULATION BASED   Change to Diagram Contents
KH07A DEMAND FOR ELECTIVE ADMISSION: NUMBER OF PATIENTS WHO HAVE DEFERRED ADMISSION WAITING AT THE END OF THE QUARTER, PROVIDER BASED   Change to Diagram Contents
KH07AR DEMAND FOR ELECTIVE ADMISSION: POSITION AT THE END OF THE QUARTER, RESPONSIBLE POPULATION BASED   Change to Diagram Contents
KH07 DEMAND FOR ELECTIVE ADMISSION: POSITION AT THE END OF THE QUARTER, PROVIDER BASED   Change to Diagram Contents
KH09 CONSULTANT OUT-PATIENT ATTENDANCE ACTIVITY & ACCIDENT AND EMERGENCY SERVICES ACTIVITY   Change to Diagram Contents
KT24 SUMMARY OF CLINICAL PSYCHOLOGY SERVICES   Change to Diagram Contents
KT26 SUMMARY OF OCCUPATIONAL THERAPY SERVICES   Change to Diagram Contents
KT27 SUMMARY OF PHYSIOTHERAPY SERVICES   Change to Diagram Contents
KT29 SUMMARY OF SPEECH THERAPY SERVICES   Change to Diagram Contents
MDW1 MEDICAL/DENTAL CENSUS   Change to Diagram Contents
MDW2 MEDICAL/DENTAL CENSUS   Change to Diagram Contents
MH020 MENTAL HEALTH CARE SPELL   Change to Diagram Contents
MH060 MENTAL HEALTH: PATIENT PROCEDURES   Change to Diagram Contents
MS010 GP HOSPITAL COMMUNICATION MESSAGES - CLINICAL INFORMATION   Change to Diagram Contents
MS020 GP HOSPITAL COMMUNICATION MESSAGES - SERVICE REPORTS   Change to Diagram Contents
NCDS3 NATIONAL CANCER DATA SET PART 3   Change to Diagram Contents
PC010 GENERAL MEDICAL PRACTITIONERS AND POSTS IN GP PRACTICES   Change to Diagram Contents
PC020 GMPS CLAIMS AND PAYMENTS/REIMBURSEMENTS FROM PRIMARY CARE TRUSTS   Change to Diagram Contents
PC090 GENERAL MEDICAL PRACTITIONERS' PARTNERSHIPS AND PERSONS' REGISTRATION   Change to Diagram Contents
PC100 PRESCRIBING AND DISPENSING   Change to Diagram Contents
PC120 GENERAL OPHTHALMIC SERVICES   Change to Diagram Contents
PC130 EMERGENCY DENTAL SERVICES   Change to Diagram Contents
QF01 DEMAND FOR ELECTIVE ADMISSION: POSITION AT THE END OF THE QUARTER, RESPONSIBLE POPULATION BASED   Change to Diagram Contents
QM08 OUT-PATIENT FIRST ATTENDANCES - PROVIDER   Change to Diagram Contents
QM08R OUT-PATIENT FIRST ATTENDANCES: RESPONSIBLE POPULATION BASED   Change to Diagram Contents
SBE515 OPHTHALMIC SERVICES SIGHT TESTS, SPECTACLE SUPPLY AND REPAIRS   Change to Diagram Contents
WF030 WORKFORCE MEDICAL AND DENTAL POSTS   Change to Diagram Contents
WF040 EMPLOYEE CONTRACT   Change to Diagram Contents
WF050 EMPLOYEE QUALIFICATIONS   Change to Diagram Contents
 
Supporting Information
AD010   Change to Supporting Information
CC010   Change to Supporting Information
CL010   Change to Supporting Information
CL020   Change to Supporting Information
HP010   Change to Supporting Information
HP030   Change to Supporting Information
HP050   Change to Supporting Information
HP060   Change to Supporting Information
HP070   Change to Supporting Information
HP080   Change to Supporting Information
HP170   Change to Supporting Information
HP180   Change to Supporting Information
HP200   Change to Supporting Information
HP230   Change to Supporting Information
HP240   Change to Supporting Information
HP250   Change to Supporting Information
HP260   Change to Supporting Information
HP270   Change to Supporting Information
HP320   Change to Supporting Information
HP340   Change to Supporting Information
HP350   Change to Supporting Information
HP360   Change to Supporting Information
MS010   Change to Supporting Information
MS020   Change to Supporting Information
PC010   Change to Supporting Information
PC020   Change to Supporting Information
PC100   Change to Supporting Information
PC120   Change to Supporting Information
PRACTITIONER CODES   Change to Supporting Information
SPECIALTY FUNCTION CODES   Change to Name
SPECIALTY FUNCTION CODES renamed MAIN SPECIALTY+TREATMENT FUNCTION CODES   Change to Supporting Information
WF030   Change to Supporting Information
 
Packages
SUPPORTING INFORMATION   Change to Description

Name:Barbara Fogarty
Date:29 September 2003
Sponsor:Data Standards Team

Note: Additions shown in highlighted with a blue background. Deletions are shown using strikeout.


ACCIDENT AND EMERGENCY ATTENDANCE

Change to Class: Change to Description

An individual visit by one PATIENT to an ACCIDENT AND EMERGENCY DEPARTMENT to receive treatment from the accident and emergency service.

Note that the accident and emergency service may be provided by staff from other SPECIALTIES. Note that the accident and emergency service may be provided by staff from other MAIN SPECIALTIES.

During an ACCIDENT AND EMERGENCY ATTENDANCE the PATIENT may temporarily leave the ACCIDENT AND EMERGENCY DEPARTMENT, e.g. for an X-ray, whilst still under the responsibility of the ACCIDENT AND EMERGENCY DEPARTMENT.

ACCIDENT AND EMERGENCY ATTENDANCES may be as a result of a request from a GENERAL PRACTITIONER for help with diagnosis or treatment.

Attendances at OUT-PATIENT CLINICS run in the ACCIDENT AND EMERGENCY DEPARTMENT should not be recorded as ACCIDENT AND EMERGENCY ATTENDANCES but should be recorded as OUT-PATIENT ATTENDANCE CONSULTANT or CLINIC ATTENDANCE NON-CONSULTANT depending upon the type of OUT-PATIENT CLINIC attended.

Any facility set up to receive and treat emergency cases is regarded as an ACCIDENT AND EMERGENCY DEPARTMENT for this purpose.

ACCIDENT AND EMERGENCY ATTENDANCES include both first and follow-up attendances. A follow-up attendance is any subsequent ACCIDENT AND EMERGENCY ATTENDANCE at the same ACCIDENT AND EMERGENCY DEPARTMENT for the same incident.

Each ACCIDENT AND EMERGENCY ATTENDANCE, which is a first attendance or an unplanned follow-up attendance, should be assigned an A+E STREAM.

This class is also known by these names:
ContextAlias
pluralACCIDENT AND EMERGENCY ATTENDANCES


top

ACCIDENT AND EMERGENCY EPISODE

Change to Class: Change to Description

The visits to an ACCIDENT AND EMERGENCY DEPARTMENT of one PATIENT for a particular incident. The PATIENT may receive treatment during the episode from the accident and emergency service and from other SPECIALTIES. The PATIENT may receive treatment during the episode from the accident and emergency service and from other MAIN SPECIALTIES.



This class is also known by these names:
ContextAlias
pluralACCIDENT AND EMERGENCY EPISODES


top

AUGMENTED CARE PERIOD

Change to Class: Change to Description

A period of time within a CONSULTANT EPISODE (HOSPITAL PROVIDER) during which a PATIENT requires close observation and intervention by additional, specially trained staff using medical equipment not routinely available on general hospital wards.

Excluded from this is care provided to neonates, which is recorded elsewhere. Also excluded from this is care provided on general wards, A&E, Radiology departments, labour wards and Special Care Baby Units.

A PATIENT may receive both Intensive and High Dependency levels of care within one AUGMENTED CARE PERIOD.

An AUGMENTED CARE PERIOD must have only one AUGMENTED CARE LOCATION; if the location changes, a new AUGMENTED CARE PERIOD begins.

If the responsibility for the PATIENT'S CONSULTANT EPISODE (HOSPITAL PROVIDER) transfers from one CONSULTANT to another while the PATIENT is receiving augmented care, the AUGMENTED CARE PERIOD ends and another one starts under the new CONSULTANT EPISODE (HOSPITAL PROVIDER).

The CONSULTANT clinically managing the PATIENT during the AUGMENTED CARE PERIOD is not necessarily the same as the CONSULTANT responsible for the CONSULTANT EPISODE (HOSPITAL PROVIDER). The SPECIALTY FUNCTION of the CONSULTANT clinically managing the PATIENT during the AUGMENTED CARE PERIOD should be recorded. The MAIN SPECIALTY of the CONSULTANT clinically managing the PATIENT during the AUGMENTED CARE PERIOD should be recorded.

In the event of multiple SPECIALTY involvement in an AUGMENTED CARE PERIOD where no SPECIALTY is identified as being responsible the SPECIALTY FUNCTION of the CONSULTANT admitting the PATIENT to the AUGMENTED CARE PERIOD is recorded. In the event of multiple specialty involvement in an AUGMENTED CARE PERIOD where no single specialty is identified as being responsible the MAIN SPECIALTY of the CONSULTANT admitting the PATIENT to the AUGMENTED CARE PERIOD is recorded.

Within an AUGMENTED CARE PERIOD, where a PATIENT is cared for by a team of specialists within an Intensive Care rota the SPECIALTY FUNCTION of the clinical director of the team is recorded. Within an AUGMENTED CARE PERIOD, where a PATIENT is cared for by a team of specialists within an Intensive Care rota the MAIN SPECIALTY of the clinical director of the team is recorded.

An AUGMENTED CARE PERIOD does not include the following:

a. Surgical and anaesthetic intra-operative care
b. Post-operative care within an operating department
c. Cardiac (coronary) care
d. Imaging procedures
e. Endoscopy procedures



This class is also known by these names:
ContextAlias
pluralAUGMENTED CARE PERIODS


top

AUGMENTED CARE PERIOD

Change to Class: Change to Relationships

Each AUGMENTED CARE PERIOD
must be within one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
must be classified for the managing CONSULTANT by one and only one SPECIALTY FUNCTION
must be classified for the managing consultant by one and only one MAIN SPECIALTY


top

CARE EPISODE

Change to Class: New Class

CARE EPISODE

The time a patient spends in the continuous care of one or more CARE PROFESSIONALS.

The care is the responsibility of a lead CARE PROFESSIONAL. This responsibility may be equally shared by two or more JOINT LEAD CARE PROFESSIONALS. Where two or more CARE PROFESSIONALS are jointly responsible for the care of the PATIENT one must be nominated as the lead CARE PROFESSIONAL for the CARE EPISODE. Social and other care may be incorporated within the CARE EPISODE but this may not be the responsibility of the lead CARE PROFESSIONAL.

A PATIENT may not have concurrent CARE EPISODES within a HOSPITAL PROVIDER SPELL. Where the lead responsibility is transferred from one care professional to another within a HOSPITAL PROVIDER SPELL, the CARE EPISODE will end and a new one start. An intervention by a CARE PROFESSIONAL with responsibility for a particular procedure does not end the episode. The episode only ends if overall responsibility for the patient is transferred.



This class is also known by these names:
ContextAlias
pluralCARE EPISODES

Attributes of this Class are:
KSTART DATE
OEND DATE

Each CARE EPISODE
Kmust be under the nominated lead responsibility for care of one and only one CARE PROFESSIONAL
Kmust be the continuous care of one and only one PATIENT
may be related to one or more DAY CARE ATTENDANCE
may be from one and only one HOSPITAL PROVIDER SPELL
may be under the joint care of one or more JOINT LEAD CARE PROFESSIONAL
may be associated with one or more PATIENT DIAGNOSIS
may be if in hospital and as a result of an RTA, part of one and only one ROAD TRAFFIC ACCIDENT TREATMENT
may be related to one and only one SERVICE PROVIDED
may be classified for treatment by one and only one TREATMENT FUNCTION


top

CLINICAL INTERVENTION

Change to Class: Change to Relationships

Each CLINICAL INTERVENTION
Kmust be associated with one and only one PATIENT
may be endocrine therapy for one and only one CANCER CARE SPELL
may be endochrine therapy for one and only one CANCER CARE SPELL
may be associated with one or more CARE PROFESSIONAL INVOLVEMENT
may be related to one or more CLINICAL INVESTIGATION RESULT ITEM
may be associated with one or more HEALTH CARE PROFESSIONAL INVOLVEMENT
may be classified by one or more INTERVENTION CLASSIFICATION ASSOCIATION
may be related to one and only one SERVICE PROVIDED


top

CLINICAL INVESTIGATION SERVICE PROVIDER

Change to Class: Change to Relationships

Each CLINICAL INVESTIGATION SERVICE PROVIDER
must be related to one and only one CLINICAL INVESTIGATION RESULT ITEM
or must be related to one and only one RADIOLOGY INVESTIGATION PLAN
must be related to one and only one HEALTH CARE PROFESSIONAL
must be related to one and only one CARE PROFESSIONAL
or must be related to one and only one ORGANISATION


top

CLINIC ATTENDANCE NURSE

Change to Class: Change to Description

A type of CLINIC ATTENDANCE NON-CONSULTANT.

An attendance at a NURSE CLINIC.

Note: Local arrangements for apportioning attendances to the relevant SPECIALTY FUNCTION may be made instead of recording this for each attendance. Note: Local arrangements for apportioning attendances to the relevant TREATMENT FUNCTION may be made instead of recording this for each attendance.



This class is also known by these names:
ContextAlias
pluralCLINIC ATTENDANCES NURSE


top

CONSULTANT

Change to Class: Change to Super Type, Change to Description, Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A PERSON contracted by a HEALTH CARE PROVIDER who has been appointed by a CONSULTANTS' appointment committee. He or she must be a member of a Royal College or Faculty. This includes GENERAL PRACTITIONERS in cases where a GENERAL PRACTITIONER is responsible for PATIENT care and has an arrangement with the HEALTH CARE PROVIDER. The main SPECIALTY of a GENERAL PRACTITIONER will always be General Practice. The MAIN SPECIALTY of a GENERAL PRACTITIONER will always be General Practice. For diagnostic departments, this includes a non-medical scientist of equivalent standing (to a CONSULTANT).



This class is also known by these names:
ContextAlias
pluralCONSULTANTS


top

CONSULTANT

Change to Class: Change to Relationships

Each CONSULTANT
must be contracted as main specialty by a provider for one and only one SPECIALTY
must be contracted as main specialty by a provider for one and only one MAIN SPECIALTY
may be responsible for one or more ANTI-CANCER DRUG PROGRAMME
may be related to one or more CONSULTANT CLINIC
may be related to one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be related to one or more CONSULTANT OUT-PATIENT EPISODE
may be contracted for one or more CONSULTANT SPECIALTY FUNCTION
may be related to one or more DOMICILIARY CONSULTATION
may be related to one or more ELECTIVE ADMISSION LIST ENTRY
may be responsible for one or more FACE TO FACE CONTACT OPTICAL
may be related to one or more ISOTOPE PROCEDURE DEPARTMENT
may be responsible for one or more NURSING HOME STAY (CONSULTANT CARE)
may be related to one or more OPERATING THEATRE SESSION
may be related to one or more OPERATING THEATRE SESSION
may be related to one or more PATHOLOGY DEPARTMENT
may be related to one or more PATIENT PROCEDURE
may be related to one or more PHYSIOLOGICAL MEASUREMENT DEPARTMENT
may be related to one or more RADIOLOGY DEPARTMENT
may be responsible for one or more RADIOTHERAPY TREATMENT COURSE
may be related to one or more REFERRAL REQUEST
may be related to one or more RIGHT OF ADMISSION
may be related to one or more SHARED CARE CONSULTANT
may be related to one or more SHARED CARE OUT-PATIENT CONSULTANT
may be related to one or more SHARED CLINIC CONSULTANT
may be related to one or more THEATRE CASE
may be related to one or more WARD INTENDED BED USE


top

CONSULTANT CLINIC

Change to Class: Change to Super Type

A type of OUT-PATIENT CLINIC.

An administrative arrangement enabling PATIENTS to see a CONSULTANT, the CONSULTANT's staff and associated health professionals. The holding of a clinic provides the opportunity for consultation, investigation and treatment. PATIENTS normally attend by prior appointment. Although a CONSULTANT is in overall charge, the CONSULTANT may not be present on all occasions that the clinic is held. However, a member of the CONSULTANT's firm or locum for such a member, must always be present. An individual CONSULTANT may run more than one clinic in the same or different LOCATIONS. This also includes clinics run by GENERAL PRACTITIONERS acting as CONSULTANT (see definition of 'CONSULTANT').

Clinics not controlled by a CONSULTANT (or GENERAL PRACTITIONER) should not be included, e.g. those run by midwives (see MIDWIFE CLINIC). CONSULTANT CLINIC SESSIONS are actual occurrences of CONSULTANT CLINICS.



This class is also known by these names:
ContextAlias
pluralCONSULTANT CLINICS


top

CONSULTANT EPISODE (ACUTE HOME-BASED)

Change to Class: Change to Relationships

Each CONSULTANT EPISODE (ACUTE HOME-BASED)
Kmust be classified for main specialty of responsible consultant by one and only one CONSULTANT SPECIALTY FUNCTION
Kmust be an episode of care for one and only one PATIENT
must be acute home-based care for a patient at one and only one ADDRESS ASSOCIATION
must be acute home-based care within one and only one SERVICE PROVIDED
may be recorded by one or more ACUTE HOME-BASED CONTACT
may be associated with one or more PATIENT DIAGNOSIS
may be associated with one or more PATIENT PROCEDURE


top

CONSULTANT EPISODE (HOSPITAL PROVIDER)

Change to Class: Change to Super Type

A type of CARE EPISODE

The time a PATIENT spends in the continuous care of one CONSULTANT using HOSPITAL SITE or NURSING HOME bed(s) of one HEALTH CARE PROVIDER or, in the case of shared care, in the care of two or more CONSULTANTS. Where care is provided by two or more CONSULTANTS within the same episode, one CONSULTANT will take overriding responsibility for the patient and only one CONSULTANT EPISODE (HOSPITAL PROVIDER) is recorded. Additional CONSULTANTS participating in the care of PATIENT are defined as SHARED CARE CONSULTANTS. A CONSULTANT EPISODE (HOSPITAL PROVIDER) includes those episodes for which a GMP is acting as a CONSULTANT.

A PATIENT going on HOME LEAVE, or LEAVE OF ABSENCE for 28 days or less, or has a current period of ABSENCE WITHOUT LEAVE of 28 days or less, does not interrupt the CONSULTANT EPISODE (HOSPITAL PROVIDER).

A PATIENT may not have concurrent CONSULTANT EPISODES (HOSPITAL PROVIDER) but can have CONSULTANT OUT-PATIENT EPISODES overlapping with a CONSULTANT EPISODE (HOSPITAL PROVIDER). A CONSULTANT EPISODE (HOSPITAL PROVIDER) must not overlap with a NURSING EPISODE for the same PATIENT.

Any time spent as a LODGED PATIENT before being admitted to a WARD is included in the first CONSULTANT EPISODE (HOSPITAL PROVIDER).

A CONSULTANT transfer occurs when the responsibility for a PATIENT transfers from one CONSULTANT (or GMP acting as a CONSULTANT) to another within a HOSPITAL PROVIDER SPELL. In this case one CONSULTANT EPISODE (HOSPITAL PROVIDER) will end and another one begin.

A transfer of responsibility may occur from a CONSULTANT to the PATIENT's own GMP (not acting as CONSULTANT) with the PATIENT still in a WARD or NURSING HOME to receive nursing care. In this case the CONSULTANT EPISODE (HOSPITAL PROVIDER) will end and a NURSING EPISODE will begin.

A transfer of responsibility from the PATIENT's own GMP to a CONSULTANT while the PATIENT is in a WARD or NURSING HOME for nursing care will end the NURSING EPISODE and begin a CONSULTANT EPISODE (HOSPITAL PROVIDER).



This class is also known by these names:
ContextAlias
pluralCONSULTANT EPISODES (HOSPITAL PROVIDER)


top

CONSULTANT EPISODE (HOSPITAL PROVIDER)

Change to Class: Change to Attributes

Attributes of this Class are:
KEPISODE NUMBER
OEND DATE
EPISODE TYPE
OPSYCHIATRIC PATIENT STATUS
START DATE


top

CONSULTANT EPISODE (HOSPITAL PROVIDER)

Change to Class: Change to Relationships

Each CONSULTANT EPISODE (HOSPITAL PROVIDER)
Kmust be related to one and only one HOSPITAL PROVIDER SPELL
must be classified for main specialty of responsible consultant by one and only one CONSULTANT SPECIALTY FUNCTION
Kmust be the responsibility of one and only one CONSULTANT
may be associated with one or more AUGMENTED CARE PERIOD
may be classified for treatment specialty interest by one and only one CONSULTANT SPECIALTY FUNCTION
may be related to one or more DAY CARE ATTENDANCE
may be related to one or more LABOUR AND DELIVERY
may be related to one and only one LOCAL SUB-SPECIALTY
may be related to one or more PATIENT DIAGNOSIS
may be related to one or more PATIENT PROCEDURE
may be if in hospital and as a result of an RTA, part of one and only one ROAD TRAFFIC ACCIDENT TREATMENT
may be related to one and only one SERVICE PROVIDED
may be related to one or more SHARED CARE CONSULTANT


top

CONSULTANT OUT-PATIENT EPISODE

Change to Class: Change to Relationships

Each CONSULTANT OUT-PATIENT EPISODE
Kmust be the responsibility of one and only one CONSULTANT
Kmust be related to one and only one PATIENT
must be classified for main specialty by one and only one CONSULTANT SPECIALTY FUNCTION
must be related to one and only one LOCAL SUB-SPECIALTY
may be related to one or more ADMINISTRATIVE CATEGORY IN EPISODE
may be classified for treatment specialty interest by one and only one CONSULTANT SPECIALTY FUNCTION
may be related to one or more DISABLEMENT APPLIANCE
may be related to one or more OUT-PATIENT APPOINTMENT CONSULTANT
may be related to one or more OUT-PATIENT ATTENDANCE CONSULTANT
may be care or treatment provided within one and only one SERVICE PROVIDED
may be related to one or more SHARED CARE OUT-PATIENT CONSULTANT
may be classified for treatment function by one and only one TREATMENT FUNCTION


top

CONSULTANT SPECIALTY FUNCTION

Change to Class: Change to Name

CONSULTANT SPECIALTY FUNCTION


top

CONSULTANT SPECIALTY FUNCTION renamed CONSULTANT SPECIALTY FUNCTION

Change to Class: Change to Aliases, Change to Description, Change to Description

A SPECIALTY FUNCTION which may apply for a CONSULTANT according to the main SPECIALTY or a SPECIALTY interest for the CONSULTANT. This will be the SPECIALTY under which the PATIENT is treated. This links the TREATMENT FUNCTIONS that apply to a particular CONSULTANT and provides information on the treatment interests of the CONSULTANT.



This class is also known by these names:
ContextAlias
pluralCONSULTANT SPECIALTY FUNCTIONS


top

CONSULTANT SPECIALTY FUNCTION

Change to Class: Change to Relationships

Each CONSULTANT SPECIALTY FUNCTION
Kmust be contractually provided by one and only one CONSULTANT
Kmust be related to one and only one SPECIALTY FUNCTION
Kmust be related to one and only one TREATMENT FUNCTION
may be the classifier for the main specialty of one or more CONSULTANT EPISODE (ACUTE HOME-BASED)
may be classifier for treatment specialty interest of one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be classifier for main specialty of one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be classifier for treatment specialty interest of one or more CONSULTANT OUT-PATIENT EPISODE
may be classifier for main specialty of one or more CONSULTANT OUT-PATIENT EPISODE
may be classifier for treatment specialty interest of one or more ELECTIVE ADMISSION LIST
may be classifier for main specialty of one or more ELECTIVE ADMISSION LIST
may be classifier for treatment specialty interest of one or more ELECTIVE ADMISSION LIST ENTRY
may be the classifier for the main specialty of one or more RESPONSIBLE MEDICAL OFFICER ASSIGNMENT


top

DAY CARE ATTENDANCE

Change to Class: Change to Description

One attendance, or expected attendance, by a PATIENT at a particular DAY CARE SESSION. This will either be by a regular attender or by a PATIENT currently using a hospital bed (including HOME LEAVE and LEAVE OF ABSENCE for a period of 28 days or less).

If the PATIENT is currently subject to a MENTAL HEALTH CARE SPELL and during attendance at the facility is in contact with the HEALTH CARE PROFESSIONAL who is their allocated Care Programme Approach care coordinator then a FACE TO FACE CONTACT CPA CARE COORDINATOR should also be recorded. If the PATIENT is currently subject to a MENTAL HEALTH CARE SPELL and during attendance at the facility is in contact with the CARE PROFESSIONAL who is their allocated Care Programme Approach care coordinator then a FACE TO FACE CONTACT CPA CARE COORDINATOR should also be recorded.



This class is also known by these names:
ContextAlias
pluralDAY CARE ATTENDANCES


top

DAY CARE ATTENDANCE

Change to Class: Change to Relationships

Each DAY CARE ATTENDANCE
Kmust be related to one and only one DAY CARE SESSION
Kmust be if patient using a hospital bed within one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
K or must be if patient using a hospital bed, within one and only one MIDWIFE EPISODE
K or must be if patient using a hospital bed, within one and only one NURSING EPISODE
K or must be if patient not using hospital bed within one and only one REGULAR ATTENDER EPISODE
Kmust be if patient using a hospital bed within one and only one CARE EPISODE
K or must be if patient not using a hospital bed within one and only one REGULAR ATTENDER EPISODE
may be for treatment for one or more PATIENT PROCEDURE


top

DAY CARE SESSION

Change to Class: Change to Relationships

Each DAY CARE SESSION
Kmust be related to one and only one DAY CARE FACILITY
may be the responsibility of one and only one CARE PROFESSIONAL
may be related to one or more DAY CARE ATTENDANCE
may be the responsibility of one and only one HEALTH CARE PROFESSIONAL


top

DISPENSED ITEM

Change to Class: Change to Relationships

Each DISPENSED ITEM
Kmust be dispensed in response to one and only one PRESCRIPTION
must be a record of the dispensing of one and only one NHS NOTIONAL PACK SIZE
or must be a record of the dispensing of one and only one PROPRIETARY PRODUCT IN PACK
must be dispensed by one and only one HEALTH CARE PROFESSIONAL
must be dispensed by one and only one CARE PROFESSIONAL
must be dispensed to one and only one PATIENT


top

DRUG TREATMENT

Change to Class: Change to Relationships

Each DRUG TREATMENT
must be prescribed by one and only one HEALTH CARE PROFESSIONAL
must be prescribed by one and only one CARE PROFESSIONAL
may be related to one or more DRUG DOSAGE AND ADMINISTRATION


top

ELECTIVE ADMISSION LIST

Change to Class: Change to Relationships

Each ELECTIVE ADMISSION LIST
Kmust be related to one and only one HEALTH CARE PROVIDER
Kmust be related to one and only one SPECIALTY FUNCTION
may be classified for treatment specialty interest by one and only one CONSULTANT SPECIALTY FUNCTION
may be classified for main specialty of responsible consultant by one and only one CONSULTANT SPECIALTY FUNCTION
Kmust be classified for treatment function by one and only one TREATMENT FUNCTION
may be the responsibility of one and only one CARE PROFESSIONAL
may be related to one or more ELECTIVE ADMISSION LIST ENTRY
may be classified for Consultant main specialty by one and only one MAIN SPECIALTY


top

ELECTIVE ADMISSION LIST ENTRY

Change to Class: Change to Relationships

Each ELECTIVE ADMISSION LIST ENTRY
Kmust be related to one and only one ELECTIVE ADMISSION LIST
must be the result of one and only one DECISION TO ADMIT
must be related to one and only one PATIENT
may be shared care by one and only one CONSULTANT
may be classified for treatment specialty interest by one and only one CONSULTANT SPECIALTY FUNCTION
may be related to one or more ELECTIVE ADMISSION SUSPENSION DETAIL
may be related to one or more HOSPITAL PROVIDER SPELL
may be intended for treatment at one and only one HOSPITAL SITE
may be related to one or more INTENDED PATIENT PROCEDURE
may be classified by one and only one LOCAL SUB-SPECIALTY
may be classified for shared care by one and only one MAIN SPECIALTY
may be related to one or more OFFER OF ADMISSION
may be related to one and only one SERVICE PROVIDED
may be classified for shared care by one and only one SPECIALTY FUNCTION
may be classified for treatment function by one and only one TREATMENT FUNCTION


top

FACE TO FACE CONTACT OPTICAL

Change to Class: Change to Description

A face to face contact with a PATIENT for activity related to the prescribing of optical appliances including sight testing and related work, as well as similar diagnostic work carried out by CONSULTANTS with a SPECIALTY of Medical Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONERS or OPHTHALMIC OPTICIANS. A face to face contact with a PATIENT for activity related to the prescribing of optical appliances including sight testing and related work, as well as similar diagnostic work carried out by CONSULTANTS with a MAIN SPECIALTY of Medical Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONERS or OPHTHALMIC OPTICIANS.



This class is also known by these names:
ContextAlias
pluralFACE TO FACE CONTACTS OPTICAL


top

GENERAL MEDICAL PRACTITIONER REGISTRAR

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A fully registered medical practitioner who is being trained in general practice under an arrangement approved by the Secretary of State.

References:
Statement of Fees and Allowances Payable to General Medical Practitioners in England and Wales.



This class is also known by these names:
ContextAlias
pluralGENERAL MEDICAL PRACTITIONER REGISTRARS


top

GENERAL PRACTITIONER

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A HEALTH CARE PRACTITIONER qualified for General Practice providing healthcare for a particular ORGANISATION; a GENERAL PRACTITIONER may act as either a GENERAL MEDICAL PRACTITIONER or a GENERAL DENTAL PRACTITIONER.

GENERAL PRACTITIONER may be abbreviated to GP.



This class is also known by these names:
ContextAlias
pluralGENERAL PRACTITIONERS


top

GMP PRACTICE CONSULTATION

Change to Class: Change to Description

A consultation by a HEALTH CARE PROFESSIONAL to a PERSON for the provision of health care within a GENERAL MEDICAL PRACTITIONER PRACTICE. A consultation by a CARE PROFESSIONAL to a PERSON for the provision of health care within a GENERAL MEDICAL PRACTITIONER PRACTICE.

The PATIENT should have a GMP PRACTICE CONSULTATION within 24 hours of REQUEST FOR APPOINTMENT DATE and REQUEST FOR APPOINTMENT TIME if requesting to see a HEALTH CARE PROFESSIONAL other than a GENERAL MEDICAL PRACTITIONER. The PATIENT should have a GMP PRACTICE CONSULTATION within 24 hours of REQUEST FOR APPOINTMENT DATE and REQUEST FOR APPOINTMENT TIME if requesting to see a CARE PROFESSIONAL other than a GENERAL MEDICAL PRACTITIONER. The PATIENT should have a GMP PRACTICE CONSULTATION to see a GENERAL MEDICAL PRACTITIONER within 48 hours of requesting an appointment.



This class is also known by these names:
ContextAlias
pluralGMP PRACTICE CONSULTATIONS


top

GMP PRACTICE CONSULTATION

Change to Class: Change to Relationships

Each GMP PRACTICE CONSULTATION
Kmust be given by one and only one HEALTH CARE PROFESSIONAL
Kmust be given by one and only one CARE PROFESSIONAL
Kmust be a consultation for one and only one PERSON
must be a consultation within one and only one GENERAL MEDICAL PRACTITIONER PRACTICE


top

HEALTH CARE PROFESSIONAL

Change to Class: Change to Name

HEALTH CARE PROFESSIONAL
CARE PROFESSIONAL


top

HEALTH CARE PROFESSIONAL renamed CARE PROFESSIONAL

Change to Class: Change to Aliases

A type of PERSON ROLE IN ORGANISATION.

A type of PERSON who is professionally qualified to practice the delivery of health care services and is contracted to or provides healthcare for a particular ORGANISATION or HEALTH CARE PROVIDER. A type of PERSON who is professionally qualified to practise the delivery of health care services and is contracted to or provides healthcare for a particular ORGANISATION or HEALTH CARE PROVIDER.



This class is also known by these names:
ContextAlias
pluralHEALTH CARE PROFESSIONALS
pluralCARE PROFESSIONALS


top

HEALTH CARE PROFESSIONAL

Change to Class: Change to Relationships

Each HEALTH CARE PROFESSIONAL Each CARE PROFESSIONAL
may be the lead care professional for one or more CARE EPISODE
may be the participant in one or more CARE PROFESSIONAL INVOLVEMENT
may be related to one or more CLINICAL INVESTIGATION SERVICE PROVIDER
may be responsible for one or more DAY CARE SESSION
may be the dispenser of one or more DISPENSED ITEM
may be the prescriber of one or more DRUG TREATMENT
may be responsible for one or more ELECTIVE ADMISSION LIST
may be the provider of one or more GMP PRACTICE CONSULTATION
may be the participant in one or more HEALTH CARE PROFESSIONAL INVOLVEMENT
may be the evaluator of one or more HONOS SCORE FOR PERSON
may be associated with one or more ITEM OF SERVICE DELIVERY ROLE
may be identified as one or more JOINT LEAD CARE PROFESSIONAL
may be the person responsible for one or more PATIENT PROCEDURE
may be the observer of one or more PERSON OBSERVATION
may be the issuer of one or more PRESCRIPTION
may be related to one or more RADIOLOGY INVESTIGATION PLAN
may be the originator of one or more REFERRAL REQUEST
may be related as requester of one or more REQUEST FOR DIAGNOSTIC TEST
may be related as provider to one or more REQUEST FOR DIAGNOSTIC TEST
may be the recipient of one or more SERVICE REPORT COPY
may be the requester of one or more SERVICE REPORT HEADER
may be recorder of one or more SERVICE REPORT HEADER


top

HEALTH CARE PROFESSIONAL INVOLVEMENT

Change to Class: Change to Name

HEALTH CARE PROFESSIONAL INVOLVEMENT
CARE PROFESSIONAL INVOLVEMENT


top

HEALTH CARE PROFESSIONAL INVOLVEMENT renamed CARE PROFESSIONAL INVOLVEMENT

Change to Class: Change to Aliases, Change to Description

The participation of a HEALTH CARE PROFESSIONAL in a CLINICAL INTERVENTION. The participation of a CARE PROFESSIONAL in a CLINICAL INTERVENTION.



This class is also known by these names:
ContextAlias
pluralHEALTH CARE PROFESSIONAL INVOLVEMENTS
pluralCARE PROFESSIONAL INVOLVEMENTS


top

HEALTH CARE PROFESSIONAL INVOLVEMENT

Change to Class: Change to Relationships

Each HEALTH CARE PROFESSIONAL INVOLVEMENT Each CARE PROFESSIONAL INVOLVEMENT
Kmust be the involvement of one and only one CARE PROFESSIONAL
Kmust be involved with one and only one CLINICAL INTERVENTION
Kmust be the involvement of one and only one HEALTH CARE PROFESSIONAL


top

HONOS SCORE FOR PERSON

Change to Class: Change to Description

A particular HONOS SCORE for a PATIENT assessed by a HEALTH CARE PROFESSIONAL or MENTAL HEALTH CARE TEAM MEMBER. A particular HONOS SCORE for a PATIENT assessed by a CARE PROFESSIONAL or MENTAL HEALTH CARE TEAM MEMBER.



This class is also known by these names:
ContextAlias
pluralHONOS SCORES FOR PERSONS


top

HONOS SCORE FOR PERSON

Change to Class: Change to Relationships

Each HONOS SCORE FOR PERSON
Kmust be for one and only one HONOS RATING
Kmust be the score for one and only one PATIENT
Kmust be evaluated by one and only one HEALTH CARE PROFESSIONAL
Kmust be evaluated by one and only one CARE PROFESSIONAL
K or must be evaluated by one and only one MENTAL HEALTH CARE TEAM MEMBER
may be the score for one and only one CARE PROGRAMME APPROACH REVIEW


top

HOSPITAL PROVIDER SPELL

Change to Class: Change to Relationships

Each HOSPITAL PROVIDER SPELL
Kmust be related to one and only one PATIENT
may be related to one and only one DECISION TO ADMIT
or may be related to one and only one ELECTIVE ADMISSION LIST ENTRY
must be provided by one and only one HOSPITAL PROVIDER
may be related to one or more ADMINISTRATIVE CATEGORY IN SPELL
may be related to one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be the hospital spell for one or more CARE EPISODE
may be related to one or more HOME LEAVE
may be related to one or more HOSPITAL STAY
may be related to one or more LODGED PATIENT
may be related to one or more MIDWIFE EPISODE
may be related to one or more NEONATAL LEVEL OF CARE PERIOD
may be related to one or more NURSING EPISODE
may be related to one or more NURSING HOME STAY (CONSULTANT CARE)
may be related to one and only one PREGNANCY EPISODE
may be related to one or more WARD STAY


top

INDEPENDENT HEALTH CARE REGISTRATION

Change to Class: Change to Description

A type of ORGANISATION SITE REGISTRATION.

This may be the registration of an independent hospital, an independent clinic or an independent medical agency which is not owned or managed by the NHS.

An independent hospital is an establishment the main purpose of which is to provide medical or psychiatric treatment for illness or mental disorder or palliative care; or in which any of the INDEPENDENT HEALTH CARE SERVICES are provided (whether or not other services are also provided).

It is also any establishment in which treatment or nursing (or both) is provided for persons liable to be detained under the Mental Health Act 1983.

An establishment must register as an independent hospital if it provides treatment under anaesthesia or sedation, even if this is on a day case basis. If the establishment does not provide overnight beds for any patient and does not provide treatment under general anaesthesia or sedation, then the establishment should be registered as an independent clinic.

An independent clinic is an establishment in which services are provided by medical HEALTH CARE PROFESSIONALS. An independent clinic is an establishment in which services are provided by medical CARE PROFESSIONALS.

An independent medical agency is an undertaking which is not an independent clinic which consists of or includes the provision of services by medical HEALTH CARE PROFESSIONALS. An independent medical agency is an undertaking which is not an independent clinic which consists of or includes the provision of services by medical CARE PROFESSIONALS.

References:
National Care Standards Commission registration April 2002.



This class is also known by these names:
ContextAlias
pluralINDEPENDENT HEALTH CARE REGISTRATIONS


top

ITEM OF SERVICE DELIVERY ROLE

Change to Class: Change to Description

The role undertaken by a HEALTH CARE PROFESSIONAL in an ITEM OF SERVICE DELIVERY. The role undertaken by a CARE PROFESSIONAL in an ITEM OF SERVICE DELIVERY.



This class is also known by these names:
ContextAlias
pluralITEM OF SERVICE DELIVERY ROLES


top

ITEM OF SERVICE DELIVERY ROLE

Change to Class: Change to Relationships

Each ITEM OF SERVICE DELIVERY ROLE
Kmust be undertaken by one and only one HEALTH CARE PROFESSIONAL
Kmust be undertaken by one and only one CARE PROFESSIONAL
Kmust be undertaken as part of one and only one ITEM OF SERVICE DELIVERY


top

JOINT LEAD CARE PROFESSIONAL

Change to Class: New Class

JOINT LEAD CARE PROFESSIONAL

The care professional who has equal, joint lead responsibility for the continuing care of a PATIENT during a CARE EPISODE.



This class is also known by these names:
ContextAlias
pluralJOINT LEAD CARE PROFESSIONALS

This class has no attributes.

Each JOINT LEAD CARE PROFESSIONAL
Kmust be the joint lead care professional for one and only one CARE EPISODE
Kmust be identified as one and only one CARE PROFESSIONAL


top

LOCAL SUB-SPECIALTY

Change to Class: Change to Description

A locally defined division of clinical work which may cross SPECIALTY boundaries, e.g. Coronary Care. A locally defined division of clinical work which may cross MAIN SPECIALTY boundaries, e.g. Coronary Care.



This class is also known by these names:
ContextAlias
pluralLOCAL SUB-SPECIALTIES


top

MEDICAL AND DENTAL POST

Change to Class: Change to Relationships

Each MEDICAL AND DENTAL POST
Kmust be the responsibility of one and only one ORGANISATION
must be assigned as main to one and only one MAIN SPECIALTY
must be related to one and only one PAYSCALE
must be assigned as main to one and only one SPECIALTY
must be related to one and only one STAFF GROUP PLANNED
may be related to one or more MEDICAL AND DENTAL POST APPORTIONMENT
may be related to one or more MEDICAL AND DENTAL POST BY LOCATION
may be related to one or more MEDICAL AND DENTAL POST BY SPECIALTY
may be related to one or more MEDICAL AND DENTAL STAFF POSTING
may be related to one and only one ROTATIONAL ARRANGEMENT


top

MEDICAL AND DENTAL POST BY SPECIALTY

Change to Class: Change to Description

The identification of each SPECIALTY where the work of a MEDICAL AND DENTAL POST involves work in more than one SPECIALTY. The identification of each MAIN SPECIALTY where the work of a MEDICAL AND DENTAL POST involves work in more than one MAIN SPECIALTY.



This class is also known by these names:
ContextAlias
pluralMEDICAL AND DENTAL POSTS BY SPECIALTY


top

MEDICAL AND DENTAL POST BY SPECIALTY

Change to Class: Change to Relationships

Each MEDICAL AND DENTAL POST BY SPECIALTY
Kmust be related to one and only one MAIN SPECIALTY
Kmust be related to one and only one MEDICAL AND DENTAL POST
Kmust be related to one and only one SPECIALTY


top

MEDICAL AND DENTAL SPECIALTY INTEREST

Change to Class: Change to Description

Identifies each SPECIALTY in which a doctor has expressed interest and is recorded for the EMPLOYEE. Identifies each MAIN SPECIALTY in which a doctor has expressed interest and is recorded for the EMPLOYEE.



This class is also known by these names:
ContextAlias
pluralMEDICAL AND DENTAL SPECIALTY INTERESTS


top

MEDICAL AND DENTAL SPECIALTY INTEREST

Change to Class: Change to Relationships

Each MEDICAL AND DENTAL SPECIALTY INTEREST
Kmust be related to one and only one EMPLOYEE
Kmust be related to one and only one SPECIALTY
Kmust be related to one and only one MAIN SPECIALTY


top

MHCS SPECIALTY ASSOCIATION

Change to Class: Change to Description

An association between a MENTAL HEALTH CARE SPELL and a SPECIALTY FUNCTION which for the period of time of the association reflects the main psychiatric specialty activity for the PATIENT subject to the MENTAL HEALTH CARE SPELL. An association between a MENTAL HEALTH CARE SPELL and a MAIN SPECIALTY which for the period of time of the association reflects the main psychiatric specialty activity for the PATIENT subject to the MENTAL HEALTH CARE SPELL. In cases where a PATIENT is receiving psychotherapy as well as substantial psychiatric input, the general psychiatric specialty should be used.

The main specialty may change during the course of the MENTAL HEALTH CARE SPELL. This will end the previous association and start a new one.



This class is also known by these names:
ContextAlias
pluralMHCS SPECIALTY ASSOCIATIONS


top

MHCS SPECIALTY ASSOCIATION

Change to Class: Change to Relationships

Each MHCS SPECIALTY ASSOCIATION
Kmust be an association with one and only one MAIN SPECIALTY
Kmust be an association with one and only one MENTAL HEALTH CARE SPELL
Kmust be an association with one and only one SPECIALTY FUNCTION


top

MIDWIFE

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A person whose name is included in the Nursing and Midwifery Council register for nurses, midwives and health visitors, and who is contracted as a MIDWIFE to a HEALTH CARE PROVIDER.



This class is also known by these names:
ContextAlias
pluralMIDWIVES


top

MIDWIFE EPISODE

Change to Class: Change to Description

A type of CARE EPISODE.

A continuous period of time a client (PATIENT) uses a bed or delivery facility as part of a HOSPITAL PROVIDER SPELL or NURSING HOME STAY (MIDWIFE CARE), under the direct care of a MIDWIFE. This may be during a PREGNANCY EPISODE for the mother but may also be for a baby following a REGISTRABLE BIRTH.

The MIDWIFE with overall responsibility for a MIDWIFE EPISODE must be identified. If the responsible MIDWIFE changes then a new MIDWIFE or CONSULTANT EPISODE (HOSPITAL PROVIDER) begins. An intervention by a healthcare professional with responsibility for a particular procedure does not end the episode. The episode would end only if overall responsibility for the patient is transferred.

Jas's Test



This class is also known by these names:
ContextAlias
pluralMIDWIFE EPISODES


top

MIDWIFE EPISODE

Change to Class: Change to Relationships

Each MIDWIFE EPISODE
Kmust be related to one and only one PATIENT
or must be within one and only one HOSPITAL PROVIDER SPELL
or must be within one and only one NURSING HOME STAY (MIDWIFE CARE)
must be within one and only one NURSING HOME STAY (MIDWIFE CARE)
must be related to one and only one MIDWIFE
may be related to one or more DAY CARE ATTENDANCE
may be related to one or more LABOUR AND DELIVERY
may be to one and only one PREGNANCY EPISODE
may be related to one and only one SERVICE PROVIDED


top

NURSE

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A person whose name is included in the Nursing and Midwifery Council register for nurses, midwives and health visitors, and who is contracted as a NURSES to a HEALTH CARE PROVIDER.



This class is also known by these names:
ContextAlias
pluralNURSES


top

NURSING EPISODE

Change to Class: Change to Description

A continuous period of residential nursing care for a client (PATIENT) given on site 24 hours a day, with a nominated NURSE responsible for and available to the client/patients in circumstances when the responsibility for medical care is provided by the PATIENT's own GMP. A type of CARE EPISODE.

The NURSES with overall responsibility for a NURSING EPISODE must be identified. If the responsible NURSES changes then a new NURSING EPISODE begins. A continuous period of residential nursing care for a client (PATIENT) given on site 24 hours a day as part of a HOSPITAL PROVIDER SPELL or CARE HOME STAY (NURSING CARE), under the direct care of a NURSE.

The NURSE with overall responsibility for a NURSING EPISODE must be identified. If the responsible NURSE changes then a new NURSING EPISODE or CONSULTANT EPISODE (HOSPITAL PROVIDER) begins.

During a NURSING EPISODE the PATIENT is either in a NURSING HOME or in one or more WARDS of a HOSPITAL SITE. In some circumstances a PATIENT may take HOME LEAVE, or LEAVE OF ABSENCE for 28 days or less, or has a current period of ABSENCE WITHOUT LEAVE of 28 days or less, which does not interrupt the NURSING EPISODE.



This class is also known by these names:
ContextAlias
pluralNURSING EPISODES


top

NURSING EPISODE

Change to Class: Change to Relationships

Each NURSING EPISODE
Kmust be related to one and only one PATIENT
must be if patient in hospital within one and only one HOSPITAL PROVIDER SPELL
or must be if patient in nursing home within one and only one NURSING HOME STAY (NURSING CARE)
must be if patient in nursing home within one and only one CARE HOME STAY (NURSING CARE)
must be related to one and only one NURSE
may be related to one or more DAY CARE ATTENDANCE
may be if in hospital and as a result of an RTA, part of one and only one ROAD TRAFFIC ACCIDENT TREATMENT
may be related to one and only one SERVICE PROVIDED


top

OPERATING THEATRE INTENDED SPECIALTY

Change to Class: Change to Description

The operational planning intent for an OPERATING THEATRE in terms of the number of sessions planned by SPECIALTY FUNCTION. The operational planning intent for an OPERATING THEATRE in terms of the number of sessions planned by TREATMENT FUNCTION.



This class is also known by these names:
ContextAlias
pluralOPERATING THEATRE INTENDED SPECIALTIES


top

OPERATING THEATRE INTENDED SPECIALTY

Change to Class: Change to Relationships

Each OPERATING THEATRE INTENDED SPECIALTY
Kmust be related to one and only one OPERATING THEATRE OPERATIONAL PLAN
Kmust be related to one and only one SPECIALTY FUNCTION
Kmust be related to one and only one TREATMENT FUNCTION


top

OPERATING THEATRE SESSION

Change to Class: Change to Description

A period of OPERATING THEATRE time allocated to one or more consultant firms (CONSULTANT).

A session is either scheduled or unscheduled.

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

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

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

An OPERATING THEATRE SESSION should be considered cancelled if the time slot allocation is not used to perform at least one operation.



This class is also known by these names:
ContextAlias
pluralOPERATING THEATRE SESSIONS


top

OPERATING THEATRE SESSION

Change to Class: Change to Relationships

Each OPERATING THEATRE SESSION
Kmust be related to one and only one OPERATING THEATRE
may be the actual responsibility of one and only one CONSULTANT
may be planned for one or more CONSULTANT
may be related to one and only one SPECIALTY FUNCTION
may be related to one or more THEATRE CASE
may be cancelled due to one and only one THEATRE SESSION CANCELLATION REASON
may be related to one and only one TREATMENT FUNCTION


top

OPHTHALMIC MEDICAL PRACTITIONER

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A person whose name is registered with the General Medical Council and the Ophthalmic Qualification Committee, and who is contracted as an OPHTHALMIC MEDICAL PRACTITIONERS to a HEALTH AUTHORITY



This class is also known by these names:
ContextAlias
pluralOPHTHALMIC MEDICAL PRACTITIONERS


top

OPHTHALMIC OPTICIAN

Change to Class: Change to Description

A type of HEALTH CARE PROFESSIONAL. A type of CARE PROFESSIONAL.

A person whose name is registered with the General Ophthalmic Council as an OPHTHALMIC OPTICIANS (or optometrist) and who is contracted as an OPHTHALMIC OPTICIANS to a HEALTH AUTHORITY.



This class is also known by these names:
ContextAlias
pluralOPHTHALMIC OPTICIANS


top

OPHTHALMOLOGY SERVICE

Change to Class: Change to Description

A type of SERVICE POINT.

A separate entity, delivering services in the SPECIALTY of ophthalmology. A separate entity, delivering services in the MAIN SPECIALTY of ophthalmology.



This class is also known by these names:
ContextAlias
pluralOPHTHALMOLOGY SERVICES


top

OPHTHALMOLOGY SERVICE

Change to Class: Change to Relationships

Each OPHTHALMOLOGY SERVICE
must be related to one and only one SPECIALTY
must be related to one and only one MAIN SPECIALTY


top

OPTICIAN SITE

Change to Class: Change to Description

A type of ORGANISATION SITE.

An OPTICIAN SITES is an ORGANISATION SITE that is a premises from which CONSULTANTS with a SPECIALTY of Medical Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONERS and/or OPHTHALMIC OPTICIANS operate. An OPTICIAN SITE is an ORGANISATION SITE that is a premises from which CONSULTANTS with a MAIN SPECIALTY of Medical Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONERS and/or OPHTHALMIC OPTICIANS operate.



This class is also known by these names:
ContextAlias
pluralOPTICIAN SITES


top

OUT-PATIENT ATTENDANCE CONSULTANT

Change to Class: Change to Description

An attendance at which a PATIENT is seen by a CONSULTANT, in respect of one referral, that is not a visit to the home of a PATIENT for which a fee is payable under paragraph 140 of the Terms and Conditions of Service. For the purposes of this definition 'CONSULTANT' includes a member of the CONSULTANT's firm or locum for such a member.

If a PATIENT is seen by a CONSULTANT at a CONSULTANT CLINIC then this will be a CLINIC ATTENDANCE CONSULTANT. An attendance may involve more than one person (e.g. a family). The number of attendances to be recorded should be the number of PATIENTS for whom the particular CONSULTANT has identifiable individual records and which will be maintained as a result of the attendance.

A visit to the home of a PATIENT made at the instance of a hospital or specialist to review the urgency of a proposed admission to hospital, or to continue to supervise treatment initiated or prescribed at a hospital or clinic is covered by this definition.

OUT-PATIENT ATTENDANCE CONSULTANT also includes a PATIENT being seen by a CONSULTANT from a different SPECIALTY during a CONSULTANT EPISODE (HOSPITAL PROVIDER) in circumstances where there is no transfer of responsibility for the care of the PATIENT. OUT-PATIENT ATTENDANCE CONSULTANT also includes a PATIENT being seen by a CONSULTANT from a different MAIN SPECIALTY during a CONSULTANT EPISODE (HOSPITAL PROVIDER) in circumstances where there is no transfer of responsibility for the care of the PATIENT.

If the PATIENT is currently subject to a MENTAL HEALTH CARE SPELL and the consultant they are in contact with during attendance is their allocated Care Programme Approach care coordinator then a FACE TO FACE CONTACT CPA CARE COORDINATOR should also be recorded.



This class is also known by these names:
ContextAlias
pluralOUT-PATIENT ATTENDANCES CONSULTANT


top

PATIENT

Change to Class: Change to Relationships

Each PATIENT
may be absent for one or more ABSENCE WITHOUT LEAVE
may be related to one or more ACCIDENT AND EMERGENCY EPISODE
may be the subject of one or more CANCER CARE SPELL
may be the subject of one or more CARE EPISODE
may be associated with one or more CLINICAL INTERVENTION
may be related to one or more COMMUNITY EPISODE
may be the subject of one or more CONSULTANT EPISODE (ACUTE HOME-BASED)
may be related to one or more CONSULTANT OUT-PATIENT EPISODE
may be related to one or more DECISION TO ADMIT
may be related to one or more DENTAL EPISODE
may be related to one DISABLEMENT APPLIANCE
may be related to one or more DISABLEMENT APPLIANCE REPAIR
may be in receipt of one or more DISPENSED ITEM
may be related to one or more DOMICILIARY CONSULTATION
may be related to one or more ELECTIVE ADMISSION LIST ENTRY
may be related to one or more EMERGENCY DENTAL ATTENDANCE
may be related to one or more FACE TO FACE CONTACT DENTAL
may be the subject of one or more FACE TO FACE CONTACT OPTICAL
may be related to one or more GENITO-URINARY EPISODE
may be related to one or more HOME DIALYSIS EPISODE
may be related to one or more HOME LEAVE
may be the subject of one or more HONOS SCORE FOR PERSON
may be related to one or more HOSPITAL PROVIDER SPELL
may be granted leave for one or more LEAVE OF ABSENCE
may be related to one or more LEGAL STATUS
may be related to one or more LITHOTRIPSY COURSE ATTENDANCE
may be related to one or more MATERNITY DOMICILIARY VISIT
may be subject to one or more MENTAL HEALTH CARE SPELL
may be related to one or more MIDWIFE EPISODE
may be related to one or more NURSING EPISODE
may be related to one or more NURSING HOME STAY (MIDWIFE CARE)
may be related to one or more NURSING HOME STAY (NURSING CARE)
may be in receipt of health care services under one or more OUT OF AREA TREATMENT
may be related to one or more OUT-PATIENT APPOINTMENT
may be related to one or more PATIENT JOURNEY
may be issued with one or more POWERED WHEELCHAIR
may be related to one or more PREGNANCY EPISODE
may be in receipt of one or more PRESCRIPTION
may be related to one or more PROFESSIONAL STAFF GROUP EPISODE
may be related to one or more RADIOTHERAPY TREATMENT COURSE
may be related to one or more REFERRAL FOR BIOPSY
may be related to one or more REFERRAL FOR BREAST ASSESSMENT
may be related to one or more REFERRAL FOR BREAST TREATMENT
may be related to one or more REFERRAL FOR SCREENING TEST
may be related to one or more REFERRAL REQUEST
may be related to one or more REGULAR ATTENDER EPISODE
may be related to one or more REQUEST FOR DIAGNOSTIC TEST
may be related to one or more RESIDENTIAL CARE OR GROUP HOME STAY
may be the subject of one or more ROAD TRAFFIC ACCIDENT TREATMENT
may be identified as needing one or more SECURE ACCOMMODATION REQUIREMENT
may be related to one or more SERVICE REPORT HEADER
may be have one or more TELEPHONE CONTACT NHS DIRECT (MENTAL HEALTH)
may be related to one or more THEATRE CASE
may be associated with one or more TOBACCO USAGE
may be related to one or more WARD ATTENDANCE
may be issued with one or more WHEELCHAIR SERVICES VOUCHER


top

PATIENT DIAGNOSIS

Change to Class: Change to Relationships

Each PATIENT DIAGNOSIS
may be recorded for one and only one CONSULTANT EPISODE (ACUTE HOME-BASED)
or may be related to one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
or may be related to one and only one OUT-PATIENT ATTENDANCE CONSULTANT
may be the primary diagnosis of one or more CANCER CARE SPELL
may be the presenting condition for one and only one CARE EPISODE
may be recorded for one and only one CARE PROGRAMME APPROACH REVIEW
may be recorded for highest one and only one NEONATAL LEVEL OF CARE PERIOD


top

PATIENT PROCEDURE

Change to Class: Change to Relationships

Each PATIENT PROCEDURE
must be performed on a patient within one and only one CONSULTANT EPISODE (ACUTE HOME-BASED)
or must be related to one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
or must be performed on a patient within one and only one DAY CARE ATTENDANCE
or must be related to one and only one LABOUR AND DELIVERY
or must be related to one and only one OUT-PATIENT ATTENDANCE CONSULTANT
or must be related to one and only one WARD ATTENDANCE
must be related to one or more PATIENT PROCEDURE CLASSIFICATION
may be performed as treatment during one and only one CANCER CARE SPELL
may be the responsibility as surgeon of one and only one CARE PROFESSIONAL
may be recorded by one and only one CARE PROGRAMME APPROACH REVIEW
may be the cause of complications recorded as one or more CLINICAL DIAGNOSIS FOR PERSON
may be the responsibility as anaesthetist of one and only one CONSULTANT
may be the responsibility as surgeon of one and only one HEALTH CARE PROFESSIONAL
may be performed in response to one and only one REFERRAL FOR BREAST TREATMENT
may be the reason for one or more REQUEST FOR PATHOLOGY INVESTIGATION
may be during one and only one THEATRE CASE


top

PERSON OBSERVATION

Change to Class: Change to Description

Observations made regarding a PERSON. These observations do not include information about a treatment or intervention. The observation may be a CLINICAL DIAGNOSIS FOR PERSON. The observer may be a related PERSON or a HEALTH CARE PROFESSIONAL. The observer may be a related PERSON or a CARE PROFESSIONAL. PERSON OBSERVATIONS may be recorded during, or as a result of, a course of treatment.

PERSON OBSERVATIONS include CARDIAC ARREST, ACUTE MYOCARDIAL INFARCTION HISTORY ITEM and CO-MORBIDITY INDEX FOR ADULTS.

References:
The version 1.1 NHS Standard EDIFACT Messages for Pathology Requests and Reports, 2001
The Version 1.0 Trial NHS Standard EDIFACT Messages for GP-Hospital Communications - 17.5.95



This class is also known by these names:
ContextAlias
pluralPERSON OBSERVATIONS


top

PERSON OBSERVATION

Change to Class: Change to Relationships

Each PERSON OBSERVATION
Kmust be an observation of one and only one PERSON
must be observed by one and only one HEALTH CARE PROFESSIONAL
must be observed by one and only one CARE PROFESSIONAL
or must be observed by one and only one PERSON
may be the observation in one or more PERSON OBSERVATION WITHIN CARE SPELL
may be related to one and only one SERVICE PROVIDED


top

PRESCRIPTION

Change to Class: Change to Relationships

Each PRESCRIPTION
must be a request from one and only one HEALTH CARE PROFESSIONAL
must be a request from one and only one CARE PROFESSIONAL
must be a request to dispense to one and only one PATIENT
may be wholly or partially satisfied by the dispensing of one or more DISPENSED ITEM
may be a request to dispense one or more PRESCRIBED ITEM


top

PROFESSIONAL STAFF GROUP CONTACT

Change to Class: Change to Description

A single occasion involving contact between a PATIENT or his/her proxy and one or more members of a professional staff group discipline, including paid support staff working for a professional staff group discipline.

A proxy contact is a single occasion involving contact between a client/patient or his/her proxy, and one or more members of a professional staff group discipline or relevant staff group for community service. Contacts with proxies count as face-to-face contacts only if the contact is in lieu of the contact with the client, and the proxy is able more effectively than the client to ensure that specific professional advice devised for the client is followed. This is most likely to be the case where the client is unable to communicate effectively say for an infant, or for a person who is mentally ill or learning disabilities.

For PROFESSIONAL STAFF GROUP SERVICES, face to face contacts comprise both:

a. Attendances lasting from the arrival to the departure of the patient
b. Visits lasting from the arrival to the departure of professional staff group staff

One or more members of the professional staff group discipline may be in contact with one or more PATIENTS at the same time and PATIENTS may be seen in association with staff from other disciplines. Contacts should be recorded as follows:

a. If one or more staff of the same discipline are in contact with one patient at the same time, this should be recorded as one face to face contact
b. If staff see a patient with staff of other disciplines, this should be recorded as one face to face contact for each discipline involved
c. If one or more staff of one discipline are in contact with a group of patients at the same time, each patient should be recorded as one face to face contact
d. If staff from different disciplines are in contact with a group of patients at the same time, each patient should be recorded as one face to face contact for each discipline involved

For physiotherapy, it may not be practical to collect data about all face-to-face contacts; however as a minimum, INITIAL CONTACTS and FIRST CONTACTS IN FINANCIAL YEARS should be recorded.

If the PATIENT is currently subject to a MENTAL HEALTH CARE SPELL and the member of the professional staff group discipline in contact is also their allocated Care Programme Approach care coordinator then a FACE TO FACE CONTACT CPA CARE COORDINATOR should also be recorded.

Note: When face-to-face contacts are used for attributing professional staff group costs to SPECIALTIES , it will be necessary to distinguish between those contacts by PATIENTS using a hospital bed, attenders at CONSULTANT CLINICS and attenders at DAY CARE FACILITIES . Note: When face-to-face contacts are used for attributing professional staff group costs to MAIN SPECIALTIES , it will be necessary to distinguish between those contacts by PATIENTS using a hospital bed, attenders at CONSULTANT CLINICS and attenders at DAY CARE FACILITIES .



This class is also known by these names:
ContextAlias
pluralPROFESSIONAL STAFF GROUP CONTACTS


top

PROFESSIONAL STAFF GROUP EPISODE

Change to Class: Change to Relationships

Each PROFESSIONAL STAFF GROUP EPISODE
Kmust be related to one and only one PATIENT
Kmust be related to one and only one PROFESSIONAL STAFF GROUP SERVICE
may be related to one or more DISABLEMENT APPLIANCE
may be related to one or more PROFESSIONAL STAFF GROUP CONTACT
may be related to one and only one SERVICE PROVIDED
may be classified from source of referral by one and only one SPECIALTY FUNCTION
may be classified from source of referral by one and only one TREATMENT FUNCTION


top

RADIOLOGY DEPARTMENT

Change to Class: Change to Description

A unit which is managed as a separate entity by a CONSULTANT or non-medical scientist of equivalent standing in the SPECIALTY of radiology which deals with requests for radiological or isotope procedures. A unit which is managed as a separate entity by a CONSULTANT or non-medical scientist of equivalent standing in the MAIN SPECIALTY of radiology which deals with requests for radiological or isotope procedures.



This class is also known by these names:
ContextAlias
pluralRADIOLOGY DEPARTMENTS


top

RADIOLOGY INVESTIGATION PLAN

Change to Class: Change to Relationships

Each RADIOLOGY INVESTIGATION PLAN
Kmust be plan for one and only one IMAGING OR RADIODIAGNOSTIC EVENT
must be planned by one and only one HEALTH CARE PROFESSIONAL
must be planned by one and only one CARE PROFESSIONAL
or must be planned by one and only one RADIOLOGY DEPARTMENT
may be related to one or more CLINICAL INVESTIGATION SERVICE PROVIDER


top

REFERRAL REQUEST

Change to Class: Change to Relationships

Each REFERRAL REQUEST
Kmust be related to one and only one PATIENT
must be a referral to one and only one CONSULTANT
or must be a referral to one and only one SERVICE POINT
must be made by one and only one HEALTH CARE PROFESSIONAL
must be made by one and only one CARE PROFESSIONAL
or must be made by one and only one ORGANISATION
may be the initiator of one or more CANCER CARE SPELL
may be associated with one or more CANCER CARE SPELL DELAY
may be related to one and only one LOCAL SUB-SPECIALTY
may be associated with one or more OUT-PATIENT REFERRAL STATUS
may be related to one or more PLANNED SERVICE TO BE PROVIDED
may be a referral with subsequently one or more REFERRAL REQUEST
may be subsequent to an original one REFERRAL REQUEST
may be a request for colposcopy from one and only one SCREENING TEST
may be the initiator of one or more SERVICE PROVIDED
may be related to one and only one SPECIALTY FUNCTION
may be related to one or more TRANSPORT REQUIREMENT
may be related to one and only one TREATMENT FUNCTION


top

REGULAR ATTENDER EPISODE

Change to Class: Change to Relationships

Each REGULAR ATTENDER EPISODE
Kmust be related to one and only one PATIENT
may be related to one or more ADMINISTRATIVE CATEGORY IN EPISODE
may be related to one or more DAY CARE ATTENDANCE
may be provided as part of one and only one SERVICE PROVIDED


top

REQUEST FOR DIAGNOSTIC TEST

Change to Class: Change to Description

A request for a single diagnostic investigation or procedure for an individual PATIENT or any human or, for pathology, non-human source.

Each REQUEST FOR DIAGNOSTIC TEST may have a sub-type of REQUEST FOR ISOTOPE PROCEDURE, REQUEST FOR PHYSIOLOGICAL MEASUREMENT, REQUEST FOR PATHOLOGY INVESTIGATION or REQUEST FOR RADIOLOGICAL PROCEDURE.

When a REQUEST FOR DIAGNOSTIC TEST is used to apportion costs to SPECIALTY, distinction should be made between those for PATIENTS using a hospital bed, out-patients and attendees at DAY CARE FACILITIES . When a REQUEST FOR DIAGNOSTIC TEST is used to apportion costs to MAIN SPECIALTY, distinction should be made between those for PATIENTS using a hospital bed, out-patients and attendees at DAY CARE FACILITIES .



This class is also known by these names:
ContextAlias
pluralREQUESTS FOR DIAGNOSTIC TEST


top

REQUEST FOR DIAGNOSTIC TEST

Change to Class: Change to Relationships

Each REQUEST FOR DIAGNOSTIC TEST
Kmust be processed by one and only one SERVICE POINT
may be an order to one and only one HEALTH CARE PROFESSIONAL
may be an order to one and only one CARE PROFESSIONAL
or may be an order to one and only one ORGANISATION
may be requested by one and only one HEALTH CARE PROFESSIONAL
may be requested by one and only one CARE PROFESSIONAL
or may be requested by one and only one ORGANISATION
may be except Category II requests from one and only one LOCATION
may be related to one and only one PATIENT
may be a request with subsequently one or more REQUEST FOR DIAGNOSTIC TEST
may be subsequent to an original one REQUEST FOR DIAGNOSTIC TEST
may be related to one and only one SERVICE PROVIDED
may be initiated within one and only one SPECIALTY FUNCTION
may be initiated within one and only one TREATMENT FUNCTION


top

RESPONSIBLE MEDICAL OFFICER ASSIGNMENT

Change to Class: Change to Description

An assignment of a CONSULTANT within a particular SPECIALTY FUNCTION to a MENTAL HEALTH CARE SPELL. An assignment of a CONSULTANT within a particular MAIN SPECIALTY to a MENTAL HEALTH CARE SPELL.

There will be only one CONSULTANT assigned to a PATIENT at any one time. These assignments may change during the course of a MENTAL HEALTH CARE SPELL, though not necessarily at the time of a CARE PROGRAMME APPROACH REVIEW.



This class is also known by these names:
ContextAlias
pluralRESPONSIBLE MEDICAL OFFICER ASSIGNMENTS


top

RESPONSIBLE MEDICAL OFFICER ASSIGNMENT

Change to Class: Change to Relationships

Each RESPONSIBLE MEDICAL OFFICER ASSIGNMENT
Kmust be an assignment of one and only one CONSULTANT SPECIALTY FUNCTION
Kmust be an assignment of one and only one MAIN SPECIALTY
Kmust be an assignment within one and only one MENTAL HEALTH CARE SPELL


top

RIGHT OF ADMISSION

Change to Class: Change to Relationships

Each RIGHT OF ADMISSION
Kmust be related to one and only one HEALTH CARE PROVIDER
may be an admission right for one and only one ORGANISATION SITE
or may be an admission right for one and only one SPECIALTY FUNCTION
or may be an admission right for one and only one TREATMENT FUNCTION
or may be an admission right for one and only one WARD
must be the right of one and only one CONSULTANT
or must be the right of one and only one MIDWIFE
or must be the right of one and only one NURSE
may be related to one or more DECISION TO ADMIT


top

ROAD TRAFFIC ACCIDENT TREATMENT

Change to Class: Change to Relationships

Each ROAD TRAFFIC ACCIDENT TREATMENT
Kmust be for one and only one PATIENT
may be if patient admitted to hospital, made up of one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be if patient admitted to hospital, made up of one or more NURSING EPISODE
may be if patient admitted to hospital, made up of one or more CARE EPISODE
may be associated with one or more RTA TREATMENT BY OTHER PROVIDER


top

ROTATIONAL ARRANGEMENT

Change to Class: Change to Description

A training scheme to give junior doctors a range of experience in different SPECIALTIES . Doctors appointed to rotational arrangements will move from time to time between different blocks of work each of which will be in a particular SPECIALTY. A training scheme to give junior doctors a range of experience in different MAIN SPECIALTIES . Doctors appointed to rotational arrangements will move from time to time between different blocks of work each of which will be in a particular MAIN SPECIALTY.



This class is also known by these names:
ContextAlias
pluralROTATIONAL ARRANGEMENTS


top

SERVICE PROVIDED

Change to Class: Change to Relationships

Each SERVICE PROVIDED
Kmust be a treatment or service provided by one and only one HEALTH CARE PROVIDER
may be part of one and only one HEALTH PROGRAMME
or may be related to one and only one SURVEILLANCE PROGRAMME STAGE
may be related to one or more GROUP SESSION
or may be related to one or more HEALTH PROMOTION OTHER ACTIVITY
or may be related to one or more PERSON IN A CONTACT TRACING PROGRAMME
or may be related to one or more PERSON IN A SCREENING PROGRAMME
may be related to one or more ACCIDENT AND EMERGENCY DEPARTMENT
may be related to one or more ACCIDENT AND EMERGENCY EPISODE
may be related to one or more ADMINISTRATIVE CATEGORY IN EPISODE
may be related to one or more ADMINISTRATIVE CATEGORY IN SPELL
may be related to one or more AMBULANCE SERVICE
may be provided as one or more ANTI-CANCER DRUG PROGRAMME
may be related to one or more AUDIOLOGY ATTENDANCE
may be related to one or more CARE EPISODE
may be provided within one and only one CARE PLAN
may be provided as one or more CARE PROGRAMME APPROACH EPISODE
may be for care responsibility part of one and only one CARE SPELL
may be related to one or more CLINICAL INTERVENTION
may be related to one or more CLINIC ATTENDANCE NON-CONSULTANT
may be related to one or more COMMUNITY EPISODE
may be provided as one or more CONSULTANT EPISODE (ACUTE HOME-BASED)
may be related to one or more CONSULTANT EPISODE (HOSPITAL PROVIDER)
may be provided as one or more CONSULTANT OUT-PATIENT EPISODE
may be related to one or more DENTAL EPISODE
may be related to one or more DENTAL STAFF MEMBER IN PROGRAMME
may be related to one or more DOMICILIARY CONSULTATION
may be related to one or more DRUG MISUSE EPISODE
may be related to one or more ELECTIVE ADMISSION LIST ENTRY
may be related to one or more FACE TO FACE CONTACT OPTICAL
may be provided as one or more FACE TO FACE CONTACT SOCIAL WORKER
may be related to one or more FAMILY PLANNING DOMICILIARY VISIT
may be related to one or more HEALTH PROMOTION ACTIVITY HIV AND AIDS
may be related to one or more HEALTHY PERSON STAY
may be related to one or more HOME ASSESSMENT VISIT
may be related to one or more HOME DIALYSIS EPISODE
may be provided as one or more HOME HELP VISIT
may be related to one or more IMMUNISATION PROGRAMME FOR PERSON
may be related to one or more LABOUR AND DELIVERY
may be related to one or more LITHOTRIPSY COURSE ATTENDANCE
may be provided in one and only one LOCATION
may be related to one or more MATERNITY DOMICILIARY VISIT
may be related to one or more MIDWIFE EPISODE
may be related to one or more NHS SERVICE AGREEMENT CHANGE
may be related to one or more NURSE OR MIDWIFE CONTACT
may be related to one or more NURSING EPISODE
may be provided as one or more NURSING HOME STAY (CONSULTANT CARE)
may be related to one or more NURSING HOME STAY (NURSING CARE)
may be related to one or more OUT-PATIENT CLINIC
may be related to one or more OVERSEAS VISITOR STATUS
may be provided as one or more PALLIATIVE CARE EPISODE
may be related to one or more PATIENT JOURNEY
may be related to one or more PERSON IN ADVICE AND SUPPORT PROGRAMME
may be related to one or more PERSON IN A SURVEILLANCE STAGE
may be related to one or more PERSON OBSERVATION
may be providing one or more PERSON SMOKING CESSATION EPISODE
may be related to one and only one PLANNED CANCER TREATMENT
may be related to one or more POST MORTEM
may be related to one or more PROFESSIONAL STAFF GROUP EPISODE
may be related to one or more PROFESSIONAL STAFF GROUP SERVICE
may be related to one or more RADIOTHERAPY TREATMENT COURSE
may be initiated by one and only one REFERRAL REQUEST
may be provided as one or more REGULAR ATTENDER EPISODE
may be related to one or more REQUEST FOR DIAGNOSTIC TEST
may be provided as one or more RESIDENTIAL CARE OR GROUP HOME STAY
may be subdivided into one or more SERVICE PROVIDED
may be a subdivision of one SERVICE PROVIDED
may be related to one or more SERVICE PROVIDED UNDER AGREEMENT
may be provided at one or more SERVICE PROVISION POINT
may be related to one or more SERVICE REPORTED
may be reported by one and only one SERVICE REPORT HEADER
may be provided as one or more SHELTERED WORK ATTENDANCE
may be part of one and only one SMOKING CESSATION SERVICE
may be provided as one or more SOCIAL SERVICES STATUTORY ASSESSMENT
may be related to one or more VASECTOMY PERFORMED
may be related to one or more WARD ATTENDANCE
may be related to one or more WARD STAY


top

SERVICE REPORT COPY

Change to Class: Change to Relationships

Each SERVICE REPORT COPY
Kmust be related to one and only one SERVICE REPORT HEADER
must be issued to one and only one HEALTH CARE PROFESSIONAL
must be issued to one and only one CARE PROFESSIONAL
or must be issued to one and only one ORGANISATION


top

SERVICE REPORT HEADER

Change to Class: Change to Relationships

Each SERVICE REPORT HEADER
must be issued by one and only one HEALTH CARE PROFESSIONAL
must be issued by one and only one CARE PROFESSIONAL
or must be issued by one and only one ORGANISATION
must be requested by one and only one HEALTH CARE PROFESSIONAL
must be requested by one and only one CARE PROFESSIONAL
or must be requested by one and only one ORGANISATION
may be related to one and only one PATIENT
may be related to one or more PLANNED SERVICE TO BE PROVIDED
may be related to one or more SERVICE PROVIDED
may be related to one or more SERVICE REPORT COPY
may be composed of one or more SERVICE REPORTED
may be referenced by one or more SERVICE REPORT HEADER
may be a reference to one SERVICE REPORT HEADER


top

SHARED CARE CONSULTANT

Change to Class: Change to Relationships

Each SHARED CARE CONSULTANT
Kmust be a role of one and only one CONSULTANT
Kmust be equally sharing in the care during one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
must be related to one and only one SPECIALTY FUNCTION
must be related to one and only one MAIN SPECIALTY


top

SHARED CLINIC CONSULTANT

Change to Class: Change to Description

This is a CONSULTANT conducting an out-patient clinic jointly with another. If CONSULTANTS from two or more SPECIALTIES run a clinic jointly, the combination of their main SPECIALTIES should be used to classify the clinic. If CONSULTANTS from two or more MAIN SPECIALTIES run a clinic jointly, the clinic is classified by an appropriate TREATMENT FUNCTION or LOCAL SUB-SPECIALTY. For central returns and HES the activity should be recorded under the TREATMENT FUNCTION CODE which best describes the activity. A PATIENT attending such a clinic would see two or more CONSULTANTS at the same time. This specifically excludes CONSULTANTS acting only in an advisory capacity.



This class is also known by these names:
ContextAlias
pluralSHARED CLINIC CONSULTANTS


top

SIGHT TEST

Change to Class: Change to Description

A type of FACE TO FACE CONTACT OPTICAL.

A sight test carried out by a CONSULTANT with a SPECIALTY of General Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONER or an OPHTHALMIC OPTICIAN. A sight test carried out by a CONSULTANT with a MAIN SPECIALTY of General Ophthalmology, OPHTHALMIC MEDICAL PRACTITIONER or an OPHTHALMIC OPTICIAN.



This class is also known by these names:
ContextAlias
pluralSIGHT TESTS


top

SPECIALTY

Change to Class: Change to Name

SPECIALTY
MAIN SPECIALTY


top

SPECIALTY renamed MAIN SPECIALTY

Change to Class: Change to Description

SPECIALTIES are divisions of clinical work which may be defined by body systems (dermatology), age (paediatrics), clinical technology (nuclear medicine), clinical function (rheumatology) group of diseases (oncology) or combinations of these factors. Only SPECIALTY titles recognised by the Royal Colleges and Faculties should be used. Specialties are divisions of clinical work which may be defined by body systems (dermatology), age (paediatrics), clinical technology (nuclear medicine), clinical function (rheumatology) group of diseases (oncology) or combinations of these factors. Only Specialty titles recognised by the Royal Colleges and Faculties should be used. This list is maintained by the European Specialist Medical Qualifications Order 1995 and European Primary and Specialist Dental Qualifications Regulations 1998.

Each CONSULTANT should be assigned a main SPECIALTY by the ORGANISATION to which the CONSULTANT is contracted. For physicians and surgeons with a generalist component to their work the main SPECIALTY should be general medicine or general surgery. Each CONSULTANT should be assigned a MAIN SPECIALTY by the ORGANISATION to which the CONSULTANT is contracted. For physicians and surgeons with a generalist component to their work the MAIN SPECIALTY should be general medicine or general surgery. The hallmark of a general physician or general surgeon is the continued care of unselected emergency referrals. The main SPECIALTY is specific to a HEALTH CARE PROVIDER. If, for example, a CONSULTANT physician working in two HEALTH CARE PROVIDERS has a generalist component to the work in one and not the other, general medicine is only assigned as the main SPECIALTY in the former case. CONSULTANTS in general medicine or general surgery may also have specialist interests and these should be recorded as well as the main SPECIALTY. The MAIN SPECIALTY is specific to a HEALTH CARE PROVIDER. If, for example, a CONSULTANT physician working in two HEALTH CARE PROVIDERS has a generalist component to the work in one and not the other, general medicine is only assigned as the MAIN SPECIALTY in the former case. CONSULTANTS in general medicine or general surgery may also have specialist interests and these should be recorded as well as the MAIN SPECIALTY.

The initial source of the information should be the designation on the CONSULTANT's contract. This should be checked periodically against the work a CONSULTANT is actually doing so that the statistics can relate to a CONSULTANT's current type of work.

The main SPECIALTY only should be used for the purpose of producing aggregated activity and SPECIALTY costing statistics and for Workforce statistics where links with activity and finance are required. The MAIN SPECIALTY only should be used for the purpose of producing Specialty costing statistics and for Workforce statistics where links with activity and finance are required. Other specialist interests of CONSULTANTS may be recorded for workforce planning purposes.

This will be used to indicate the skill level of medical and dental employees.



This class is also known by these names:
Context Alias
plural SPECIALTIES
plural MAIN SPECIALTIES


    SPECIALTY

    Change to Class: Change to Attributes

    Attributes of this Class are:
    KSPECIALTY CODE
    KMAIN SPECIALTY CODE
    MEDICAL AND DENTAL POST SPECIALTY GROUP


    top

    SPECIALTY renamed MAIN SPECIALTY

    Change to Class: Change to Relationships

    Each SPECIALTY Each MAIN SPECIALTY
    may be the main specialty of the consultant clinically managing one or more AUGMENTED CARE PERIOD
    may be related to one or more CONSULTANT
    may be classifier for main specialty of one or more ELECTIVE ADMISSION LIST
    may be related for shared care to one or more ELECTIVE ADMISSION LIST ENTRY
    may be related to one or more MEDICAL AND DENTAL POST
    may be related to one or more MEDICAL AND DENTAL POST BY SPECIALTY
    may be related to one or more MEDICAL AND DENTAL SPECIALTY INTEREST
    may be for an association with one or more MHCS SPECIALTY ASSOCIATION
    may be related to one or more OPHTHALMOLOGY SERVICE
    may be the classifier for the main specialty of one or more RESPONSIBLE MEDICAL OFFICER ASSIGNMENT
    may be related to one or more SHARED CARE CONSULTANT


    top

    SPECIALTY FUNCTION

    Change to Class: Change to Name

    SPECIALTY FUNCTION
    TREATMENT FUNCTION


    top

    SPECIALTY FUNCTION renamed TREATMENT FUNCTION

    Change to Class: Change to Description

    A division of clinical work to a lower level than that designated by Royal Colleges and Faculties. A division of clinical work based on MAIN SPECIALTY but incorporating approved sub-specialties and treatment interests used by lead CARE PROFESSIONALS including CONSULTANTS.



    This class is also known by these names:
    ContextAlias
    pluralSPECIALTY FUNCTIONS
    pluralTREATMENT FUNCTIONS


    top

    SPECIALTY FUNCTION

    Change to Class: Change to Attributes

    Attributes of this Class are:
    KSPECIALTY FUNCTION CODE
    KTREATMENT FUNCTION CODE


    top

    SPECIALTY FUNCTION

    Change to Class: Change to Relationships

    Each SPECIALTY FUNCTION Each TREATMENT FUNCTION
    may be the main specialty of the consultant clinically managing one or more AUGMENTED CARE PERIOD
    may be the classifier for treatment in one or more CARE EPISODE
    may be classifier for treatment function of one or more CONSULTANT OUT-PATIENT EPISODE
    may be related to one or more CONSULTANT SPECIALTY FUNCTION
    may be related to one or more ELECTIVE ADMISSION LIST
    may be related for shared care to one or more ELECTIVE ADMISSION LIST ENTRY
    may be for an association with one or more MHCS SPECIALTY ASSOCIATION
    may be classifier for treatment function of one or more ELECTIVE ADMISSION LIST
    may be classifier for treatment function of one or more ELECTIVE ADMISSION LIST ENTRY
    may be related to one or more OPERATING THEATRE INTENDED SPECIALTY
    may be related to one or more OPERATING THEATRE SESSION
    may be a classification of one or more PROFESSIONAL STAFF GROUP EPISODE
    may be related to one or more REFERRAL REQUEST
    may be related to one or more REQUEST FOR DIAGNOSTIC TEST
    may be related to one or more RIGHT OF ADMISSION
    may be related to one or more SHARED CARE CONSULTANT
    may be related to one or more THEATRE CASE
    may be related to one or more WARD INTENDED BED USE


    top

    THEATRE CASE

    Change to Class: Change to Relationships

    Each THEATRE CASE
    Kmust be related to one and only one OPERATING THEATRE SESSION
    must be related to one and only one PATIENT
    may be for emergency and unscheduled sessions the responsibility of one and only one CONSULTANT
    may be related to one or more PATIENT PROCEDURE
    may be related to one and only one SPECIALTY FUNCTION
    may be related to one and only one TREATMENT FUNCTION


    top

    WARD INTENDED BED USE

    Change to Class: Change to Description

    The intended use of the ward bed stock by SPECIALTY FUNCTION. The intended use of the ward bed stock by TREATMENT FUNCTION.



    This class is also known by these names:
    ContextAlias
    pluralWARD INTENDED BED USES


    top

    WARD INTENDED BED USE

    Change to Class: Change to Relationships

    Each WARD INTENDED BED USE
    Kmust be commonly used by one and only one SPECIALTY FUNCTION
    Kmust be commonly used by one and only one TREATMENT FUNCTION
    Kmust be related to one and only one WARD OPERATIONAL PLAN
    may be commonly used by one and only one CONSULTANT


    top

    WARD OPERATIONAL PLAN

    Change to Class: Change to Description

    This is a statement of the operational planning intent for a particular WARD, including intended time and bed availability, SPECIALTY, BROAD PATIENT GROUP and CLINICAL CARE INTENSITY. This is a statement of the operational planning intent for a particular WARD, including intended time and bed availability, TREATMENT FUNCTION, BROAD PATIENT GROUP and CLINICAL CARE INTENSITY.

    Bed availability, in the above, is expressed as the WARD Total Beds Intended (Consultant Care, Nursing Care and Midwife Care) available for the use of PATIENTS. This should reflect the number of places available for patient care rather than just a count of physical devices that may be used as a bed.

    A bed includes any device that may be used to permit a PATIENT to lie down when the need to do so is as a consequence of the PATIENT's condition rather than the need for active intervention such as examination, diagnostic investigation, manipulation/treatment, or transport. Cots should be included in statistics about beds where appropriate.

    It should be noted that:

    a. A couch or trolley should be considered as a bed provided it is used regularly to permit a PATIENT to lie down rather than for merely examination or transport. An example of such an arrangement is a day surgery ward furnished with trolleys
    b. A PATIENT may need to use a bed, couch or trolley whilst attending for a specific short procedure taking an hour or less, such as an endoscopy. If such devices are being used only because of the active intervention and not because of the PATIENT'S condition, they should NOT be counted as beds for statistical purposes
    c. A PATIENT needing a lengthy procedure such as renal dialysis may use a bed or other means of support such as a couch or special chair. Whatever the device used it should be counted as a bed if used regularly for this purpose
    d. Some procedures require narcosis. If this necessitates the PATIENT to lie down, the bed, couch or trolley can be counted as a hospital bed if used regularly for this purpose
    e. A device specifically and solely for the purpose of delivery should not be counted as a bed if another device is normally reserved for antenatal and postnatal care. Details of the facilities available for delivery in a maternity ward should be included in a ward inventory



    This class is also known by these names:
    ContextAlias
    pluralWARD OPERATIONAL PLANS


    top

    CLAIMING GMP RELATIONSHIP

    Change to Attribute: Change to Description

    The relationship between a claiming GENERAL MEDICAL PRACTITIONER and the HEALTH CARE PROFESSIONAL who delivered the item of service or treatment. The relationship between a claiming GENERAL MEDICAL PRACTITIONER and the CARE PROFESSIONAL who delivered the item of service or treatment.

    Classification:
    a. Same GMP
    b. Partner of claiming GMP
    c. Member of the same Group Practice other than the Partner of the claiming GMP
    d. Assistant employed by the GMP, Practice or Group Practice
    e. Associate Doctor
    f. Deputy or Locum employed by the GMP, Practice or Group Practice
    g. Trainee GMP employed by the GMP, Practice or Group Practice
    h. GMP in a non-commercial rota of not more than 10 GMPs
    i. GMP in a non-commercial rota of more than 10 GMPs
    j. Commercial deputising service
    k. Other



    This attribute is also known by these names:
    ContextAlias
    pluralCLAIMING GMP RELATIONSHIPS


    top

    DEPARTMENT TYPE

    Change to Attribute: Change to Description

    This is used to record the type of ISOTOPE PROCEDURE DEPARTMENT, based on the SPECIALTY of the head of department, or the type of PHYSIOLOGICAL MEASUREMENT DEPARTMENT. This is used to record the type of ISOTOPE PROCEDURE DEPARTMENT, based on the MAIN SPECIALTY of the head of department, or the type of PHYSIOLOGICAL MEASUREMENT DEPARTMENT.

    Classification:
    a. ISOTOPE PROCEDURE DEPARTMENT
    i. nuclear medicine
    ii. medical physics
    iii. other
    b. PHYSIOLOGICAL MEASUREMENT DEPARTMENT
    i. electrocardiography
    ii. electroencephalography
    iii. respiratory function



    This attribute is also known by these names:
    ContextAlias
    pluralDEPARTMENT TYPES


    top

    ELECTIVE ADMISSION LIST NUMBER

    Change to Attribute: Change to Description

    An identifier to make an ELECTIVE ADMISSION LIST unique within SPECIALTY FUNCTION. An identifier to make an ELECTIVE ADMISSION LIST unique within TREATMENT FUNCTION.



    This attribute is also known by these names:
    ContextAlias
    pluralELECTIVE ADMISSION LIST NUMBERS


    top

    GYNAECOLOGICAL ONCOLOGY ACCREDITATION

    Change to Attribute: Change to Description

    An indicator of accreditation in Gynaecological Oncology for the HEALTH CARE PROFESSIONAL. An indicator of accreditation in Gynaecological Oncology for the CARE PROFESSIONAL.

    National codes:
    Y Yes
    N No

    References:
    National Cancer Data Set Version 1.3_ISB October 2002



    This attribute is also known by these names:
    ContextAlias
    pluralGYNAECOLOGICAL_ONCOLOGY_ACCREDITATIONS


    top

    HONOS SCORE DATE

    Change to Attribute: Change to Description

    The date on which a HEALTH CARE PROFESSIONAL evaluated a person for a particular rating of a HONOS SCORE. The date on which a CARE PROFESSIONAL evaluated a person for a particular rating of a HONOS SCORE.



    This attribute is also known by these names:
    ContextAlias
    pluralHONOS SCORE DATES


    top

    MEDICAL AND DENTAL POST SPECIALTY GROUP

    Change to Attribute: Change to Description

    A grouping of SPECIALTIES used to classify MEDICAL AND DENTAL POSTS. A grouping of MAIN SPECIALTIES used to classify MEDICAL AND DENTAL POSTS.

    Classification:
    a. Medicine
    b. Surgery
    c. Obstetrics and Gynaecology
    d. Pathology
    e. Anaesthetics
    f. Paediatrics
    g. Accident and Emergency
    h. Radiology
    i. Psychiatry
    j. Dentistry



    This attribute is also known by these names:
    ContextAlias
    pluralMEDICAL AND DENTAL POST SPECIALTY GROUPS


    top

    PRESCRIPTION DATE

    Change to Attribute: Change to Description

    The date on which the PRESCRIPTION was signed by the HEALTH CARE PROFESSIONAL. The date on which the PRESCRIPTION was signed by the CARE PROFESSIONAL.



    This attribute is also known by these names:
    ContextAlias
    pluralPRESCRIPTION DATES


    top

    REQUEST FOR APPOINTMENT DATE

    Change to Attribute: Change to Description

    The date on which a PATIENT requested an appointment to see a HEALTH CARE PROFESSIONAL. The date on which a PATIENT requested an appointment to see a CARE PROFESSIONAL.



    This attribute is also known by these names:
    ContextAlias
    pluralREQUESTS FOR APPOINTMENT DATE


    top

    REQUEST FOR APPOINTMENT TIME

    Change to Attribute: Change to Description

    The time, recorded using the 24 hour clock, when a PATIENT requested to see a HEALTH CARE PROFESSIONAL. The time, recorded using the 24 hour clock, when a PATIENT requested to see a CARE PROFESSIONAL.



    This attribute is also known by these names:
    ContextAlias
    pluralREQUESTS FOR APPOINTMENT TIME


    top

    SESSION IDENTIFIER

    Change to Attribute: Change to Description

    This uniquely identifies an OPERATING THEATRE SESSION so that when sessions are cancelled by one CONSULTANT and held by another, the SPECIALTIES of the CONSULTANTS can be compared. This uniquely identifies an OPERATING THEATRE SESSION so that when sessions are cancelled by one CONSULTANT and held by another, the MAIN SPECIALTIES of the CONSULTANTS can be compared.



    This attribute is also known by these names:
    ContextAlias
    pluralSESSION IDENTIFIERS


    top

    SPECIALIST HIV SKILLS AVAILABLE

    Change to Attribute: Change to Description

    The availability of a HEALTH CARE PROFESSIONAL to other HEALTH CARE PROFESSIONALS expressed in terms of availability within x hours/days where x is the maximum amount of time one might have to wait. The availability of a CARE PROFESSIONAL to other CARE PROFESSIONALS expressed in terms of availability within x hours/days where x is the maximum amount of time one might have to wait.



    This attribute is also known by these names:
    ContextAlias
    pluralSPECIALIST HIV SKILLS AVAILABLE


    top

    SPECIALIST REGISTRAR FLAG

    Change to Attribute: Change to Description

    Indicates that the HEALTH CARE PROFESSIONAL who carries out a procedure is a specialist paediatric registrar. Indicates that the CARE PROFESSIONAL who carries out a procedure is a specialist paediatric registrar.



    This attribute is also known by these names:
    ContextAlias
    pluralSPECIALIST REGISTRAR FLAG


    top

    SPECIALTY CODE

    Change to Attribute: Change to Name

    SPECIALTY CODE
    MAIN SPECIALTY CODE


    top

    SPECIALTY CODE renamed MAIN SPECIALTY CODE

    Change to Attribute: Change to Aliases, Change to Description

    A unique code identifying each SPECIALTY designated by Royal Colleges. A unique code identifying each MAIN SPECIALTY designated by Royal Colleges. This is the same as the occupation codes describing specialties.



    This attribute is also known by these names:
    ContextAlias
    pluralSPECIALTY CODES
    pluralMAIN SPECIALTY CODES


    top

    SPECIALTY FUNCTION CODE

    Change to Attribute: Change to Name

    SPECIALTY FUNCTION CODE
    TREATMENT FUNCTION CODE


    top

    SPECIALTY FUNCTION CODE renamed TREATMENT FUNCTION CODE

    Change to Attribute: Change to Aliases, Change to Description

    A unique identifier for a SPECIALTY FUNCTION. A unique identifier for a TREATMENT FUNCTION.



    This attribute is also known by these names:
    ContextAlias
    pluralSPECIALTY FUNCTION CODES
    pluralTREATMENT FUNCTION CODES


    top

    ADMISSIONS (MENTAL HEALTH)

    Change to Data Element: Change to Description

    Format/length: n3
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    ADMISSIONS (MENTAL HEALTH) is an optional data item note in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

    a. one or more HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL has a START DATE within the REPORTING PERIOD
    a. one or more HOSPITAL PROVIDER SPELLS within the MENTAL HEALTH CARE SPELL has a START DATE within the REPORTING PERIOD
    and
    b. where the HOSPITAL PROVIDER SPELL contains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTIONS being 700, 710,712, 713 and 715. This includes both HOSPITAL STAYS and CARE HOME STAYS (CONSULTANT CARE) within the HOSPITAL PROVIDER SPELL.
    b. where the HOSPITAL PROVIDER SPELLcontains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715. This includes both HOSPITAL STAYS and CARE HOME STAYS (CONSULTANT CARE) within the HOSPITAL PROVIDER SPELL.

    It is the total number of such HOSPITAL PROVIDER SPELLS started within the REPORTING PERIOD.



    This data element is also known by these names:
    ContextAlias
    pluralADMISSIONS (MENTAL HEALTH)


    top

    BED DAYS (MENTAL HEALTH)

    Change to Data Element: Change to Description

    Format/length: n3
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    BED DAYS (MENTAL HEALTH) is an optional data item note in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

    a. one or more CONSULTANT EPISODE (HOSPITAL PROVIDER) within the MENTAL HEALTH CARE SPELL has occurred during the REPORTING PERIOD
    and
    b. where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTION being 700, 710,712, 713 and 715.
    b. where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

    It is the total number of bed days within the REPORTING PERIOD. Each period of bed days is recorded by a CONSULTANT EPISODE (HOSPITAL PROVIDER) within a HOSPITAL PROVIDER SPELL and there may be more than one such episode or stay during the course of a MENTAL HEALTH CARE SPELL. This excludes any admissions to HOSPITAL PROVIDER SPELL where the PATIENT CLASSIFICATION is National Code 2 'Day case admission'. This includes both HOSPITAL STAYS and CARE HOME STAYS (CONSULTANT CARE) within the HOSPITAL PROVIDER SPELL.

    There is a START DATE and END DATE for each CONSULTANT EPISODE (HOSPITAL PROVIDER) and the calculation is based upon those bed days which have occurred during the REPORTING PERIOD adjusted for where periods of bed days overlap the START DATE and/or END DATE of the REPORTING PERIOD (this includes where the period of bed days has not yet ended). Where such overlaps occur the START DATE and/or END DATE of the REPORTING PERIOD should be used instead of that of the CONSULTANT EPISODE (HOSPITAL PROVIDER).

    BED DAYS (MENTAL HEALTH) is the sum of the calculated periods of bed days and should be recorded left justified with leading zeros. The calculation should be adjusted for any periods of LEAVE OF ABSENCE or ABSENCE WITHOUT LEAVE of 28 days or less.

    A PATIENT going on HOME LEAVE, or LEAVE OF ABSENCE for 28 days or less, or who has a current period of ABSENCE WITHOUT LEAVE of 28 days or less, does not interrupt the CONSULTANT EPISODE (HOSPITAL PROVIDER) but are not using a bed during their period of absence.



    This data element is also known by these names:
    ContextAlias
    pluralBED DAYS (MENTAL HEALTH)


    top

    BED DAYS (MENTAL HEALTH INTENSIVE)

    Change to Data Element: Change to Description

    Format/length: n3
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    BED DAYS (MENTAL HEALTH INTENSIVE) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

    a. one or more CONSULTANT EPISODES (HOSPITAL PROVIDER) within the MENTAL HEALTH CARE SPELL has occurred during the REPORTING PERIOD
    and
    b. where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTIONS being 700, 710,712, 713 and 715.
    b. where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.
    and
    c. where the PATIENT was admitted to a bed in a WARD with a CLINICAL CARE INTENSITY National Code 51'Specially designated ward for patients needing containment and more intensive management. This is not to be confused with intensive nursing where a patient may require one to one nursing while on a standard ward'.

    It is the total number of bed days within the REPORTING PERIOD. Each period of bed days is recorded by a CONSULTANT EPISODE (HOSPITAL PROVIDER) within a HOSPITAL PROVIDER SPELL and there may be more than one such episode or stay during the course of a MENTAL HEALTH CARE SPELL. This excludes any admissions to HOSPITAL PROVIDER SPELLS where the PATIENT CLASSIFICATION is National Code 2 'Day case admission'. This includes both HOSPITAL STAYS and CARE HOME STAYS (CONSULTANT CARE) within the HOSPITAL PROVIDER SPELL.

    There is a START DATE and END DATE for each CONSULTANT EPISODE (HOSPITAL PROVIDER) or CARE HOME STAY (CONSULTANT CARE) and the calculation is based upon those bed days which have occurred during the REPORTING PERIOD adjusted for where periods of bed days overlap the START DATE and/or END DATE of the REPORTING PERIOD (this includes where the period of bed days has not yet ended). Where such overlaps occur the START DATE and/or END DATE of the REPORTING PERIOD should be used instead of that of the CONSULTANT EPISODE (HOSPITAL PROVIDER).

    BED DAYS (MENTAL HEALTH INTENSIVE) is the sum of the calculated periods of bed days and should be recorded left justified with leading zeros. The calculation should be adjusted for any periods of LEAVE OF ABSENCE or ABSENCE WITHOUT LEAVE of 28 days or less.

    A PATIENT going on HOME LEAVE, or LEAVE OF ABSENCE for 28 days or less, or who has a current period of ABSENCE WITHOUT LEAVE of 28 days or less, does not interrupt the CONSULTANT EPISODE (HOSPITAL PROVIDER) but are not using a bed during their period of absence.



    This data element is also known by these names:
    ContextAlias
    pluralBED DAYS (MENTAL HEALTH INTENSIVE)


    top

    BED DAYS (MENTAL HEALTH MEDIUM SECURE)

    Change to Data Element: Change to Description

    Format/length: n3
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    BED DAYS (MENTAL HEALTH MEDIUM SECURE) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

    a. one or more CONSULTANT EPISODE (HOSPITAL PROVIDER) within the MENTAL HEALTH CARE SPELL has occurred during the REPORTING PERIOD
    and
    b. where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTIONS being 700, 710,712, 713 and 715.
    b. where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.
    and
    c. where the PATIENT was admitted to an ORGANISATION SITE, SERVICE POINT or WARD with a SECURE ACCOMMODATION TYPE classification b. 'Medium secure accommodation, a secure facility providing care at a regional level under the care of a forensic psychiatrist. This excludes high security accommodation in HOSPITAL SITE approved to provide high security psychiatric services'.

    It is the total number of bed days within the REPORTING PERIOD. Each period of bed days is recorded by a CONSULTANT EPISODE (HOSPITAL PROVIDER) within a HOSPITAL PROVIDER SPELL and there may be more than one such episode or stay during the course of a MENTAL HEALTH CARE SPELL. This excludes any admissions to HOSPITAL PROVIDER SPELLS where the PATIENT CLASSIFICATION is National Code 2 'Day case admission'. This includes both HOSPITAL STAYS and CARE HOME STAY (CONSULTANT CARE) within the HOSPITAL PROVIDER SPELL.

    There is a START DATE and END DATE for each CONSULTANT EPISODE (HOSPITAL PROVIDER) and the calculation is based upon those bed days which have occurred during the REPORTING PERIOD adjusted for where periods of bed days overlap the START DATE and/or END DATE of the REPORTING PERIOD (this includes where the period of bed days has not yet ended). Where such overlaps occur the START DATE and/or END DATE of the REPORTING PERIOD should be used instead of that of the CONSULTANT EPISODE (HOSPITAL PROVIDER).

    BED DAYS (MENTAL HEALTH MEDIUM SECURE) is the sum of the calculated periods of bed days and should be recorded left justified with leading zeros. The calculation should be adjusted for any periods of LEAVE OF ABSENCE or ABSENCE WITHOUT LEAVE of 28 days or less.

    A PATIENT going on HOME LEAVE, or LEAVE OF ABSENCE for 28 days or less, or who has a current period of ABSENCE WITHOUT LEAVE of 28 days or less, does not interrupt the CONSULTANT EPISODE (HOSPITAL PROVIDER) but are not using a bed during their period of absence.



    This data element is also known by these names:
    ContextAlias
    pluralBED DAYS (MENTAL HEALTH MEDIUM SECURE)


    top

    CARE PROFESSIONAL CODE (REQUESTED BY)

    Change to Data Element: Change to Description

    Format/length: an8
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    The code of the HEALTH CARE PROFESSIONAL who requests the REQUEST FOR DIAGNOSTIC TEST for suspected cancer. The code of the CARE PROFESSIONAL who requests the REQUEST FOR DIAGNOSTIC TEST for suspected cancer. This is not required if the request comes from a GENERAL MEDICAL PRACTITIONER.


    top

    CODE OF RESPONSIBLE HCP (OPCS)

    Change to Data Element: Change to Name

    CODE OF RESPONSIBLE HCP (OPCS)
    RESPONSIBLE CARE PROFESSIONAL CODE (OPCS)


    top

    CODE OF RESPONSIBLE HCP (OPCS) renamed RESPONSIBLE CARE PROFESSIONAL CODE (OPCS)

    Change to Data Element: Change to Aliases, Change to Description

    Format/length: an8
    HES item: See Table below
    National Codes:
    Default Codes: C9999998 - Consultant, GMC code not known
    D9999998 - Dentist, DPB code not known
    G9999998 - General Medical Practitioner, GMP code not known
    H9999998 - Other health care professional
    H9999998 - Other care professional
    M9999998 - Midwife
    N9999998 - Nurse
    P9999998 - Non-consultant doctor, GMC code not known

    CODE OF RESPONSIBLE HCP (OPCS) is the GMC, DPB or other professional registration code for the HEALTH CARE PROFESSIONAL undertaking the OPCS-4 classified operative PATIENT PROCEDURE. This will usually, but not exclusively, be the lead health care professional or a junior member of the same team. RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) is the GMC, DPB or other professional registration code for the CARE PROFESSIONAL undertaking the OPCS-4 classified operative PATIENT PROCEDURE. This will usually, but not exclusively, be the lead care professional or a junior member of the same team.

    Where the actual professional registration code is unknown or the professional is not a doctor or a dentist, the appropriate default code should be used.



    This data element is also known by these names:
    ContextAlias
    pluralCODES OF RESPONSIBLE HCPS (OPCS)
    pluralRESPONSIBLE CARE PROFESSIONAL CODES (OPCS)


    top

    COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH)

    Change to Data Element: Change to Description

    Format/length: an50
    HES item:
    National Codes:
    Default Codes:  

    Notes:
    COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

    a. one or more periods of no HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL has occurred within the REPORTING PERIOD
    and
    b. where one or more HOSPITAL PROVIDER SPELL has occurred within the MENTAL HEALTH CARE SPELL, containing at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTION being 700, 710,712, 713 and 715.
    b. where one or more HOSPITAL PROVIDER SPELL has occurred within the MENTAL HEALTH CARE SPELL, containing at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

    For the list, the length in days between each HOSPITAL PROVIDER SPELL is calculated from the DISCHARGE DATE of one spell and either the START DATE of the next HOSPITAL PROVIDER SPELL which follows it, if one is recorded, or the end of the REPORTING PERIOD if not.

    Where there is no HOSPITAL PROVIDER SPELL in being at the START DATE of the REPORTING PERIOD then use the DISCHARGE DATE of the last HOSPITAL PROVIDER SPELL in the MENTAL HEALTH CARE SPELL before the START DATE of the REPORTING PERIOD if any exists. Otherwise no entry in the list should be made in respect of days before the first HOSPITAL PROVIDER SPELL.

    Where there is no HOSPITAL PROVIDER SPELL in being at the END DATE of the REPORTING PERIOD the END DATE of the REPORTING PERIOD should be used.

    A suffix is attached to each calculated period length, the suffixes are:

    C - where the PATIENT has still not been readmitted to hospital by the end of the REPORTING PERIOD but the MENTAL HEALTH CARE SPELL is continuing
    E - where the PATIENT has still not been readmitted to hospital by the end of the REPORTING PERIOD but the MENTAL HEALTH CARE SPELL has finished before the end of the REPORTING PERIOD
    P - where the discharge date initiating the survival times is within the MENTAL HEALTH CARE SPELL but before the start of the REPORTING PERIOD
    blank where an admission terminates the survival period within the MENTAL HEALTH CARE SPELL and within the REPORTING PERIOD

    The calculated length of days (plus their suffix) are recorded within the COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH) in ascending DISCHARGE DATE of the previous HOSPITAL PROVIDER SPELL sequence.



    This data element is also known by these names:
    ContextAlias
    pluralCOMMUNITY SURVIVAL TIMES LISTS (MENTAL HEALTH)


    top

    CONSULTANT CODE

    Change to Data Element: Change to Description

    Format/length: an8
    HES item: CONSULT
    National Codes:
    Default Codes: C9999998 - Consultant code not known
      D9999998 - Dentist code not known
      M9999998 - Not applicable - Midwife
      N9999998 - Not applicable - Nurse

    Notes:
    This is the GMC code for the CONSULTANT, which is the unique identifier for the consultant as a PERSON, i.e. the PERSON IDENTIFIER TYPE classification 'Consultant Code - GMC'. For GPs working as Consultants, the GP's GMC code should be used, see data item note for GMP (CODE OF REGISTERED OR REFERRING GMP).

    The GMC code is an eight character alphanumeric code based on the GMC registration number; the first character will be the letter `C'; characters 2 to 7 will be the doctor's GMC number, see PRACTITIONER CODES.

    If a dental consultant is not registered with the GMC, the Dentists' Practice Board number has to be used prefixed with D.

    For NHS patients treated overseas, the commissioner of the overseas treatment is responsible for ensuring that the overseas doctor is provided with a GMC code. In the case of overseas doctors the default code C9999998 should only be used where no GMC code has been assigned.

    All MIDWIFE EPISODES are identified in the Admitted Patient Care CDS and HES by a pseudo main consultant specialty code, 560, see Specialty Function Codes. All MIDWIFE EPISODES are identified in the Admitted Patient Care CDS and HES by a pseudo main consultant specialty code, 560, see Main Specialty+Treatment Function Codes. A default code is used in the CONSULTANT CODE field to show that a MIDWIFE is the responsible professional. Note that the midwife's own code is not used.

    All NURSING EPISODES are identified in the Admitted Patient CDS and HES by a pseudo main consultant specialty code, 950, see Speciality Function Codes. All NURSING EPISODES are identified in the Admitted Patient CDS and HES by a pseudo main consultant specialty code, 950, see Main Specialty+Treatment Function Codes. A default code is used in the CONSULTANT CODES field to show that a NURSE is the responsible professional. Note that the nurse's own Nursing and Midwifery Council code is not used.



    This data element is also known by these names:
    ContextAlias
    pluralCONSULTANT CODES


    top

    CONSULTANT SPECIALTY FUNCTION CODE

    Change to Data Element: Change to Name

    CONSULTANT SPECIALTY FUNCTION CODE
    TREATMENT FUNCTION CODE


      top

      CONSULTANT SPECIALTY FUNCTION CODE renamed TREATMENT FUNCTION CODE

      Change to Data Element: Change to Description

      Format/length: n3
      HES item: TRETSPEF
      National Codes:
      Default codes: 199 - Non-UK provider; specialty function not known, treatment mainly surgical
      499 - Non-UK provider; specialty function not known, treatment mainly medical


      Notes:
      This is the specialty under which the PATIENT is treated. It may be the same as the SPECIALTY FUNCTION CODE recorded as the consultant's main SPECIALTY or a different specialty function which will be the consultant's interest specialty. Both the main specialty function and the interest specialty function should be based on one of the Royal College specialties, see Speciality Function Codes.

      This is the TREATMENT FUNCTION under which the PATIENT is treated. It may be the same as the MAIN SPECIALTY CODE recorded as the consultant's MAIN SPECIALTY or a different TREATMENT FUNCTION which will be the CARE PROFESSIONALS treatment interest. See Main Specialty and Treatment Function Codes for the full list of valid codes.

      All MIDWIFE EPISODES and NURSING EPISODES are identified in the Admitted Patient care CDS and HES by a pseudo consultant specialty code of 560 for midwives and 950 for nurses, see Specialty Function Codes.

      MIDWIFE EPISODES and NURSING EPISODES may use any appropriate TREATMENT FUNCTION CODE. The pseudo consultant specialty code of 560 for midwives and 950 for nurses must only be used for MAIN SPECIALTY CODE see See Main Specialty and Treatment Function Codes.

      The default codes 199 and 499 are only applicable for overseas health care providers.



      This data element is also known by these names:
      Context Alias
      plural CONSULTANT SPECIALTY FUNCTION CODES


        CONTACTS (CONSULTANT PSYCHOTHERAPY)

        Change to Data Element: Change to Description

        Format/length: n3
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        CONTACTS (CONSULTANT PSYCHOTHERAPY) is an optional data item note in the Mental Health Minimum Data Set (MHMDS) collection record and should only be present if:

        a. one or more OUT-PATIENT ATTENDANCE CONSULTANT within the MENTAL HEALTH CARE SPELL has occurred during the REPORTING PERIOD
        and
        b. where the main CONSULTANT SPECIALTY FUNCTION for the CONSULTANT is 713 'PSYCHOTHERAPY'
        b. where the MAIN SPECIALTY for the CONSULTANT is 713 'PSYCHOTHERAPY'

        It is the total number of such attendances within the REPORTING PERIOD. Each such attendance is recorded by an OUT-PATIENT ATTENDANCE CONSULTANT and there may be more than one recorded during the course of a REPORTING PERIOD.

        There is a ATTENDANCE DATE for each OUT-PATIENT ATTENDANCE CONSULTANT and the calculation is based upon those attendances which have occurred during the REPORTING PERIOD. Where the CONSULTANT is also the allocated Care Programme Approach care coordinator for the PATIENT then a FACE TO FACE CONTACT CPA CARE COORDINATOR should also be recorded.



        This data element is also known by these names:
        ContextAlias
        pluralCONTACTS (CONSULTANT PSYCHOTHERAPISTS)


        top

        DISCHARGES (MENTAL HEALTH)

        Change to Data Element: Change to Description

        Format/length: n3
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        DISCHARGES (MENTAL HEALTH) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

        a. one or more HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL has a DISCHARGE DATE within the REPORTING PERIOD
        and
        b. where the HOSPITAL PROVIDER SPELL contains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTION being 700, 710,712, 713 and 715.
        b. where the HOSPITAL PROVIDER SPELL contains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

        It is the total number of such discharges from HOSPITAL PROVIDER SPELL within the REPORTING PERIOD.


        top

        ELECTIVE ADMISSION LIST

        Change to Data Element: Change to Description

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

        Notes:
        An ELECTIVE ADMISSION LISTS is a list of one or more PATIENTS waiting for admission to hospital with or without a to come in date. An ELECTIVE ADMISSION LIST is a list of one or more PATIENTS waiting for admission to hospital with or without a to come in date. It does not include PATIENTS waiting for a first OUT-PATIENT APPOINTMENT CONSULTANT. Lists can be maintained in several forms, using either computer or manual systems, including CONSULTANTS' diaries. They may be kept by SPECIALTY FUNCTION CODE or for an individual consultant. They may be kept by TREATMENT FUNCTION CODE or for an individual CARE PROFESSIONAL.

        A PATIENT can be on more than one ELECTIVE ADMISSION LISTS. This may be because the PATIENT needs treatment for more than one condition or because the PATIENT has been placed on the list of more than one provider for the same condition.

        It is also possible for a PATIENT to be entered on an ELECTIVE ADMISSION LISTS more than once, either for a different condition or for the same condition, where two or more admissions are required. For example, a PATIENT would have two ELECTIVE ADMISSION LIST ENTRIES on a list where the intention was to perform two or more operations requiring two or more admissions, such as repair of inguinal hernia and operation on varicose veins. Only one ELECTIVE ADMISSION LIST ENTRY should be made in the event of the intention to perform two or more procedures during one admission.

        PATIENTS already in a hospital bed who are waiting for transfer in the same provider unit or to another provider unit cannot be included in an ELECTIVE ADMISSION LISTS. The ELECTIVE ADMISSION LISTS is only for PATIENTS without a current provider spell waiting for admission to hospital to start a HOSPITAL PROVIDER SPELL.



        This data element is also known by these names:
        ContextAlias
        pluralELECTIVE ADMISSION LISTS


        top

        FIRST CONTACT TIMES LIST (MENTAL HEALTH)

        Change to Data Element: Change to Description

        Format/length: an50
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        FIRST CONTACT TIMES LIST (MENTAL HEALTH) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if one or more HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL has ended within the REPORTING PERIOD.

        One entry should be made in the list for each HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL ending within the REPORTING PERIOD. The entry is the number of days elapsing from the DISCHARGE DATE of the HOSPITAL PROVIDER SPELL to the first subsequent clinical contact or to the end of the MENTAL HEALTH CARE SPELL or to the end of the REPORTING PERIOD whichever is the soonest. Clinical contacts may be any of the following:

        a. a PROFESSIONAL STAFF GROUP CONTACT with PROFESSIONAL STAFF GROUP TYPE classification of b. Clinical Psychology, d. Occupational Therapy or e. Physiotherapy
        or
        b. an OUT-PATIENT ATTENDANCE CONSULTANT with a CONSULTANT with a main CONSULTANT SPECIALTY FUNCTION of 713 Psychotherapy
        b. an OUT-PATIENT ATTENDANCE CONSULTANT with a CONSULTANT with a main TREATMENT FUNCTION of 713 Psychotherapy
        or
        c. a FACE TO FACE CONTACT COMMUNITY CARE with COMMUNITY NURSE STAFF GROUP classification of b. Community Psychiatric Nurses - providing mental illness services
        or
        d. a FACE TO FACE CONTACT SOCIAL WORKER
        or
        e. a DAY CARE ATTENDANCE with DAY CARE FUNCTION classification e. Mental Illness
        or
        f. a CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTION being 700, 710,712, 713 and 715.
        f. a CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

        A suffix is attached to each calculated period length, the suffixes are:

        D - where a following contact occurs before the end of the REPORTING PERIOD
        W where no contact has occurred between the DISCHARGE DATE and the end of the REPORTING PERIOD or the end of the MENTAL HEALTH CARE SPELL whichever is the sooner. .

        The calculated length of days (plus their suffix) are recorded within the FIRST CONTACT TIMES LIST (MENTAL HEALTH) in ascending contact date sequence.



        This data element is also known by these names:
        ContextAlias
        pluralFIRST CONTACT TIMES LISTS (MENTAL HEALTH)


        top

        HOSPITAL STAYS LIST (MENTAL HEALTH)

        Change to Data Element: Change to Description

        Format/length: an50
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        HOSPITAL STAYS LIST (MENTAL HEALTH) is optional in the Mental Health Minimum Data Set (MHMDS) collection record. It should only be present if:

        a. one or more HOSPITAL PROVIDER SPELL within the MENTAL HEALTH CARE SPELL has occurred wholly or partly within the REPORTING PERIOD
        and
        b. where the HOSPITAL PROVIDER SPELL contains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTIONS being 700, 710,712, 713 and 715.
        b. where the HOSPITAL PROVIDER SPELL contains at least one CONSULTANT EPISODE (HOSPITAL PROVIDER) where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

        For the list, the length in days of each HOSPITAL PROVIDER SPELL is calculated from the START DATE and DISCHARGE DATE of the HOSPITAL PROVIDER SPELL. Where there is no DISCHARGE DATE the END DATE of the REPORTING PERIOD should be used. A suffix is attached to each calculated stay length, the suffixes are:

        B where the START DATE of the HOSPITAL PROVIDER SPELL is before the START DATE of the REPORTING PERIOD
        C where the DISCHARGE DATE of the HOSPITAL PROVIDER SPELL is after the END DATE of the REPORTING PERIOD
        blank where START DATE and DISCHARGE DATE of the HOSPITAL PROVIDER SPELL are within the START DATE and END DATE of the REPORTING PERIOD.

        The calculated length of days (plus their suffix) are recorded within the HOSPITAL STAYS LIST (MENTAL HEALTH) in ascending START DATE of HOSPITAL PROVIDER SPELL sequence.



        This data element is also known by these names:
        ContextAlias
        pluralHOSPITAL STAYS LISTS (MENTAL HEALTH)


        top

        ORGANISATION CODE (REQUESTED BY)

        Change to Data Element: Change to Description

        Format/length: an5
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        This is the ORGANISATION CODE of the ORGANISATION at which the HEALTH CARE PROFESSIONAL who requested the REQUEST FOR DIAGNOSTIC TEST for suspected cancer is based. This is the ORGANISATION CODE of the ORGANISATION at which the CARE PROFESSIONAL who requested the REQUEST FOR DIAGNOSTIC TEST for suspected cancer is based.


        top

        OUT-PATIENT ATTENDANCE CONSULTANT

        Change to Data Element: Change to Description

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

        Notes:
        A series of OUT-PATIENT ATTENDANCES CONSULTANT will form a CONSULTANT OUT-PATIENT EPISODE, generated from a single referral. Note that it is possible to have two CONSULTANT OUT-PATIENT EPISODES with the same consultant for different clinical conditions, if two referrals are made.

        An attendance may involve more than one PERSON - for example, a family. The number of attendances to be recorded should be the number of PATIENTS for whom the consultant has identifiable individual records and which will be maintained as a result of the attendance. Note that OUT-PATIENT ATTENDANCES CONSULTANT can take place outside a clinic session, and can take place at the PATIENTs normal place of residence.

        A PATIENT attending a WARD for examination or care will be counted as an OUT-PATIENT ATTENDANCE CONSULTANT if he/she is seen by a doctor. If they are only seen by a NURSE, they are a WARD ATTENDER.

        An OUT-PATIENT ATTENDANCE CONSULTANT should also be recorded where a PATIENT is seen by a CONSULTANT from a different SPECIALTY during a CONSULTANT EPISODE (HOSPITAL PROVIDER) where there is no transfer of responsibility for the care of the PATIENT. An OUT-PATIENT ATTENDANCE CONSULTANT should also be recorded where a PATIENT is seen by a CONSULTANT from a different MAIN SPECIALTY during a CONSULTANT EPISODE (HOSPITAL PROVIDER) where there is no transfer of responsibility for the care of the PATIENT. For example, a patient who is admitted to hospital under a Gastroenterology specialty following an overdose may be seen while still in hospital by a psychiatrist who has been asked to assess their mental condition. The assessment by the psychiatrist should be recorded as an OUT-PATIENT ATTENDANCE CONSULTANT.



        This data element is also known by these names:
        ContextAlias
        pluralOUT-PATIENT ATTENDANCE CONSULTANTS


        top

        OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH)

        Change to Data Element: Change to Description

        Format/length: n3
        HES item:
        National Codes:
        Default Codes:  

        Notes:
        OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH) is the same as entity type OUT-PATIENT ATTENDANCE CONSULTANT.

        OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH) is an optional data item note in the Mental Health Minimum Data Set (MHMDS) collection record and should only be present if:

        a. one or more OUT-PATIENT ATTENDANCE CONSULTANT within the MENTAL HEALTH CARE SPELL has occurred during the REPORTING PERIOD
        and
        b. where the main CONSULTANT SPECIALTY FUNCTION of the CONSULTANT is for an adult or mental illness SPECIALTY FUNCTION. The adult or mental illness SPECIALTY FUNCTIONS being 700, 710,712, 713 and 715.
        b. where the main TREATMENT FUNCTION of the CONSULTANT is for an adult or mental illness MAIN SPECIALTY. The adult or mental illness MAIN SPECIALTIES being 700, 710,712, 713 and 715.

        It is the total number of such attendances within the REPORTING PERIOD. Each such attendance is recorded by an OUT-PATIENT ATTENDANCE CONSULTANT and there may be more than one recorded during the course of a REPORTING PERIOD.

        There is an ATTENDANCE DATE for each OUT-PATIENT ATTENDANCE CONSULTANT and the calculation is based upon those attendances which have occurred during the REPORTING PERIOD.



        This data element is also known by these names:
        ContextAlias
        pluralOUT-PATIENT ATTENDANCE CONSULTANTS (MENTAL HEALTH)


        top

        PSYCHIATRIC PATIENT

        Change to Data Element: Change to Description

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

        Notes:
        A PATIENT under the care of a CONSULTANT in one of the psychiatric specialties, see Specialty Function Codes. A PATIENT under the care of a CONSULTANT in one of the psychiatric specialties, see Main Specialty+Treatment Function Codes.



        This data element is also known by these names:
        ContextAlias
        pluralPSYCHIATRIC PATIENTS


        top

        REFERRER CODE

        Change to Data Element: Change to Description

        Format/length: an8
        HES item: REFERRER
        National Codes:
        Default Codes:C9999998 - Consultant Code not known
        R9999981 - Referrer other than GMP, GDP or Consultant
        X9999998 - Not applicable: or not known

        Notes:
        This requires the code of the PERSON making the referral. This will normally be a HEALTH CARE PROFESSIONAL - a GMP or a consultant. This will normally be a CARE PROFESSIONAL - a GMP or a consultant.

        The intention is for this item to reflect the actual (true) referrer. For example, following a GMP referral, a consultant may subsequently refer the PATIENT to another consultant within the HOSPITAL PROVIDER SPELL. The code of the consultant making the referral and the consultant's organisation should be recorded in the CDS rather than the code of the GMP referrer. This also applies where a CONSULTANT refers an NHS patient to another doctor for NHS-commissioned treatment at another NHS Trust, a non-NHS provider, or an overseas provider. Where the Consultant Code is unknown, the default value C9999998 should be used.

        In all other cases, the code of the referring GMP should be recorded, if applicable.

        See CONSULTANT CODE and GMP (CODE OF REGISTERED OR REFERRING GMP) for the codes available for consultants and General Medical and Dental Practitioners, MoD and Prison Doctors. See also NHS Administrative Codes.

        If the Referrer code is not known or not applicable e.g., the patient has self-presented, the default code (X9999998) should be used.



        This data element is also known by these names:
        ContextAlias
        pluralREFERRER CODES


        top

        SPECIALTY FUNCTION CODE

        Change to Data Element: Change to Name

        SPECIALTY FUNCTION CODE
        MAIN SPECIALTY CODE


        top

        SPECIALTY FUNCTION CODE renamed MAIN SPECIALTY CODE

        Change to Data Element: Change to Description

        Format/length: n3
        HES item: MAINSPEF
        National Codes:
        Default Codes: 199 - Non-UK provider; specialty function not known, treatment mainly surgical
        499 - Non-UK provider; specialty function not known, treatment mainly medical


        Notes:
        SPECIALTY FUNCTION, based on SPECIALTY, classifies clinical work divisions more precisely for a limited number of specialties. See Speciality Function Codes for the full list of codes.

        This is the specialty in which the CONSULTANT is contracted or recognised. MAIN SPECIALTY classifies clinical work divisions more precisely for a limited number of specialties.

        See Main Specialty+Treatment Function Codes for the full list of codes.

        All MIDWIFE EPISODES and NURSING EPISODES are identified in the Admitted Patient Care CDS and HES by a pseudo main consultant specialty code of 560 for midwives and 950 for nurses, see Specialty Function Codes.

        All MIDWIFE EPISODES and NURSING EPISODES are identified in the Admitted Patient Care CDS and HES by a pseudo MAIN SPECIALTY CODE of 560 for midwives and 950 for nurses.

        The default codes 199 and 499 are only applicable for overseas providers.



        This data element is also known by these names:
        ContextAlias
        pluralSPECIALTY FUNCTION CODES
        pluralMAIN SPECIALTY CODES


          SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD)

          Change to Data Element: Change to Name

          SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD)
          MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD)


          top

          SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) renamed MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD)

          Change to Data Element: Change to Description

          Format/length: n3
          HES item: ACPSPEF
          National Codes:
          Default Codes:

          Notes:
          This is the main specialty of the CONSULTANT clinically managing one or more AUGMENTED CARE PERIODS. This consultant is not necessarily the same as the consultant responsible for the CONSULTANT EPISODE (HOSPITAL PROVIDER).

          Where a PATIENT is cared for by a team of specialists within an Intensive Care rota, the specialty of the clinical director of the team is recorded.

          In the event of multiple specialty involvement in an augmented care period where no specialty is identified as being responsible, the SPECIALTY FUNCTION CODE of the consultant admitting the PATIENT to the augmented care period is recorded. See Speciality Function Codes for the full list of codes. In the event of multiple specialty involvement in an augmented care period where no specialty is identified as being responsible, the MAIN SPECIALTY CODE of the consultant admitting the PATIENT to the augmented care period is recorded. See Main Specialty+Treatment Function Codes for the full list of codes.



          This data element is also known by these names:
          ContextAlias
          pluralSPECIALTY FUNCTION CODES (AUGMENTED CARE PERIOD)
          pluralMAIN SPECIALTY CODES (AUGMENTED CARE PERIOD)



            SPECIALTY FUNCTION CODE (MENTAL HEALTH)

            Change to Data Element: Change to Name

            SPECIALTY FUNCTION CODE (MENTAL HEALTH)
            MAIN SPECIALTY CODE (MENTAL HEALTH)


            top

            SPECIALTY FUNCTION CODE (MENTAL HEALTH) renamed MAIN SPECIALTY CODE (MENTAL HEALTH)

            Change to Data Element: Change to Description

            Format/length: n3
            HES item:
            National Codes:
            Default Codes:  

            Notes:
            The latest main psychiatric specialty recorded for the PATIENT within a MENTAL HEALTH CARE SPELL.

            Where MHCS SPECIALTY ASSOCIATIONS are recorded it is the SPECIALTY FUNCTION CODE of the SPECIALTY FUNCTION associated with the MHCS SPECIALTY ASSOCIATION with the latest START DATE within the MENTAL HEALTH CARE SPELL. Where MHCS SPECIALTY ASSOCIATIONS are recorded it is the TREATMENT FUNCTION CODE of the TREATMENT FUNCTION associated with the MHCS SPECIALTY ASSOCIATION with the latest START DATE within the MENTAL HEALTH CARE SPELL.

            Where MHCS SPECIALTY ASSOCIATION are not recorded it is the CONSULTANT SPECIALTY FUNCTION of:

            CONSULTANT EPISODE (ACUTE HOME-BASED)
            or CONSULTANT EPISODE (HOSPITAL PROVIDER)
            or CONSULTANT OUT-PATIENT EPISODE

            with the latest START DATE within the assembled MENTAL HEALTH CARE SPELL.

            See Specialty Function Codes for the full list of codes. See Main Specialty+Treatment Function Codes for the full list of codes.



            This data element is also known by these names:
            ContextAlias
            pluralSPECIALTY FUNCTION CODES (MENTAL HEALTH)


            top

            ADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODE

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING DATA SET (CDS)

            ADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODE

            The Admitted Patient Care Birth Episode Commissioning Data Set Type carries the data for a finished or unfinished Birth Episode. A Birth Episode record is required when there has been a delivery resulting in a registrable birth. This may take place in either NHS hospitals or in non-NHS hospitals funded by the NHS. The information is taken from the birth notification for each baby born and added to the baby's record.

            The column headed Opt (Optionality) shows whether the data element is Mandatory (M) or Optional (O) in this specific CDS.

            The column headed U/A (Unfinished Episode / Annual Census) indicates whether the data element is required to be recorded on an unfinished Birth Episode record and on an End of Year Census record, which is required for all unfinished Birth Episodes at midnight on 31 March.

            An R in the U/A column indicates that it is required to be present, a blank indicates that it is not required to be present.

            The column headed HES indicates whether the data element is extracted from the NWCS database for Hospital Episode Statistics. A filled circle in the column indicates that it is extracted if present, a blank indicates that it is not extracted. Note that HES records contain derived items. The table below indicates the base data from which these items are derived, and the CDS/HES cross reference table will show the derivation.

            Opt CDS Data Element U/A HES
            Person Group (Patient):

            To carry the personal details of the Patient (the baby). One occurrence of this Group is permitted.
            M LOCAL PATIENT IDENTIFIER R "
            M ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) R  
            M ORGANISATION CODE TYPE R  
            O NHS NUMBER R "
            M BIRTH DATE R "
            M BIRTH WEIGHT R "
            M LIVE OR STILL BIRTH R "
            O ETHNIC CATEGORY R  
            M NHS NUMBER STATUS INDICATOR R "
            M SEX R "
            O NAME FORMAT CODE R  
            O PATIENT NAME R  
              Note:
            For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.

            Birth Episodes do not carry address details for a baby. By local agreement, it may be assumed that the baby's address details are identical to that of the mother whose details may be carried in the Person Group (Mother) of the Birth Occurrence Group.
               
            (HCA) Hospital Provider Spell - Activity Characteristics:

            To carry the details of the Spell containing the Birth Episode. One occurrence of this Group is permitted.
            M HOSPITAL PROVIDER SPELL NUMBER R "
            M ADMINISTRATIVE CATEGORY
            (on admission)
            R "
            M PATIENT CLASSIFICATION R "
            M ADMISSION METHOD (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)   "
            M DISCHARGE METHOD (HOSPITAL PROVIDER SPELL)   "
            M SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) R "
            M START DATE (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DATE (HOSPITAL PROVIDER SPELL)   "
            (HCA) Consultant Episode - Activity Characteristics:

            To carry the details of the Birth Episode undergone by the Patient. One occurrence of this Group is permitted.
            M EPISODE NUMBER R "
            M LAST EPISODE IN SPELL INDICATOR R "
            M NEONATAL LEVEL OF CARE R "
            M OPERATION STATUS
            (per episode)
            R "
            M NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE R "
            M START DATE (EPISODE) R "
            M END DATE (EPISODE)   "
            (HCA) Consultant Episode - Service Agreement Details:

            To carry the details of the Service Agreement for the Birth Episode.
            M COMMISSIONING SERIAL NUMBER R "
            O NHS SERVICE AGREEMENT LINE NUMBER R  
            O PROVIDER REFERENCE NUMBER    
            M COMMISSIONER REFERENCE NUMBER R  
            M ORGANISATION CODE (CODE OF PROVIDER) R "
            M ORGANISATION CODE TYPE    
            M ORGANISATION CODE (CODE OF COMMISSIONER) R "
            M ORGANISATION CODE TYPE    
            (HCA) Consultant Episode - Person Group (Consultant):

            To carry the details of the responsible Consultant, Midwife or Nurse. One occurrence of this Group is permitted.
            M CONSULTANT CODE R "
            M SPECIALTY FUNCTION CODE R "
            M MAIN SPECIALTY CODE R "
            M CONSULTANT SPECIALTY FUNCTION CODE R "
            M TREATMENT FUNCTION CODE R "
            (HCA) Consultant Episode - Clinical Information Group (ICD):

            To carry the details of the ICD Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            M DIAGNOSIS SCHEME IN USE R  
            M PRIMARY DIAGNOSIS (ICD) R "
            M SECONDARY DIAGNOSIS (ICD)
            (1st to 12th, there may be up to 12 repetitions)
            R "
            (HCA) Consultant Episode - Clinical Information Group (READ):

            To carry the details of the READ Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE    
            O PRIMARY DIAGNOSIS (READ)    
            O SECONDARY DIAGNOSIS (READ)
            (1st to 12th, there may be up to 12 repetitions)
               
            (HCA) Consultant Episode - Clinical Activity Group (OPCS):

            To carry the details of the OPCS coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            M PROCEDURE SCHEME IN USE    
            M PRIMARY PROCEDURE (OPCS)   "
            M PROCEDURE DATE   "
            M PROCEDURE (OPCS)
            (2nd to 12th, there may be up to 11 repetitions)
              "
            M PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
              "
            (HCA) Consultant Episode - Clinical Activity Group (READ):

            To carry the details of the READ coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            O PROCEDURE SCHEME IN USE    
            O PRIMARY PROCEDURE (READ)    
            O PROCEDURE DATE    
            O PROCEDURE (READ)
            (2nd to 12th, there may be up to 11 repetitions)
               
            O PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
               
            (HCA) Consultant Episode - Location Group - Start of Episode:

            To carry the details of the location at the start of the Consultant/ Midwife/ Nurse Episode (eg the ward). One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS R  
            M SITE CODE (OF TREATMENT)
            (at start of episode)
            R "
            M ORGANISATION CODE TYPE R  
            O INTENDED CLINICAL CARE INTENSITY R "
            O AGE GROUP INTENDED R "
            O SEX OF PATIENTS R "
            O WARD DAY PERIOD AVAILABILITY R "
            O WARD NIGHT PERIOD AVAILABILITY R "
            (HCA) Consultant Episode - Location Group - Ward Stay:

            To carry the details of one or more Ward Stays. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)    
            M ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            O START DATE
            (at start of stay)
               
            O END DATE
            (at end of stay)
               
            (HCA) Consultant Episode - Location Group - End of Episode:

            To carry the details of the location at the end of the Consultant/ Midwife/ Nurse Episode (eg the ward). One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)
            (at end of episode)
               
            M ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            (HCA) Augmented Care Period:

            To carry the details of the Augmented Care undergone by the Patient. Up to the 9 most recent Augmented Care Periods that occur during a Consultant/ Midwife/ Nurse Episode may be included.
            M AUGMENTED CARE PERIOD NUMBER R "
            O AUGMENTED CARE PERIOD LOCAL IDENTIFIER R "
            M START DATE (AUGMENTED CARE PERIOD) R "
            M AUGMENTED CARE PERIOD SOURCE R "
            M INTENSIVE CARE LEVEL DAYS R "
            M HIGH DEPENDENCY CARE LEVEL DAYS R "
            M NUMBER OF ORGAN SYSTEMS SUPPORTED
            for intensive care level only)
            R "
            M AUGMENTED CARE PLANNED INDICATOR R "
            M AUGMENTED CARE OUTCOME INDICATOR   "
            M AUGMENTED CARE PERIOD DISPOSAL   "
            M END DATE (AUGMENTED CARE PERIOD)   "
            M SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) R "
            M MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) R "
            M LOCATION CLASS R  
            M AUGMENTED CARE LOCATION R "
            (HCA) GP Registration:

            To carry the details of the baby's mother's Registered GMP. One occurrence of this Group is permitted.
            M GMP (CODE OF REGISTERED OR REFERRING GMP) R "
            O CODE OF GP PRACTICE (REGISTERED GMP) R "
            O ORGANISATION CODE TYPE    
            (HCA) Referral:

            To carry the details of the referrer. This will be the referral that led to the mother's Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted.
            M REFERRER CODE R "
            M REFERRING ORGANISATION CODE R "
            M ORGANISATION CODE TYPE    
            (HCA) Pregnancy Activity Characteristics:

            To carry the number of babies resulting from this pregnancy. One occurrence of this Group is permitted.
            M NUMBER OF BABIES R "
            (HCA) Antenatal Care Activity Characteristics:

            To carry details of the start of the antenatal care. One occurrence of this Group is permitted.
            M FIRST ANTENATAL ASSESSMENT DATE R "
            (HCA) Antenatal Care Person Group (Responsible Clinician):

            To carry details of the responsible clinician. One occurrence of this Group is permitted.
            M GMP (CODE OF GMP RESPONSIBLE FOR ANTENATAL CARE) R  
            O CODE OF GP PRACTICE (REGISTERED GMP - ANTENATAL CARE) R  
            O ORGANISATION CODE TYPE    
            (HCA) Antenatal Care Location Group (Delivery Place Intended):

            To carry details of the intended delivery place. One occurrence of this Group is permitted.
            M LOCATION CLASS R  
            M DELIVERY PLACE CHANGE REASON R "
            M DELIVERY PLACE TYPE (INTENDED) R "
            (HCA) Hospital Labour/Delivery Activity Characteristics:

            To carry details of the Labour/Delivery. One occurrence of this Group is permitted.
            M ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY R "
            M ANAESTHETIC GIVEN POST LABOUR OR DELIVERY R "
            O GESTATION LENGTH (LABOUR ONSET) R  
            M LABOUR OR DELIVERY ONSET METHOD R "
            M DELIVERY DATE R  
            (HCA) Birth Occurrence Activity Characteristics:

            To carry details of the birth occurrence. One occurrence of this Group is permitted.
            M BIRTH ORDER R "
            M DELIVERY METHOD R "
            M GESTATION LENGTH (ASSESSMENT) R "
            M RESUSCITATION METHOD R "
            M STATUS OF PERSON CONDUCTING DELIVERY R "
            (HCA) Birth Occurrence Person Group (Mother):

            To carry the personal details of the baby's mother. One occurrence of this Group is permitted.
            O LOCAL PATIENT IDENTIFIER (MOTHER) R  
            O ORGANISATION CODE (LOCAL PATIENT IDENTIFIER (MOTHER)) R  
            O ORGANISATION CODE TYPE (MOTHER)    
            O NHS NUMBER (MOTHER) R  
            O NHS NUMBER STATUS INDICATOR (MOTHER) R  
            M BIRTH DATE (MOTHER) R "
            O ADDRESS FORMAT CODE (MOTHER)    
            O PATIENT USUAL ADDRESS (MOTHER)    
            M POSTCODE OF USUAL ADDRESS R "
            M ORGANISATION CODE (PCT OF RESIDENCE) R "
            M ORGANISATION CODE TYPE    
            (HCA) Birth Occurrence Location - Delivery Place Actual:

            To carry the type of place where delivery actually occurred. One occurrence of this Group within each Birth Group is permitted.
            M LOCATION CLASS    
            M DELIVERY PLACE TYPE (ACTUAL) R "
            (HCA) Healthcare Resource Group Activity - Activity Characteristics:

            To carry the details of the Healthcare Resource Group and will be mandatory from 01/10/2001. Each CDS may contain only a single occurrence of this Group.
            M HEALTHCARE RESOURCE GROUP CODE   "
            M HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER   "
            (HCA) Healthcare Resource Group Activity - Clinical Activity Group:

            To carry the details of the HRG Dominant Grouping Variable - Procedure. Note that this will not apply when no operation was carried out. In this case, the segment referring to HRG Dominant Grouping Variable - Procedure should be omitted. Only one Procedure either OPCS or READ may be specified
            O PROCEDURE SCHEME IN USE    
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE   "


            top

            ADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODE

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING DATA SET (CDS)

            ADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODE

            The Admitted Patient Care Delivery Episode Commissioning Data Set Type carries the data for a finished or unfinished General Consultant/ Midwife/ Nurse Delivery Episode. A Delivery Episode record is required when there has been a delivery resulting in a registrable birth. This may take place in either NHS hospitals or in non-NHS hospitals funded by the NHS. The information is taken from the birth notification for each baby born and added to the mother's record.

            The column headed Opt (Optionality) shows whether the Data element is Mandatory (M) or Optional (O) in this specific CDS.

            The column headed U/A (Unfinished Episode / Annual Census) indicates whether the Data element is required to be recorded on an unfinished Consultant/ Midwife/ Nurse Delivery Episode record and on an End of Year Census record. The census requires that an Unfinished Delivery Episode record for all unfinished Delivery Episodes at midnight on 31 March is sent. An R in the U/A column indicates that it is required to be present, a blank indicates that it is not required to be present.

            The column headed HES indicates whether the data element is extracted from the NWCS database for Hospital Episode Statistics. A filled circle in the column indicates that it is extracted if present, a blank indicates that it is not extracted. Note that HES records contain derived items. The table below indicates the base data from which these items are derived, and the CDS/HES cross reference table will show the derivation.

            Opt CDS Data element U/A HES
            Person Group (Patient):

            To carry the personal details of the Patient. One occurrence of this Group is permitted.
            M LOCAL PATIENT IDENTIFIER R "
            M ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) R  
            M ORGANISATION CODE TYPE    
            M NHS NUMBER R "
            M BIRTH DATE R "
            O CARER SUPPORT INDICATOR R "
            M LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION)
            (psychiatric patients only)
            R "
            M ETHNIC CATEGORY R "
            M MARITAL STATUS
            (psychiatric patients only)
            R "
            M NHS NUMBER STATUS INDICATOR R "
            M SEX R "
            M PREGNANCY TOTAL PREVIOUS PREGNANCIES   "
            O NAME FORMAT CODE R  
            O PATIENT NAME R  
            O ADDRESS FORMAT CODE    
            O PATIENT USUAL ADDRESS R  
            M POSTCODE OF USUAL ADDRESS R "
            M ORGANISATION CODE (PCT OF RESIDENCE) R "
            M ORGANISATION CODE TYPE R  
              Note:
            For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.
               
            (HCA) Hospital Provider Spell - Activity Characteristics:

            To carry the details of the Spell containing the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted.
            M HOSPITAL PROVIDER SPELL NUMBER R "
            M ADMINISTRATIVE CATEGORY
            (on admission)
            R "
            M PATIENT CLASSIFICATION R "
            M ADMISSION METHOD (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)   "
            M DISCHARGE METHOD (HOSPITAL PROVIDER SPELL)   "
            M SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) R "
            M START DATE (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DATE (HOSPITAL PROVIDER SPELL)   "
            (HCA) Consultant Episode - Activity Characteristics:

            To carry the details of the Consultant/ Midwife/ Nurse Episode undergone by the Patient. One occurrence of this Group is permitted.
            M EPISODE NUMBER R "
            M LAST EPISODE IN SPELL INDICATOR R "
            M OPERATION STATUS
            (per episode)
            R "
            M PSYCHIATRIC PATIENT STATUS R "
            M NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE R "
            M START DATE (EPISODE) R "
            M END DATE (EPISODE)   "
            (HCA) Consultant Episode - Service Agreement Details:

            To carry the details of the Service Agreement for the Consultant/ Midwife/ Nurse Episode.
            M COMMISSIONING SERIAL NUMBER R "
            O NHS SERVICE AGREEMENT LINE NUMBER R  
            O PROVIDER REFERENCE NUMBER    
            M COMMISSIONER REFERENCE NUMBER R  
            M ORGANISATION CODE (CODE OF PROVIDER) R "
            M ORGANISATION CODE TYPE    
            M ORGANISATION CODE (CODE OF COMMISSIONER) R "
            M ORGANISATION CODE TYPE    
            (HCA) Consultant Episode - Person Group (Consultant):

            To carry the details of the responsible Consultant, Midwife or Nurse. One occurrence of this Group is permitted.
            M CONSULTANT CODE R "
            M SPECIALTY FUNCTION CODE R "
            M MAIN SPECIALTY CODE R "
            M CONSULTANT SPECIALTY FUNCTION CODE R "
            M TREATMENT FUNCTION CODE R "
            (HCA) Consultant Episode - Clinical Information Group (ICD):

            To carry the details of the ICD Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            M DIAGNOSIS SCHEME IN USE    
            M PRIMARY DIAGNOSIS (ICD)   "
            M SECONDARY DIAGNOSIS (ICD)
            (1st to 12th, there may be up to 12 repetitions)
              "
            (HCA) Consultant Episode - Clinical Information Group (READ):

            To carry the details of the READ Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE    
            O PRIMARY DIAGNOSIS (READ)    
            O SECONDARY DIAGNOSIS (READ)
            (1st to 12th, there may be up to 12 repetitions)
               
            (HCA) Consultant Episode - Clinical Activity Group (OPCS):

            To carry the details of the OPCS coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            M PROCEDURE SCHEME IN USE    
            M PRIMARY PROCEDURE (OPCS)   "
            M PROCEDURE DATE   "
            M PROCEDURE (OPCS)
            (2nd to 12th, there may be up to 11 repetitions)
              "
            M PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
              "
            (HCA) Consultant Episode - Clinical Activity Group (READ):

            To carry the details of the READ coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            O PROCEDURE SCHEME IN USE    
            O PRIMARY PROCEDURE (READ)    
            O PROCEDURE DATE    
            O PROCEDURE (READ)
            (2nd to 12th, there may be up to 11 repetitions)
               
            O PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
               
            (HCA) Consultant Episode - Location Group - Start of Episode:

            To carry the details of the location at the start of the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS R  
            M SITE CODE (OF TREATMENT)
            (at start of episode)
            R "
            M ORGANISATION CODE TYPE R  
            O INTENDED CLINICAL CARE INTENSITY R "
            O AGE GROUP INTENDED R "
            O SEX OF PATIENTS R "
            O WARD DAY PERIOD AVAILABILITY R "
            O WARD NIGHT PERIOD AVAILABILITY R "
            (HCA) Consultant Episode - Location Group - Ward Stay:

            To carry the details of one or more Ward Stays. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            O LOCATION CLASS    
            O SITE CODE (OF TREATMENT)    
            O ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            O START DATE
            (at start of stay)
               
            O END DATE
            (at end of stay)
               
            (HCA) Consultant Episode - Location Group - End of Episode:

            To carry the details of the location at the end of the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            O LOCATION CLASS    
            O SITE CODE (OF TREATMENT)
            (at end of episode)
               
            O ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            (HCA) Augmented Care Period:

            To carry the details of the Augmented Care undergone by the Patient. Up to the 9 most recent Augmented Care Periods that occur during a Consultant/ Midwife/ Nurse Episode may be included.
            M AUGMENTED CARE PERIOD NUMBER R "
            O AUGMENTED CARE PERIOD LOCAL IDENTIFIER R "
            M START DATE (AUGMENTED CARE PERIOD) R "
            M AUGMENTED CARE PERIOD SOURCE R "
            M INTENSIVE CARE LEVEL DAYS R "
            M HIGH DEPENDENCY CARE LEVEL DAYS R "
            M NUMBER OF ORGAN SYSTEMS SUPPORTED
            for intensive care level only)
            R "
            M AUGMENTED CARE PLANNED INDICATOR R "
            M AUGMENTED CARE OUTCOME INDICATOR   "
            M AUGMENTED CARE PERIOD DISPOSAL   "
            M END DATE (AUGMENTED CARE PERIOD)   "
            M SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) R "
            M MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) R "
            M LOCATION CLASS R  
            M AUGMENTED CARE LOCATION R "
            (HCA) GP Registration:

            To carry the details of the Patient's Registered GMP. One occurrence of this Group is permitted.
            M GMP (CODE OF REGISTERED OR REFERRING GMP) R "
            O CODE OF GP PRACTICE (REGISTERED GMP) R "
            O ORGANISATION CODE TYPE    
            (HCA) Referral:

            To carry the details of the referrer. One occurrence of this Group is permitted.
            M REFERRER CODE R "
            M REFERRING ORGANISATION CODE R "
            M ORGANISATION CODE TYPE    
            (HCA) Pregnancy Activity Characteristics:

            To carry the number of babies resulting from this pregnancy. One occurrence of this Group is permitted.
            M NUMBER OF BABIES R "
            (HCA) Antenatal Care Activity Characteristics:

            To carry details of the start of the antenatal care. One occurrence of this Group is permitted.
            M FIRST ANTENATAL ASSESSMENT DATE R "
            (HCA) Antenatal Care Person Group (Responsible Clinician):

            To carry details of the responsible clinician. One occurrence of this Group is permitted.
            M GMP (CODE OF GMP RESPONSIBLE FOR ANTENATAL CARE) R  
            O CODE OF GP PRACTICE (REGISTERED GMP - ANTENATAL CARE)    
            O ORGANISATION CODE TYPE    
            (HCA) Antenatal Care Location Group (Delivery Place Intended):

            To carry details of the intended delivery place. One occurrence of this Group is permitted.
            M LOCATION CLASS R  
            M DELIVERY PLACE CHANGE REASON R "
            M DELIVERY PLACE TYPE (INTENDED) R "
            (HCA) Hospital Labour/Delivery Activity Characteristics:

            To carry details of the Labour/Delivery. One occurrence of this Group is permitted.
            M ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY R "
            M ANAESTHETIC GIVEN POST LABOUR OR DELIVERY R "
            O GESTATION LENGTH (LABOUR ONSET) R  
            M LABOUR OR DELIVERY ONSET METHOD R "
            M DELIVERY DATE R  
            (HCA) Birth Occurrence Activity Characteristics:

            To carry details of the birth occurrence(s). Up to nine occurrences of the Birth Group are permitted.
            M BIRTH ORDER R "
            M DELIVERY METHOD R "
            M GESTATION LENGTH (ASSESSMENT) R "
            M RESUSCITATION METHOD R "
            M STATUS OF PERSON CONDUCTING DELIVERY R "
            (HCA) Birth Occurrence Person Group (Baby):

            To carry the personal details of the birth occurrence(s). One occurrence of this Group within each Birth Group is permitted.
            O LOCAL PATIENT IDENTIFIER (BABY) R  
            O ORGANISATION CODE (LOCAL PATIENT IDENTIFIER (BABY)) R  
            O ORGANISATION CODE TYPE (BABY)    
            O NHS NUMBER (BABY) R  
            O NHS NUMBER STATUS INDICATOR (BABY) R  
            M BIRTH DATE (BABY) R "
            M BIRTH WEIGHT R "
            M LIVE OR STILL BIRTH R "
            M SEX (BABY) R "
            (HCA) Birth Occurrence Location - Delivery Place Actual:

            To carry the type of place where delivery actually occurred. One occurrence of this Group within each Birth Group is permitted.
            M LOCATION CLASS R  
            M DELIVERY PLACE TYPE (ACTUAL) R "
            (HCA) Healthcare Resource Group Activity - Activity Characteristics:

            To carry the details of the Healthcare Resource Group and will be mandatory from 01/10/2001. Each CDS may contain only a single occurrence of this Group.
            M HEALTHCARE RESOURCE GROUP CODE   "
            M HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER   "
            (HCA) Healthcare Resource Group Activity - Clinical Activity Group:

            To carry the details of the HRG Dominant Grouping Variable - Procedure. Note that this will not apply when no operation was carried out. In this case, the segment referring to HRG Dominant Grouping Variable - Procedure should be omitted. Only one Procedure either OPCS or READ may be specified
            O PROCEDURE SCHEME IN USE    
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE   "


            top

            ADMITTED PATIENT CARE CDS TYPE - DETAINED AND - OR LONG TERM PSYCHIATRIC CENSUS

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING DATA SET (CDS)

            ADMITTED PATIENT CARE CDS TYPE - DETAINED AND - OR LONG TERM PSYCHIATRIC CENSUS

            The Admitted Patient Care Detained and/or Long Term Psychiatric Census Commissioning Data Set Type carries the data for a Detained and/or Long Term Psychiatric Census. This is a snapshot of a general episode, unfinished as at 31 March, for which either the patient is detained or the episode is part of a Hospital Provider Spell which has lasted longer than one year and for which the majority of time has been spent under the care of a consultant in one of the psychiatric specialties.

            In the case of Trust mergers and demergers occurring, where the Hospital Provider Spell would have lasted longer than one year except for the merger/demerger, patients should be included. The Organisation Code (Code of Provider) will be that of the organisation in existence as at the 31st March census date.

            The column headed Opt (Optionality) shows whether the data element is Mandatory (M) or Optional (O) in the CDS.

            The column headed HES indicates whether the data element is extracted from the NWCS database for Hospital Episode Statistics. A filled circle in the column indicates that it is extracted if present, a blank indicates that it is not extracted. Note that HES records contain derived items. The table below indicates the base data from which these items are derived, and the CDS/HES cross reference table will show the derivation.

            Opt CDS data element U/A HES
            Person Group (Patient):

            To carry the personal details of the Patient. One occurrence of this Group is permitted.
            M LOCAL PATIENT IDENTIFIER   "
            M ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)    
            M ORGANISATION CODE TYPE    
            M NHS NUMBER   "
            M BIRTH DATE   "
            O CARER SUPPORT INDICATOR   "
            M LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION)   "
            M LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE)   "
            M ETHNIC CATEGORY   "
            M MARITAL STATUS   "
            M NHS NUMBER STATUS INDICATOR   "
            M SEX   "
            M DATE DETENTION COMMENCED   "
            M AGE AT CENSUS   "
            M DURATION OF CARE TO PSYCHIATRIC CENSUS DATE   "
            M DURATION OF DETENTION   "
            M MENTAL CATEGORY   "
            M STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS   "
            O NAME FORMAT CODE    
            O PATIENT NAME    
            O ADDRESS FORMAT CODE    
            O PATIENT USUAL ADDRESS    
            M POSTCODE OF USUAL ADDRESS   "
            M ORGANISATION CODE (PCT OF RESIDENCE)   "
            M ORGANISATION CODE TYPE    
              Note:
            For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.
               
            (HCA) Hospital Provider Spell - Activity Characteristics:

            To carry the details of the Spell containing the Consultant Episode on the Psychiatric Census Date. One occurrence of this Group is permitted.
            M HOSPITAL PROVIDER SPELL NUMBER   "
            M ADMINISTRATIVE CATEGORY
            (on admission)
              "
            M PATIENT CLASSIFICATION   "
            M ADMISSION METHOD (HOSPITAL PROVIDER SPELL)   "
            M DISCHARGE METHOD (HOSPITAL PROVIDER SPELL)   "
            M DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)   "
            M START DATE (HOSPITAL PROVIDER SPELL)   "
            (HCA) Consultant Episode - Activity Characteristics:

            To carry the details of the Consultant Episode on the Psychiatric Census Date. One occurrence of this Group is permitted.
            M EPISODE NUMBER   "
            M PSYCHIATRIC PATIENT STATUS   "
            M START DATE (CONSULTANT EPISODE)   "
            (HCA) Consultant Episode - Service Agreement Details:

            To carry the details of the Service Agreement for the Consultant Episode on the Psychiatric Census Date.
            M COMMISSIONING SERIAL NUMBER   "
            O NHS SERVICE AGREEMENT LINE NUMBER    
            O PROVIDER REFERENCE NUMBER    
            M COMMISSIONER REFERENCE NUMBER    
            M ORGANISATION CODE (CODE OF PROVIDER)   "
            M ORGANISATION CODE TYPE    
            M ORGANISATION CODE (CODE OF COMMISSIONER)   "
            M ORGANISATION CODE TYPE    
            (HCA) Consultant Episode - Person Group (Consultant):

            To carry the details of the responsible Consultant on the Psychiatric Census Date. One occurrence of this Group is permitted.
            M CONSULTANT CODE   "
            M SPECIALTY FUNCTION CODE   "
            M MAIN SPECIALTY CODE   "
            M CONSULTANT SPECIALTY FUNCTION CODE   "
            M TREATMENT FUNCTION CODE   "
            (HCA) Consultant Episode - Clinical Information Group (ICD):

            To carry the details of the ICD Diagnosis Scheme and the Diagnoses on the Psychiatric Census Date. Up to 13 occurrences of this Group are permitted.
            M DIAGNOSIS SCHEME IN USE    
            M PRIMARY DIAGNOSIS (ICD)   "
            M SECONDARY DIAGNOSIS (ICD)
            (1st to 12th, there may be up to 12 repetitions)
              "
            (HCA) Consultant Episode - Clinical Information Group (READ):

            To carry the details of the READ Diagnosis Scheme and the Diagnoses on the Psychiatric Census Date. Up to 13 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE    
            O PRIMARY DIAGNOSIS (READ)    
            O SECONDARY DIAGNOSIS (READ)
            (1st to 12th, there may be up to 12 repetitions)
               
            (HCA) Consultant Episode - Location Group - Start of Episode:

            To carry the details of the Ward Type at the start of the Consultant Episode. One occurrence of this Group is permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)
            (at start of episode)
              "
            M ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY   "
            O AGE GROUP INTENDED   "
            O SEX OF PATIENTS   "
            O WARD DAY PERIOD AVAILABILITY   "
            O WARD NIGHT PERIOD AVAILABILITY   "
            (HCA) Consultant Episode - Location Group - Ward Stay at Psychiatric Census Date:

            To carry the details of the Ward Type at Psychiatric Census Date. One occurrence of this Group is permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)   "
            M ORGANISATION CODE TYPE    
            M INTENDED CLINICAL CARE INTENSITY   "
            M AGE GROUP INTENDED   "
            M SEX OF PATIENTS   "
            M WARD DAY PERIOD AVAILABILITY   "
            M WARD NIGHT PERIOD AVAILABILITY   "
            M DETAINED AND (OR) LONG TERM PSYCHIATRIC CENSUS DATE   "
            (HCA) GP Registration:

            To carry the details of the Patient's Registered GMP. One occurrence of this Group is permitted.
            M GMP (CODE OF REGISTERED OR REFERRING GMP)   "
            O CODE OF GP PRACTICE (REGISTERED GMP)   "
            O ORGANISATION CODE TYPE    
            (HCA) Referral:

            To carry the details of the referrer. One occurrence of this Group is permitted.
            M REFERRER CODE   "
            M REFERRING ORGANISATION CODE   "
            M ORGANISATION CODE TYPE    
            (HCA) Elective Admission List Entry:

            To carry the details of the Elective Admission List Entry. One occurrence of this Group is permitted.
            M DURATION OF ELECTIVE WAIT   "
            M INTENDED MANAGEMENT   "
            M DECIDED TO ADMIT DATE
            (for this provider)
              "
            (HCA) Healthcare Resource Group Activity - Activity Characteristics:

            To carry the details of the Healthcare Resource Group where required. If users do not want to send HRGs, the segments may be omitted. Each CDS may contain only a single occurrence of this Group.
            O HEALTHCARE RESOURCE GROUP CODE   "
            O HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER   "
            (HCA) Healthcare Resource Group Activity - Clinical Activity Group:

            To carry the details of the HRG Dominant Grouping Variable - Procedure. Only one Procedure either OPCS or READ may be specified
            O PROCEDURE SCHEME IN USE    
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE   "


            top

            ADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODE

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING DATA SET (CDS)

            ADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODE

            The Admitted Patient Care General Episode Commissioning Data Set Type carries the data for a finished or unfinished General Consultant/ Midwife/ Nurse Episode. It covers all NHS and private Admitted Patient Care (day case and inpatient) activity taking place in any acute, community, psychiatric NHS Trust or Primary Care Trust or other NHS hospital under the care of a consultant, midwife or nurse. Additionally, NHS funded Admitted Patient Care taking place in non-NHS hospitals and institutions is required.

            The column headed Opt (Optionality) shows whether the data element is Mandatory M or Optional O.

            The column headed U/A (Unfinished Episode / Annual Census) indicates whether the data element is required to be recorded on an unfinished Consultant/ Midwife/ Nurse Episode record and on an End of Year Census record. An R in the U/A column idicates that it is required to be present, a blank indicates that it is not required to be present.

            An Unfinished General Episode record is required for all unfinished general episodes at midnight on 31 March. Unfinished General Episode records are also required for short-stay informal psychiatric patients who are resident in hospital or on leave of absence (home leave) on 31 March and who have been in hospital for less than 12 months.

            The column headed HES indicates whether the data element is extracted from the NWCS database for Hospital Episode Statistics. A filled circle in the column indicates that it is extracted if present, a blank indicates that it is not extracted. Note that HES records contain derived items. The table below indicate the base data from which these items are derived, and the CDS/HES cross reference table will show the derivation.

            Opt CDS data element U/A HES
            Person Group (Patient):

            To carry the personal details of the Patient. One occurrence of this Group is permitted.
            M LOCAL PATIENT IDENTIFIER R "
            M ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) R  
            M ORGANISATION CODE TYPE R  
            M NHS NUMBER R "
            M BIRTH DATE R "
            O CARER SUPPORT INDICATOR R "
            M LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION)
            (psychiatric patients only)
            R "
            M ETHNIC CATEGORY R "
            M MARITAL STATUS
            (psychiatric patients only)
            R "
            M NHS NUMBER STATUS INDICATOR R "
            M SEX R "
            O NAME FORMAT CODE R  
            O PATIENT NAME R  
            O ADDRESS FORMAT CODE    
            O PATIENT USUAL ADDRESS R  
            M POSTCODE OF USUAL ADDRESS R "
            M ORGANISATION CODE (PCT OF RESIDENCE) R "
            M ORGANISATION CODE TYPE R  
              Note:
            For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.
               
            (HCA) Hospital Provider Spell - Activity Characteristics:

            To carry the details of the Spell containing the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted.
            M HOSPITAL PROVIDER SPELL NUMBER R "
            M ADMINISTRATIVE CATEGORY
            (on admission)
            R "
            M PATIENT CLASSIFICATION R "
            M ADMISSION METHOD (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)   "
            M DISCHARGE METHOD (HOSPITAL PROVIDER SPELL)   "
            M SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) R "
            M START DATE (HOSPITAL PROVIDER SPELL) R "
            M DISCHARGE DATE (HOSPITAL PROVIDER SPELL)   "
            (HCA) Consultant Episode - Activity Characteristics:

            To carry the details of the Consultant/ Midwife/ Nurse Episode undergone by the Patient. One occurrence of this Group is permitted.
            M EPISODE NUMBER R "
            M FIRST REGULAR DAY OR NIGHT ADMISSION R "
            M LAST EPISODE IN SPELL INDICATOR R "
            M NEONATAL LEVEL OF CARE R "
            M OPERATION STATUS
            (per episode)
            R "
            M PSYCHIATRIC PATIENT STATUS R "
            M NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE R "
            M START DATE (EPISODE) R "
            M END DATE (EPISODE)   "
            (HCA) Consultant Episode - Service Agreement Details:

            To carry the details of the Service Agreement for the Consultant/ Midwife/ Nurse Episode.
            M COMMISSIONING SERIAL NUMBER R "
            O NHS SERVICE AGREEMENT LINE NUMBER R  
            O PROVIDER REFERENCE NUMBER    
            M COMMISSIONER REFERENCE NUMBER R  
            M ORGANISATION CODE (CODE OF PROVIDER) R "
            M ORGANISATION CODE TYPE    
            M ORGANISATION CODE (CODE OF COMMISSIONER) R "
            M ORGANISATION CODE TYPE    
            (HCA) Consultant Episode - Person Group (Consultant):

            To carry the details of the responsible Consultant, Midwife or Nurse. One occurrence of this Group is permitted.
            M CONSULTANT CODE R "
            M SPECIALTY FUNCTION CODE R "
            M MAIN SPECIALTY CODE R "
            M CONSULTANT SPECIALTY FUNCTION CODE R "
            M TREATMENT FUNCTION CODE R "
            (HCA) Consultant Episode - Clinical Information Group (ICD):

            To carry the details of the ICD Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            M DIAGNOSIS SCHEME IN USE    
            M PRIMARY DIAGNOSIS (ICD)   "
            M SECONDARY DIAGNOSIS (ICD)
            (1st to 12th, there may be up to 12 repetitions)
              "
            (HCA) Consultant Episode - Clinical Information Group (READ):

            To carry the details of the READ Diagnosis Scheme and the Diagnoses. Up to 13 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE    
            O PRIMARY DIAGNOSIS (READ)    
            O SECONDARY DIAGNOSIS (READ)
            (1st to 12th, there may be up to 12 repetitions)
               
            (HCA) Consultant Episode - Clinical Activity Group (OPCS):

            To carry the details of the OPCS coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            M PROCEDURE SCHEME IN USE    
            M PRIMARY PROCEDURE (OPCS)   "
            M PROCEDURE DATE   "
            M PROCEDURE (OPCS)
            (2nd to 12th, there may be up to 11 repetitions)
              "
            M PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
              "
            (HCA) Consultant Episode - Clinical Activity Group (READ):

            To carry the details of the READ coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            O PROCEDURE SCHEME IN USE    
            O PRIMARY PROCEDURE (READ)    
            O PROCEDURE DATE    
            O PROCEDURE (READ)
            (2nd to 12th, there may be up to 11 repetitions)
               
            O PROCEDURE DATE
            (2nd to 12th, there may be up to 11 repetitions)
               
            (HCA) Consultant Episode - Location Group - Start of Episode:

            To carry the details of the location at the start of the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS R  
            M SITE CODE (OF TREATMENT)
            (at start of episode)
            R "
            M ORGANISATION CODE TYPE R  
            O INTENDED CLINICAL CARE INTENSITY R "
            O AGE GROUP INTENDED R "
            O SEX OF PATIENTS R "
            O WARD DAY PERIOD AVAILABILITY R "
            O WARD NIGHT PERIOD AVAILABILITY R "
            (HCA) Consultant Episode - Location Group - Ward Stay:

            To carry the details of one or more Ward Stays. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)    
            M ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            O START DATE
            (at start of stay)
               
            O END DATE
            (at end of stay)
               
            (HCA) Consultant Episode - Location Group - End of Episode:

            To carry the details of the location at the end of the Consultant/ Midwife/ Nurse Episode. One occurrence of this Group is permitted. Up to 99 occurrences of Location Groups (in total - all types) are permitted.
            M LOCATION CLASS    
            M SITE CODE (OF TREATMENT)
            (at end of episode)
               
            M ORGANISATION CODE TYPE    
            O INTENDED CLINICAL CARE INTENSITY    
            O AGE GROUP INTENDED    
            O SEX OF PATIENTS    
            O WARD DAY PERIOD AVAILABILITY    
            O WARD NIGHT PERIOD AVAILABILITY    
            (HCA) Augmented Care Period:

            To carry the details of the Augmented Care undergone by the Patient. Up to the 9 most recent Augmented Care Periods that occur during a Consultant/ Midwife/ Nurse Episode may be included.
            M AUGMENTED CARE PERIOD NUMBER R "
            O AUGMENTED CARE PERIOD LOCAL IDENTIFIER R "
            M START DATE (AUGMENTED CARE PERIOD) R "
            M AUGMENTED CARE PERIOD SOURCE R "
            M INTENSIVE CARE LEVEL DAYS R "
            M HIGH DEPENDENCY CARE LEVEL DAYS R "
            M NUMBER OF ORGAN SYSTEMS SUPPORTED
            for intensive care level only)
            R "
            M AUGMENTED CARE PLANNED INDICATOR R "
            M AUGMENTED CARE OUTCOME INDICATOR   "
            M AUGMENTED CARE PERIOD DISPOSAL   "
            M END DATE (AUGMENTED CARE PERIOD)   "
            M SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) R "
            M MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) R "
            M LOCATION CLASS R  
            M AUGMENTED CARE LOCATION R "
            (HCA) GP Registration:

            To carry the details of the Patient's Registered GMP. One occurrence of this Group is permitted.
            M GMP (CODE OF REGISTERED OR REFERRING GMP) R "
            O CODE OF GP PRACTICE (REGISTERED GMP) R "
            O ORGANISATION CODE TYPE R  
            (HCA) Referral:

            To carry the details of the referrer. One occurrence of this Group is permitted.
            M REFERRER CODE R "
            M REFERRING ORGANISATION CODE R "
            M ORGANISATION CODE TYPE R  
            (HCA) Elective Admission List Entry:

            To carry the details of the Elective Admission List Entry. One occurrence of this Group is permitted.
            M DURATION OF ELECTIVE WAIT R "
            M INTENDED MANAGEMENT R "
            M DECIDED TO ADMIT DATE
            (for this provider)
            R "
            (HCA) Healthcare Resource Group Activity - Activity Characteristics:

            To carry the details of the Healthcare Resource Group. This is mandatory from 01/10/2001. One occurrence of this Group is permitted.
            M HEALTHCARE RESOURCE GROUP CODE   "
            M HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER   "
            (HCA) Healthcare Resource Group Activity - Clinical Activity Group:

            To carry the details of the HRG Dominant Grouping Variable - Procedure. Note that this will not apply when no operation was carried out. In this case, the segment referring to HRG Dominant Grouping Variable - Procedure should be omitted. Only one Procedure either OPCS or READ may be specified
            O PROCEDURE SCHEME IN USE    
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE   "


            top

            ELECTIVE ADMISSION LIST CMDS-END OF PERIOD CENSUS

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING MINIMUM DATA SET (CMDS)

            ELECTIVE ADMISSION LIST CMDS-End of Period Census

            The Elective Admission List CMDS is split into two data sets or lists of data items. The first data set consists of records of individual patients waiting for elective admission at a specified point in time, called the End of Period Census. The mandatory End of Period Census CMDS must flow for all booked, planned and waiting list admissions.

            The End of Period Census carries details of all patients currently on an Elective Admission List. For this reason the Removal Details are not included in the Census, since they apply to patients who have been taken off the list. If agreed locally, the Removal details may be included in the End of Period Census, to give a complete picture of a patient's waiting list experience.

            The information should be sent within one month of the end of the period to which it relates, unless a shorter time scale has been stipulated by the recipient. For example, the information for April should be sent by the end of May.

            In the table below, the column headed Opt shows the optionality with M denoting Mandatory and O denoting Optional.

            Opt CMDS Data Item
            Commissioning Details
            M ORGANISATION CODE (CODE OF PROVIDER)
            M ORGANISATION CODE (CODE OF COMMISSIONER)
            M COMMISSIONING SERIAL NUMBER
            O NHS SERVICE AGREEMENT LINE NUMBER
            M COMMISSIONER REFERENCE NUMBER
            Patient Details
            M NHS NUMBER
            M NHS NUMBER STATUS INDICATOR
            O PATIENT NAME
            O NAME FORMAT CODE
            O PATIENT USUAL ADDRESS
            M POSTCODE OF USUAL ADDRESS
            M ORGANISATION CODE (PCT OF RESIDENCE)
            M SEX
            O CARER SUPPORT INDICATOR
            M BIRTH DATE
            M BIRTH DATE STATUS
            M GMP (CODE OF REGISTERED OR REFERRING GMP)
            O CODE OF GP PRACTICE (REGISTERED GMP)
            M LOCAL PATIENT IDENTIFIER
            Referral Details
            M REFERRER CODE
            M REFERRING ORGANISATION CODE
            Elective Admission List Details
            M ELECTIVE ADMISSION LIST ENTRY NUMBER
            M ADMINISTRATIVE CATEGORY
            M ELECTIVE ADMISSION TYPE
            M DECIDED TO ADMIT DATE
            (for this provider)
            M DECIDED TO ADMIT DATE STATUS
            M ORIGINAL DECIDED TO ADMIT DATE
            M ORIGINAL DECIDED TO ADMIT DATE STATUS
            O GUARANTEED ADMISSION DATE
            O GUARANTEED ADMISSION DATE STATUS
            M INTENDED PROCEDURE STATUS
            O INTENDED PROCEDURE (OPCS)
            O INTENDED PROCEDURE 2 (OPCS)
            O INTENDED PROCEDURE 3 (OPCS)
            O INTENDED PROCEDURE (READ)
            O INTENDED PROCEDURE 2 (READ)
            O INTENDED PROCEDURE 3 (READ)
            M INTENDED MANAGEMENT
            O INTENDED SITE CODE (OF TREATMENT)
            M PRIORITY TYPE
            (new patients)
            M ELECTIVE ADMISSION LIST STATUS
            M SPECIALTY FUNCTION CODE
            M MAIN SPECIALTY CODE
            M CONSULTANT SPECIALTY FUNCTION CODE
            M TREATMENT FUNCTION CODE
            O LOCAL SUB-SPECIALTY CODE
            M CONSULTANT CODE
            M DATE OF ELECTIVE ADMISSION LIST CENSUS
            M LAST DNA OR PATIENT CANCELLED DATE
            M LAST DNA OR PATIENT CANCELLED DATE STATUS
            O WAITING LIST ENTRY LAST REVIEWED DATE
            O WAITING LIST ENTRY LAST REVIEWED DATE STATUS
            Commissioning Change Details
            O NHS SERVICE AGREEMENT CHANGE TYPE
            O NHS SERVICE AGREEMENT CHANGE DATE
            O NHS SERVICE AGREEMENT CHANGE DATE STATUS
            Suspension Details
            M COUNT OF DAYS SUSPENDED
            Offer of Admission Details
            M OFFERED FOR ADMISSION DATE
            M OFFERED FOR ADMISSION DATE STATUS
            O ADMISSION OFFER OUTCOME
            Healthcare Resource Group Details
            O HEALTHCARE RESOURCE GROUP CODE
            O HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE

            top


            ELECTIVE ADMISSION LIST CMDS-EVENT DURING PERIOD

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING MINIMUM DATA SET (CMDS)

            ELECTIVE ADMISSION LIST CMDS-Event During Period

            The Event During Period CMDS gives details of all events - patients added or removed from the Elective Admission List - that have taken place during the period.

            This CMDS is intended from those providers / commissioners who have the capability to implement transaction-based processing.

            The optional Event During Period CMDSs, if implemented, should flow as required, i.e. whenever an event takes place. They should be supplemented by an annual End of Period Census.

            In the table below, the column headed Opt shows the optionality with M denoting Mandatory and O denoting Optional.

            Opt CMDS Data Item
            Commissioning Details
            M ORGANISATION CODE (CODE OF PROVIDER)
            M ORGANISATION CODE (CODE OF COMMISSIONER)
            M COMMISSIONING SERIAL NUMBER
            O NHS SERVICE AGREEMENT LINE NUMBER
            M COMMISSIONER REFERENCE NUMBER
            Patient Details
            M NHS NUMBER
            M NHS NUMBER STATUS INDICATOR
            O PATIENT NAME
            O NAME FORMAT CODE
            O PATIENT USUAL ADDRESS
            M POSTCODE OF USUAL ADDRESS
            M ORGANISATION CODE (PCT OF RESIDENCE)
            M SEX
            O CARER SUPPORT INDICATOR
            M BIRTH DATE
            M BIRTH DATE STATUS
            M GMP (CODE OF REGISTERED OR REFERRING GMP)
            O CODE OF GP PRACTICE (REGISTERED GMP)
            M LOCAL PATIENT IDENTIFIER
            Referral Details
            M REFERRER CODE
            M REFERRING ORGANISATION CODE
            Elective Admission List Details
            M ELECTIVE ADMISSION LIST ENTRY NUMBER
            M ELECTIVE ADMISSION LIST RECORD TYPE
            M ADMINISTRATIVE CATEGORY
            M ELECTIVE ADMISSION TYPE
            M DECIDED TO ADMIT DATE
            (for this provider)
            M DECIDED TO ADMIT DATE STATUS
            M ORIGINAL DECIDED TO ADMIT DATE
            M ORIGINAL DECIDED TO ADMIT DATE STATUS
            O GUARANTEED ADMISSION DATE
            O GUARANTEED ADMISSION DATE STATUS
            M INTENDED PROCEDURE STATUS
            O INTENDED PROCEDURE (OPCS)
            O INTENDED PROCEDURE 2 (OPCS)
            O INTENDED PROCEDURE 3 (OPCS)
            O INTENDED PROCEDURE (READ)
            O INTENDED PROCEDURE 2 (READ)
            O INTENDED PROCEDURE 3 (READ)
            M INTENDED MANAGEMENT
            O INTENDED SITE CODE (OF TREATMENT)
            M PRIORITY TYPE
            (new patients)
            M ELECTIVE ADMISSION LIST STATUS
            M SPECIALTY FUNCTION CODE
            M MAIN SPECIALTY CODE
            M CONSULTANT SPECIALTY FUNCTION CODE
            M TREATMENT FUNCTION CODE
            O LOCAL SUB-SPECIALTY CODE
            M CONSULTANT CODE
            M LAST DNA OR PATIENT CANCELLED DATE
            M LAST DNA OR PATIENT CANCELLED DATE STATUS
            O WAITING LIST ENTRY LAST REVIEWED DATE
            O WAITING LIST ENTRY LAST REVIEWED DATE STATUS
            Commissioning Change Details
            O NHS SERVICE AGREEMENT CHANGE TYPE
            O NHS SERVICE AGREEMENT CHANGE DATE
            O NHS SERVICE AGREEMENT CHANGE DATE STATUS
            Suspension Details
            M SUSPENSION START DATE
            M SUSPENSION START DATE STATUS
            M SUSPENSION END DATE
            M SUSPENSION END DATE STATUS
            Offer of Admission Details
            M OFFERED FOR ADMISSION DATE
            M OFFERED FOR ADMISSION DATE STATUS
            O ADMISSION OFFER OUTCOME
            Elective Admission Removal Details
            M ELECTIVE ADMISSION LIST REMOVAL DATE
            M ELECTIVE ADMISSION LIST REMOVAL DATE STATUS
            M ELECTIVE ADMISSION LIST REMOVAL REASON
            Healthcare Resource Group Details
            O HEALTHCARE RESOURCE GROUP CODE
            O HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER
            O HRG DOMINANT GROUPING VARIABLE-PROCEDURE


            top

            GP REFERRAL LETTER CMDS

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING MINIMUM DATA SET (CMDS)

            GP REFERRAL LETTER CMDS

            This data set contains details about the commissioned provider, the patient and the referral itself. Clinical details are not part of the data set but are usually included in the letter.

            Unlike most of the data sets covered in the NHS Data Dictionary, the GP Referrral Letter data set is received from GPs, rather than sent to them, and is used to input details of the referral into the hospital computer system.

            The information required about the patient is the standard data set. The OVERSEAS VISTORS STATUS CLASSIFICATION is required to indicate whether a patient not normally resident in the UK should pay for the services provided.

            The referral details identify the GP and the Practice from which the referral is made, the CORRESPONDENCE ADDRESS and GP CONTACT TELEPHONE NUMBERS identifies the contact address and telephone number specifically for contact regarding the referral.

            In the table below, the column headed Opt shows the optionality with M denoting Mandatory and O denoting Optional.

            Opt CMDS Data Item
            Commissioning Details
            M ORGANISATION CODE (CODE OF PROVIDER)
            M ORGANISATION CODE (CODE OF COMMISSIONER)
            M COMMISSIONING SERIAL NUMBER
            Patient Details
            M NHS NUMBER
            O NHS NUMBER STATUS INDICATOR
            O PATIENT NAME
            O PATIENT USUAL ADDRESS
            M POSTCODE OF USUAL ADDRESS
            M SEX
            M BIRTH DATE
            M BIRTH DATE STATUS
            M GMP (CODE OF REGISTERED OR REFERRING GMP)
            M GP NAME (NAME OF REGISTERED OR REFERRING GMP)
            M OVERSEAS VISITORS STATUS CLASSIFICATION
            Referral Details
            M GMP (CODE OF REGISTERED OR REFERRING GMP)
            M GP NAME (NAME OF REGISTERED OR REFERRING GMP)
            M CODE OF GP PRACTICE (REFERRING PRACTICE)
            M CORRESPONDENCE ADDRESS
            M POSTCODE OF CORRESPONDENCE ADDRESS
            M GP CONTACT TELEPHONE NUMBER
            M REFERRAL REQUEST RECEIVED DATE
            M REFERRAL REQUEST RECEIVED DATE STATUS
            M CONSULTANT CODE
            M SPECIALTY FUNCTION CODE
            M TREATMENT FUNCTION CODE
            M LOCAL PATIENT IDENTIFIER


            top

            HES - CDS DATA ITEMS CROSS REFERENCED BY HES ITEM - TABLE 2

            Change to Data Set (CDS, CMDS, HES): Change to Table

            HOSPITAL EPISODE STATISTICS (HES)

            HES / CDS Data Elements cross referenced by HES Item - Table 2
            CDS Type key:

            G = General Episode
            D = Delivery Episode
            B = Birth Episode
            PC = Detained and or Long Term Psychiatric Census
            OD = Other Delivery
            OB = Other Birth

            " = Mandatory for this CDS Type
            O = Optional for this CDS Type

            HES Item HES Name CDS Data Element CDS TYPE
            G D B PC OD OB
            ADMINISTRATIVE CATEGORY (on admission) ADMINCAT ADMINISTRATIVE CATEGORY (on admission) " " " "    
            ADMISSION METHOD (HOSPITAL PROVIDER SPELL) ADMIMETH ADMISSION METHOD (HOSPITAL PROVIDER SPELL) " " " "    
            AGE AT CENSUS CENSAGE AGE AT CENSUS       "    
            ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY DELPREAN ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY   " "   " "
            ANAESTHETIC GIVEN POST LABOUR OR DELIVERY DELPOSAN ANAESTHETIC GIVEN POST LABOUR OR DELIVERY   " "   " "
            AUGMENTED CARE LOCAL IDENTIFIER APLOCID AUGMENTED CARE PERIOD LOCAL IDENTIFIER O O O      
            AUGMENTED CARE LOCATION ACPLOC AUGMENTED CARE LOCATION " " "      
            AUGMENTED CARE OUTCOME INDICATOR ACPOUT AUGMENTED CARE OUTCOME INDICATOR " " "      
            AUGMENTED CARE PERIOD DISPOSAL ACPDISP AUGMENTED CARE PERIOD DISPOSAL " " "      
            AUGMENTED CARE PERIOD NUMBER ACPN AUGMENTED CARE PERIOD NUMBER " " "      
            AUGMENTED CARE PERIOD SOURCE ACPSOUR AUGMENTED CARE PERIOD SOURCE " " "      
            AUGMENTED CARE PLANNED INDICATOR ACPPLAN AUGMENTED CARE PLANNED INDICATOR " " "      
            BIRTH DATE DOB BIRTH DATE " " " " " "
            BIRTH DATE (BABY) DOBBABY BIRTH DATE (BABY)   "     "  
            BIRTH DATE (MOTHER) MOTDOB BIRTH DATE (MOTHER)     "     "
            BIRTH ORDER BIRORDER BIRTH ORDER   " "   " "
            BIRTH WEIGHT BIRWEIT BIRTH WEIGHT   " "   " "
            CARER SUPPORT INDICATOR CARERSI CARER SUPPORT INDICATOR O   O O    
            CATEGORY OF PATIENT CATEGORY Not in CDS            
            CODE OF GP PRACTICE (REGISTERED GMP) GPPRAC CODE OF GP PRACTICE (REGISTERED GMP) O O O O O O
            COMMISSIONING SERIAL NUMBER CSNUM COMMISSIONING SERIAL NUMBER " " " " " "
            CONSULTANT CODE CONSULT CONSULTANT CODE " " " "    
            CONSULTANT SPECIALTY FUNCTION CODE TRETSPEF CONSULTANT SPECIALTY FUNCTION CODE " " " "    
            DATE DETENTION COMMENCED DETNDATE DATE DETENTION COMMENCED       "    
            DECIDED TO ADMIT DATE ELECDATE DECIDED TO ADMIT DATE (for this provider) "     "    
            DELIVERY METHOD DELMETH DELIVERY METHOD   " "   " "
            DELIVERY PLACE CHANGE REASON DELCHANG DELIVERY PLACE CHANGE REASON   " "   " "
            DELIVERY PLACE TYPE (ACTUAL) DELPLACE DELIVERY PLACE TYPE (ACTUAL)   " "   " "
            DELIVERY PLACE TYPE (INTENDED) DELINTEN DELIVERY PLACE TYPE (INTENDED)   " "   " "
            DETAINED AND OR LONG TERM PSYCHIATRIC CENSUS DATE CENDATE DETAINED AND (OR) LONG TERM PSYCHIATRIC CENSUS DATE       "    
            DISCHARGE DATE (HOSPITAL PROVIDER SPELL) DISDATE DISCHARGE DATE (HOSPITAL PROVIDER SPELL) " " "      
            DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) DISDEST DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) " " "      
            DISCHARGE METHOD (HOSPITAL PROVIDER SPELL) DISMETH DISCHARGE METHOD (HOSPITAL PROVIDER SPELL) " " "      
            DURATION OF CARE TO PSYCHIATRIC CENSUS DATE CENDUR DURATION OF CARE TO PSYCHIATRIC CENSUS DATE       "    
            DURATION OF DETENTION DETDUR DURATION OF DETENTION       "    
            DURATION OF ELECTIVE WAIT ELECDUR DURATION OF ELECTIVE WAIT "     "    
            END DATE (AUGMENTED CARE PERIOD) ACPEND END DATE (AUGMENTED CARE PERIOD) " " "      
            END DATE (CONSULTANT, NURSE OR MIDWIFE EPISODE) EPIEND END DATE (EPISODE) " " "      
            EPISODE NUMBER EPIORDER EPISODE NUMBER " " " "    
            EPISODE STATUS EPISTAT Not in CDS            
            EPISODE TYPE EPITYPE Not in CDS            
            ETHNIC CATEGORY ETHNOS ETHNIC CATEGORY " " O " " O
            FIRST ANTENATAL ASSESSMENT DATE ANASDATE FIRST ANTENATAL ASSESSMENT DATE   " "   " "
            FIRST REGULAR DAY OR NIGHT ADMISSION FIRSTREG FIRST REGULAR DAY OR NIGHT ADMISSION "          
            GESTATION LENGTH GESTAT GESTATION LENGTH   " "   " "
            GMP (CODE OF REGISTERED OR REFERRING GMP) REGGMP GMP (CODE OF REGISTERED OR REFERRING GMP) " " " " " "
            HEALTHCARE RESOURCE GROUP CODE HRGNHS HEALTHCARE RESOURCE GROUP CODE " " " "    
            HEALTHCARE RESOURCE GROUP CODE - VERSION NUMBER HRGNHSVN HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER " " " "    
            HIGH DEPENDENCY CARE LEVEL DAYS DEPDAYS HIGH DEPENDENCY CARE LEVEL DAYS " " "      
            HOSPITAL PROVIDER SPELL NUMBER PROVSPNO HOSPITAL PROVIDER SPELL NUMBER " " " "    
            HRG DOMINANT GROUPING VARIABLE - PROCEDURE DOMPROC HRG DOMINANT GROUPING VARIABLE-PROCEDURE O O O O    
            INTENDED MANAGEMENT INTMANIG INTENDED MANAGEMENT "     "    
            INTENSIVE CARE LEVEL DAYS INTDAYS INTENSIVE CARE LEVEL DAYS " " "      
            LABOUR OR DELIVERY ONSET METHOD DELONSET LABOUR OR DELIVERY ONSET METHOD   " "   " "
            LAST EPISODE IN SPELL INDICATOR SPELEND LAST EPISODE IN SPELL INDICATOR " " "      
            LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE) LEGLSTAT LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE)       "    
            LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION) LEGLCAT LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION) " "   "    
            LIVE OR STILL BIRTH BIRSTATE LIVE OR STILL BIRTH   " "   " "
            LOCAL PATIENT IDENTIFIER LOPATID LOCAL PATIENT IDENTIFIER " " " " " "
            MAIN SPECIALTY CODE MAINSPEF MAIN SPECIALTY CODE " " " "    
            MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) ACPSPEF MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) " " "      
            MARITAL STATUS MARSTAT MARITAL STATUS " "   " "  
            MENTAL CATEGORY MENTCAT MENTAL CATEGORY       "    
            NEONATAL LEVEL OF CARE NEOCARE NEONATAL LEVEL OF CARE "   "      
            NHS NUMBER NEWNHSNO NHS NUMBER " " O O " O
            NHS NUMBER STATUS INDICATOR NHSNOIND NHS NUMBER STATUS INDICATOR " " " " " "
            NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE NUMACP NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE " " "      
            NUMBER OF BABIES NUMBABY NUMBER OF BABIES   " "   " "
            NUMBER OF ORGAN SYSTEMS SUPPORTED (for intensive care level only) ORGSUP NUMBER OF ORGAN SYSTEMS SUPPORTED " " "      
            OPERATION (OPCS-4) OPERATN2
            - OPERATN12
            PROCEDURE (OPCS) " " "      
            OPERATION STATUS (per episode) OPERSTAT OPERATION STATUS (per episode) " " "      
            ORGANISATION CODE (CODE OF COMMISSIONER) PURCODE ORGANISATION CODE (CODE OF COMMISSIONER) " " " " " "
            ORGANISATION CODE (CODE OF PROVIDER) PROCODE ORGANISATION CODE (CODE OF PROVIDER) " " " " " "
            ORGANISATION CODE (PCT OF RESIDENCE) PCTR ORGANISATION CODE " " " " " "
            PATIENT CLASSIFICATION CLASSPAT PATIENT CLASSIFICATION " " " "    
            POSTCODE OF USUAL ADDRESS HOMEADD POSTCODE OF USUAL ADDRESS " " " " " "
            PREGNANCY TOTAL PREVIOUS PREGNANCIES NUMPREG PREGNANCY TOTAL PREVIOUS PREGNANCIES   "     "  
            PRIMARY (ICD-10) CENDIAG1 PRIMARY DIAGNOSIS (ICD)       "    
            PRIMARY (ICD-10) DIAG_1 PRIMARY DIAGNOSIS (ICD) " " "      
            PRIMARY OPERATION (OPCS-4) OPERATN1 PRIMARY OPERATION (OPCS-4) " " "      
            PRIMARY PROCEDURE DATE OPDATE1 PROCEDURE DATE " " "      
            PSYCHIATRIC PATIENT STATUS ADMISTAT PSYCHIATRIC PATIENT STATUS " "   "    
            RECORD TYPE RECTYPE Not in CDS            
            REFERRER CODE REFERRER REFERRER CODE " " " "    
            REFERRING ORGANISATION CODE REFERORG REFERRING ORGANISATION CODE " " " "    
            RESUCITATION METHOD BIRRESUS RESUSCITATION METHOD   " "   " "
            SECOND - TWELFTH OPERATION DATE OPDATE2
            - OPDATE 12
            PROCEDURE DATE " " "      
            SECONDARY (ICD-10) CENDIAG3
            - CENDIAG14
            SECONDARY DIAGNOSIS (ICD)       "    
            SECONDARY (ICD-10) DIAG_3
            - DIAG_14
            SECONDARY DIAGNOSIS (ICD) " " "      
            SEX SEX SEX " " " " " "
            SEX (BABY) SEXBABY SEX (BABY)   "     "  
            SITE CODE (OF TREATMENT) (at start of episode) SITETRET SITE CODE (OF TREATMENT) " " " "    
            SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) ADMISORC SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) " " " "    
            SPECIALTY FUNCTION CODE MAINSPEF SPECIALTY FUNCTION CODE " " " "    
            SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) ACPSPEF SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) " " "      
            START DATE (AUGMENTED CARE PERIOD) ACPSTAR START DATE (AUGMENTED CARE PERIOD) " " "      
            START DATE (CONSULTANT, NURSE OR MIDWIFE EPISODE) EPISTART START DATE (EPISODE) " " " "    
            START DATE (HOSPITAL PROVIDER SPELL) ADMIDATE START DATE (HOSPITAL PROVIDER SPELL) " " " "    
            STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS CENSAT STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS       "    
            STATUS OF PERSON CONDUCTING DELIVERY DELSTAT STATUS OF PERSON CONDUCTING DELIVERY   " "   " "
            TREATMENT FUNCTION CODE TRETSPEF TREATMENT FUNCTION CODE " " " "    
            WARD TYPE AT PSYCHIATRIC CENSUS DATE CENWARD Not in CDS            
            WARD TYPE AT START OF EPISODE WARDSTRT Not in CDS            


            top

            HES - CDS DATA ITEMS CROSS REFERENCED BY HES NAME - TABLE 1

            Change to Data Set (CDS, CMDS, HES): Change to Table

            HOSPITAL EPISODE STATISTICS (HES)

            HES / CDS Data Elements cross referenced by HES Name - Table 1
            CDS Type key:

            G = General Episode
            D = Delivery Episode
            B = Birth Episode
            PC = Detained and or Long Term Psychiatric Census
            OD = Other Delivery
            OB = Other Birth

            " = Mandatory for this CDS Type
            O = Optional for this CDS Type

            HES Name HES Item CDS Data Element CDS TYPE
                  G D B PC OD OB
            ACPDISP AUGMENTED CARE PERIOD DISPOSAL AUGMENTED CARE PERIOD DISPOSAL " " "      
            ACPEND END DATE (AUGMENTED CARE PERIOD) END DATE (AUGMENTED CARE PERIOD) " " "      
            ACPLOC AUGMENTED CARE LOCATION AUGMENTED CARE LOCATION " " "      
            ACPN AUGMENTED CARE PERIOD NUMBER AUGMENTED CARE PERIOD NUMBER " " "      
            ACPOUT AUGMENTED CARE OUTCOME INDICATOR AUGMENTED CARE OUTCOME INDICATOR " " "      
            ACPPLAN AUGMENTED CARE PLANNED INDCATOR AUGMENTED CARE PLANNED INDICATOR " " "      
            ACPSOUR AUGMENTED CARE PERIOD SOURCE AUGMENTED CARE PERIOD SOURCE " " "      
            ACPSPEF SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) SPECIALTY FUNCTION CODE (AUGMENTED CARE PERIOD) " " "      
            ACPSPEF MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) MAIN SPECIALTY CODE (AUGMENTED CARE PERIOD) " " "      
            ACPSTAR START DATE (AUGMENTED CARE PERIOD) START DATE (AUGMENTED CARE PERIOD) " " "      
            ADMIDATE START DATE (HOSPITAL PROVIDER SPELL) START DATE (HOSPITAL PROVIDER SPELL) " " " "    
            ADMIMETH ADMISSION METHOD (HOSPITAL PROVIDER SPELL ADMISSION METHOD (HOSPITAL PROVIDER SPELL) " " " "    
            ADMINCAT ADMINISTRATIVE CATEGORY (on admission) ADMINISTRATIVE CATEGORY (on admission) " " " "    
            ADMISORC SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) SOURCE OF ADMISSION (HOSPITAL PROVIDER SPELL) " " " "    
            ADMISTAT PSYCHIATRIC PATIENT STATUS PSYCHIATRIC PATIENT STATUS " "   "    
            ANASDATE FIRST ANTENATAL ASSESSMENT DATE FIRST ANTENATAL ASSESSMENT DATE   " "   " "
            APLOCID AUGMENTED CARE LOCAL IDENTIFIER AUGMENTED CARE PERIOD LOCAL IDENTIFIER O O O      
            BIRORDER BIRTH ORDER BIRTH ORDER   " "   " "
            BIRRESUS RESUCITATION METHOD RESUSCITATION METHOD   " "   " "
            BIRSTATE LIVE OR STILL BIRTH LIVE OR STILL BIRTH   " "   " "
            BIRWEIT BIRTH WEIGHT BIRTH WEIGHT   " "   " "
            CATEGORY CATEGORY OF PATIENT Not in CDS            
            CARERSI CARER SUPPORT INDICATOR CARER SUPPORT INDICATOR O   O O    
            CENDATE DETAINED AND OR LONG TERM PSYCHIATRIC CENSUS DATE DETAINED AND (OR) LONG TERM PSYCHIATRIC CENSUS DATE       "    
            CENDIAG1 PRIMARY (ICD-10) PRIMARY DIAGNOSIS (ICD)       "    
            CENDIAG3
             CENDIAG14
            SECONDARY (ICD-10) SECONDARY DIAGNOSIS (ICD)       "    
            CENDUR DURATION OF CARE TO PSYCHIATRIC CENSUS DATE DURATION OF CARE TO PSYCHIATRIC CENSUS DATE       "    
            CENSAGE AGE AT CENSUS AGE AT CENSUS       "    
            CENSAT STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS STATUS OF PATIENT INCLUDED IN THE PSYCHIATRIC CENSUS       "    
            CENWARD WARD TYPE AT PSYCHIATRIC CENSUS DATE Not in CDS       "    
            CLASSPAT PATIENT CLASSIFICATION PATIENT CLASSIFICATION " " " "    
            CONSULT CONSULTANT CODE CONSULTANT CODE " " " "    
            CSNUM COMMISSIONING SERIAL NUMBER COMMISSIONING SERIAL NUMBER " " " " " "
            DELCHANG DELIVERY PLACE CHANGE REASON DELIVERY PLACE CHANGE REASON   " "   " "
            DELINTEN DELIVERY PLACE TYPE (INTENDED) DELIVERY PLACE TYPE (INTENDED)   " "   " "
            DELMETH DELIVERY METHOD DELIVERY METHOD   " "   " "
            DELONSET LABOUR OR DELIVERY ONSET METHOD LABOUR OR DELIVERY ONSET METHOD   " "   " "
            DELPLACE DELIVERY PLACE TYPE (ACTUAL) DELIVERY PLACE TYPE (ACTUAL)   " "   " "
            DELPOSAN ANAESTHETIC GIVEN POST LABOUR OR DELIVERY ANAESTHETIC GIVEN POST LABOUR OR DELIVERY   " "   " "
            DELSTAT STATUS OF PERSON CONDUCTING DELIVERY STATUS OF PERSON CONDUCTING DELIVERY   " "   " "
            DEPDAYS HIGH DEPENDENCY CARE LEVEL DAYS HIGH DEPENDENCY CARE LEVEL DAYS " " "      
            DELPREAN ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY ANAESTHETIC GIVEN DURING LABOUR OR DELIVERY   " "   " "
            DETDUR DURATION OF DETENTION DURATION OF DETENTION       "    
            DETNDATE DATE DETENTION COMMENCED DATE DETENTION COMMENCED       "    
            DIAG_1 PRIMARY (ICD-10) PRIMARY (ICD-10) " " "      
            DIAG_3
            - DIAG_14
            SECONDARY (ICD-10) SECONDARY DIAGNOSIS (ICD) " " "      
            DISDATE DISCHARGE DATE (HOSPITAL PROVIDER SPELL) DISCHARGE DATE (HOSPITAL PROVIDER SPELL) " " "      
            DISDEST DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) " " "      
            DISMETH DISCHARGE METHOD (HOSPITAL PROVIDER SPELL) DISCHARGE METHOD (HOSPITAL PROVIDER SPELL) " " "      
            DOB BIRTH DATE BIRTH DATE " " " " " "
            DOBBABY BIRTH DATE (BABY) BIRTH DATE (BABY)   "     "  
            DOMPROC HRG DOMINANT GROUPING VARIABLE - PROCEDURE HRG DOMINANT GROUPING VARIABLE-PROCEDURE O O O O    
            ELECDATE DECIDED TO ADMIT DATE DECIDED TO ADMIT DATE (for this provider) "     "    
            ELECDUR DURATION OF ELECTIVE WAIT DURATION OF ELECTIVE WAIT "     "    
            EPIEND END DATE (CONSULTANT, NURSE OR MIDWIFE EPISODE) END DATE (EPISODE) " " "      
            EPIORDER EPISODE NUMBER EPISODE NUMBER " " " "    
            EPISTART START DATE (CONSULTANT, NURSE OR MIDWIFE EPISODE) START DATE (EPISODE), " " " "    
            EPISTAT EPISODE STATUS Not in CDS            
            EPITYPE EPISODE TYPE Not in CDS            
            ETHNOS ETHNIC CATEGORY ETHNIC CATEGORY " " O " " O
            FIRSTREG FIRST REGULAR DAY OR NIGHT ADMISSION FIRST REGULAR DAY OR NIGHT ADMISSION "          
            GESTAT GESTATION LENGTH GESTATION LENGTH   " "   " "
            GPPRAC CODE OF GP PRACTICE (REGISTERED GMP) CODE OF GP PRACTICE (REGISTERED GMP) O O O O O O
            HOMEADD POSTCODE OF USUAL ADDRESS POSTCODE OF USUAL ADDRESS " " " " " "
            HRGNHS HEALTHCARE RESOURCE GROUP CODE HEALTHCARE RESOURCE GROUP CODE " " " "    
            HRGNHSVN HEALTHCARE RESOURCE GROUP CODE - VERSION NUMBER HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER " " " "    
            INTDAYS INTENSIVE CARE LEVEL DAYS INTENSIVE CARE LEVEL DAYS " " "      
            INTMANIG INTENDED MANAGEMENT INTENDED MANAGEMENT "     "    
            LEGLCAT LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION) LEGAL STATUS CLASSIFICATION CODE (ON ADMISSION) " "   "    
            LEGLSTAT LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE) LEGAL STATUS CLASSIFICATION CODE (AT CENSUS DATE)       "    
            LOPATID LOCAL PATIENT IDENTIFIER LOCAL PATIENT IDENTIFIER " " " " " "
            MAINSPEF SPECIALTY FUNCTION CODE SPECIALTY FUNCTION CODE " " " "    
            MAINSPEF MAIN SPECIALTY CODE MAIN SPECIALTY CODE " " " "    
            MARSTAT MARITAL STATUS MARITAL STATUS " "   " "  
            MENTCAT MENTAL CATEGORY MENTAL CATEGORY       "    
            MOTDOB BIRTH DATE (MOTHER) BIRTH DATE (MOTHER)     "     "
            NEOCARE NEONATAL LEVEL OF CARE NEONATAL LEVEL OF CARE "   "      
            NEWNHSNO NHS NUMBER NHS NUMBER " " O " O O
            NHSNOIND NHS NUMBER STATUS INDICATOR NHS NUMBER STATUS INDICATOR " " " " " "
            NUMACP NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE NUMBER OF AUGMENTED CARE PERIODS WITHIN EPISODE " " "      
            NUMBABY NUMBER OF BABIES NUMBER OF BABIES   " "   " "
            NUMPREG PREGNANCY TOTAL PREVIOUS PREGNANCIES PREGNANCY TOTAL PREVIOUS PREGNANCIES   "     "  
            OPDATE1 PRIMARY PROCEDURE DATE PROCEDURE DATE " " "      
            OPDATE2
            OPDATE 12
            SECOND - TWELFTH OPERATION DATE PROCEDURE DATE " " "      
            OPERATN1 PRIMARY OPERATION (OPCS-4) PRIMARY PROCEDURE (OPCS) " " "      
            OPERATN2
            - OPERATN12
            OPERATION (OPCS-4) PROCEDURE (OPCS) " " "      
            OPERSTAT OPERATION STATUS (per episode) OPERATION STATUS (per episode) " " "      
            ORGSUP NUMBER OF ORGAN SYSTEMS SUPPORTED (for intensive care level only) NUMBER OF ORGAN SYSTEMS SUPPORTED (for intensive care level only) " " "      
            PCTR ORGANISATION CODE (PCT OF RESIDENCE) ORGANISATION CODE " " " " " "
            PROCODE ORGANISATION CODE (CODE OF PROVIDER) ORGANISATION CODE (CODE OF PROVIDER) " " " " " "
            PROVSPNO HOSPITAL PROVIDER SPELL NUMBER HOSPITAL PROVIDER SPELL NUMBER " " " "    
            PURCODE ORGANISATION CODE (CODE OF COMMISSIONER) ORGANISATION CODE (CODE OF COMMISSIONER) " " " " " "
            RECTYPE RECORD TYPE Not in CDS            
            REFERORG REFERRING ORGANISATION CODE REFERRING ORGANISATION CODE " " " "    
            REFERRER REFERRER CODE REFERRER CODE " " " "    
            REGGMP GMP (CODE OF REGISTERED OR REFERRING GMP) GMP (CODE OF REGISTERED OR REFERRING GMP) " " " " " "
            SEX SEX SEX " " " " " "
            SEXBABY SEX (BABY) SEX (BABY)   "     "  
            SITETRET SITE CODE (OF TREATMENT) (at start of episode) SITE CODE (OF TREATMENT) (at start of episode) " " " "    
            SPELEND LAST EPISODE IN SPELL INDICATOR LAST EPISODE IN SPELL INDICATOR " " "      
            TRETSPEF CONSULTANT SPECIALTY FUNCTION CODE CONSULTANT SPECIALTY FUNCTION CODE " " " "    
            TRETSPEF TREATMENT FUNCTION CODE TREATMENT FUNCTION CODE " " " "    
            WARDSTRT WARD TYPE AT START OF EPISODE Not in CDS            


            top

            MENTAL HEALTH MINIMUM DATA SET

            Change to Data Set (CDS, CMDS, HES): Change to Table

            Mental Health Minimum Data Set

            The Mental Health Minimum Data Set (MHMDS) concerns adult patients (including elderly) who receive care in NHS specialist mental health services. This care is delivered within a Mental Health Care Spell. For some patients care will comprise a small number of out-patient attendances over a few weeks. For others, it may extend over many years and include hospital, community, out-patient and day care attendances which may commonly overlap.

            The MHMDS is assembled and produced for a defined period of time known as the Reporting Period (which may be monthly, quarterly or annually) and comprises a data set record for each Mental Health Care Spell which occurs wholly or partially within the Reporting Period.

            Patient Demographics
            ORGANISATION CODE (CODE OF PROVIDER)
            ORGANISATION CODE (CODE OF COMMISSIONER)
            REPORTING PERIOD (MENTAL HEALTH)
            NHS NUMBER
            ELECTORAL WARD OF USUAL ADDRESS
            ORGANISATION CODE (PCT OF RESIDENCE)
            SEX
            MARITAL STATUS
            BIRTH DATE
            CODE OF GP PRACTICE (REGISTERED GMP)
            ORGANISATION CODE (PCT OF GP PRACTICE)
            LOCAL PATIENT IDENTIFIER
            SOCIAL SERVICES CLIENT IDENTIFIER
            ETHNIC CATEGORY
            YEAR OF FIRST KNOWN PSYCHIATRIC CARE
            Mental Health Care Spell Activity
            CARE SPELL IDENTIFIER (MENTAL HEALTH)
            CARE SPELL NUMBER IN REPORTING PERIOD
            SPECIALTY FUNCTION CODE (MENTAL HEALTH)
            MAIN SPECIALTY CODE (MENTAL HEALTH)
            START DATE (MENTAL HEALTH CARE SPELL)
            SOURCE OF REFERRAL FOR MENTAL HEALTH
            END DATE (MENTAL HEALTH CARE SPELL)
            MENTAL HEALTH CARE SPELL END CODE
            SPELL DAYS IN REPORTING PERIOD
            SUSPENDED DAYS IN REPORTING PERIOD
            MHCS SUSPENSION REASON (AT END OF REPORTING PERIOD)
            CPA STANDARD DAYS
            CPA ENHANCED DAYS
            CPA LEVEL (AT END OF REPORTING PERIOD)
            OCCUPATION (CPA CARE COORDINATOR)
            DATE LAST SEEN (CPA CARE COORDINATOR)
            DAYS LIABLE FOR DETENTION
            DAYS OF SUPERVISED DISCHARGE
            LEGAL STATUS CLASSIFICATION CODE (AT END OF REPORTING PERIOD)
            LEGAL STATUS RESTRICTIVENESS (HIGHEST IN REPORTING PERIOD)
            MHC WITHOUT PATIENT CONSENT IN REPORTING PERIOD
            SSSA (NUMBER FOR DETENTION)
            SSSA (NUMBER FOR COMMUNITY CARE)
            DIAGNOSIS (ICD FIRST MOST RECENT)
            DIAGNOSIS (ICD SECOND MOST RECENT)
            DIAGNOSIS (ICD THIRD MOST RECENT)
            DIAGNOSIS (ICD FOURTH MOST RECENT)
            DIAGNOSIS (ICD FIFTH MOST RECENT)
            DIAGNOSIS (ICD SIXTH MOST RECENT)
            DIAGNOSIS (ICD SEVENTH MOST RECENT)
            DIAGNOSIS (ICD EIGHTH MOST RECENT)
            DIAGNOSIS (ICD NINTH MOST RECENT)
            DIAGNOSIS (ICD TENTH MOST RECENT)
            DIAGNOSIS (ICD ELEVENTH MOST RECENT)
            DIAGNOSIS (ICD TWELFTH MOST RECENT)
            HONOS RATING (FIRST IN MHCS)
            HONOS SCORE DATE (FIRST IN MHCS)
            HONOS RATING (MOST RECENT IN MHCS)
            HONOS SCORE DATE (MOST RECENT IN MHCS)
            HONOS RATING (WORST EVER RECORDED)
            HONOS SCORE DATE (WORST EVER RECORDED)
            HONOS RATING (BEST IN LAST TWELVE MONTHS)
            HONOS SCORE DATE (BEST IN LAST TWELVE MONTHS)
            Mental Health Package
            BED DAYS (MENTAL HEALTH)
            BED DAYS (MENTAL HEALTH MEDIUM SECURE)
            BED DAYS (MENTAL HEALTH INTENSIVE)
            CARE DAYS (ACUTE HOME-BASED)
            BED DAYS (MENTAL HEALTH NHS COMMUNITY CARE)
            RESIDENTIAL MH NON-NHS COMMUNITY CARE INDICATOR
            DAY CARE ATTENDANCE (MENTAL HEALTH NHS SITE)
            DAY CARE ATTENDANCE MH NON-NHS SITE INDICATOR
            SHELTERED WORK ATTENDANCE INDICATOR
            OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH)
            CONTACTS (COMMUNITY PSYCHIATRIC NURSE)
            CONTACTS (CLINICAL PSYCHOLOGIST)
            CONTACTS (OCCUPATIONAL THERAPIST)
            SOCIAL WORKER INVOLVEMENT
            HOME HELP VISIT INDICATOR
            PROCEDURE (READ FIRST MOST RECENT)
            PROCEDURE (READ SECOND MOST RECENT)
            PROCEDURE (READ THIRD MOST RECENT)
            PROCEDURE (READ FOURTH MOST RECENT)
            PROCEDURE (READ FIFTH MOST RECENT)
            PROCEDURE (READ SIXTH MOST RECENT)
            PROCEDURE (READ SEVENTH MOST RECENT)
            PROCEDURE (READ EIGHTH MOST RECENT)
            PROCEDURE (READ NINTH MOST RECENT)
            PROCEDURE (READ TENTH MOST RECENT)
            PROCEDURE (READ ELEVENTH MOST RECENT)
            PROCEDURE (READ TWELFTH MOST RECENT)
            PROCEDURE (ECT TREATMENTS ADMINISTERED)
            ADMISSIONS (MENTAL HEALTH)
            DISCHARGES (MENTAL HEALTH)
            HOSPITAL STAYS LIST (MENTAL HEALTH)
            COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH)
            FIRST CONTACT TIMES LIST (MENTAL HEALTH)
            POSTCODE OF USUAL ADDRESS
            MENTAL HEALTH CARE TEAM TYPE (AT END OF REPORTING PERIOD)
            CONTACTS (PHYSIOTHERAPIST)
            CONTACTS (CONSULTANT PSYCHOTHERAPY)
            CONTACTS (SOCIAL WORKER)
            OUT-PATIENT DID NOT ATTENDS (MENTAL HEALTH)
            DAY CARE DID NOT ATTENDS (MENTAL HEALTH NHS SITE)
            CONTACTS (NHS DIRECT MENTAL HEALTH)
            CARE PROGRAMME APPROACH REVIEWS (IN REPORTING PERIOD)
            SPELL DEFINITION TYPE (ASSEMBLER MHCS)
            MENTAL HEALTH CARE AND LEGAL STATUS HISTORY


            top

            OUT-PATIENT ATTENDANCE CDS TYPE

            Change to Data Set (CDS, CMDS, HES): Change to Table

            COMMISSIONING DATA SET (CDS)

            OUT-PATIENT ATTENDANCE CDS TYPE

            The Out-Patient Attendance Commissioning Data Set Type carries the data for an Out-Patient Attendance or a missed appointment. The data set only applies for Consultant attendances and appointments.

            The column headed Opt (Optionality) shows whether the Data item is Mandatory M, Optional O or Must Not Be Used *.

            Opt CDS Data Item U/A
            Person Group (Patient):

            To carry the personal details of the Patient. One occurrence of this Group is permitted.
            M LOCAL PATIENT IDENTIFIER  
            M ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)  
            M ORGANISATION CODE TYPE  
            M NHS NUMBER  
            M BIRTH DATE  
            O CARER SUPPORT INDICATOR  
            * ETHNIC CATEGORY  
            * MARITAL STATUS
            (psychiatric patients only)
             
            M NHS NUMBER STATUS INDICATOR  
            M SEX  
            O NAME FORMAT CODE  
            O PATIENT NAME  
            O ADDRESS FORMAT CODE  
            O PATIENT USUAL ADDRESS  
            M POSTCODE OF USUAL ADDRESS  
            M ORGANISATION CODE (PCT OF RESIDENCE)  
            M ORGANISATION CODE TYPE  
              Note:
            For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.
             
            (HCA) Consultant Out-Patient Episode - Person Group (Consultant):

            To carry the details of the responsible Consultant. One occurrence of this Group is permitted.
            M CONSULTANT CODE  
            M SPECIALTY FUNCTION CODE  
            M MAIN SPECIALTY CODE  
            M CONSULTANT SPECIALTY FUNCTION CODE  
            M TREATMENT FUNCTION CODE  
            (HCA) Consultant Out-Patient Episode - Clinical Information Group (ICD):

            To carry the details of the ICD Diagnosis Scheme and the Diagnoses. Up to 2 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE  
            O PRIMARY DIAGNOSIS (ICD)  
            O SECONDARY DIAGNOSIS (ICD)
            (1st Secondary)
             
            (HCA) Consultant Out-Patient Episode - Clinical Information Group (READ):

            To carry the details of the READ Diagnosis Scheme and the Diagnoses. Up to 2 occurrences of this Group are permitted.
            O DIAGNOSIS SCHEME IN USE  
            O PRIMARY DIAGNOSIS (READ)  
            O SECONDARY DIAGNOSIS (READ)
            (1st Secondary)
             
            (HCA) Attendance Occurrence Activity Characteristics:

            To carry the details of the Out-Patient Attendance or missed appointment.
            M ATTENDANCE IDENTIFIER  
            M ADMINISTRATIVE CATEGORY  
            M ATTENDED OR DID NOT ATTEND  
            M FIRST ATTENDANCE  
            M MEDICAL STAFF TYPE SEEING PATIENT  
            M OPERATION STATUS
            (per attendance)
             
            M OUTCOME OF ATTENDANCE  
            M APPOINTMENT DATE  
            (HCA) Attendance Occurrence - Service Agreement Details:

            To carry the details of the Service Agreement for the Out-Patient Attendance.
            M COMMISSIONING SERIAL NUMBER  
            O NHS SERVICE AGREEMENT LINE NUMBER  
            O PROVIDER REFERENCE NUMBER  
            M COMMISSIONER REFERENCE NUMBER  
            M ORGANISATION CODE (CODE OF PROVIDER)  
            M ORGANISATION CODE TYPE  
            M ORGANISATION CODE (CODE OF COMMISSIONER)  
            M ORGANISATION CODE TYPE  
            (HCA) Attendance Occurrence - Clinical Activity Group (OPCS):

            To carry the details of the OPCS coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            O PROCEDURE SCHEME IN USE  
            O PRIMARY PROCEDURE (OPCS)  
            O PROCEDURE (OPCS)
            (2nd to 12th, there may be up to 11 repetitions)
             
            (HCA) Attendance Occurrence - Clinical Activity Group (READ):

            To carry the details of the READ coded Clinical Activities undertaken. Up to 12 occurrences of this Group are permitted.
            O PROCEDURE SCHEME IN USE  
            O PRIMARY PROCEDURE (READ)  
            O PROCEDURE (READ)
            (2nd to 12th, there may be up to 11 repetitions)
             
            (HCA) Attendance Occurrence - Location Group - Out-Patient Attendance:

            To carry the details of the location for the Out-Patient Attendance - Site Code of Treatment. One occurrence of this Group is permitted. One occurrence of this Group is permitted.
            M LOCATION CLASS  
            M SITE CODE (OF TREATMENT)  
            M ORGANISATION CODE TYPE  
            (HCA) GP Registration:

            To carry the details of the Patient's Registered GMP. One occurrence of this Group is permitted.
            M GMP (CODE OF REGISTERED OR REFERRING GMP)  
            O CODE OF GP PRACTICE (REGISTERED GMP)  
            O ORGANISATION CODE TYPE  
            (HCA) Referral Activity Characteristics:

            To carry the details of the referral. One occurrence of this Group is permitted.
            M PRIORITY TYPE
             
            M SERVICE TYPE REQUESTED  
            M SOURCE OF REFERRAL FOR OUT-PATIENTS  
            M REFERRAL REQUEST RECEIVED DATE  
            (HCA) Referral Person Group:

            To carry the details of the referrer. One occurrence of this Group is permitted.
            M REFERRER CODE  
            M REFERRING ORGANISATION CODE  
            M ORGANISATION CODE TYPE  
            (HCA) Missed Appointment Occurrence:

            To carry the details of the missed appointment. One occurrence of this Group is permitted.
            M LAST DNA OR PATIENT CANCELLED DATE  
            (HCA) Healthcare Resource Group Activity - Activity Characteristics:

            To carry the details of the Healthcare Resource Group from 01/10/2001. Each CDS may contain only a single occurrence of this Group.
            O HEALTHCARE RESOURCE GROUP CODE  
            O HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER  
              Note:
            If there is no HRG agreed for the Specialty, or samples only are required for the specialty which does not include this particular out-patient attendance, the segments relating to HRGs need not be sent. HRG Dominant Grouping Variable does not apply to out-patient attendances.
             


            top

            KC61 1

            Change to Central Return Form: Change to Guidance Text

            Central Return Form Guidance

            KC61: Pathology Laboratories - Cervical Cytology and Outcome of Gynaecological Referrals

              Contextual Overview

            1. The Department, NHS Cervical Screening Programme (NHSCSP), Strategic Health Authorities and trusts require information from PATHOLOGY LABORATORIES on cervical cytology and outcome of referrals.

            1. The information helps to monitor the process of achieving the Government's target to reduce the incidence of invasive cervical cancer and to ensure that the screening programme is managed effectively. The information is used to ensure that the laboratory is achieving acceptable standards in examining smears in line with guidance provided by the NHS Cervical Screening Programme.

            1. Information on the return is also used in Public Expenditure Survey (PES) negotiations, resource allocation to the NHS and Departmental accountability.

            1. Information based on the KC61 return is published annually by the Department in the Statistical Bulletin `Cervical Screening Programme'.

              Completing Return KC61: Pathology Laboratories - Cervical Cytology and Outcome of Referrals

            1. KC61 returns are required by all PATHOLOGY LABORATORIES carrying out cervical cytology within NHS HEALTH CARE PROVIDERS. This applies to independently managed NHS laboratories, including cytopathology laboratories and also private laboratories if they are commissioned to report on smears for the NHS.

              Each return requires the ORGANISATION CODE and ORGANISATION NAME of the NHS Trust and must be signed by a CONSULTANT in one of the Pathology SPECIALTIES. It also requires the PATHOLOGY LABORATORY NAME and PATHOLOGY LABORATORY CODE. Note that PATHOLOGY LABORATORY CODES are maintained and issued by the Organisation Codes Service on behalf of the NHS Cervical Screening Programme.

            1. KC61 returns are required by all PATHOLOGY LABORATORIES carrying out cervical cytology within NHS HEALTH CARE PROVIDERS. This applies to independently managed NHS laboratories, including cytopathology laboratories and also private laboratories if they are commissioned to report on smears for the NHS.

              Each return requires the ORGANISATION CODE and ORGANISATION NAME of the NHS Trust and must be signed by a CONSULTANT in one of the Pathology MAIN SPECIALTIES. It also requires the PATHOLOGY LABORATORY NAME and PATHOLOGY LABORATORY CODE. Note that PATHOLOGY LABORATORY CODES are maintained and issued by the Organisation Codes Service on behalf of the NHS Cervical Screening Programme.

            1. A PATHOLOGY LABORATORY's KC61 return should include all the original REQUESTS FOR PATHOLOGY INVESTIGATION received by that laboratory. A REQUEST FOR PATHOLOGY INVESTIGATION forwarded to another laboratory should only be included in the first laboratory's return (except Part A3).

            1. Smears re-screened within the same Laboratory as part of internal or external quality control or for any other reason should not be included in the KC61 return. The number of requests sent to or received from another Laboratory for primary screening or other reason should be recorded in Part A3.

            1. Where more than one slide is associated with one REQUEST FOR PATHOLOGY INVESTIGATION, only the most significant CYTOLOGY RESULT TYPES may be counted for the KC61.

            1. The return KC61 is completed annually and submitted within two months of the end of the period.

            1. Parts A and B of the return relate to all smears reported by the laboratory where the smear was received and registered between 1 April of one year and 31 March of the following year. If this date is not recorded, the CERVICAL SMEAR EXAMINED DATE can be used as a proxy. Part C1 of the return relates to smears where the date of the smear which led to a referral fell in the first three months of the financial year (April, May and June). Part C2 is a duplicate of Part C1, but will collect data relating to gynaecological referrals from smears registered during the whole of the financial year prior to the current year.


            top

            KH06 1

            Change to Central Return Form: Change to Guidance Text

            Central Return Form Guidance

            KH06 - Demand for Elective Admission: Events Occurring during the Quarter (Provider Based)

            Contextual Overview

            1. The Department requires performance management measures of waiting times by HQ and Regional Offices.

            2. Information on the return is used in Public Expenditure Survey (PES) negotiations and supports, risk analysis, the production of in-patient and out-patient modelling and Departmental accountability.

            3. The Department also uses this information to help monitor nationalwaiting list trends. These are used to develop policies and indicate changes which can enable ELECTIVE ADMISSION LIST to be managed more effectively.

            4. Information based on the return is not published directly; however the details are used to confirm the provider based waiting list statistics.

            Completing Return KH06 - Demand for Elective Admission: Events Occurring during the Quarter

            5. The return KH06 is provider-based and is submitted by NHS TRUSTS and PRIMARY CARE TRUSTS regardless of where the PATIENTS live. The returns are for all PATIENTS waiting for admission to NHS hospitals, excluding planned admissions i.e. it includes PATIENTS who are:

            - private patients
            - PATIENTS from overseas

            6. KH06 relates to ELECTIVE ADMISSION LIST events - that is, all the ELECTIVE ADMISSION LIST ENTRY added as the result of a DECISION TO ADMIT, and all the removals from the ELECTIVE ADMISSION LIST during the period. The return is sub-divided into ordinary admissions and admissions that are intended to be day case admissions. Admissions are classified by SPECIALTY FUNCTION CODE. Admissions are classified by TREATMENT FUNCTION CODE.

            7. Note that PATIENTS waiting for tissue or organ transplants are classified as suspended patients and are excluded from the central return.

            8. Suspended patients are PATIENTS who have been suspended from the ELECTIVE ADMISSION LIST for medical reasons or who are unavailable for admission for a specified period because of family commitments, holidays or other reasons. During this period of suspension a PATIENT on an ELECTIVE ADMISSION LIST is unavailable for admission and therefore should not be given an OFFER OF ADMISSION for that interval.

            9. A table is provided with the return KH06 to help you make consistency checks with KH07 and KH07A. The difference line should be zero if all the data are consistent.

            10. The return relates to a three month period, the first quarter starting on 1 April and the last quarter ending on 31 March. All four quarterly returns require data collected at SPECIALTY FUNCTION CODE level. All four quarterly returns require data collected at TREATMENT FUNCTION CODE level. Returns must be submitted by the fifteenth working day after the end of the quarter.


            top

            KH06 2

            Change to Central Return Form: Change to Guidance Text

            Central Return Form Guidance

            KH06 - Demand for Elective Admission: Events Occurring during the Quarter (Provider Based)

              Part 1: Ordinary Admissions

            1. Part 1 of KH06 should be completed for admissions intended to be treated as ordinary admissions.

              Main Specialty Function and Code

            1. The ELECTIVE ADMISSION LIST ENTRY should be counted by SPECIALTY FUNCTION CODE. Note that SPECIALTY FUNCTION is based on SPECIALTY but is not identical to it.

            1. The ELECTIVE ADMISSION LIST ENTRY should be counted by TREATMENT FUNCTION CODE.

              Number of Decisions To Admit (i.e Patients added to the list)

            1. A count of PATIENTS on the ELECTIVE ADMISSION LIST who are classified as booked admissions or waiting list admissions and who have been added to an ELECTIVE ADMISSION LIST with a DECIDED TO ADMIT DATE since the last CENSUS DATE.

              Patients Admitted

            1. A count of the total PATIENTS admitted during the period. Count all PATIENTS identified as having an ADMISSION OFFER OUTCOME of Patient admitted - treatment completed. Also include those PATIENTS who have been admitted and then are subsequently sent home without treatment. i.e. PATIENTS with an ADMISSION OFFER OUTCOME of Patient admitted - treatment deferred.

              Patients admitted via a full booking system
            1. A count of PATIENTS admitted during the period via a full booking system. These PATIENTS are identified as having an ADMISSION BOOKING SYSTEM TYPE of Full booking system. Count all PATIENTS identified as having an ADMISSION OFFER OUTCOME of Patient admitted - treatment completed. Also include those PATIENTS who have been admitted and then are subsequently sent home without treatment. i.e. PATIENTS with an ADMISSION OFFER OUTCOME of Patient admitted - treatment deferred.

              Patients failed to attend

            1. A count of PATIENTS who have not attended for admission and have failed to tell the hospital in advance that they will not be coming. These PATIENTS are identified as having an ADMISSION OFFER OUTCOME of Patient failed to arrive. Do not include self-deferred admissions.

              Removals other than admissions

            1. A count of ELECTIVE ADMISSION LIST ENTRY removed from the ELECTIVE ADMISSION LIST during the period, for reasons other than admission. These are identified as entries that were removed on an ELECTIVE ADMISSION LIST REMOVAL DATE within the reporting period having an ELECTIVE ADMISSION LIST REMOVAL REASON of Patient admitted as an emergency for the same condition, Patient died or Patient removed for other reasons.

            2. It does not include suspended patients as they have not been removed from the