National Neonatal Data Set - Episodic and Daily Care

National Neonatal Data Set - Episodic and Daily Care

Overview

Introduction

The National Neonatal Data Set  consists of a defined list of data items that are extracted from electronic clinical records created by clinical staff on all admissions to Neonatal Critical Care Units in England.

The National Neonatal Data Set  is in two parts:

The two neonatal data sets comprise data items relating to PATIENT demographics, CLINICAL INTERVENTIONS, outcomes, and PATIENT DIAGNOSES. Each data item is mapped where possible to existing ISB/ SCCI  / DCB   Information Standards and Collections (including Extractions)  (such as the Neonatal Critical Care Minimum Data Set  and Maternity Services Data Set Version 1) as well as to SNOMED CT and ICD codes.

The aim of the National Neonatal Data Set  is to extract data items from electronic clinical records, create a database of these items, and make this available as a national resource to serve a variety of needs, so avoiding duplicate data collections for different purposes, minimising the burden placed upon clinical teams, and promoting data quality and completeness.

ORGANISATIONS involved in the collection may choose whether to allow identifiable or unidentifiable (anonymised) information to flow to the Neonatal Data Analysis Unit.  Where anonymised data is to flow, the appropriate 'withheld' patient and parents demographic structures should be used (i.e. those with no  PERSON IDENTIFIERS, such as NHS NUMBER  or PERSON BIRTH DATE). 

In addition, where anonymisation is required, the dates and times of events carried throughout the data set (such as SAMPLE COLLECTION DATE AND TIME, PROCEDURE DATE AND TIME (ABDOMINAL X-RAY)) should be replaced with the specific relevant year and month of the event and the NUMBER OF MINUTES (BIRTH TO EVENT).  The National Neonatal Data Set  structure allows an either/or choice for these event items throughout the data set.

Data Collection

The National Neonatal Data Set  consists of a defined list of data items that are extracted from electronic clinical records created by clinical staff relating to all neonatal critical care delivered in England.  The Neonatal Data Analysis Unit has established a database, the National Neonatal Research Database (NNRD) to hold data comprising the National Neonatal Data Set, as a national resource.

Submission Information

For submission information, see the NDAU website.  Note that all date and time fields in the National Neonatal Data Set  should be in Co-ordinated Universal Time (UTC) for submission purposes.

Further Guidance

Further guidance has been produced by the Neonatal Data Analysis Unit  and is available on their website at: NDAU website.

Mandation

The Mandation column indicates the recommendation for the inclusion of data.

  • M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present

  • R = Required: NHS business processes cannot be delivered without this data element

  • O = Optional: the inclusion of this data element is optional as required for local purposes

  • P = Pilot: this data element is for piloting use only.

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

Specification

DEMOGRAPHICS AND BIRTH INFORMATION (BABY)
Mandation Baby Demographics (Standard)

To carry the Baby's demographic details where anonymisation of the record is NOT required.One occurrence of this group is required.

R

NHS NUMBER (BABY)

M

NHS NUMBER STATUS INDICATOR CODE (BABY)

R

COMMUNITY HEALTH INDEX NUMBER (BABY)

R

HEALTH AND CARE NUMBER (BABY)

M

BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)

R

DATE TIME OF BIRTH (BABY)

M

SITE CODE (OF ACTUAL PLACE OF DELIVERY)

Or

ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)

R

BIRTH WEIGHT

O

BIRTH LENGTH

O

BIRTH HEAD CIRCUMFERENCE

O

GESTATION LENGTH (AT DELIVERY)

O

GESTATION LENGTH (REMAINING DAYS AT DELIVERY)

R

PERSON PHENOTYPIC SEX

P

PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)

O

BLOOD GROUP (BABY)

O

RHESUS GROUP (BABY)

R

BASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH)

Or
Mandation Baby Demographics (Withheld)

To carry the Baby's demographic details where anonymisation of the record IS required.One occurrence of this group is required.

M

NHS NUMBER STATUS INDICATOR CODE (BABY)

M

BABY LOCAL PATIENT IDENTIFIER (NATIONAL NEONATAL DATA SET)

R

YEAR AND MONTH OF BIRTH (BABY)

M

SITE CODE (OF ACTUAL PLACE OF DELIVERY)

Or

ORGANISATION CODE (OF ACTUAL PLACE OF DELIVERY)

R

BIRTH WEIGHT

O

BIRTH LENGTH

O

BIRTH HEAD CIRCUMFERENCE

O

GESTATION LENGTH (AT DELIVERY)

O

GESTATION LENGTH (REMAINING DAYS AT DELIVERY)

R

PERSON PHENOTYPIC SEX

P

PERSON GENOTYPIC SEX (NATIONAL NEONATAL DATA SET)

O

BLOOD GROUP (BABY)

O

RHESUS GROUP (BABY)

R

BASE DEFICIT CONCENTRATION (WORST WITHIN 12 HOURS AFTER BIRTH)

PARENTS
Mandation Parents Demographics (Standard)

To carry the Parent's demographic details where anonymisation of the record is NOT required.One occurrence of this group is permitted.

R

NHS NUMBER (MOTHER)

M

NHS NUMBER STATUS INDICATOR CODE (MOTHER)

R

COMMUNITY HEALTH INDEX NUMBER (MOTHER)

R

HEALTH AND CARE NUMBER (MOTHER)

R

YEAR OF BIRTH (MOTHER)

M

POSTCODE OF USUAL ADDRESS (MOTHER)

P

QUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET)

O

OCCUPATION MOTHER (SNOMED CT)

R

ETHNIC CATEGORY (MOTHER)

R

GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER))

R

YEAR OF BIRTH (FATHER)

R

ETHNIC CATEGORY (FATHER)

R

PARENTS CONSANGUINEOUS INDICATOR

Or
Mandation Parents Demographics (Withheld)

To carry the Parent's demographic details where anonymisation of the record IS required.One occurrence of this group is permitted.

M

NHS NUMBER STATUS INDICATOR CODE (MOTHER)

R

YEAR OF BIRTH (MOTHER)

P

QUALIFICATION ATTAINMENT LEVEL MOTHER (NATIONAL NEONATAL DATA SET)

O

OCCUPATION MOTHER (SNOMED CT)

R

ETHNIC CATEGORY (MOTHER)

R

GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION (MOTHER))

R

YEAR OF BIRTH (FATHER)

R

ETHNIC CATEGORY (FATHER)

R

PARENTS CONSANGUINEOUS INDICATOR

ANTENATAL

To carry details of the pregnancy.One occurrence of this group is required

Mandation

Data Elements

P

MOTHER ANTENATALLY BOOKED INDICATOR

M

SITE CODE (OF INTENDED PLACE OF DELIVERY)

Or

ORGANISATION CODE (OF INTENDED PLACE OF DELIVERY)

R

PREGNANCY TOTAL PREVIOUS PREGNANCIES

R

MATERNITY COMPLICATING MEDICAL DIAGNOSIS TYPE (NATIONAL NEONATAL DATA SET)

Multiple occurrences of this item are permitted

P

MATERNITY OBSTETRIC DIAGNOSIS TYPE (CURRENT PREGNANCY)

Multiple occurrences of this item are permitted

R

MATERNITY MEDICAL DIAGNOSIS TYPE (CURRENT PREGNANCY)

Multiple occurrences of this item are permitted

R

BLOOD GROUP (MOTHER)

R

RHESUS GROUP (MOTHER)

O

HAEMOGLOBINOPATHY INVESTIGATION RESULT CODE FOR NATIONAL NEONATAL DATA SET (MOTHER)

R

MOTHER CURRENT SMOKER AT BOOKING INDICATOR

O

CIGARETTES PER DAY (MOTHER AT BOOKING)

R

STEROIDS GIVEN DURING PREGNANCY TO MATURE FETAL LUNGS INDICATOR

R

ANTENATAL STEROID COURSE COMPLETION STATUS

O

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

O

INVESTIGATION RESULT CODE (MOTHER RUBELLA SCREENING)

R

LAST MENSTRUAL PERIOD DATE

Or

LAST MENSTRUAL PERIOD YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

M

ESTIMATED DATE OF DELIVERY (AGREED)

Or

ESTIMATED DATE OF DELIVERY (AGREED) YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

METHOD OF ESTIMATED DATE OF DELIVERY (AGREED)

LABOUR AND DELIVERY

To carry details of the labour and delivery.One occurrence of this group is required

Mandation

Data Elements

R

LABOUR OR DELIVERY ONSET METHOD CODE (NATIONAL NEONATAL DATA SET)

O

MECONIUM PRESENT IN LIQUOR INDICATOR

O

MEDICATION GIVEN DURING LABOUR (SNOMED CT DM+D)

Multiple occurrences of this item are permitted

R

RUPTURE OF MEMBRANES DATE TIME

Or

RUPTURE OF MEMBRANES YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

O

SIGNIFICANT MATERNAL PYREXIA IN LABOUR INDICATOR

O

INTRAPARTUM ANTIBIOTICS GIVEN INDICATOR

R

PRESENTATION AT DELIVERY

M

MODE OF DELIVERY

P

IN LABOUR BEFORE CAESARIAN SECTION INDICATOR

P

DELIVERY INSTRUMENT TYPE

Multiple occurrences of this item are permitted

R

BIRTH ORDER (MATERNITY SERVICES)

R

NUMBER OF FETUSES (NOTED DURING PREGNANCY EPISODE)

O

TIME BETWEEN DELIVERY AND SPONTANEOUS RESPIRATION CODE

R

APGAR SCORE (1 MINUTE)

R

APGAR SCORE (5 MINUTES)

R

APGAR SCORE (10 MINUTES)

R

NEONATAL RESUSCITATION METHOD (NATIONAL NEONATAL DATA SET)

O

NEONATAL RESUSCITATION DRUG (SNOMED CT DM+D)

Multiple occurrences of this item are permitted

P

UMBILICAL CORD CLAMPED IMMEDIATELY AFTER BIRTH INDICATOR

P

TIME BETWEEN DELIVERY AND UMBILICAL CORD CLAMPING

P

UMBILICAL CORD MILKING PERFORMED INDICATOR

O

UMBILICAL CORD BLOOD PH LEVEL (ARTERIAL)

O

UMBILICAL CORD BLOOD PH LEVEL (VENOUS)

O

UMBILICAL CORD BLOOD PARTIAL PRESSURE CARBON DIOXIDE (ARTERIAL)

O

UMBILICAL CORD BLOOD PARTIAL PRESSURE CARBON DIOXIDE (VENOUS)

O

UMBILICAL CORD BLOOD LACTATE LEVEL

R

UMBILICAL CORD BLOOD BASE EXCESS CONCENTRATION (ARTERIAL)

R

UMBILICAL CORD BLOOD BASE EXCESS CONCENTRATION (VENOUS)

R

SURFACTANT GIVEN INDICATOR (DURING RESUSCITATION)

ADMISSION TO NEONATAL CRITICAL CARE

To carry details of the admission to Neonatal Critical Care.One occurrence of this group is required.

Mandation

Data Elements

M

CRITICAL CARE START DATE AND TIME

Or

CRITICAL CARE START YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

M

SITE CODE (OF ADMITTING NEONATAL UNIT)

Or

ORGANISATION CODE (OF ADMITTING NEONATAL UNIT)

R

EPISODE NUMBER (NEONATAL CRITICAL CARE SPELL)

R

SITE CODE (ADMITTED FROM TO NEONATAL UNIT)

Or

ORGANISATION CODE (ADMITTED FROM TO NEONATAL UNIT)

O

LOCATION IN HOSPITAL TYPE (BABY ADMITTED FROM)

R

PRIMARY CATEGORY OF CARE REQUIRED ON ADMISSION TO NEONATAL CRITICAL CARE

M

TEMPERATURE RECORDED AFTER ADMISSION TO NEONATAL CRITICAL CARE INDICATOR

M

TEMPERATURE (ON ADMISSION TO NEONATAL CRITICAL CARE)

R

OBSERVATION DATE AND TIME (TEMPERATURE)

Or

OBSERVATION YEAR AND MONTH (TEMPERATURE)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

MEAN ARTERIAL BLOOD PRESSURE (ON ADMISSION TO NEONATAL CRITICAL CARE)

R

HEART RATE (ON ADMISSION TO NEONATAL CRITICAL CARE)

O

RESPIRATORY RATE (ON ADMISSION TO NEONATAL CRITICAL CARE)

O

OXYGEN SATURATION (ON ADMISSION TO NEONATAL CRITICAL CARE)

O

BLOOD GLUCOSE CONCENTRATION (ON ADMISSION TO NEONATAL CRITICAL CARE)

R

DIAGNOSIS (ICD ON ADMISSION TO NEONATAL CRITICAL CARE)

Multiple occurrences of this item are permitted

And/Or

DIAGNOSIS (SNOMED CT ON ADMISSION TO NEONATAL CRITICAL CARE)

Multiple occurrences of this item are permitted

O

PARENTAL CONSENT TO ADMINISTER VITAMIN K INDICATOR

O

VITAMIN K ADMINISTERED INDICATOR

O

VITAMIN K ROUTE OF ADMINISTRATION

O

CARE PROFESSIONAL JOB ROLE CODE (COMPLETING NEONATAL INTENSIVE CARE UNIT ADMISSION FORM)

M

PARENTS SEEN BY SENIOR STAFF MEMBER WITHIN 24 HOURS OF ADMISSION INDICATOR

M

PARENTS SEEN BY SENIOR STAFF MEMBER DATE AND TIME

Or

PARENTS SEEN BY SENIOR STAFF MEMBER YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

DISCHARGE FROM NEONATAL CRITICAL CARE UNIT
Mandation Discharge Details

To carry details of the discharge from the Neonatal Intensive Care Unit.One occurrence of this group is permitted.

M

CRITICAL CARE DISCHARGE DATE AND TIME

Or

CRITICAL CARE DISCHARGE YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

M

DESTINATION ON DISCHARGE FROM NEONATAL CRITICAL CARE

R

TRANSFERRED FOR FURTHER CARE TYPE (NATIONAL NEONATAL DATA SET)

O

WARD TYPE DISCHARGED TO (NATIONAL NEONATAL DATA SET)

R

SITE CODE (RECEIVING)

Or

ORGANISATION CODE (RECEIVING)

R

PERSON DEATH DATE AND TIME (DURING NEONATAL CRITICAL CARE PERIOD)

Or

PERSON DEATH YEAR AND MONTH (DURING NEONATAL CRITICAL CARE PERIOD)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

DEATH CAUSE ICD CODE (DURING NEONATAL CRITICAL CARE PERIOD)

Multiple occurrences of this item are permitted

O

POST MORTEM CARRIED OUT INDICATOR

O

PARENTAL CONSENT TO POST MORTEM INDICATOR

O

POST MORTEM CONFIRMED NECROTISING ENTEROCOLITIS DIAGNOSIS INDICATOR

O

RECEIVING OXYGEN THERAPY ON DISCHARGE INDICATOR

O

SITE CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)

Or

ORGANISATION CODE (TWO YEAR NEONATAL OUTCOMES ASSESSMENT RESPONSIBILITY)

R

DIAGNOSIS (ICD RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)

Multiple occurrences of this item are permitted

And/Or

DIAGNOSIS (SNOMED CT RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)

Multiple occurrences of this item are permitted

Mandation Procedures Recorded At Discharge

To carry details of procedures recorded at discharge.Multiple occurrences of this group are permitted.

PROCEDURE (OPCS RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)

PROCEDURE (SNOMED CT RECORDED ON DISCHARGE FROM NEONATAL CRITICAL CARE)

Mandation Choice 1

PROCEDURE DATE AND TIME (DURING NEONATAL CRITICAL CARE PERIOD)

PROCEDURE YEAR AND MONTH (DURING NEONATAL CRITICAL CARE PERIOD)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

CLINICAL TRIALS (EPISODIC)

To carry details of Clinical Trial enrolment at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

Mandation

Data Elements

O

CLINICAL TRIAL NAME

O

CLINICAL TRIAL MEDICATION ADMINISTERED NAME

Multiple occurrences of this item are permitted

INFECTION CULTURES (EPISODIC)
Mandation Infection Culture Indicators

To carry indicators relating to Infection Cultures undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is permitted.

P

INFECTION CULTURE TEST INDICATOR (BLOOD)

P

INFECTION CULTURE TEST INDICATOR (CEREBROSPINAL FLUID)

P

INFECTION CULTURE TEST INDICATOR (URINE)

Mandation Infection Cultures

To carry information relating to Infection Cultures at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

R

SAMPLE COLLECTION DATE AND TIME

Or

SAMPLE COLLECTION YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

SAMPLE TYPE (NATIONAL NEONATAL DATA SET)

R

CLINICAL SIGN OBSERVED AT SAMPLE COLLECTION

Multiple occurrences of this item are permitted

R

SAMPLE TEST RESULT ORGANISM TYPE (SNOMED CT)

Multiple occurrences of this item are permitted

O

SAMPLE ANTIBIOTIC SENSITIVITY RESULT (SNOMED CT DM+D)

Multiple occurrences of this item are permitted

ABDOMINAL X-RAYS (EPISODIC)
Mandation Abdominal X-Ray Indicator

To carry an indicator relating to Abdominal X-Rays undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is permitted.

P

ABDOMINAL X-RAY PERFORMED INDICATOR

Mandation Abdominal X-Rays

To carry information relating to Abdominal X-Rays at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

R

PROCEDURE DATE AND TIME (ABDOMINAL X-RAY)

Or

PROCEDURE YEAR AND MONTH (ABDOMINAL X-RAY)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

ABDOMINAL X-RAY PERFORMED TO INVESTIGATE ABDOMINAL SIGNS INDICATOR

R

CONDITION SEEN IN ABDOMEN DURING X-RAY

Multiple occurrences of this item are permitted

R

ABDOMINAL X-RAY PERFORMED REASON

Multiple occurrences of this item are permitted

R

TRANSFERRED FROM NEONATAL INTENSIVE CARE UNIT FOR NECROTISING ENTEROCOLITIS MANAGEMENT INDICATOR

R

LAPAROTOMY FOR NECROTISING ENTEROCOLITIS INDICATION CODE

R

VISUAL INSPECTION CONFIRMED NECROTISING ENTEROCOLITIS DURING LAPAROTOMY INDICATOR

R

HISTOLOGY CONFIRMED NECROTISING ENTEROCOLITIS FOLLOWING LAPAROTOMY INDICATOR

R

PERITONEAL DRAIN INSERTED FOLLOWING ABDOMINAL X-RAY INDICATOR

RETINOPATHY OF PREMATURITY SCREENING (EPISODIC)
Mandation Retinopathy of Prematurity Screening Indicator

To carry an indicator relating to Retinopathy of Prematurity Screening undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is required.

M

RETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR

Mandation Retinopathy of Prematurity Screening

To carry information relating to Retinopathy of Prematurity Screening at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

R

PROCEDURE DATE AND TIME (RETINOPATHY OF PREMATURITY SCREENING)

Or

PROCEDURE YEAR AND MONTH (RETINOPATHY OF PREMATURITY SCREENING)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

SITE CODE (OF RETINOPATHY OF PREMATURITY SCREENING)

Or

ORGANISATION CODE (OF RETINOPATHY OF PREMATURITY SCREENING)

R

RETINOPATHY OF PREMATURITY STAGE (LEFT EYE)

R

RETINOPATHY OF PREMATURITY STAGE (RIGHT EYE)

R

RETINOPATHY OF PREMATURITY CLOCK HOURS MAXIMUM STAGE (LEFT EYE)

R

RETINOPATHY OF PREMATURITY CLOCK HOURS MAXIMUM STAGE (RIGHT EYE)

R

RETINOPATHY OF PREMATURITY MAXIMUM ZONE (LEFT EYE)

R

RETINOPATHY OF PREMATURITY MAXIMUM ZONE (RIGHT EYE)

R

RETINOPATHY OF PREMATURITY PLUS DISEASE STATUS (LEFT EYE)

R

RETINOPATHY OF PREMATURITY PLUS DISEASE STATUS (RIGHT EYE)

R

RETINOPATHY OF PREMATURITY SCREENING OUTCOME STATUS CODE

CRANIAL ULTRASOUND SCANS (EPISODIC)
Mandation Cranial Ultrasound Scan Indicator

To carry an indicator relating to Cranial Ultrasound Scans undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is permitted.

P

CRANIAL ULTRASOUND SCAN PERFORMED INDICATOR

Mandation Cranial Ultrasound Scan

To carry information relating to Cranial Ultrasound Scans at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

R

PROCEDURE DATE AND TIME (CRANIAL ULTRASOUND SCAN)

Or

PROCEDURE YEAR AND MONTH (CRANIAL ULTRASOUND SCAN)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

O

INTRAVENTRICULAR HAEMORRHAGE GRADE (LEFT SIDE)

O

PORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (LEFT SIDE)

O

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

O

INTRAVENTRICULAR HAEMORRHAGE GRADE (RIGHT SIDE)

O

PORENCEPHALIC CYST VISIBLE DURING CRANIAL ULTRASOUND SCAN INDICATOR (RIGHT SIDE)

O

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

O

CYSTIC PERIVENTRICULAR LEUKOMALACIA OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR

O

POST HAEMORRHAGIC HYDROCEPHALUS OBSERVED DURING CRANIAL ULTRASOUND SCAN INDICATOR

NEWBORN BLOOD SPOT BIOCHEMICAL SCREENING (EPISODIC)
Mandation Newborn Blood Spot Test Indicator

To carry an indicator relating to Newborn Blood Spot Tests undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is required.

M

NEWBORN BLOOD SPOT TEST PERFORMED INDICATOR

Mandation Newborn Blood Spot Screening

To carry details of Newborn Blood Spot Biochemical Screening undertaken at any time in the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

BLOOD SPOT CARD COMPLETION DATE

BLOOD SPOT CARD COMPLETION YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

NEWBORN HEARING SCREENING (EPISODIC)
Mandation Newborn Hearing Screening Indicator

To carry an indicator relating to Newborn Hearing Screening undertaken at any time during the Neonatal Critical Care Period.One occurrence of this group is permitted.

P

NEWBORN HEARING SCREENING PERFORMED INDICATOR

Mandation Newborn Hearing Screening

To carry information relating to Newborn Hearing Screening at any time during the Neonatal Critical Care Period.Multiple occurrences of this group are permitted.

R

PROCEDURE DATE AND TIME (NEWBORN HEARING SCREENING)

Or

PROCEDURE YEAR AND MONTH (NEWBORN HEARING SCREENING)

And

NUMBER OF MINUTES (BIRTH TO EVENT)

O

NEWBORN HEARING SCREENING OUTCOME LEFT EAR (NATIONAL NEONATAL DATA SET)

O

NEWBORN HEARING SCREENING OUTCOME RIGHT EAR (NATIONAL NEONATAL DATA SET)

O

NEWBORN HEARING SCREENING TEST TYPE

DAILY CARE INFORMATION
Mandation Daily Care General Information

To carry General Information relating to Daily Care.Multiple occurrences of this group are permitted (at least one occurrence is required).

M

NEONATAL CRITICAL CARE DAILY CARE DATE

Or

NEONATAL CRITICAL CARE DAILY CARE YEAR AND MONTH

And

NUMBER OF MINUTES (BIRTH TO EVENT)

R

PERSON WEIGHT IN GRAMS

O

HEAD CIRCUMFERENCE IN CENTIMETRES

O

PERSON LENGTH IN CENTIMETRES

R

LOCATION OF HIGHEST LEVEL OF CARE

R

PATIENT RECEIVING ONE TO ONE NURSING CARE INDICATOR

R

CARER RESIDENT INDICATION CODE (NATIONAL NEONATAL DATA SET)

R

DIAGNOSIS (ICD ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Multiple occurrences of this item are permitted

And/Or

DIAGNOSIS (SNOMED CT ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Multiple occurrences of this item are permitted

R

PROCEDURE (OPCS ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Multiple occurrences of this item are permitted

And/Or

PROCEDURE (SNOMED CT ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Multiple occurrences of this item are permitted

R

PERSON ACCOMPANYING TRANSPORTED PATIENT

Multiple occurrences of this item are permitted

Mandation Daily Care Respiratory

To carry Respiratory information relating to Daily Care.One occurrence of this group is required.

P

RESPIRATORY SUPPORT DEVICE TYPE (NATIONAL NEONATAL DATA SET)

Multiple occurrences of this item are permitted

P

RESPIRATORY SUPPORT MODE (NATIONAL NEONATAL DATA SET)

Multiple occurrences of this item are permitted

R

NITRIC OXIDE GIVEN INDICATOR

R

CHEST DRAIN IN SITU INDICATOR

R

TRACHEOSTOMY TUBE IN SITU INDICATOR

R

REPLOGLE TUBE IN SITU INDICATOR

R

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

P

FRACTION OF INSPIRED OXYGEN PERCENTAGE

Mandation Daily Care Cardiovascular

To carry Cardiovascular information relating to Daily Care.One occurrence of this group is required.

R

CONTINUOUS INFUSION OF PULMONARY VASODILATOR RECEIVED INDICATOR

R

INOTROPE INFUSION RECEIVED INDICATOR

R

PROSTAGLANDIN INFUSION RECEIVED INDICATOR

R

TREATMENT TYPE FOR PATENT DUCTUS ARTERIOSUS

Multiple occurrences of this item are permitted

Mandation Daily Care Gastrointestinal

To carry Gastrointestinal information relating to Daily Care.One occurrence of this group is required.

R

PERITONEAL DIALYSIS RECEIVED INDICATOR

R

HAEMOFILTRATION RECEIVED INDICATOR

R

TREATMENT TYPE FOR NECROTISING ENTEROCOLITIS

R

MORE THAN THREE RECTAL WASHOUTS RECEIVED INDICATOR

R

STOMA PRESENT INDICATOR

Mandation Daily Care Blood Transfusion

To carry Blood Transfusion information relating to Daily Care.Multiple occurrences of this group are permitted.

R

BLOOD TRANSFUSION TYPE

R

BLOOD TRANSFUSION PRODUCT TYPE

Multiple occurrences of this item are permitted

Mandation Daily Care Neurology

To carry Neurology information relating to Daily Care.One occurrence of this group is required.

R

CENTRAL TONE STATUS

R

NEONATAL CONSCIOUSNESS STATUS

R

SEIZURE OCCURRED INDICATOR

R

NEONATAL ABSTINENCE SYNDROME OBSERVED INDICATOR

R

BRAIN ACTIVITY SCAN PERFORMED INDICATOR

R

THERAPEUTIC HYPOTHERMIA INDUCED INDICATOR

R

HYPOXIC ISCHEMIC ENCEPHALOPATHY GRADE (HIGHEST ON NEONATAL CRITICAL CARE DAILY CARE DATE)

Mandation Daily Care Retinopathy of Prematurity Screening

To carry Retinopathy of Prematurity information relating to Daily Care.One occurrence of this group is required.

R

RETINOPATHY OF PREMATURITY SCREENING PERFORMED INDICATOR

Mandation Daily Care Fluids and Feeding

To carry Fluids and Feeding information relating to Daily Care.One occurrence of this group is required.

R

VASCULAR LINE TYPE IN SITU

Multiple occurrences of this item are permitted

R

PARENTERAL NUTRITION RECEIVED INDICATOR

R

INTRAVENOUS INFUSION OF GLUCOSE AND ELECTROLYTE SOLUTION RECEIVED INDICATOR

R

ENTERAL FEED TYPE GIVEN

Multiple occurrences of this item are permitted

R

FORMULA MILK OR MILK FORTIFIER TYPE

Multiple occurrences of this item are permitted

Or

FORMULA MILK OR MILK FORTIFIER TYPE (SNOMED CT DM+D)

Multiple occurrences of this item are permitted

R

TOTAL VOLUME OF MILK RECEIVED

O

ENTERAL FEEDING METHOD

Multiple occurrences of this item are permitted

Mandation Daily Care Infections

To carry Infection information relating to Daily Care.One occurrence of this group is required.

R

SEPSIS SUSPECTED INDICATOR

Mandation Daily Care Jaundice

To carry Jaundice information relating to Daily Care.One occurrence of this group is required.

R

PHOTOTHERAPY RECEIVED INDICATOR

Mandation Daily Care Medication

To carry Medication Administered information relating to Daily Care.One occurrence of this group is permitted.

R

MEDICATION GIVEN DURING NEONATAL CRITICAL CARE DAILY CARE DATE (SNOMED CT DM+D)

Multiple occurrences of this item are permitted

Also Known As

This data set is also known by these names:

Context Alias
Short name Episodic and Daily Care