Change Request
 

NHS Connecting for Health

NHS Data Model and Dictionary Service

Reference: Change Request 1294
Version No:1.0
Subject:March 2012 Release Patch
Effective Date:Immediate
Reason for Change:Patch
Publication Date:20 March 2012

Background:

This patch updates the NHS Data Model and Dictionary in preparation for the March 2012 Release and includes:

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

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Summary of changes:

Data Set
CANCER REGISTRATION DATA SET   Changed Description
COMMUNITY INFORMATION DATA SET   Changed Description
GENITOURINARY MEDICINE CLINIC ACTIVITY DATA SET   Changed Description
IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DATA SET   Changed Description
NATIONAL CANCER DATA SET   Changed Description
QUARTERLY BED AVAILABILITY AND OCCUPANCY DATA SET (KH03)   Changed Description
SYSTEMIC ANTI-CANCER THERAPY DATA SET   Changed Description
 
Supporting Information
CDS BUSINESS RULES   Changed Description
CDS NOTATION   Changed Description
COMMUNITY HEALTH PARTNERSHIP (SCOTLAND) renamed from COMMUNITY HEALTH PARTNERSHIPS (SCOTLAND)   Changed Description, Aliases, Name
NHS POSTCODE DIRECTORY   Changed Description
WHAT'S NEW: MARCH 2012 renamed from WHAT'S NEW: JANUARY 2012   Changed Description, Name
 
Class Definitions
CONSULTANT   Changed Description
LANGUAGE CLASSIFICATION   Changed Description
PERSON PROPERTY   Changed Description
SERVICE   Changed Description
 
Attribute Definitions
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS   Changed Description
CIGARETTES PER DAY   Changed Aliases
LANGUAGE CLASSIFICATION CODE   Changed Description
OVERSEAS VISITORS STATUS CLASSIFICATION   Changed Description
REFERRAL TO TREATMENT PERIOD END DATE   Changed Description
REFERRAL TO TREATMENT PERIOD START DATE   Changed Description
 
Data Elements
ACCOMMODATION STATUS DATE   Changed Description
DATE FIRST SEEN   Changed Description
DEATH CAUSE ICD CODE (CONDITION)   Changed Description
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE)   Changed Description
IMAGING CODE (NICIP)   Changed Description
IMAGING CODE (SNOMED-CT)   Changed Description
NHS NUMBER STATUS INDICATOR   Changed Description
NHS NUMBER STATUS INDICATOR (BABY)   Changed Description
NHS NUMBER STATUS INDICATOR (MOTHER)   Changed Description
NHS NUMBER STATUS INDICATOR CODE   Changed Description
NHS NUMBER STATUS INDICATOR CODE (BABY)   Changed Description
NHS NUMBER STATUS INDICATOR CODE (MOTHER)   Changed Description
ORGANISATION CODE (CODE OF PROVIDER)   Changed Description
PATIENT PATHWAY IDENTIFIER   Changed Description
PERSON INITIAL (FIRST)   Changed Description
PREFERRED COMMUNICATION LANGUAGE   Changed Description
PRESCRIPTION DATE   Changed Description
PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION)   Changed Description
PRESCRIPTION IDENTIFIER   Changed Description
PRESCRIPTION PROVIDED INDICATOR (ANTI-HYPERTENSIVES)   Changed Description
PRESCRIPTION PROVIDED INDICATOR (STATINS)   Changed Description
PREVIOUS SYMPTOM INDICATOR   Changed Description
PRIMARY REASON FOR REFERRAL (COMMUNITY CARE)   Changed Description
RADIOTHERAPY INTENT   Changed Description
REFERRING CARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)   Changed Description
REMOVALS OTHER THAN ADMISSION   Changed Description
REMOVALS OTHER THAN ADMISSION (DAY CASE)   Changed Description
REMOVALS OTHER THAN ADMISSION (ORDINARY)   Changed Description
RENAL SUPPORT DAYS   Changed Description
REPLACEMENT APPOINTMENT BOOKED DATE (COMMUNITY CARE)   Changed Description
REPLACEMENT APPOINTMENT DATE OFFERED (COMMUNITY CARE)   Changed Description
RESPONSE CATEGORY   Changed Description
RESUSCITATION METHOD   Changed Description
RESUSCITATION METHOD CODE   Changed Description
REVIEW DATE   Changed Description
WAITING TIME ADJUSTMENT REASON (TREATMENT)   Changed Description
 

Date:20 March 2012
Sponsor:Richard Kavanagh, NHS Connecting for Health

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

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CANCER REGISTRATION DATA SET

Change to Data Set: Changed Description

Cancer Registration Data Set Overview

Please note that the Cancer Registration Data Set will be replaced by the Cancer Outcomes and Services Data Set which is planned to be mandated from 1 January 2013. For further details, see the National Cancer Intelligence Network (NCIN) website.

Data Set Data Elements 
DEMOGRAPHICS:
It is anticipated that some of the demographic data items listed below will be collected by every provider with which the patient has contact.
Where this information is exchanged, the appropriate data item name should be used to identify the particular instance of the data.
Notes:
NHS NUMBER  
LOCAL PATIENT IDENTIFIER  
ORGANISATION CODE (CODE OF PROVIDER)  
CARE SPELL IDENTIFIER  
PERSON FAMILY NAME  
PERSON GIVEN NAME  
PATIENT USUAL ADDRESS (AT DIAGNOSIS)  
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)  
PERSON GENDER CURRENT  
PERSON BIRTH DATE  
GENERAL MEDICAL PRACTITIONER (SPECIFIED) This need only be collected by those sites who find it difficult to collect the GP Practice Code below.
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)  
ORGANISATION CODE (RESPONSIBLE PCT) This need not be collected directly by clinical staff
PERSON FAMILY NAME (AT BIRTH) This is not usually readily available from a hospital PAS system. It should be collected prospectively on contact with the patient.
ETHNIC CATEGORY  
REFERRALS 
REFERRING ORGANISATION CODE  
REFERRER CODE  
CANCER REFERRAL PRIORITY TYPE  
CANCER REFERRAL DECISION DATE  
REFERRAL REQUEST RECEIVED DATE  
CONSULTANT CODE Referred to
MAIN SPECIALTY CODE Can be derived from consultant code
DATE FIRST SEEN  
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS)  
DELAY REASON COMMENT (FIRST SEEN)  
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE  
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS  
WAITING TIME ADJUSTMENT (FIRST SEEN)  
WAITING TIME ADJUSTMENT REASON (FIRST SEEN)  
SOURCE OF REFERRAL FOR OUT-PATIENTS  
SITE CODE (OF IMAGING)  
CLINICAL INTERVENTION DATE (CANCER IMAGING)  
CANCER IMAGING MODALITY  
ANATOMICAL EXAMINATION SITE  
INVASIVE LESION SIZE (RADIOLOGICAL DETERMINATION)  
DIAGNOSIS:
These fields should record the definitive diagnosis as known to the hospital in question, based on the information available at the time the items were completed. There will be only one definitive diagnosis entry held.
 
DIAGNOSIS DATE (CANCER)  
PRIMARY DIAGNOSIS (ICD)  
TUMOUR LATERALITY  
BASIS OF DIAGNOSIS (CANCER)  
HISTOLOGY (SNOMED)  
GRADE OF DIFFERENTIATION (AT DIAGNOSIS)  
CANCER CARE PLAN:
There may be a number of cancer care plans, on different dates.
 
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR Was this cancer care plan discussed at an MDT meeting?
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) The date of the MDT meeting at which the cancer care plan was discussed
CARE PLAN AGREED DATE  
RECURRENCE INDICATOR  
CANCER CARE PLAN INTENT  
PLANNED CANCER TREATMENT TYPE  
TREATMENT TYPE SEQUENCE  
NO CANCER TREATMENT REASON  
CO-MORBIDITY INDEX FOR ADULTSInvestigations into the possible use of the ACE-27 coding system are continuing.
PERFORMANCE STATUS (ADULT)  
STAGING:
These fields should be recorded at the time that the first cancer care plan is agreed. Cancer registries require the first pre-treatment stage, i.e. the stage at diagnosis.
 
T CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (T CATEGORY)  
N CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (N CATEGORY)  
M CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (M CATEGORY)  
TNM CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (TNM CATEGORY)  
SITE SPECIFIC STAGING CLASSIFICATION  
TNM CATEGORY (INTEGRATED)  
T CATEGORY (INTEGRATED STAGE)  
N CATEGORY (INTEGRATED STAGE)  
M CATEGORY (INTEGRATED STAGE)  
SURGERY AND OTHER PROCEDURES:
This can be adapted for other procedures including interventional radiology, laser treatment, endoscopies etc. and photo-dynamic procedures. This also includes procedures offered as supportive care.
 
SITE CODE (OF SURGERY)  
CONSULTANT CODE Managing consultant code
MAIN SPECIALTY CODE Can be derived from consultant code
CANCER TREATMENT INTENT  
DECISION TO TREAT DATE (SURGERY)  
START DATE (SURGERY HOSPITAL PROVIDER SPELL)  
PROCEDURE DATE  
PRIMARY PROCEDURE (OPCS)  
PROCEDURE (OPCS) This may occur more than once
DISCHARGE DATE (HOSPITAL PROVIDER SPELL)  
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)  
PATHOLOGY DETAILS:
It is expected that all the data items on the minimum RCPath data set will be collected. The pathology data items below are a subset of that data set. A patient may have any number of pathology reports, and there may be more than one pathology report per specimen. If the original report is reviewed or revised, then a new pathology module will need to be completed and dated, with the data item 'Second Opinion' on the RCPath data set marked as 'Y'
 
PATHOLOGY INVESTIGATION TYPE  
SAMPLE RECEIPT DATE  
INVESTIGATION RESULT DATE  
CONSULTANT CODE (PATHOLOGIST)  
ORGANISATION CODE (OF REPORTING PATHOLOGY)  
PRIMARY DIAGNOSIS (ICD)  
TUMOUR LATERALITY  
INVASIVE LESION SIZE  
SYNCHRONOUS TUMOUR INDICATOR  
HISTOLOGY (SNOMED)  
GRADE OF DIFFERENTIATION  
CANCER VASCULAR OR LYMPHATIC INVASION  
EXCISION MARGIN  
NODES EXAMINED NUMBER  
NODES POSITIVE NUMBER  
T CATEGORY (PATHOLOGICAL)  
N CATEGORY (PATHOLOGICAL)  
M CATEGORY (PATHOLOGICAL)  
TNM CATEGORY (PATHOLOGICAL)  
SERVICE REPORT IDENTIFIER  
SERVICE REPORT STATUS  
SPECIMEN NATURE  
ORGANISATION CODE (REQUESTED BY)  
CARE PROFESSIONAL CODE (REQUESTED BY)  
T CATEGORY EXTENDED (PATHOLOGICAL)  
M CATEGORY EXTENDED (PATHOLOGICAL)  
CHEMOTHERAPY AND OTHER DRUGS:
Chemotherapy and/or other anti-Cancer and/or Supportive drugs given to the patient during their treatment.
 
SITE CODE (OF CANCER DRUG TREATMENT)  
CONSULTANT CODE Managing Consultant
MAIN SPECIALTY CODE Can be derived from consultant code
DECISION TO TREAT DATE (ANTI-CANCER DRUG REGIMEN)  
DRUG THERAPY TYPE  
DRUG TREATMENT INTENT  
DRUG REGIMEN ACRONYM  
START DATE (ANTI-CANCER DRUG REGIMEN)  
RADIOTHERAPY 
Radiotherapy (Teletherapy):
A course of teletherapy is defined as a string of prescriptions which are consecutive.
 
SITE CODE (OF TELETHERAPY)  
CONSULTANT CODE Managing consultant
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE)  
CANCER TREATMENT INTENT  
ANATOMICAL EXAMINATION SITE  
START DATE (TELETHERAPY TREATMENT COURSE)  
Radiotherapy (Brachytherapy):
A course of brachytherapy is defined as a string of prescriptions which are consecutive.
 
SITE CODE (OF BRACHYTHERAPY)  
CONSULTANT CODE Managing Consultant
DECISION TO TREAT DATE (BRACHYTHERAPY TREATMENT COURSE)  
CANCER TREATMENT INTENT  
BRACHYTHERAPY TYPE  
ANATOMICAL EXAMINATION SITE  
START DATE (BRACHYTHERAPY TREATMENT COURSE)  
PALLIATIVE CARE:
It is expected that this section will be completed whenever an intervention occurs that involves one face-to-face contact with the patient. It is expected that a Cancer Care Plan will also be completed for the Palliative Care Management Plan.
The Palliative Care data items are in the process of being developed.
DECISION TO TREAT DATE (SPECIALIST PALLIATIVE TREATMENT COURSE)  
START DATE (SPECIALIST PALLIATIVE TREATMENT COURSE)  
CLINICAL TRIALS:
Additional information corresponding to patients ineligible for a trial, or whether there is no trial available, can be recorded if required.
Clinical Trials information will be completed for every Clinical Trial in which the patient is involved
PATIENT TRIAL STATUS (CANCER)  
CANCER CLINICAL TRIAL TREATMENT TYPE  
DEATH DETAILS 
PERSON DEATH DATE  
DEATH LOCATION TYPE  
DEATH CAUSE IDENTIFICATION METHOD  
The data items below will usually not be collected directly by the Trust; information would come from Cancer Registries. 
DEATH CAUSE CODE (IMMEDIATE)  
DEATH CAUSE CODE (CONDITION)  
DEATH CAUSE CODE (UNDERLYING)  
DEATH CAUSE CODE (SIGNIFICANT)  

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COMMUNITY INFORMATION DATA SET

Change to Data Set: Changed Description

Community Information Data Set Overview

The Community Information Data Set is initially being introduced for local use only, from 1 April 2012. A future Information Standards Notice will be published to notify providers and system suppliers of the requirement to flow the data set nationally, and give further details relating to unique record identifiers and how the data will be handled by the receiving system.  The layout of the data set shown below, and the definition of the Mandatory, Required or Optional column, show the data inclusion requirements which will apply when the data is required to flow nationally, to enable providers and system suppliers to prepare the data for national flow.The Community Information Data Set has been introduced for local use only, from 1 April 2012.

A future Information Standards Notice will be published to notify providers and system suppliers of the requirement to flow the data set nationally, and give further details relating to unique record identifiers and how the data will be handled by the receiving system.

The layout of the data set shown below, and the definition of the Mandatory, Required or Optional column, show the data inclusion requirements which will apply when the data is required to flow nationally, to enable providers and system suppliers to prepare the data for national flow.

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

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

Note - Items in the M/R/O column which are shown with notation P, have not yet been defined by the NHS Data Model and Dictionary Service, or approved by the Information Standards Board for Health and Social Care, and are included to facilitate piloting and testing of future Department of Health data requirements, prior to formal inclusion in later versions of the data set.  These items have been included in the data set layout because the Community Information Data Set XML Schema Version 1.Note: items in the M/R/O column which are shown with notation P, have not yet been defined by the NHS Data Model and Dictionary Service, or approved by the Information Standards Board for Health and Social Care, and are included to facilitate piloting and testing of future Department of Health data requirements, prior to formal inclusion in later versions of the data set.
These items have been included in the data set layout because the Community Information Data Set XML Schema Version 1.0.0 includes the facility to submit these items to support the piloting activities.  Unless ORGANISATIONS are engaged in these piloting activities, they should NOT submit any data item marked P. Unless ORGANISATIONS are engaged in these piloting activities, they should NOT submit any data item marked P.

PERSON

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MCIDS UNIQUE IDENTIFIER
MORGANISATION CODE (PROVIDER AT RECORD CREATION)
OCIDS PRIME RECIPIENT IDENTITY
OCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Identity Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
MNHS NUMBER STATUS INDICATOR CODE
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE

Patient Characteristics:
To carry the details of the patient's characteristics. 
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RPERSON BIRTH DATE
RPERSON DEATH DATE
RPOSTCODE OF USUAL ADDRESS
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
RORGANISATION CODE (PCT OF GP PRACTICE)
RPERSON GENDER CODE CURRENT 
PEMPLOYMENT STATUS
RETHNIC CATEGORY 
OPREFERRED COMMUNICATION LANGUAGE
PCARER SUPPORT INDICATOR
PPATIENT CARE RESPONSIBILITY INDICATOR
RORGANISATION CODE (PCT OF RESIDENCE)

Patient Disability:
To carry the disability details of the patient.  
Eleven occurrences of this group are permitted.
M/R/OData Set Data Elements
PDISABILITY CODE

Patient Death Details:
To carry the death details of the patient. This group is only required where the patient is on an End of Life Care Pathway.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RDEATH LOCATION TYPE (PREFERRED)
RDEATH LOCATION TYPE (ACTUAL)
PDEATH NOT AT PREFERRED LOCATION REASON CODE


SERVICE REFERRAL

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MCIDS UNIQUE IDENTIFIER
MORGANISATION CODE (PROVIDER AT RECORD CREATION)
OCIDS PRIME RECIPIENT IDENTITY
OCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Identity Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
MNHS NUMBER STATUS INDICATOR CODE
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE

Referral Details:
To carry the referral details.
One occurrence of this group is required.
M/R/OData Set Data Elements
RSERVICE REQUEST IDENTIFIER
MREFERRAL REQUEST RECEIVED DATE
RREFERRAL REQUEST RECEIVED TIME
RORGANISATION CODE (CODE OF COMMISSIONER) 
RSERVICE TYPE REFERRED TO (COMMUNITY CARE)
RSOURCE OF REFERRAL FOR COMMUNITY
OREFERRING ORGANISATION CODE
OREFERRING CARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)
RPRIORITY TYPE CODE

Referral Reason:
To carry the referral reason details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RPRIMARY REASON FOR REFERRAL (COMMUNITY CARE)
OOTHER REASON FOR REFERRAL (COMMUNITY CARE) 
Six occurrences of this data item are permitted

Diagnosis at Referral:
To carry the details of the diagnosis at referral. 
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
PDIAGNOSIS SCHEME IN USE
PDIAGNOSIS AT REFERRAL (COMMUNITY CARE)
Twelve occurrences of this data item are permitted

Referral Closure:
To carry the referral closure details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RREFERRAL CLOSURE DATE (COMMUNITY CARE)
RREFERRAL CLOSURE REASON (COMMUNITY CARE)
RDISCHARGE DATE (COMMUNITY HEALTH SERVICE)
RDISCHARGE LETTER ISSUED DATE (COMMUNITY CARE)


REFERRAL TO TREATMENT

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MCIDS UNIQUE IDENTIFIER
MORGANISATION CODE (PROVIDER AT RECORD CREATION)
OCIDS PRIME RECIPIENT IDENTITY
OCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Identity Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
MNHS NUMBER STATUS INDICATOR CODE
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE

Referral To Treatment Period:
To carry the details of Referral To Treatment Periods during the Patient Pathway.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
RSERVICE REQUEST IDENTIFIER
RCOMMUNITY CARE CONTACT IDENTIFIER
RUNIQUE BOOKING REFERENCE NUMBER (CONVERTED)
RPATIENT PATHWAY IDENTIFIER
RORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER)
RWAITING TIME MEASUREMENT TYPE
RREFERRAL TO TREATMENT PERIOD START DATE
RREFERRAL TO TREATMENT PERIOD END DATE
RREFERRAL TO TREATMENT PERIOD STATUS


CARE CONTACT ACTIVITY

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MCIDS UNIQUE IDENTIFIER
MORGANISATION CODE (PROVIDER AT RECORD CREATION)
OCIDS PRIME RECIPIENT IDENTITY
OCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
MNHS NUMBER STATUS INDICATOR CODE
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
MNHS NUMBER STATUS INDICATOR CODE

Care Contact Details:
To carry the details of the care contact.
One occurrence of this group is required.
M/R/OData Set Data Elements
RCOMMUNITY CARE CONTACT IDENTIFIER
RSERVICE REQUEST IDENTIFIER
RORGANISATION CODE (CODE OF COMMISSIONER) 
MCARE CONTACT DATE
RCARE CONTACT TIME
RCLINICAL CONTACT DURATION OF CARE CONTACT
RCARE CONTACT TYPE (COMMUNITY CARE)
RCARE CONTACT SUBJECT
RCONSULTATION MEDIUM USED 
RACTIVITY LOCATION TYPE CODE
OSITE CODE (OF TREATMENT)
RATTENDED OR DID NOT ATTEND CODE 

Care Professional Staff Group Details:
To carry the details of the Care Professional Staff Group. 
Ten occurrences of this group are permitted.
M/R/OData Set Data Elements
RCARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)

Appointment Offer Details:
To carry the details of the appointment offer.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
OEARLIEST REASONABLE OFFER DATE
OEARLIEST CLINICALLY APPROPRIATE DATE

Activity Cancellation Details:
To carry the Activity Cancellation details.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
RCARE CONTACT CANCELLATION DATE
RCARE CONTACT CANCELLATION REASON
RREPLACEMENT APPOINTMENT BOOKED DATE (COMMUNITY CARE)
RREPLACEMENT APPOINTMENT DATE OFFERED (COMMUNITY CARE)

Assessment Tool Used Details:
To carry the details of the Assessment Tool used. 
Six occurrences of this group are permitted.
M/R/OData Set Data Elements
PASSESSMENT TOOL TYPE (COMMUNITY CARE)
PASSESSMENT RATING SCALE (COMMUNITY ASSESSMENT TOOL)
PPERSON SCORE (COMMUNITY ASSESSMENT TOOL)

Care Contact Activity Details:
To carry the details of the activities performed at the care contact.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
MCOMMUNITY CARE ACTIVITY TYPE CODE
OGROUP THERAPY INDICATOR (COMMUNITY CARE)
OCLINICAL CONTACT DURATION OF CARE ACTIVITY

Nutritional Assessment Outcomes:
To carry details of Nutritional Assessments. 
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PNUTRITIONAL ASSESSMENT DATE

Anxiety or Depression Assessment Outcomes:
To carry details of Anxiety or Depression Assessments.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PANXIETY OR DEPRESSION ASSESSMENT DATE

Falls Outcomes:
To carry details of Falls.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PFALL REPORTED DATE
PFALL SEVERITY OF HARM CODE

Venous Leg Ulcer Wounds Initial Assessment Outcome:
To carry details of Venous Leg Ulcer Wounds Initial Assessment outcome. 
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PVENOUS LEG ULCER WOUNDS INITIAL ASSESSMENT DATE
PVENOUS LEG ULCER WOUNDS AT INITIAL ASSESSMENT TOTAL

Venous Leg Ulcer Wounds Subsequent Assessment Outcomes:
To carry details of Venous Leg Ulcer Wounds Subsequent Assessment outcomes.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PVENOUS LEG ULCER WOUNDS SUBSEQUENT ASSESSMENT DATE
PVENOUS LEG ULCER WOUNDS AT SUBSEQUENT ASSESSMENT TOTAL

Pressure Ulcer Assessment Outcomes:
To carry details of Pressure Ulcer Assessments.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PPRESSURE ULCER ASSESSMENT DATE
PPRESSURE ULCER CLASSIFICATION CODE
PINCIPIENT PRESSURE ULCER INDICATOR

Other Outcomes:
To carry details of other outcome measures.
Multiple occurrences of this group are permitted.
M/R/OData Set Data Elements
PPROBLEM TYPE
POUTCOME TYPE
POUTCOME MEASURE
POUTCOME VALUE


GROUP SESSION

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
MCIDS UNIQUE IDENTIFIER
MORGANISATION CODE (PROVIDER AT RECORD CREATION)
OCIDS PRIME RECIPIENT IDENTITY
OCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

Group Session Details:
To carry the details of the Group Session.
One occurrence of this group is required.
M/R/OData Set Data Elements
RGROUP SESSION IDENTIFIER (COMMUNITY CARE)
RORGANISATION CODE (CODE OF COMMISSIONER) 
MGROUP SESSION DATE
RCLINICAL CONTACT DURATION OF GROUP SESSION
RGROUP SESSION TYPE CODE (COMMUNITY CARE)
RNUMBER OF GROUP SESSION PARTICIPANTS (COMMUNITY CARE)
OACTIVITY LOCATION TYPE CODE
OSITE CODE (OF TREATMENT)

Care Professional Staff Group Details:
To carry the details of the Care Professional Staff Group. 
Ten occurrences of this group are permitted.
M/R/OData Set Data Elements
RCARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)

Group Session Cancellation Details:
To carry the cancellation details of the Group Session.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PGROUP SESSION CANCELLATION REASON (COMMUNITY CARE)


INDIRECT PATIENT ACTIVITY

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PCIDS UNIQUE IDENTIFIER
PORGANISATION CODE (PROVIDER AT RECORD CREATION)
PCIDS PRIME RECIPIENT IDENTITY
PCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Identity Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
PNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
PNHS NUMBER STATUS INDICATOR CODE
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
PNHS NUMBER STATUS INDICATOR CODE

Indirect Patient Activity Details:
To carry the details of the Indirect Patient Activity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
PINDIRECT PATIENT ACTIVITY IDENTIFIER
PSERVICE REQUEST IDENTIFIER
PORGANISATION CODE (CODE OF COMMISSIONER)
PINDIRECT PATIENT ACTIVITY DATE
PINDIRECT PATIENT ACTIVITY DURATION
PINDIRECT PATIENT ACTIVITY TYPE CODE (COMMUNITY CARE)

Care Professional Staff Group Details:
To carry the Care Professional Staff Group.
Ten occurrences of this group are permitted.
M/R/OData Set Data Elements
PCARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)


ONWARD REFERRAL

Record Identity and Recipients:
To carry the unique record identifier and the recipient organisations.  
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PCIDS UNIQUE IDENTIFIER
PORGANISATION CODE (PROVIDER AT RECORD CREATION)
PCIDS PRIME RECIPIENT IDENTITY
PCIDS COPY RECIPIENT IDENTITY
Multiple occurrences of this data item are permitted

One of the following Patient Identity Data Group Structures must be used:
Patient Identity (Standard):
To carry the details of the patient where there is no requirement to withhold the patient's identity. 
One occurrence of this group is required.
M/R/OData Set Data Elements
PNHS NUMBER
and/or
LOCAL PATIENT IDENTIFIER
and
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
PNHS NUMBER STATUS INDICATOR CODE
PORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
OR
Patient Identity (Withheld):
To carry the details of the patient where the patient details are withheld. 
One occurrence of this group is required.
M/R/OData Set Data Elements
PNHS NUMBER STATUS INDICATOR CODE

Onward Referral:
To carry the details of the onward referral.
One occurrence of this group is permitted.
M/R/OData Set Data Elements
PONWARD REFERRAL IDENTIFIER
PSERVICE REQUEST IDENTIFIER
PREASON FOR ONWARD REFERRAL (COMMUNITY CARE)
PONWARD REFERRAL DATE
PORGANISATION CODE (RECEIVING)

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GENITOURINARY MEDICINE CLINIC ACTIVITY DATA SET

Change to Data Set: Changed Description

Genitourinary Medicine Clinic Activity Data Set Overview

The Opt (Optionality) column indicates the NHS 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.
OptData Set Data Elements
M
 
SITE CODE (OF TREATMENT) 
M
 
LOCAL PATIENT IDENTIFIER 
R

R
 
SEXUAL HEALTH AND HIV ACTIVITY PROPERTY TYPE
or
DIAGNOSTIC OR PROCEDURE CODING (SEXUAL HEALTH AND HUMAN IMMUNODEFICIENCY VIRUS RELEVANT READ CODES) 
R
 
PERSON GENDER CURRENT 
R
 
AGE AT ATTENDANCE DATE 
R
 
SEXUAL ORIENTATION (CURRENT) 
R
 
ETHNIC CATEGORY 
R
 
COUNTRY CODE (BIRTH) 
R
 
ORGANISATION CODE (PCT OF RESIDENCE) 
R
 
LOWER LAYER SUPER OUTPUT AREA (RESIDENCE) 
R
 
FIRST ATTENDANCE 
M
 
ATTENDANCE DATE 

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IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES DATA SET

Change to Data Set: Changed Description

Improving Access to Psychological Therapies Data Set Overview

The Improving Access to Psychological Therapies Data Set has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012.

The Mandatory or Required (M/R) 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.
PERSONAL AND DEMOGRAPHIC DETAILS

Patient details:
To carry Patient Demographic details.
One occurrence of this group is permitted.
M/R Data Set Data Elements 
RNHS NUMBER 
RNHS NUMBER STATUS INDICATOR CODE 
MLOCAL PATIENT IDENTIFIER 
MORGANISATION CODE (CODE OF PROVIDER) 
MPERSON BIRTH DATE 
RPERSON GENDER CODE CURRENT 
MPOSTCODE OF USUAL ADDRESS 
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
RETHNIC CATEGORY 
RRELIGIOUS OR OTHER BELIEF SYSTEM AFFILIATION CODE 
RSEXUAL ORIENTATION (CURRENT) 
REX-BRITISH ARMED FORCES INDICATOR 
RLONG TERM PHYSICAL HEALTH CONDITION INDICATOR (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 

DISABILITY

Patient Disability details:
To carry details of the Patient's Perceived Disability.
Many occurrences of this group are permitted (one for each disability).
M/R Data Set Data Elements 
RNHS NUMBER 
RLOCAL PATIENT IDENTIFIER 
RORGANISATION CODE (CODE OF PROVIDER) 
RDISABILITY CODE 

REFERRAL DETAILS

Improving Access to Psychological Therapies Referral details:
To carry details of the Referral.
Many occurrences of this group are permitted (one occurrence for each Referral).
M/R Data Set Data Elements 
RNHS NUMBER 
MLOCAL PATIENT IDENTIFIER 
MORGANISATION CODE (CODE OF PROVIDER) 
MSERVICE REQUEST IDENTIFIER 
RREFERRAL REQUEST RECEIVED DATE 
RSOURCE OF REFERRAL FOR MENTAL HEALTH 
RSERVICE REQUEST ACCEPTANCE INDICATOR 
RORGANISATION CODE (CODE OF COMMISSIONER) 
RPROVISIONAL DIAGNOSIS (ICD) 
RYEAR AND MONTH OF SYMPTOMS ONSET (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 
RPREVIOUS SYMPTOM INDICATOR 
RIMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES CARE SPELL END CODE 
REND DATE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 

APPOINTMENT DETAILS

Improving Access to Psychological Therapies Appointment details:
To carry details of each Appointment.
Many occurrences of this group are permitted (one occurrence for each Appointment).
M/R Data Set Data Elements 
RNHS NUMBER 
MLOCAL PATIENT IDENTIFIER 
MORGANISATION CODE (CODE OF PROVIDER) 
MSERVICE REQUEST IDENTIFIER 
MAPPOINTMENT DATE 
RCARE PROFESSIONAL ROLE CODE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 
MATTENDED OR DID NOT ATTEND CODE 
RCLINICAL CONTACT DURATION OF APPOINTMENT 
RAPPOINTMENT TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES) 
RCONSULTATION MEDIUM USED 
RTHERAPY TYPE (IMPROVING ACCESS TO PSYCHOLOGICAL THERAPIES)
(Up to four types may be recorded for each APPOINTMENT)
REMPLOYMENT STATUS 
REMPLOYMENT SUPPORT SUITABILITY INDICATOR 
REMPLOYMENT SUPPORT REFERRAL DATE 
RPSYCHOTROPIC MEDICATION USAGE 
RSTATUTORY SICK PAY INDICATOR 
RPHQ-9 TOTAL SCORE 
RGENERALISED ANXIETY DISORDER SCORE 
RWORK AND SOCIAL ADJUSTMENT SCALE SCORE 
RAGORAPHOBIA MOBILITY INVENTORY SCORE (WHEN ACCOMPANIED) 
RAGORAPHOBIA MOBILITY INVENTORY SCORE (WHEN ALONE) 
RAGORAPHOBIA SCORE 
RGENERALISED ANXIETY DISORDER PENN STATE WORRY SCORE 
RHEALTH ANXIETY INVENTORY SHORT WEEK SCALE SCORE 
ROBSESSIVE COMPULSIVE DISORDER INVENTORY SCORE 
RPANIC DISORDER SEVERITY SCALE SCORE 
RPOST TRAUMATIC STRESS DISORDER IMPACT OF EVENTS SCALE REVISED SCORE 
RSOCIAL PHOBIA INVENTORY SCORE 
RSOCIAL PHOBIA SCORE 
RSPECIFIC PHOBIA SCORE 

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NATIONAL CANCER DATA SET

Change to Data Set: Changed Description

National Cancer Data Set Overview

Please note that the National Cancer Data Set will be replaced by the Cancer Outcomes and Services Data Set which is planned to be mandated from 1 January 2013. For further details, see the National Cancer Intelligence Network (NCIN) website.

Site Specific Cancers

Brain and Central Nervous System
Breast Cancer
Colorectal Cancer
Lung Cancer
Head and Neck Cancer
Sarcoma
Skin Cancer
Urological Cancer
Upper GI Cancer
Gynaecological Cancer

Data Set Data Element
Demographics
NHS NUMBER 
LOCAL PATIENT IDENTIFIER 
ORGANISATION CODE (CODE OF PROVIDER) 
CARE SPELL IDENTIFIER 
PERSON FAMILY NAME 
PERSON GIVEN NAME 
PATIENT USUAL ADDRESS (AT DIAGNOSIS) 
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS) 
SEX 
BIRTH DATE 
GENERAL MEDICAL PRACTITIONER (SPECIFIED) 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
ORGANISATION CODE (RESPONSIBLE PCT) 
PERSON FAMILY NAME (AT BIRTH) 
ETHNIC CATEGORY 
Referrals
SOURCE OF REFERRAL FOR CANCER 
REFERRING ORGANISATION CODE 
REFERRER CODE 
CANCER REFERRAL PRIORITY TYPE 
CANCER REFERRAL DECISION DATE 
REFERRAL REQUEST RECEIVED DATE 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
DATE FIRST SEEN 
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS) 
DELAY REASON COMMENT (FIRST SEEN) 
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE 
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS 
WAITING TIME ADJUSTMENT (FIRST SEEN) 
WAITING TIME ADJUSTMENT REASON (FIRST SEEN) 
SOURCE OF REFERRAL FOR OUT-PATIENTS 
Imaging
SITE CODE (OF IMAGING) 
CLINICAL INTERVENTION DATE (CANCER IMAGING) 
CANCER IMAGING MODALITY 
ANATOMICAL EXAMINATION SITE 
INVASIVE LESION SIZE (RADIOLOGICAL DETERMINATION) 
Diagnosis
DIAGNOSIS DATE (CANCER) 
PRIMARY DIAGNOSIS (ICD) 
TUMOUR LATERALITY 
BASIS OF DIAGNOSIS (CANCER) 
HISTOLOGY (SNOMED) 
GRADE OF DIFFERENTIATION (AT DIAGNOSIS) 
Cancer Care Plan
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR 
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) 
CARE PLAN AGREED DATE 
RECURRENCE INDICATOR 
CANCER CARE PLAN INTENT 
PLANNED CANCER TREATMENT TYPE 
TREATMENT TYPE SEQUENCE 
NO CANCER TREATMENT REASON 
PERFORMANCE STATUS (ADULT) 
Staging
T CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (T CATEGORY) 
N CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (N CATEGORY) 
M CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (M CATEGORY) 
TNM CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (TNM CATEGORY) 
SITE SPECIFIC STAGING CLASSIFICATION 
TNM CATEGORY (INTEGRATED) 
T CATEGORY (INTEGRATED STAGE) 
N CATEGORY (INTEGRATED STAGE) 
M CATEGORY (INTEGRATED STAGE) 
Surgery and Other Procedures
SITE CODE (OF SURGERY) 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
CANCER TREATMENT INTENT 
DECISION TO TREAT DATE (SURGERY) 
START DATE (SURGERY HOSPITAL PROVIDER SPELL) 
PROCEDURE DATE 
PRIMARY PROCEDURE (OPCS) 
PROCEDURE (OPCS) 
DISCHARGE DATE (HOSPITAL PROVIDER SPELL) 
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) 
Pathology Details
PATHOLOGY INVESTIGATION TYPE 
SAMPLE RECEIPT DATE 
INVESTIGATION RESULT DATE 
CONSULTANT CODE (PATHOLOGIST) 
ORGANISATION CODE (OF REPORTING PATHOLOGY) 
PRIMARY DIAGNOSIS (ICD) 
TUMOUR LATERALITY 
INVASIVE LESION SIZE 
SYNCHRONOUS TUMOUR INDICATOR 
HISTOLOGY (SNOMED) 
GRADE OF DIFFERENTIATION 
CANCER VASCULAR OR LYMPHATIC INVASION 
EXCISION MARGIN 
NODES EXAMINED NUMBER 
NODES POSITIVE NUMBER 
T CATEGORY (PATHOLOGICAL) 
N CATEGORY (PATHOLOGICAL) 
M CATEGORY (PATHOLOGICAL) 
TNM CATEGORY (PATHOLOGICAL) 
SERVICE REPORT IDENTIFIER 
SERVICE REPORT STATUS 
SPECIMEN NATURE 
ORGANISATION CODE (REQUESTED BY) 
CARE PROFESSIONAL CODE (REQUESTED BY) 
T CATEGORY EXTENDED (PATHOLOGICAL) 
M CATEGORY EXTENDED (PATHOLOGICAL) 
Chemotherapy and other drugs
SITE CODE (OF CANCER DRUG TREATMENT) 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
DECISION TO TREAT DATE (ANTI-CANCER DRUG REGIMEN) 
DRUG THERAPY TYPE 
DRUG TREATMENT INTENT 
DRUG REGIMEN ACRONYM 
START DATE (ANTI-CANCER DRUG REGIMEN) 
RECORDED HEIGHT (CANCER DRUG TREATMENT) 
RECORDED WEIGHT (CANCER DRUG TREATMENT) 
PERSON BODY SURFACE AREA (PRETREATMENT) 
CREATININE CLEARANCE 
START DATE (ANTI-CANCER DRUG FRACTION) 
ANTI-CANCER DRUG CYCLE IDENTIFIER 
DAY NUMBER (ANTI-CANCER DRUG CYCLE) 
DURATION OF ANTI-CANCER DRUG CYCLE 
DRUG PROGRAMME RESPONSE 
PLANNED TREATMENT CHANGE REASON 
HEALTHCARE RESOURCE GROUP CODE 
Radiotherapy (Teletherapy)
SITE CODE (OF TELETHERAPY) 
CONSULTANT CODE 
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE) 
CANCER TREATMENT INTENT 
START DATE (TELETHERAPY TREATMENT COURSE) 
END DATE (TELETHERAPY TREATMENT COURSE) 
RADIOTHERAPY PRESCRIBED DOSE 
TELETHERAPY PRESCRIBED FRACTIONS 
RADIOTHERAPY PRESCRIBED DURATION 
RADIOTHERAPY ACTUAL DOSE 
TELETHERAPY ACTUAL FRACTIONS 
DURATION OF TELETHERAPY TREATMENT COURSE 
TELETHERAPY BEAM TYPE 
TELETHERAPY BEAM ENERGY 
TELETHERAPY FIELDS CLASSIFICATION 
TELETHERAPY COMPLEXITY GROUP 
RADIOTHERAPY ANAESTHETIC 
TELETHERAPY MULTIPLE PLANNING 
HEALTHCARE RESOURCE GROUP CODE 
TREATMENT COURSE STATUS 
Radiotherapy (Brachytherapy)
SITE CODE (OF BRACHYTHERAPY) 
CONSULTANT CODE 
DECISION TO TREAT DATE (BRACHYTHERAPY TREATMENT COURSE) 
CANCER TREATMENT INTENT 
BRACHYTHERAPY TYPE 
START DATE (BRACHYTHERAPY TREATMENT COURSE) 
END DATE (BRACHYTHERAPY TREATMENT COURSE) 
RADIOTHERAPY PRESCRIBED DOSE 
BRACHYTHERAPY PRESCRIBED FRACTIONS 
RADIOTHERAPY PRESCRIBED DURATION 
RADIOTHERAPY ACTUAL DOSE 
BRACHYTHERAPY DOSE RATE 
DURATION OF BRACHYTHERAPY TREATMENT COURSE 
BRACHYTHERAPY ISOTOPE TYPE 
RADIOTHERAPY ANAESTHETIC 
UNSEALED SOURCE PATIENT TYPE 
BRACHYTHERAPY DELIVERY TYPE 
HEALTHCARE RESOURCE GROUP CODE 
TREATMENT COURSE STATUS 
Palliative Care
DECISION TO TREAT DATE (SPECIALIST PALLIATIVE TREATMENT COURSE) 
START DATE (SPECIALIST PALLIATIVE TREATMENT COURSE) 
Clinical Trials
PATIENT TRIAL STATUS (CANCER) 
CANCER CLINICAL TRIAL TREATMENT TYPE 
Clinical Status Assessment
CLINICAL STATUS ASSESSMENT DATE (CANCER) 
PRIMARY TUMOUR STATUS 
NODAL STATUS 
METASTATIC STATUS 
MARKER RESPONSE STATUS 
PERFORMANCE STATUS (ADULT) 
TREATMENT TYPE (CANCER MORBIDITY) 
MORBIDITY CODE (CANCER SURGERY) 
PATIENT FOLLOW-UP STATUS (CANCER) 
MORBIDITY CODE (CHEMOTHERAPY) 
MORBIDITY CODE (RADIOTHERAPY) 
MORBIDITY CODE (COMBINATION) 
Death Details
PERSON DEATH DATE 
DEATH LOCATION TYPE 
DEATH CAUSE IDENTIFICATION METHOD 
DEATH CAUSE CANCER 
DEATH CAUSE CODE (IMMEDIATE) 
DEATH CAUSE CODE (CONDITION) 
DEATH CAUSE CODE (UNDERLYING) 
DEATH CAUSE CODE (SIGNIFICANT) 
DEATH CODE DISCREPANCY ORIGINATOR 

Data Set Data Element
Waiting Times Details
WAITING TIME ADJUSTMENT (DECISION TO TREAT) 
WAITING TIME ADJUSTMENT (TREATMENT) 
WAITING TIME ADJUSTMENT REASON (DECISION TO TREAT) 
WAITING TIME ADJUSTMENT REASON (TREATMENT) 
DELAY REASON REFERRAL TO TREATMENT (CANCER) 
DELAY REASON (DECISION TO TREATMENT) 
DELAY REASON COMMENT (REFERRAL TO TREATMENT) 
DELAY REASON COMMENT (DECISION TO TREATMENT) 
DECISION TO TREAT DATE (ACTIVE MONITORING) 
START DATE (ACTIVE MONITORING) 
Site-Specific Data Elements

Brain and Central Nervous System

Brain and Central Nervous System
Data Set Data Element
-

Breast Cancer

Breast Cancer
Data Set Data Element
DIAGNOSTIC ROUTE 
BREAST CANCER NURSE SEEN 
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) 
MENSTRUAL STATUS 
LMP DATE 
CLINICAL EXAMINATION FINDINGS (BREAST CANCER) 
ENDOCRINE THERAPY TYPE 
MARKER LYMPH NODE RESULT 

Colorectal Cancer

Colorectal Cancer
Data Set Data Element
DIAGNOSTIC ROUTE 
COLORECTAL NURSE OR STOMA THERAPIST SEEN 
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) 
GRADE OF RESPONSIBLE HCP 
PATIENT PROCEDURE RESULT (COLONOSCOPY) 
COLONOSCOPY INCOMPLETE REASON 
COLORECTAL NURSE OR STOMA THERAPIST SEEN 
SURGICAL URGENCY 
THEATRE CASE START TIME 
MARKER LYMPH NODE RESULT 

Head and Neck Cancer

Head and Neck Cancer
Data Set Data Element
PATIENT HISTORY (CANCER DIAGNOSIS) 
YEAR CANCER DIAGNOSED 
PREVIOUS TREATMENT ELSEWHERE 
TOBACCO USAGE TYPE 
SMOKING STATUS 
TOBACCO CHEWING HISTORY 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
ALCOHOL STATUS 
QUALITY OF LIFE (AT DIAGNOSIS) 
SYMPTOMS FIRST NOTED DATE 
FAMILY OR SURNAME OF RELATION WITH CANCER 
RELATIONSHIP TO PERSON 
PRIMARY DIAGNOSIS OF RELATION (ICD) 
NUTRITIONAL SUPPORT PROVIDED (CANCER) 
NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER) 
NUTRITIONAL PROCEDURE (OPCS) 
NUTRITIONAL PROCEDURE COMPLICATION (ICD) 
CONTACT DATE (DIETICIAN INITIAL) 
CANCER DENTAL ASSESSMENT DATE 
IMAGE REQUEST DATE 
SPEECH AND SWALLOWING ASSESSMENT DATE 

Lung Cancer

Lung Cancer
Data Set Data Element
SMOKING STATUS 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
COPD PRESENT 
FEV1 ABSOLUTE AMOUNT 
FEV1 PERCENTAGE 

Sarcoma

Sarcoma
Data Set Data Element
BONE SARCOMA LOCATION 
CLOSEST MARGIN 
NECROSIS 
SARCOMA CONDITION FIRST SEEN 
SARCOMA LARGEST DIAMETER 
SARCOMA PART SITE 
SARCOMA PREDISPOSING CONDITION (FAMILY) 
SARCOMA PREDISPOSING CONDITION (OTHER PHYSICAL) 
SARCOMA RELATION TO DEEP FASCIA 
SARCOMA SURGICAL MARGIN 
SARCOMA SURGICAL PROCEDURE TYPE 
SARCOMA TUMOUR SITE 
SOFT TISSUE SARCOMA LOCATION 

Skin Cancer

Skin Cancer
Data Set Data Element
BASAL CELL CLINICAL MORPHOLOGY 
CLINICAL EXCISION MARGIN 
DERMATOLOGIST BODY SITE (SKIN CANCER CARE SPELL) 
DERMATOLOGIST BODY SITE (SKIN CANCER LESION) 
DISTRIBUTION OF LESIONS PRESENT 
GENETICALLY DETERMINED SKIN CANCER TYPE 
NEW LESIONS TREATED NUMBER (CHEMOTHERAPY) 
NEW LESIONS TREATED NUMBER (RADIOTHERAPY) 
NEW LESIONS TREATED NUMBER (SURGERY) 
PATHOLOGY SPECIMEN TYPE 
PATIENT ON IMMUNOSUPPRESSIVE THERAPY 
PERINEURAL INVASION 
PREVIOUS SKIN CANCER 
RECURRENT LESIONS TREATED NUMBER (CHEMOTHERAPY) 
RECURRENT LESIONS TREATED NUMBER (RADIOTHERAPY) 
RECURRENT LESIONS TREATED NUMBER (SURGERY) 
SKIN CANCER LARGEST CLINICAL DIAMETER (SKIN CANCER CARE SPELL) 
SKIN CANCER LARGEST CLINICAL DIAMETER (SKIN CANCER LESION) 
SKIN CANCER NEW RECURRENT INDICATOR 
SKIN CANCER SUBSEQUENT DIAGNOSIS DATE 
SKIN LYMPHOMA CLINICAL MORPHOLOGY 
SKIN TCELL CLINICAL VARIANT 
SKIN TCELL SURFACE AREA 
SKIN TUMOUR STATUS 

Urological Cancer

Urological Cancer
Data Set Data Element
SERUM TUMOUR MARKER PSA 
S CATEGORY FINAL PRETREATMENT 
DRUG ROUTE OF ADMINISTRATION 

Upper GI Cancer

Upper GI Cancer
Data Set Data Element
POSSUM SCORE (AT DIAGNOSIS) 
POSSUM SCORE (AFTER SURGERY) 
RELATIONSHIP TO PERSON 
PRIMARY DIAGNOSIS OF RELATION (ICD) 
SMOKING STATUS 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
ALCOHOL STATUS 
CO-MORBIDITY (ICD) 
CLINICAL SIGN OR SYMPTOM (ICD) 

Gynaecological Cancer

Gynaecological Cancer
Data Set Data Element
GYNAECOLOGICAL ONCOLOGY ACCREDITATION 

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QUARTERLY BED AVAILABILITY AND OCCUPANCY DATA SET (KH03)

Change to Data Set: Changed Description

Quarterly Bed Availability and Occupancy Data Set Overview

M/RData Set Data Elements
M/RData Set Data Elements
Organisation details - To carry details of the responsible Health Care Provider.
One occurrence of each Data Element is required.
MORGANISATION CODE (CODE OF PROVIDER)
MREPORTING PERIOD START DATE
MREPORTING PERIOD END DATE
Bed Availability and Occupancy by Main Specialty Category Code. This group is mandatory.
Multiple occurrences are required, one for each Main Specialty Category Code reported.
MMAIN SPECIALTY CATEGORY CODE FOR BED AVAILABILITY AND OCCUPANCY
MBED DAYS IN WARDS OPEN DAY ONLY (AVAILABLE)
MBED DAYS IN WARDS OPEN DAY ONLY (OCCUPIED)
MBED DAYS IN WARDS OPEN OVERNIGHT (AVAILABLE)
MBED DAYS IN WARDS OPEN OVERNIGHT (OCCUPIED)
Bed Occupancy by Care Professional Main Specialty Code. This group is required where totals are available.
Multiple occurrences of this group are permitted, one for each Care Professional Main Specialty Code reported.
RCARE PROFESSIONAL MAIN SPECIALTY CODE
RBED DAYS IN WARDS OPEN DAY ONLY (OCCUPIED)
RBED DAYS IN WARDS OPEN OVERNIGHT (OCCUPIED)

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SYSTEMIC ANTI-CANCER THERAPY DATA SET

Change to Data Set: Changed Description

Systemic Anti-Cancer Therapy Data Set Overview

The Systemic Anti-Cancer Therapy Data Set has been incorporated early to allow users to see the changes, but please note that the implementation date is 1 April 2012.

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

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

To carry personal, organisation and consultant details.
One occurrence of this group is required.
 
M/R/OData Set Data Elements
MNHS NUMBER 
MPERSON BIRTH DATE 
RPERSON GENDER CODE CURRENT 
RETHNIC CATEGORY 
MPOSTCODE OF USUAL ADDRESS 
RGENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
RCONSULTANT CODE (INITIATED SYSTEMIC ANTI-CANCER THERAPY) 
RCARE PROFESSIONAL MAIN SPECIALTY CODE (START SYSTEMIC ANTI-CANCER THERAPY) 
MORGANISATION CODE (CODE OF PROVIDER) 

CLINICAL STATUS

To carry the clinical status details.
One occurrence of this group is required.
 
M/R/OData Set Data Elements
MPRIMARY DIAGNOSIS (ICD AT START SYSTEMIC ANTI-CANCER THERAPY)
and/or
MORPHOLOGY (ICD-O AT START SYSTEMIC ANTI-CANCER THERAPY) 
RTNM CATEGORY (FINAL PRETREATMENT) 

PROGRAMME AND REGIMEN

To carry details of the Systemic Anti-Cancer Therapy Programme and Systemic Anti-Cancer Drug Regimen.
Multiple occurrences of this group are permitted (at least one must be present).
 
M/R/OData Set Data Elements
RSYSTEMIC ANTI-CANCER THERAPY PROGRAMME NUMBER 
RANTI-CANCER REGIMEN NUMBER 
RDRUG TREATMENT INTENT 
MDRUG REGIMEN ACRONYM 
RPERSON HEIGHT IN METRES 
RPERSON WEIGHT 
RPERFORMANCE STATUS (ADULT)
or
PERFORMANCE STATUS (YOUNG PERSON) 
RCO-MORBIDITY ADJUSTMENT INDICATOR 
RDECISION TO TREAT DATE (ANTI-CANCER DRUG REGIMEN) 
MSTART DATE (ANTI-CANCER DRUG REGIMEN) 
RCLINICAL TRIAL INDICATOR 
RCHEMO-RADIATION INDICATOR 
RNUMBER OF SYSTEMIC ANTI-CANCER THERAPY CYCLES PLANNED 

CYCLE

To carry details of each Systemic Anti-Cancer Therapy Cycle.
Multiple occurrences of this group are permitted (at least one must be present).
 
M/R/OData Set Data Elements
MANTI-CANCER DRUG CYCLE IDENTIFIER 
RSTART DATE (SYSTEMIC ANTI-CANCER DRUG CYCLE) 
OPERSON WEIGHT 
RPERFORMANCE STATUS (ADULT)
or
PERFORMANCE STATUS (YOUNG PERSON) 
RPRIMARY PROCEDURE (OPCS) 

DRUG DETAILS

To carry details of the Systemic Anti-Cancer Therapy Drugs.
Multiple occurrences of this group are permitted (one occurrence for each Systemic Anti-Cancer Therapy Drug - at least one must be present).
 
M/R/OData Set Data Elements
RSYSTEMIC ANTI-CANCER DRUG NAME 
RCHEMOTHERAPY ACTUAL DOSE 
RSYSTEMIC ANTI-CANCER THERAPY DRUG ROUTE OF ADMINISTRATION 
RSYSTEMIC ANTI-CANCER THERAPY ADMINISTRATION DATE 
RORGANISATION CODE (CODE OF PROVIDER) 
RPRIMARY PROCEDURE (OPCS) 

OUTCOME

To carry details of the outcome / summary.
One occurrence of this group is permitted.
 
M/R/OData Set Data Elements
RSTART DATE (FINAL SYSTEMIC ANTI-CANCER THERAPY) 
RSYSTEMIC ANTI-CANCER THERAPY REGIMEN MODIFICATION INDICATOR (DOSE REDUCTION) 
RSYSTEMIC ANTI-CANCER THERAPY REGIMEN MODIFICATION INDICATOR (TIME DELAY) 
RSYSTEMIC ANTI-CANCER THERAPY REGIMEN MODIFICATION INDICATOR (DAYS REDUCED) 
RPLANNED TREATMENT CHANGE REASON 
RPERSON DEATH DATE 

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CDS BUSINESS RULES

Change to Supporting Information: Changed Description

The Commissioning Data Sets have notation to identify the business and/or processing rules which apply to individual Data Elements.  This notation appears in the Rules column of the Commissioning Data Set details page. 

Population Validation

All Data Elements are subject to length validation.  Some Data Elements are also subject to format and content validation against a list of permitted values defined in the NHS Data Model and Dictionary. The value lists are held on the Attribute which the Data Element is based on, plus default codes which are held on the Data Element itself.

RULEPOPULATION VALIDATION
FThe format is validated, for example the format of a DATE must comply with the XML standard.
VThe Data Element is validated against an explicit list of permitted values as defined in the NHS Data Model and Dictionary.

  
Business Rules

Some Data Elements are subject to additional Business Rules as indicated below:

PREFIXBUSINESS RULES: H - Healthcare Resource Group Business Rules
H4This Data Element is used by the Secondary Uses Service to derive the Healthcare Resource Group 4.
Failure to correctly populate this data element is likely to result in an incorrect Healthcare Resource Group, usually associated with lower levels of healthcare resource.

PREFIXBUSINESS RULES: I - CDS-XML Schema Anomalies and Issues
I1This is a known schema anomaly and has been registered for future resolution.
I2See the specifications in the NHS Data Model and Dictionary for the specific format characteristics of this Data Element.
I3There is no national requirement to flow Healthcare Resource Group 4 (HRG4) through the Commissioning Data Sets, see DSCN 17/2008.

PREFIXBUSINESS RULES: N - NHS Data Standards and Policy Rules
N1Psychiatric PATIENTS only.
N2Not defined or approved by the Information Standards Board for Health and Social Care.
N3The definition and value list for this data is under review.
N4Up to 20 codes per daily activity occurrence may be recorded.
N5This data should only flow in Commissioning Data Set versions 6-0 and 6-1 for PATIENTS detained under the Mental Health Act prior to the Mental Health Act 2007.
N6This data should only flow in Commissioning Data Set version 6-1  for PATIENTS detained under the Mental Health Act 2007.
N7From Commissioning Data Set version 6-0 onwards, the use of the DETAINED AND (OR) LONG TERM PSYCHIATRIC CENSUS DATE in the location group is optional as it must be carried in the Episode Characteristics.

PREFIXBUSINESS RULES: S - Secondary Uses Service Business Rules
S1This mandatory Commissioning Data Set date is used as the originating date to determine the mandatory CDS ACTIVITY DATE.
S2The Secondary Uses Service DOES NOT support the use of the CDS TEST INDICATOR. Therefore this Data Element must not be used.
S3See Security Issues and Patient Confidentiality, for further information.
S4Used to ensure the correct sequencing of multiple and/or subsequent Commissioning Data Set submissions.
S5These ORGANISATION CODES must be present and registered with the Secondary Uses Service. The Commissioning Data Set Schema does not validate the content value of this data.
S6All CDS REPORT PERIOD START DATES and CDS REPORT PERIOD END DATES must be consistent in all Commissioning Data Set records contained in a BULK Interchange submission.
The CDS REPORT PERIOD START DATE must be on or before the CDS REPORT PERIOD END DATE.
The CDS ACTIVITY DATE is a mandatory data element and must fall within the period defined.
See the Commissioning Data Set Submission Protocol.
S7See the Commissioning Data Set Addressing Grid.
S8These Data Elements are required for correct processing by the Secondary Uses Service. If omitted, the Secondary Uses Service will reject the Commissioning Data Set data.
S9The CDS UNIQUE IDENTIFIER is a mandatory data item when using the Net Change Protocol. When using the Bulk Update Protocol this data item is optional but it is strongly advised that where it can be correctly generated and maintained it should be used. See the Commissioning Data Set Submission Protocol.
S10For CDS V6 Type 170 - Admitted Patient Care - Detained and/or Long Term Psychiatric Census Commissioning Data Set, the CDS ACTIVITY DATE contains the CDS CENSUS DATE which is also the DETAINED AND (OR) LONG TERM PSYCHIATRIC CENSUS DATE.
S11For the following CDS TYPES, the  CDS ACTIVITY DATE must contain the DATE OF ELECTIVE ADMISSION LIST CENSUS which is usually the end of the Period being reported:
CDS V6 Type 030 - Elective Admission List - End of Period Census (Standard) Commissioning Data Set
CDS V6 Type 040 - Elective Admission List - End Of Period Census (Old) Commissioning Data Set
CDS V6 Type 050 - Elective Admission List - End Of Period Census (New) Commissioning Data Set
S12These PERSON BIRTH DATE Data Elements must use DATES between 01/01/1880 and 31/12/2999 in order to pass validation
S13Data Elements reporting a DATE (which is not a PERSON BIRTH DATE Data Element) must use dates between 01/01/1900 and 31/12/2999 in order to pass validation
S14For Data Elements reporting a TIME, the hour portion must be between 00 and 23 inclusive in order to pass validation

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CDS NOTATION

Change to Supporting Information: Changed Description

The Commissioning Data Set is the basic structure used for the submission of commissioning data to the Secondary Uses Service and is designed to be capable of individually conveying many different Commissioning Data Set structures, encompassing Accident and Emergency Attendances, Out-Patient Attendances, Admitted Patient Care and Elective Admission List.

Commissioning Data Set Messages have been defined in specific components known as a CDS TYPE.

Specific notation is used to indicate the requirements of the CDS-XML Message Schema Design conditions for submission of data in the Commissioning Data Sets.

The structure of the Commissioning Data Set message is shown by the use of Data Groups and Sub Groups within those Data Groups.  For each Data Group, Sub Group and individual Data Element, the allowed cardinality at each level is also shown in the "Status" and "Repeats" columns.

The CDS TYPE specifications must therefore be read in this hierarchy, using the Status and Repeat conditions within the Data Groups and Sub Groups, to determine the requirements for the individual Data Elements.


Status Column Notation

The Notation used for the "STATUS" column is as follows:

STATUSMEANINGDESCRIPTION
MMANDATORYThis signifies that the collection and submission of this Commissioning Data Set data is deemed MANDATORY and its presence is necessary for the CDS TYPE to be correctly validated and accepted for processing by the Secondary Uses Service.

If a data item is shown as MANDATORY, this should also be regarded as REQUIRED by the Department of Health.

In most instances, data marked as MANDATORY in a Sub Group will result in its parent Data Group also being marked as mandatory, but this is not always the case.

For instance, although the Consultant Episode - Clinical Diagnosis Group (ICD) is marked as R=REQUIRED (and therefore need not actually be populated), if it is used then both the DIAGNOSIS SCHEME IN USE and the PRIMARY DIAGNOSIS (ICD) are marked as M=MANDATORY and must both be present.

RREQUIREDThis signifies that the collection and submission of this Commissioning Data Set data is deemed REQUIRED by the Department of Health to comply with authorised NHS Standards, Policies and Directives. Therefore whenever a Commissioning Data Set is collected and subsequently submitted to the Secondary Uses Service, this data must be supported and populated into the relevant data sets if the data is available.

Note that "temporal" conditions may mean that there are instances where this directive cannot be fulfilled.

For instance in a CDS V6 Type 130 - Admitted Patient Care - Finished General Episode CDS, ICD and OPCS data elements are marked as "Required" indicating that this data should be included.  However, if at the time of submission to the Secondary Uses Service this data remains incomplete (perhaps awaiting coding in the ORGANISATION), the remaining data in the CDS record should still be submitted. Once the ORGANISATION has updated its systems with the data, the CDS TYPE relating to that ACTIVITY should then be resubmitted to the Secondary Uses Service.

OOPTIONALThis signifies that the collection and submission of this Commissioning Data Set data is OPTIONAL. Its inclusion in the Commissioning Data Set is therefore determined by "local agreement" between the ORGANISATIONS exchanging the data.

Note that even if marked O=OPTIONAL, any data included in a Commissioning Data Set submission to the Secondary Uses Service must comply with its specification published in the NHS Data Model and Dictionary otherwise the data may be deemed invalid and rejected.

XXThis is used where the Data Element has been included in the Commissioning Data Set design, usually for pilot use, but is not yet authorised for transmission by the wider NHS. The Data Element will be in italics and not linked to the Data Element where one exists.

Repeats Column Notation

The Notation used for the "REPEATS" column is as follows:

REPEATSDESCRIPTION
0..1This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 0 to a maximum of 1.
0..9This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 0 to a maximum of 9.
0..*This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 0 to an unlimited maximum.
1..1This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 1 to a maximum of 1.
1..97This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 1 to a maximum of 97.
1..*This signifies that the permitted occurrences of the Data Group, Sub Group or individual Data Element are from a minimum of 1 to an unlimited maximum.

Rules Column Notation

An entry in the "Rules" column shows that a specific Rule applies to submission of an individual Data Element.  These meaning of these Rules can be found  in Commissioning Data Set Business Rules.

The meaning of these Rules can be found in Commissioning Data Set Business Rules.


Notation Examples

The following are examples of some common scenarios.

EXAMPLE 1:
A MANDATORY Data Group with differing Sub-Groups and component data status conditions.

The following example shows a MANDATORY Data Group - therefore the Data Group must be present for the CDS TYPE to be validated and accepted for processing by the Secondary Uses Service.

When a Data Group is used:

  1. All MANDATORY Sub Groups and/or Data Elements must be present
  2. Any REQUIRED Sub Groups and/or Data Elements must be present if the data is available
  3. Any OPTIONAL Sub Groups and/or Data Elements may be omitted

The following data structure is one of three options when completing the Patient Identity Data Group:

1..1DATA GROUP: VERIFIED IDENTITY STRUCTURE
Must be used where the
NHS NUMBER STATUS INDICATOR Code Value = 01 = Verified
Rules
R0..1DATA GROUP: LOCAL IDENTIFIER STRUCTURE 
M1..1LOCAL PATIENT IDENTIFIERF
M1..1ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)F
M1..1Data Element ComponentsRules
M1..1NHS NUMBERF
M1..1NHS NUMBER STATUS INDICATORV
M1..1POSTCODE OF USUAL ADDRESSS3
M1..1ORGANISATION CODE (PCT OF RESIDENCE)F
R0..1PERSON BIRTH DATE
(Introduced in Commissioning Data Set V6-1)
F
S3

EXPLANATION:

The parent Data Group has a "Status" of M=MANDATORY which indicates that this Data Group must be present in the Commissioning Data Set to ensure correct validation and acceptance when submitted to the Secondary Uses Service.  The parent Data Group "Repeats" = 1..1 indicates that only one occurrence of this Data Group must flow in this particular Commissioning Data Set record.

The Sub Group of "Local Identifier Structure" is marked as R=REQUIRED and therefore must be populated if the data is available. The "Repeats" notation of 0..1 indicates that population of this Sub Group is not necessary to enable the Commissioning Data Set record to be sent to the Secondary Uses Service. If it is sent, then only one occurrence of this Sub Group may flow in this particular Commissioning Data Set record.
Both Data Elements in the Sub Group are marked M=MANDATORY and must both be correctly populated.

The Sub Group of "Data Element Components" is a "generic" structure and is marked as M=MANDATORY and therefore must be populated. The "Repeats" notation of 1..1 indicates that only one occurrence of this Data Group may flow in this particular Commissioning Data Set record.  All the Data Elements marked with M=MANDATORY must be populated.  PERSON BIRTH DATE however is marked with R=REQUIRED, so must also be completed if the data is available.


EXAMPLE 2:
A REQUIRED Data Group with differing component data status conditions.

The following example shows a REQUIRED Data Group. This data must be present in the relevant Commissioning Data Set if available.  However, if submitted to the Secondary Uses Service, omission of this REQUIRED Data Group will not cause rejection.

When the Data Group is used:

  1. All MANDATORY Sub Groups and/or Data Elements must be utilised
  2. Any REQUIRED Sub Groups and/or Data Elements must be present if the data is available
  3. Any OPTIONAL Sub Groups and/or Data Elements may be omitted
NotationDATA GROUP: CONSULTANT EPISODE - CLINICAL DIAGNOSIS GROUP (ICD)
Group
Status
R
Group
Repeats
0..1
FUNCTION:
To carry the details of the ICD coded Clinical Diagnoses.
M1..1Data Element ComponentsRules
M1..1PROCEDURE SCHEME IN USEV
M1..1DATA GROUP: PRIMARY DIAGNOSISRules
M1..1PRIMARY DIAGNOSIS (ICD)F
H4
O0..*DATA GROUP: SECONDARY DIAGNOSISRules
O0..*DATA GROUP: SECONDARY DIAGNOSES Rules 
M1..1SECONDARY DIAGNOSIS (ICD)F
H4

EXPLANATION:

The Data Group "Status" = R = Required indicates that this Data Group must be populated in the relevant Commissioning Data Set if the data is available.  The Data Group "Repeats" = 0..1 indicates that population of this Data Group is not necessary to enable the Commissioning Data Set to be sent to the Secondary Uses Service. If it is sent, then only one occurrence of this Data Group may flow in this particular Commissioning Data Set record.

If the Data Group is completed then the Data Element PROCEDURE SCHEME IN USE, marked as M=MANDATORY, must be populated. The "Repeats" notation of 1..1 indicates that only one occurrence of this Data Element is valid.

If the Data Group is completed then the Data Element PRIMARY DIAGNOSIS (ICD), marked as M=MANDATORY, must be populated. The "Repeats" notation of 1..1 indicates that only one occurrence of this Data Element is valid.

If the Data Group is completed then the Sub Group "Secondary Diagnoses", marked as O=OPTIONAL, may be omitted, but if populated it must be in the correct format. The "Repeats" notation of 1..* indicates that unlimited occurrences of this Data Element are valid. Each occurrence must contain a valid SECONDARY DIAGNOSIS (ICD).

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COMMUNITY HEALTH PARTNERSHIP (SCOTLAND)  renamed from COMMUNITY HEALTH PARTNERSHIPS (SCOTLAND)

Change to Supporting Information: Changed Description, Aliases, Name

Community Health Partnerships are ORGANISATIONS in Scotland.A Community Health Partnership is an ORGANISATION in Scotland.

Community Health Partnerships have been established in Scotland as key building blocks in the modernisation of the NHS and joint services in Scotland.Community Health Partnerships have been established in Scotland as key building blocks in the modernisation of the NHS and joint services in Scotland. They have a vital role in partnership, integration and service redesign and are the key mechanism through which all primary and community based services are planned and delivered. They provide an opportunity for partners to work together to improve the lives of the local communities which they serve.

Community Health Partnerships provide a focus for the integration between primary care and specialist services and with social care and ensure that local population health improvement is placed at the heart of service planning and delivery.Community Health Partnerships provide a focus for the integration between primary care and specialist services and with social care and ensure that local population health improvement is placed at the heart of service planning and delivery.

For further information on Community Health Partnerships, see the Community Health Partnerships website.For further information on Community Health Partnerships, see the Community Health Partnerships website.

 

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COMMUNITY HEALTH PARTNERSHIP (SCOTLAND)  renamed from COMMUNITY HEALTH PARTNERSHIPS (SCOTLAND)

Change to Supporting Information: Changed Description, Aliases, Name


NHS POSTCODE DIRECTORY

Change to Supporting Information: Changed Description

Background 

The same descriptions can also be accessed via the Technology Reference Data Update Distribution Service (TRUD).

Postcodes
Character Position12345678
Formataa/na/na/nspacenaa
Coding FrameOutward CodespaceInward Code


  • The coding frame allows the use of digits 0 (zero) to 9 and the use of upper-case alpha characters; no special characters are allowed.
  • The fifth character of all standard format POSTCODES is always a space, and separates the outward and inward parts of the POSTCODE. The outward part of the POSTCODE is left-justified and can contain 2, 3 or 4 characters, and is space-filled in character positions 3 and 4 where required. The inward part of the POSTCODE is always 3 characters.

    The following table gives examples of typical POSTCODES:

    Character PositionAllocated byNotes

    1

     

    2

     

    3

     

    4

     

    5

     

    6

     

    7

     

    8

     
      
    W9   3XXRoyal Mail 
    DA1  5PLRoyal Mail 
    MK45 1TERoyal Mail 
    ZZ99 4LZODS POSTCODES for PATIENTS who are Overseas Visitors
    ZZ99 3WZODS Pseudo POSTCODES
Related Products

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WHAT'S NEW: MARCH 2012  renamed from WHAT'S NEW: JANUARY 2012

Change to Supporting Information: Changed Description, Name

Release: March 2012

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

Release: January 2012

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

Release: November 2011

Information Standards Notices and Data Dictionary Change Notices incorporated into the NHS Data Model and Dictionary:
  • CR1264 (Immediate) - ISB 1077 Amd 144/2010 Automatic Identification and Data Capture (AIDC) for Patient Identification Data Set
  • CR1274 (Immediate) - DDCN 1274/2011 CDS Prime Recipient Identity Update

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

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

Release: October 2011

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

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

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

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

Release: August 2011

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

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

Release: July 2011

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

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

Release: June 2011

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

Release: April 2011

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

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

Release: March 2011

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

Release: January 2011

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

Release: December 2010

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

Release: November 2010

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

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

Release: September 2010

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

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

Release: August 2010

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

Release: July 2010

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

Release: May 2010

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

Release: March 2010

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

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

Release: January 2010

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

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

Release: December 2009

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

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

Release: November 2009

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

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

Release: September 2009

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

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

Release: June 2009

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

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

Release: March 2009

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

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

Release: December 2008

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

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

Release: November 2008

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

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

Release: August 2008

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

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

Release: May 2008

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

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

Release: February 2008

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

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

Release: November 2007

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

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

Release: August 2007

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

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

Release: June 2007

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

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

Release: May 2007

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

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

Release: February 2007

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

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

Release: September 2006

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

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

Release: May 2006

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

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

Release: April 2006

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

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

Release: August 2005

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

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

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

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CONSULTANT

Change to Class: Changed Description

A subtype of CARE PROFESSIONAL.

A PERSON contracted by a Health Care Provider who has been appointed by a CONSULTANT's appointment committee. He or she must be a member of a Royal College or Faculty.

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 Medical Practice or General Dental Practice.

The MAIN SPECIALTY of a GENERAL PRACTITIONER will always be General Medical Practice or General Dental Practice. For diagnostic departments, this includes a non-medical scientist of equivalent standing (to a CONSULTANT).

 

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LANGUAGE CLASSIFICATION

Change to Class: Changed Description

A classification of a LANGUAGE used by a PERSON.A classification of a language used by a PERSON.

 

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PERSON PROPERTY

Change to Class: Changed Description

Subtypes of PERSON PROPERTY include:

CANCER STAGING
CARDIAC ARREST
CATEGORY VALUED PERSON OBSERVATION
DIABETES ROUTINE REVIEW RESULT
EDUCATION
EDUCATIONAL ASSESSMENT
EMPLOYMENT
MEASURED PERSON OBSERVATION
NHS CONTINUING HEALTHCARE
NHS FUNDED NURSING CARE
ORGAN DONATION CONSENT
OTHER PERSON OBSERVATION
PATIENT DIAGNOSIS
PERSON SCORE
REPERFUSION
SECURE ACCOMMODATION REQUIREMENT
SKIN CANCER LESION
TEXT VALUED PERSON OBSERVATION
THROMBOLYTIC THERAPY
TOBACCO USAGE
TREATMENT RELATED MORBIDITY

A condition or state associated with a PERSON. PERSON PROPERTIES are collected as a result of an ACTIVITY.A PERSON PROPERTY is a condition or state associated with a PERSON.

PERSON PROPERTIES are collected as a result of an ACTIVITY.

PERSON PROPERTIES for a PATIENT do not include information about a treatment or intervention. The observation may be a clinical diagnosis. The observer may be a related PERSON or a CARE PROFESSIONAL. Observations may be recorded during, or as a result of, a course of treatment.

  • The observation may be a clinical diagnosis
  • The observer may be a related PERSON or a CARE PROFESSIONAL
  • Observations may be recorded during, or as a result of, a course of treatment.

PERSON PROPERTIES include:

 

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SERVICE

Change to Class: Changed Description

An episode of care, treatment or other service provided by an ORGANISATION which may be chargeable to one or more NHS SERVICE AGREEMENTS. In most cases, the service will be for the direct benefit of a PATIENT. For example a SERVICE may be one or more of the following:

In most cases, the service will be for the direct benefit of a PATIENT.

For example a SERVICE may be one or more of the following:

aConsultant Episode (Hospital Provider) 
bConsultant Out-Patient Episode 
cHEALTHY PERSON STAY 
dAccident and Emergency Episode 
eRadiotherapy Treatment Course 
fDIAGNOSTIC TEST REQUEST 
gRegular Attender Episode 
hProfessional Staff Group Episode 
iSexual Health And HIV Episode 
jTRANSPORT REQUEST 
kStop Smoking Service 
lSexual and Reproductive Health Service 
mImproving Access to Psychological Therapies Service 

A SERVICE associated with a Care Spell may be treatment carried out by the ORGANISATION acting as the Health Care Provider as part of a Care Spell for which the lead responsibility is with another ORGANISATION.

 

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CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS

Change to Attribute: Changed Description

CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS is recorded to enable tracking of the status of REFERRAL REQUESTS for PATIENTS referred with a suspected cancer, or referred with breast symptoms with cancer not originally suspected.

Where a diagnosis of cancer is subsequently made, data on First Definitive Treatment and subsequent treatments should be recorded for PATIENTS receiving treatment within the NHS in England.  English NHS in this context refers to Health Care Provider ORGANISATIONS within England who are treating PATIENTS with cancer (where the PATIENTS have NHS NUMBERS which exist on the Patient Demographic Service database, and which can be used within the National Cancer Waiting Times Monitoring Data Set for transmission purposes) who may have been referred from outside England.  Further details can be found in Department of Health guidance at  Cancer Waiting Times Documentation and Links.

English NHS in this context refers toHealth Care Provider ORGANISATIONS within England who are treating PATIENTS with cancer (where the PATIENTS have NHS NUMBERS which exist on the Patient Demographic Service database, and which can be used within the National Cancer Waiting Times Monitoring Data Set for transmission purposes) who may have been referred from outside England.

Further details can be found in Department of Health guidance at Cancer Waiting Times Documentation and Links.

Where PATIENTS with a diagnosis of cancer do NOT receive treatment within the NHS in England, or where the diagnosed condition is not within the Department of Health list of cancer conditions (see Department of Health  guidance at Cancer Waiting Times Documentation and Links), further data need not be collected.

The classification has been listed in logical sequence rather than numeric order.

National Codes:

14Suspected primary cancer
09Under investigation following symptomatic referral, cancer not suspected (breast referrals only) (see note 1)
03No new cancer diagnosis identified by the Healthcare Provider
09Under investigation following symptomatic referral, cancer not suspected (breast referrals only) (see note 1*)
03No new cancer diagnosis identified by the Health Care Provider
10Diagnosis of new cancer confirmed - first treatment not yet planned
11Diagnosis of new cancer confirmed - English NHS first treatment planned
07Diagnosis of cancer confirmed - no English NHS treatment planned
08First treatment commenced (English NHS only)
12Diagnosis of new cancer confirmed - subsequent treatment not yet planned
13Diagnosis of new cancer confirmed - subsequent English NHS treatment planned
21Subsequent treatment commenced (English NHS only)
15Suspected recurrent cancer
16Diagnosis of recurrent cancer confirmed - first treatment not yet planned
17Diagnosis of recurrent cancer confirmed - English NHS first treatment planned
18Diagnosis of recurrent cancer confirmed - no English NHS treatment planned
19Diagnosis of recurrent cancer confirmed - subsequent treatment not yet planned
20Diagnosis of recurrent cancer confirmed - subsequent English NHS treatment planned

Note 1:  National Code 09 - Under investigation following symptomatic referral, cancer not suspected (breast referrals only) should only be used when the TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE is National Code 16 - Exhibited (non-cancer) breast symptoms - cancer not initially suspected.Note 1*:  National Code 09 - 'Under investigation following symptomatic referral, cancer not suspected (breast referrals only)' should only be used when the TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE is National Code 16 - 'Exhibited (non-cancer) breast symptoms - cancer not initially suspected.'

 

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CIGARETTES PER DAY

Change to Attribute: Changed Aliases


LANGUAGE CLASSIFICATION CODE

Change to Attribute: Changed Description

The language used by a PERSON.

National Codes:

001Akan (Ashanti)
002Albanian
003Amharic
004Arabic
005Bengali & Sylheti
006Brawa & Somali
007British Signing Language
008Cantonese
009Cantonese and Vietnamese
010Creole
011Dutch
012English
013Ethiopian
014Farsi (Persian)
015Finnish
016Flemish
017French
018French creole
019Gaelic
020German
021Greek
022Gujarati
023Hakka
024Hausa
025Hebrew
026Hindi
027Igbo (Ibo)
028Italian
029Japanese
030Korean
031Kurdish
032Lingala
033Luganda
034Makaton (sign language)
035Malayalam
036Mandarin
037Norwegian
038Pashto (Pushtoo)
039Patois
040Polish
041Portuguese
042Punjabi
043Russian
044Serbian/Croatian
045Sinhala
046Somali
048Spanish
049Swahili
050Swedish
051Sylheti
052Tagalog (Filipino)
053Tamil
054Thai
055Tigrinya
056Turkish
057Urdu
058Vietnamese
059Welsh
060Yoruba
200Other

References:
National Joint Registry Dataset: v.1: 24th March 2003

 

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OVERSEAS VISITORS STATUS CLASSIFICATION

Change to Attribute: Changed Description

A classification of OVERSEAS VISITOR STATUS.

National Codes:

1Exempt from payment - subject to Reciprocal Healthcare Agreement
2Exempt from payment - other
3To pay hotel fees only
4To pay all fees
9Charging rate not known
 

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REFERRAL TO TREATMENT PERIOD END DATE

Change to Attribute: Changed Description

The end date of a REFERRAL TO TREATMENT PERIOD.

This is a specific type of the attribute ACTIVITY DATE.

REFERRAL TO TREATMENT PERIOD END DATE will be one of the following:

the ACTIVITY DATE when the PATIENT is admitted for First Definitive Treatment.
If the start of a PATIENT's treatment is cancelled (by the Health Care Provider or PATIENT) after admission, the REFERRAL TO TREATMENT PERIOD will continue.
or

or

In the unfortunate event that a PATIENT is booked into the wrong clinic and needs to be re-referred to the right one, this will not end the REFERRAL TO TREATMENT PERIOD or restart it.In the event that a PATIENT is booked into the wrong clinic and needs to be re-referred to the right one, this will not end the REFERRAL TO TREATMENT PERIOD or restart it. The start of the REFERRAL TO TREATMENT PERIOD is still the original REFERRAL REQUEST RECEIVED DATE.

 

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REFERRAL TO TREATMENT PERIOD START DATE

Change to Attribute: Changed Description

The start date of a REFERRAL TO TREATMENT PERIOD.

This is a specific type of the attribute ACTIVITY DATE.

A REFERRAL TO TREATMENT PERIOD START DATE will be one of the following:

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ACCOMMODATION STATUS DATE

Change to Data Element: Changed Description

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


Notes:
The PERSON PROPERTY OBSERVED DATE when the ACCOMMODATION STATUS CODE was recorded.

ACCOMMODATION STATUS DATE is the PERSON PROPERTY OBSERVED DATE when the ACCOMMODATION STATUS CODE was recorded. 

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DATE FIRST SEEN

Change to Data Element: Changed Description

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

Notes:
DATE FIRST SEEN is the date that the PATIENT is first seen in the Trust that receives the first referral. This data element is mandatory for PATIENTS referred urgently by their GENERAL PRACTITIONER for suspected cancer but can also be applied to other PATIENTS.

This data element is mandatory for PATIENTS referred urgently by their GENERAL PRACTITIONER for suspected cancer but can also be applied to other PATIENTS.

The date will be one of the following, whichever is the earliest SERVICE relating to the REFERRAL REQUEST:

-first Out-Patient Appointment; this is the Attendance Date of the first Out-Patient Attendance Consultant 
-first diagnostic procedure if this precedes the first Out-Patient Appointment; this is the first Clinical Intervention Date of the Imaging or Radiodiagnostic Event or CLINICAL INTERVENTION 
-first seen as an emergency; this is the Start Date of the Hospital Provider Spell or the Arrival Date of the Accident and Emergency Attendance 
-The date the PATIENT was first seen following referral (or recall) from (or by) a Screening Unit

Date First Seen may not be the same as FIRST SEEN BY SPECIALIST DATE (CANCER) which records the first time the PATIENT sees an appropriate specialist in cancer care.

 

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DEATH CAUSE ICD CODE (CONDITION)

Change to Data Element: Changed Description

Format/Length:See DIAGNOSTIC CODING 
HES Item: 
National Codes: 
Default Codes: 

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:
DEATH CAUSE ICD CODE (CONDITION) is the same as attribute DEATH CAUSE CODE.

DEATH CAUSE ICD CODE (CONDITION) is the ICD code of the condition giving rise to death as recorded on the death certificate.

DEATH CAUSE ICD CODE (CONDITION) replaces DEATH CAUSE CODE (CONDITION) and should be used for all new and developing data sets and for XML messages.

 

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DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE)

Change to Data Element: Changed Description

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

Notes:
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE) is the same as the attribute DECISION TO TREAT DATE.

DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE) is only mandatory when applicable in the National Cancer Data Set which is when the planned First Definitive Treatment is teletherapy. 

DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE) is the DECISION TO TREAT DATE of the Planned Cancer Treatment with a PLANNED CANCER TREATMENT TYPE National Code 'Teletherapy' and where the FIRST DEFINITIVE TREATMENT PLANNED is classification 'First Definitive Treatment planned'.

From 01 January 2009, this data element is no longer used in the National Cancer Waiting Times Monitoring Data Set.  It may still be used in other data sets or collected locally if required.

 

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IMAGING CODE (NICIP)

Change to Data Element: Changed Description

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

Notes:
IMAGING CODE (NICIP) is the same as the attribute CLINICAL CLASSIFICATION CODE.IMAGING CODE (NICIP) is the same as attribute CLINICAL CLASSIFICATION CODE.

IMAGING CODE (NICIP) is the National Interim Clinical Imaging Procedure Code Set code which is used to identify both the test modality and body site of the test.

 

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IMAGING CODE (SNOMED-CT)

Change to Data Element: Changed Description

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

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

IMAGING CODE (SNOMED-CT) is the SNOMED CT concept ID which is used to identify the Diagnostic Imaging test.

The SNOMED CT Subset:

  • original ID is 611000000135
  • name is 'UK Diagnostic Imaging Procedure Concepts'.
 

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NHS NUMBER STATUS INDICATOR

Change to Data Element: Changed Description

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

Notes:

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR will be replaced with NHS NUMBER STATUS INDICATOR CODE, which should be used for all new and developing data sets and for XML messages.

 

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NHS NUMBER STATUS INDICATOR (BABY)

Change to Data Element: Changed Description

Format/length:See NHS NUMBER STATUS INDICATOR
HES item: 
National Codes: 
Default Codes: 

Notes:
The NHS NUMBER STATUS INDICATOR of the NHS NUMBER (BABY) within the Commissioning Data Set Delivery Episode and Commissioning Data Set Home Delivery.

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR (BABY) will be replaced with NHS NUMBER STATUS INDICATOR CODE (BABY), which should be used for all new and developing data sets and for XML messages.

 

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NHS NUMBER STATUS INDICATOR (MOTHER)

Change to Data Element: Changed Description

Format/Length:See NHS NUMBER STATUS INDICATOR
HES Item: 
National Codes: 
Default Codes: 

Notes:
The NHS NUMBER STATUS INDICATOR of the NHS NUMBER (MOTHER) within the Commissioning Data Set Birth Episode and Commissioning Data Set Home Birth.

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR (MOTHER) will be replaced with NHS NUMBER STATUS INDICATOR CODE (MOTHER), which should be used for all new and developing data sets and for XML messages.

 

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NHS NUMBER STATUS INDICATOR CODE

Change to Data Element: Changed Description

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

Notes:

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR CODE replaces NHS NUMBER STATUS INDICATOR and should be used for all new and developing data sets and for XML messages.

 

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NHS NUMBER STATUS INDICATOR CODE (BABY)

Change to Data Element: Changed Description

Format/Length:See NHS NUMBER STATUS INDICATOR CODE
HES Item: 
National Codes: 
Default Codes: 

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:
NHS NUMBER STATUS INDICATOR CODE (BABY) is the NHS NUMBER STATUS INDICATOR CODE of the NHS NUMBER (BABY).

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR CODE (BABY) replaces NHS NUMBER STATUS INDICATOR (BABY), and should be used for all new and developing data sets and for XML messages.

 

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NHS NUMBER STATUS INDICATOR CODE (MOTHER)

Change to Data Element: Changed Description

Format/Length:See NHS NUMBER STATUS INDICATOR CODE
HES Item: 
National Codes: 
Default Codes: 

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:
NHS NUMBER STATUS INDICATOR CODE (MOTHER) is the NHS NUMBER STATUS INDICATOR CODE of the NHS NUMBER (MOTHER).

Permitted National Codes:

01Number present and verified
02Number present but not traced
03Trace required
04Trace attempted - No match or multiple match found
05Trace needs to be resolved - (NHS Number or patient detail conflict)
05Trace needs to be resolved - (NHS Number or PATIENT detail conflict)
06Trace in progress
07Number not present and trace not required
08Trace postponed (baby under six weeks old)

NHS NUMBER STATUS INDICATOR CODE (MOTHER) replaces NHS NUMBER STATUS INDICATOR (MOTHER) and should be used for all new and developing data sets and for XML messages.

 

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ORGANISATION CODE (CODE OF PROVIDER)

Change to Data Element: Changed Description

Format/Length:an3 or an5
Format/Length:an3, an5 or an6
HES Item:PROCODE
National Codes: 
ODS Default Codes:89997 - Non-UK provider where no ORGANISATION CODE has been issued
 89999 - Non-NHS UK provider where no ORGANISATION CODE has been issued

Notes:
ORGANISATION CODE (CODE OF PROVIDER) is the same as the attribute ORGANISATION CODE.

ORGANISATION CODE (CODE OF PROVIDER) is the ORGANISATION CODE of the ORGANISATION acting as a Health Care Provider.

For the Commissioning Data Sets, this should always be the ORGANISATION CODE of the Health Care Provider receiving the Payment by Results tariff income.

 

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PATIENT PATHWAY IDENTIFIER

Change to Data Element: Changed Description

Format/length:an20
National Codes: 
Default Codes: 

Notes:
PATIENT PATHWAY IDENTIFIER is the same as PATIENT PATHWAY IDENTIFIER.

Use in Commissioning Data Set version 6-0 onwards

If the Commissioning Data Set record relates to a Referral To Treatment Period Included In Referral To Treatment Consultant-Led Waiting Times Measurement, and is of the following Commissioning Data Set Types:

then either UNIQUE BOOKING REFERENCE NUMBER (CONVERTED) or PATIENT PATHWAY IDENTIFIER must be present in the Commissioning Data Set PATIENT PATHWAY Data Group. 

 

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PERSON INITIAL (FIRST)

Change to Data Element: Changed Description

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

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:Notes:
PERSON INITIAL (FIRST) is the same as attribute PERSON NAME WORD TEXT where the PERSON NAME WORD TYPE is classification 'Person Initials'.

PERSON INITIAL (FIRST) is the first initial of the PATIENT's first name.

 

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PREFERRED COMMUNICATION LANGUAGE

Change to Data Element: Changed Description

Format/Length:an3
HES Item: 
National Codes:See LANGUAGE CLASSIFICATION CODE
Default Codes: 


Notes:
PREFERRED COMMUNICATION LANGUAGE is the same as the attribute LANGUAGE CLASSIFICATION CODE.

The language the PATIENT prefers to use for communication with a Health Care Provider.PREFERRED COMMUNICATION LANGUAGE is the language the PATIENT prefers to use for communication with a Health Care Provider.

 

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PRESCRIPTION DATE

Change to Data Element: Changed Description

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


Notes:
PRESCRIPTION DATE is the same as attribute PRESCRIPTION DATE.

 

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PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION)

Change to Data Element: Changed Description

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


Notes:
This is the PRESCRIPTION DATE where the PRESCRIBED ITEM is 'Anti-Psychotic Medication'.PRESCRIPTION DATE (ANTI-PSYCHOTIC MEDICATION) is the PRESCRIPTION DATE where the PRESCRIBED ITEM is 'Anti-Psychotic Medication'.

 

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PRESCRIPTION IDENTIFIER

Change to Data Element: Changed Description

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


Notes:

Any identifier that is unique for each PRESCRIPTION.

 PRESCRIPTION IDENTIFIER is the same as attribute PRESCRIPTION IDENTIFIER. 

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PRESCRIPTION PROVIDED INDICATOR (ANTI-HYPERTENSIVES)

Change to Data Element: Changed Description

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


Notes:
PRESCRIPTION PROVIDED INDICATOR (ANTI-HYPERTENSIVES) is the same as attribute PRESCRIPTION PROVIDED INDICATOR.

For the NHS Health Checks Data Set this is an indication of whether a PATIENT was provided with a PRESCRIPTION, where the PRESCRIPTION TYPE PROVIDED FOR NHS HEALTH CHECK is National Code 'Anti-Hypertensives', as a result of an NHS Health Check Assessment.

 

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PRESCRIPTION PROVIDED INDICATOR (STATINS)

Change to Data Element: Changed Description

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


Notes:
PRESCRIPTION PROVIDED INDICATOR (STATINS) is the same as attribute PRESCRIPTION PROVIDED INDICATOR.

For the NHS Health Checks Data Set this is an indication of whether a PATIENT was provided with a PRESCRIPTION, where the PRESCRIPTION TYPE PROVIDED FOR NHS HEALTH CHECK is National Code 'Statins', as a result of an NHS Health Check Assessment.

 

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PREVIOUS SYMPTOM INDICATOR

Change to Data Element: Changed Description

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


Notes:
PREVIOUS SYMPTOM INDICATOR is the same as attribute PREVIOUS SYMPTOM INDICATOR.

 

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PRIMARY REASON FOR REFERRAL (COMMUNITY CARE)

Change to Data Element: Changed Description

Format/Length:an3
HES Item: 
National Codes:See REASON FOR REFERRAL TO COMMUNITY CARE
Default Codes:999 - Reason for referral not known


Notes:
PRIMARY REASON FOR REFERRAL (COMMUNITY CARE) is the same as attribute REASON FOR REFERRAL TO COMMUNITY CARE.

The primary presenting condition or symptom for which the PATIENT was referred to a Community Health Service.PRIMARY REASON FOR REFERRAL (COMMUNITY CARE) is the primary presenting condition or symptom for which the PATIENT was referred to a Community Health Service.

 

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RADIOTHERAPY INTENT

Change to Data Element: Changed Description

Format/Length:an2
HES Item: 
National Codes:See RADIOTHERAPY INTENT
Default Codes:99 - unknown


Notes:
RADIOTHERAPY INTENT is the same as attribute RADIOTHERAPY INTENT.

 

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REFERRING CARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE)

Change to Data Element: Changed Description

Format/Length:an3
HES Item: 
National Codes:See CARE PROFESSIONAL STAFF GROUP FOR COMMUNITY CARE
Default Codes: 


Notes:
REFERRING CARE PROFESSIONAL STAFF GROUP (COMMUNITY CARE) is the same as attribute CARE PROFESSIONAL STAFF GROUP FOR COMMUNITY CARE.

The staff group of the CARE PROFESSIONAL who referred the PATIENT to the Community Health Service, where applicable (if the referrer is not a CARE PROFESSIONAL, for example, if the referrer is an employer, this item should be omitted).

 

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REMOVALS OTHER THAN ADMISSION

Change to Data Element: Changed Description

Format/length:n10
HES item: 
Format/Length:n10
HES Item: 
National Codes: 
Default Codes: 


Notes:
The total number of PATIENTS classified as booked admissions or WAITING LIST admissions to be admitted to a Hospital Provider Spell, who were removed from an ELECTIVE ADMISSION LIST within the REPORTING PERIOD for reasons other than admission.

REMOVALS OTHER THAN ADMISSION is the total number of PATIENTS classified as booked admissions or WAITING LIST admissions to be admitted to a Hospital Provider Spell, who were removed from an ELECTIVE ADMISSION LIST within the REPORTING PERIOD for reasons other than admission.

It includes private PATIENTS and PATIENTS who are Overseas Visitors, it excludes elective planned admissions and Suspended Patients.

It is the total of number of removals from elective admission for PATIENTS where:

 a.the ELECTIVE ADMISSION LIST REMOVAL REASON is National Code 2 'Patient admitted as an emergency for the same condition' or 3 'Patient died' or 4 'Patient removed for other reasons' 
 a.the ELECTIVE ADMISSION LIST REMOVAL REASON is National Code 2 'PATIENT admitted as an emergency for the same condition' or 3 'PATIENT died' or 4 'PATIENT removed for other reasons'
and  
 b.the ELECTIVE ADMISSION LIST REMOVAL REASON is within the period of the REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE 
  Within the REPORTING PERIOD includes where the DATE is the same as the START DATE or END DATE 
and  
 c.no ELECTIVE ADMISSION SUSPENSION DETAIL has been recorded
  or
  if recorded, the LIST SUSPENSION END DATE is before the ELECTIVE ADMISSION LIST REMOVAL DATE i.e. no period of suspension is still on-going at the DATE of removal. Where no LIST SUSPENSION END DATE has been recorded then the period of suspension is still active and should be excluded from the count
and  
 d.the ELECTIVE ADMISSION TYPE is National Code 11 'Waiting list admission' or 12 'Booked admission'
 

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REMOVALS OTHER THAN ADMISSION (DAY CASE)

Change to Data Element: Changed Description

Format/length:n10
HES item: 
Format/Length:n10
HES Item: 
National Codes: 
Default Codes: 


Notes:
The total REMOVALS OTHER THAN ADMISSION where the INTENDED MANAGEMENT for the ELECTIVE ADMISSION LIST ENTRY is 'Patient not to stay in hospital over night'.

REMOVALS OTHER THAN ADMISSION (DAY CASE) is the total REMOVALS OTHER THAN ADMISSION where the INTENDED MANAGEMENT for the ELECTIVE ADMISSION LIST ENTRY is 'PATIENT not to stay in hospital over night'. 

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REMOVALS OTHER THAN ADMISSION (ORDINARY)

Change to Data Element: Changed Description

Format/length:n10
HES item: 
National Codes: 
Default Codes: 


Notes:
The total REMOVALS OTHER THAN ADMISSION where the INTENDED MANAGEMENT for the ELECTIVE ADMISSION LIST ENTRY is 'Patient to stay in hospital for at least one night'.

REMOVALS OTHER THAN ADMISSION (ORDINARY) is the total REMOVALS OTHER THAN ADMISSION where the INTENDED MANAGEMENT for the ELECTIVE ADMISSION LIST ENTRY is  National Code 'PATIENT to stay in hospital for at least one night'. 

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RENAL SUPPORT DAYS

Change to Data Element: Changed Description

Format/length:n3
Format/Length:n3
National Codes: 
Default Codes:000 - 997 days
 998 = 998 or more days of renal support
 999 = occurred but day count not known

Notes:
The total number of days that the PATIENT received renal system support during a CRITICAL CARE PERIOD.RENAL SUPPORT DAYS is the total number of days that the PATIENT received renal system support during a CRITICAL CARE PERIOD.

This is derived from the difference between the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE for all ACTIVITY PROPERTIES where the ORGAN SYSTEM SUPPORTED is National Code 05 'Renal Support' within the CRITICAL CARE PERIOD.

 

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REPLACEMENT APPOINTMENT BOOKED DATE (COMMUNITY CARE)

Change to Data Element: Changed Description

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


Notes:
REPLACEMENT APPOINTMENT BOOKED DATE (COMMUNITY CARE) is the same as attribute REPLACEMENT APPOINTMENT BOOKED DATE FOR COMMUNITY CARE.

 

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REPLACEMENT APPOINTMENT DATE OFFERED (COMMUNITY CARE)

Change to Data Element: Changed Description

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


Notes:
REPLACEMENT APPOINTMENT DATE OFFERED (COMMUNITY CARE) is the same as attribute REPLACEMENT APPOINTMENT DATE OFFERED FOR COMMUNITY CARE.

 

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RESPONSE CATEGORY

Change to Data Element: Changed Description

Format/length:an1
HES item: 
Format/Length:an1
HES Item: 
National Codes:See RESPONSE CATEGORY
Default Codes: 

Notes:
RESPONSE CATEGORY is the same as the attribute RESPONSE CATEGORY

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RESUSCITATION METHOD

Change to Data Element: Changed Description

Format/length:n1
HES item:BIRRESUS
Format/Length:n1
HES Item:BIRRESUS
National Codes: 
Default Codes:8 - Not applicable (e.g. stillborn, where no method of resuscitation was attempted)
 9 - Not known: a validation error

Notes:
This data item is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGSRESUSCITATION METHOD is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGS

It records the means by which regular respiration of the baby was attempted. This is not recorded for stillbirths. For local purposes, the actual drugs administered should be specified.

Permitted National Codes:

1Positive pressure nil, drugs nil
2Positive pressure nil, drugs administered
3Positive pressure by mask, drugs nil
4Positive pressure by mask, drugs administered
5Positive pressure by endotracheal tube, drugs nil
6Positive pressure by endotracheal tube, drugs administered

RESUSCITATION METHOD will be replaced with RESUSCITATION METHOD CODE, which should be used for all new and developing data sets and for XML messages.

 

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RESUSCITATION METHOD CODE

Change to Data Element: Changed Description

Format/Length:an1
HES Item:BIRRESUS
National Codes: 
Default Codes:8 - Not applicable (e.g. stillborn, where no method of resuscitation was attempted)
 9 - Not known: a validation error

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

Notes:
This data item is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGSRESUSCITATION METHOD CODE is derived from RESUSCITATION METHOD POSITIVE PRESSURE and RESUSCITATION METHOD DRUGS.

It records the means by which regular respiration of the baby was attempted. This is not recorded for stillbirths. For local purposes, the actual drugs administered should be specified.

Permitted National Codes:

1Positive pressure nil, drugs nil
2Positive pressure nil, drugs administered
3Positive pressure by mask, drugs nil
4Positive pressure by mask, drugs administered
5Positive pressure by endotracheal tube, drugs nil
6Positive pressure by endotracheal tube, drugs administered

RESUSCITATION METHOD CODE replaces RESUSCITATION METHOD and should be used for all new and developing data sets and for XML messages.

 

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REVIEW DATE

Change to Data Element: Changed Description

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

Notes:
The DATE of a formal review of care carried out during a CARE CONTACT.

Notes: REVIEW DATE is the DATE of a formal review of care carried out during a CARE CONTACT. 

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WAITING TIME ADJUSTMENT REASON (TREATMENT)

Change to Data Element: Changed Description

Format/Length:an1
HES Item: 
National CodesSee WAITING TIME ADJUSTMENT REASON
Default Codes9 - No adjustment to waiting time

Notes:
WAITING TIME ADJUSTMENT REASON (TREATMENT) is the same as the attribute WAITING TIME ADJUSTMENT REASON.

This is mandatory, whenever an adjustment is appropriate as calculated and recorded by WAITING TIME ADJUSTMENT (TREATMENT). It is the prime reason for the adjustment and where there is more than one adjustment applicable, this should be the reason for the longest calculated adjustment days.

WAITING TIME ADJUSTMENT REASON (TREATMENT) should only be recorded where CANCER CARE SETTING (TREATMENT) is National Code 01 'Cancer treatment delivered as part of an Hospital Provider Spell (where PATIENT CLASSIFICATION is National Code 1 'Ordinary admission) or National Code 02 'Cancer treatment delivered as part of a Hospital Provider Spell (where PATIENT CLASSIFICATION is National Code 2 'Day case admission').WAITING TIME ADJUSTMENT REASON (TREATMENT) should only be recorded where CANCER CARE SETTING (TREATMENT) is:

 
  • National Code 01 'Cancer treatment delivered as part of a Hospital Provider Spell (where PATIENT CLASSIFICATION is National Code 1 'Ordinary admission) or
  • National Code 02 'Cancer treatment delivered as part of a Hospital Provider Spell (where PATIENT CLASSIFICATION is National Code 2 'Day case admission').
  •  

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