NHS Information Authority

Data Standards Programme

The purpose of the National Cancer Minimum Data Set is to advise organisations within the National Health Service on a transferable set of data. These data will meet the needs of clinical audit, assist in the generation of National Performance Indicators and will allow outcome assessment.

Data Standards to support parts of the National Cancer Data Set have been released earlier, in the following DSCNs:
10/2002 Data Standards: Radiotherapy Treatments
23/2002 Data Standards: Chemotherapy HRGs
30/2002 Data Standards: change to Monitoring of the Cancer Waiting Times

More information about the project and the Data Set can be found at:

http://nww.nhsia.nhs.uk/cancer/pages/default.asp

This DSCN defines the NHS data standards to support Version 1.3_ISB of the core data set.

The following National Cancer Data Set items are supported by the NHS Data Dictionary Version.2 logical model but the data item notes have not been defined as the exact format for transmission is still under discussion:

DRUG DOSAGE AND ADMIN SPECIFICATION
DRUG IDENTIFICATION (ANTI-CANCER DRUG FRACTION)
DRUG IDENTIFICATION (DOSES PER DAY) these three data items are already supported;

CO-MORBIDITY INDEX FOR ADULTS
RADIOTHERAPY ANATOMICAL TREATMENT SITE these two items are modelled in this paper.

Version 1.3_ISB of the Data Set also includes site specific data items to support seven types of cancer: Breast, Colorectal, Lung, Head & Neck, Urological, Upper Gastro-Intestinal and Gynaecological. These are defined in DSCN 54/2002.

ADDRESS ASSOCIATION

Attributes of this Class are:

K		ADDRESS ASSOCIATION TYPE
	O	END DATE
		START DATE

ANTI-CANCER DRUG PROGRAMME

Attributes of this Class are:

K		ANTI-CANCER DRUG PROGRAMME IDENTIFIER
		DRUG PROGRAMME RESPONSE
		DRUG THERAPY TYPE
		DRUG TREATMENT INTENT
	O	END DATE
		PLANNED TREATMENT CHANGE REASON
		START DATE

ANTI-CANCER DRUG PROGRAMME

Each ANTI-CANCER DRUG PROGRAMME

K	must be provided in one and only one CANCER CARE SPELL
	must be the responsibility of one and only one CONSULTANT
	must be managed by one and only one HEALTH CARE PROVIDER
	may be comprised of one or more ANTI-CANCER DRUG REGIMEN
	may be part of one and only one SERVICE PROVIDED

BODY SURFACE AREA

BODY SURFACE AREA

A type of PERSON OBSERVATION.

The surface area of a PERSON's skin, used to calculate doses of chemotherapy drugs.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	BODY SURFACE AREAS

Attributes of this Class are:

PERSON BODY SURFACE AREA

This class has no relationships.

CANCER CARE PLAN

A type of CARE PLAN.

A CARE PLAN developed within a CANCER CARE SPELL. There should be at least one PLANNED CANCER TREATMENT recorded within a CANCER CARE PLAN.

References: National Cancer Data Set Version 1.1_ISB October 20013_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER CARE PLANS

CANCER CARE PLAN

Attributes of this Class are:

		CANCER CARE PLAN INTENT
	O	MULTIDISCIPLINARY TEAM DISCUSSION DATE
	O	NO CANCER TREATMENT REASON
		RECURRENCE INDICATOR

CANCER CARE PLAN

Each CANCER CARE PLAN

	must be a plan originated by decision to treat for by one and only one one and only one HEALTH CARE PROVIDER
	may be the plan related to one or more CANCER CLINICAL STATUS ASSESSMENT
	may be a plan with one or more PLANNED CANCER TREATMENT

CANCER CARE SPELL

A type of CARE SPELL.

The period of time during which a PATIENT who has been diagnosed as suffering from a single site primary cancer may receive care. The CANCER CARE SPELL starts on the date of the REFERRAL REQUEST from whatever source to the specialist team. It ends when the PATIENT dies.

A recurrence of the original primary cancer at a secondary site is part of the same CANCER CARE SPELL.

If a PATIENT has another primary cancer this will be a new CANCER CARE SPELL.

The CANCER CARE SPELL may only involve diagnostic procedures leading to a diagnosis, for example in cases where the patient refuses treatment, or it may include treatment and follow-up.

References:
National Cancer Data Set Version 1.2 December 20013_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER CARE SPELLS

CANCER CARE SPELL

Each CANCER CARE SPELL

	must be a spell for one and only one PATIENT
	must be initiated as a result of one and only one REFERRAL REQUEST
	may be the context for one or more ANTI-CANCER DRUG PROGRAMME
	may be subject to one or more CANCER CLINICAL STATUS ASSESSMENT
	may be associated with one or more PATIENT CLINICAL TRIAL STATUS

CANCER CLINICAL STATUS ASSESSMENT

CANCER CLINICAL STATUS ASSESSMENT

The assessment of a PATIENT's clinical condition. This may take place at a review point within the PATIENT's CANCER CARE PLAN or may be required if the patient's condition changes during treatment, for example if the patient reports toxicity as a result of treatment.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER CLINICAL STATUS ASSESSMENTS

Attributes of this Class are:

K		CLINICAL STATUS ASSESSMENT DATE
		MARKER RESPONSE STATUS
		METASTATIC STATUS
		NODAL STATUS
	O	PRIMARY TUMOUR STATUS

Each CANCER CLINICAL STATUS ASSESSMENT

K	must be an assessment during one and only one CANCER CARE SPELL
	may be an assessment of treatment provided in the context of one and only one CANCER CARE PLAN
	may be an assessment which includes one or more TREATMENT RELATED MORBIDITY

CANCER CLINICAL TRIAL

CANCER CLINICAL TRIAL

A programme whereby clinical treatment related to cancer is monitored and controlled for research purposes.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER CLINICAL TRIALS

Attributes of this Class are:

K		CANCER CLINICAL TRIAL IDENTIFIER
		CANCER CLINICAL TRIAL TREATMENT TYPE

Each CANCER CLINICAL TRIAL

may be the trial for which there are one or more PATIENT CLINICAL TRIAL STATUS

CANCER SITE SPECIFIC STAGING

CANCER SITE SPECIFIC STAGING

A type of CLINICAL CLASSIFICATION.

A classification of the stage of a cancer using a site specific coding frame, for example Dukes for colorectal cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER SITE SPECIFIC STAGINGS

Attributes of this Class are:

SITE SPECIFIC STAGING CLASSIFICATION

This class has no relationships.

CANCER TNM STAGING

CANCER TNM STAGING

A type of CLINICAL CLASSIFICATION.

A classification of the extent of the spread of a cancer at the time of diagnosis using the classification system published by the Union Internationale Contre Cancer (UICC). The acronym TNM relates to the three categories for which codes are recorded, the categories being Tumour, Node and Metastasis. Each category is assigned a code, together with a factor identifying the level of certainty as to the accuracy of the code.

TNM staging can occur at different places in the patient's care pathway, e.g. pre-treatment or pathological.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CANCER TNM STAGINGS

Attributes of this Class are:

K		CANCER STAGING TYPE
K		TNM TYPE
	O	STAGING CERTAINTY FACTOR

This class has no relationships.

CARE SPELL

Attributes of this Class are:

K		CARE SPELL IDENTIFIER
	O	CARE ASSESSMENT ONLY INDICATOR
		only if care spell has ended

CARE SPELL

Each CARE SPELL

K	must be for the care or assessment of one and only one PERSON
K	may be the context for one or more PERSON OBSERVATION WITHIN CARE SPELL
	may be the spell that includes one or more CARE PLAN
	may be delivered as part of one and only one JOINT INVESTMENT PLAN
	may be the context for one or more PALLIATIVE CARE EPISODE
	may be the context for recording one or more PERSON CHARACTERISTIC
	may be the responsibility of one or more RESPONSIBLE HEALTH CARE PROVIDER
	may be associated with one or more SERVICE PROVIDED

CLINICAL INTERVENTION

Each CLINICAL INTERVENTION

K	must be associated with one and only one PATIENT
	may be related to one or more CLINICAL INVESTIGATION RESULT ITEM
	may be associated with one or more HEALTH CARE PRACTITIONER INVOLVEMENT
	may be associated with one or more HEALTH CARE PROFESSIONAL INVOLVEMENT
	may be classified by one or more INTERVENTION CLASSIFICATION ASSOCIATION
	may be related to one and only one SERVICE PROVIDED

CLINICAL INVESTIGATION SERVICE PROVIDER

Each CLINICAL INVESTIGATION SERVICE PROVIDER

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

CO-MORBIDITY INDEX FOR ADULTS

CO-MORBIDITY INDEX FOR ADULTS

A type of PERSON OBSERVATION.

A measure of the presence and severity of co-morbid conditions by use of a co-morbidity index.

Co-morbidity is a disease or illness affecting a patient in addition to but not as a result of their current condition. Co-morbidity for cancer should be recorded at the Multi-Disciplinary Team (MDT) meeting prior to the beginning of treatment.

A different coding system will be used for children.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CO-MORBIDITY INDICES FOR ADULTS

This class has no attributes.

This class has no relationships.

CONSULTANT

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

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

This class is also known by these names:

Context	Alias
plural	CONSULTANTS

CONSULTANT

Each CONSULTANT

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

CONSULTANT REFERRAL REQUEST

Each CONSULTANT REFERRAL REQUEST
This class has no relationships.

must be made by one and only one CONSULTANT

DAY CARE ATTENDANCE

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

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

This class is also known by these names:

Context	Alias
plural	DAY CARE ATTENDANCES

DAY CARE SESSION

Each DAY CARE SESSION

K	must be related to one and only one DAY CARE FACILITY
	may be related to one or more DAY CARE ATTENDANCE
	may be the responsibility of one and only one HEALTH CARE PRACTITIONER
	may be the responsibility of one and only one HEALTH CARE PROFESSIONAL

DEATH CAUSE

DEATH CAUSE

A cause of death.

There are four types of cause of death, 'immediate cause of death', 'condition giving rise to death', 'underlying condition leading to death' and 'significant condition not directly related to death'.

The DEATH CAUSE TYPE identifies which of the causes this DEATH CAUSE refers to.

This class is also known by these names:

Context	Alias
plural	DEATH CAUSES

Attributes of this Class are:

K		DEATH CAUSE CODE
K		DEATH CAUSE TYPE
	O	DEATH CAUSE CANCER

Each DEATH CAUSE

K	must be a cause in one and only one PERSON DEATH DETAILS

DISPENSED ITEM

Each DISPENSED ITEM

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

DRUG TREATMENT

Each DRUG TREATMENT

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

GENERAL MEDICAL PRACTITIONER REGISTRAR

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

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

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

This class is also known by these names:

Context	Alias
plural	GENERAL MEDICAL PRACTITIONER REGISTRARS

GENERAL PRACTITIONER

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

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

GENERAL PRACTITIONER may be abbreviated to GP.

This class is also known by these names:

Context	Alias
plural	GENERAL PRACTITIONERS

HEALTH CARE PRACTITIONER

HEALTH CARE PRACTITIONER

HEALTH CARE PROFESSIONAL

HEALTH CARE PRACTITIONER

A type of PERSON ROLE IN ORGANISATION.

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

This class is also known by these names:

Context	Alias
plural	HEALTH CARE PRACTITIONERS
plural	HEALTH CARE PROFESSIONALS

HEALTH CARE PRACTITIONER

Each HEALTH CARE PRACTITIONER Each HEALTH CARE PROFESSIONAL

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

HEALTH CARE PRACTITIONER INVOLVEMENT

HEALTH CARE PRACTITIONER INVOLVEMENT

HEALTH CARE PROFESSIONAL INVOLVEMENT

HEALTH CARE PRACTITIONER INVOLVEMENT

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

This class is also known by these names:

Context	Alias
plural	HEALTH CARE PRACTITIONER INVOLVEMENTS
plural	HEALTH CARE PROFESSIONAL INVOLVEMENTS

HEALTH CARE PRACTITIONER INVOLVEMENT

Each HEALTH CARE PRACTITIONER INVOLVEMENT Each HEALTH CARE PROFESSIONAL INVOLVEMENT

K	must be involved with one and only one CLINICAL INTERVENTION
K	must be the involvement of one and only one HEALTH CARE PRACTITIONER
K	must be the involvement of one and only one HEALTH CARE PROFESSIONAL

HEALTH CARE PROVIDER

Each HEALTH CARE PROVIDER

K	must be a role of one and only one ORGANISATION
	may be the provider of one or more ANTI-CANCER DRUG PROGRAMME
	may be originator of a decision to treat one or more CANCER CARE PLAN
	may be related to one or more DENTAL STAFF MEMBER
	may be related to one or more DOMICILIARY SERVICE
	may be related to one or more ELECTIVE ADMISSION LIST
	may be acting as one or more HOSPITAL PROVIDER
	may be the originating care provider of one or more MENTAL HEALTH CARE SPELL
	may be the transfer target for one or more MENTAL HEALTH CARE SPELL SUSPENSION
	may be related to one or more NURSE OR MIDWIFE CONTACT
	may be related to one or more OPERATING THEATRE
	may be related to one or more OUT-PATIENT CLINIC
	may be related to one or more PATHOLOGY DEPARTMENT
	may be connected with one or more PERSON ROLE IN ORGANISATION
	may be provided following decision to treat of one or more PLANNED CANCER TREATMENT
	may be related to one or more PLANNED SERVICE TO BE PROVIDED
	may be related to one or more PROFESSIONAL STAFF GROUP SERVICE
	may be the provider in one or more PROVIDER IN SERVICE AGREEMENT
	may be the provider in one or more PROVIDER OF OUT OF AREA TREATMENT
	may be related to one or more RADIOLOGY DEPARTMENT
	may be related to one or more RADIOTHERAPY DEPARTMENT
	may be responsible for one or more RESPONSIBLE HEALTH CARE PROVIDER
	may be related to one or more RIGHT OF ADMISSION
	may be delivering patient treatment or services by one or more SERVICE PROVIDED
	may be related to one or more WARD

HEIGHT

HEIGHT

A type of CHARACTERISTIC.

The height of a PERSON on a given date. The unit of measurement is metres.

This class is also known by these names:

Context	Alias
plural	HEIGHTS

Attributes of this Class are:

RECORDED HEIGHT

This class has no relationships.

HONOS SCORE FOR PERSON

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

This class is also known by these names:

Context	Alias
plural	HONOS SCORES FOR PERSONS

HONOS SCORE FOR PERSON

Each HONOS SCORE FOR PERSON

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

IMAGING OR RADIODIAGNOSTIC EVENT

Attributes of this Class are:

K		IMAGING EVENT NUMBER
		ANATOMICAL EXAMINATION SITE
		for cancers only
		CANCER IMAGING MODALITY
		for cancers only
	O	IMAGING INTERVENTION INDICATOR
		IMAGING MODALITY

ITEM OF SERVICE DELIVERY ROLE

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

This class is also known by these names:

Context	Alias
plural	ITEM OF SERVICE DELIVERY ROLES

ITEM OF SERVICE DELIVERY ROLE

Each ITEM OF SERVICE DELIVERY ROLE

K	must be undertaken by one and only one HEALTH CARE PRACTITIONER
K	must be undertaken by one and only one HEALTH CARE PROFESSIONAL
K	must be undertaken as part of one and only one ITEM OF SERVICE DELIVERY

MENTAL HEALTH CARE SPELL

Attributes of this Class are:

	O	CARE ASSESSMENT ONLY INDICATOR
		only if care spell has ended
	O	END DATE
	O	MENTAL HEALTH CARE ASSESSMENT DATE
		only if spell initiated by a referral for assessment
	O	MENTAL HEALTH CARE SPELL END CODE
	O	PATIENT INFORMED OF OUTCOME DATE
		only if spell initiated by a referral for assessment
		START DATE

MIDWIFE

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

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

This class is also known by these names:

Context	Alias
plural	MIDWIVES

NURSE

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

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

This class is also known by these names:

Context	Alias
plural	NURSES

OPHTHALMIC MEDICAL PRACTITIONER

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

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

This class is also known by these names:

Context	Alias
plural	OPHTHALMIC MEDICAL PRACTITIONERS

OPHTHALMIC OPTICIAN

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

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

This class is also known by these names:

Context	Alias
plural	OPHTHALMIC OPTICIANS

ORGANISATION

Each ORGANISATION

	may be located at one or more ADDRESS ASSOCIATION
	may be related to one or more CLINICAL INVESTIGATION SERVICE PROVIDER
	may be the subject of one or more COMMUNITY PHARMACY SITE APPLICATION
	may be related to one or more DRUG MISUSE AGENCY
	may be related to one or more EMPLOYEE CONTRACT
	may be providing services classified by one or more FUNCTIONAL GROUP
	may be associated with one or more GEOGRAPHIC AREA ASSOCIATION
	may be acting as one or more HEALTH CARE PROVIDER
	may be planning or operating one or more JOINT INVESTMENT PLAN
	may be jointly associated with one or more JOINT INVESTMENT PLAN ASSOCIATION
	may be related to one or more LOCATION
	may be related to one or more MEDICAL AND DENTAL POST
	may be the commissioner within one or more NHS SERVICE AGREEMENT
	may be related to one or more NON MEDICAL AND DENTAL POST
	may be related to one or more ORGANISATION FINANCIAL PERIOD
	may be identified by one or more ORGANISATION IDENTIFIER
	may be the allocator of one or more ORGANISATION IDENTIFIER
	may be the operator or manager of one or more ORGANISATION SITE
	may be related from one or more ORGANISATION STRUCTURE
	may be related to one or more ORGANISATION STRUCTURE
	may be related to one or more OTHER REFERRAL REQUEST
	may be related from one or more ORGANISATION STRUCTURE
	may be the allocator of one or more PERSON IDENTIFIER
	may be connected with one or more PERSON ROLE IN ORGANISATION
	may be the place of treatment for one or more PRIOR NOTIFICATION LIST ENTRY
	may be undertaking one or more RECRUITMENT
	may be related as provider to one or more REQUEST FOR DIAGNOSTIC TEST
	may be the originator of one or more REFERRAL REQUEST
	may be related as requester of one or more REQUEST FOR DIAGNOSTIC TEST
	may be related as provider to one or more REQUEST FOR DIAGNOSTIC TEST
	may be experiencing one or more RETENTION DIFFICULTY
	may be the recipient of one or more SERVICE REPORT COPY
	may be the issuer of one or more SERVICE REPORT HEADER
	may be the requester of services for one or more SERVICE REPORT HEADER
	may be subject to one or more SINGLE SEX ACCOMMODATION TARGET
	may be contacted by one or more TELE-COMMUNICATION CONTACT STRING
	may be related to one or more WRITTEN COMPLAINT

OTHER REFERRAL REQUEST

Each OTHER REFERRAL REQUEST
This class has no relationships.

may be referred by one and only one ORGANISATION

PATHOLOGY LAB INVESTIGATION RESULT ITEM

Attributes of this Class are:

	O	CANCER MARKER LYMPH NODE STATUS
	O	CANCER VASCULAR OR LYMPHATIC INVASION
	O	EXCISION MARGIN
		for cancers only
	O	GRADE OF DIFFERENTIATION
		for cancers only
	O	INVASIVE LESION SIZE
		NODES EXAMINED NUMBER
		NODES POSITIVE NUMBER
		SPECIMEN NATURE
	O	SYNCHRONOUS TUMOUR INDICATOR
		for cancers only
	O	UNIT OF MEASURE

PATIENT

Each PATIENT

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

PATIENT CLINICAL TRIAL STATUS

PATIENT CLINICAL TRIAL STATUS

The association between a PATIENT and a CANCER CLINICAL TRIAL, which indicates whether those PATIENTS who are eligible for a trial are taking part in it.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	PATIENT CLINICAL TRIAL STATUSES

Attributes of this Class are:

PATIENT TRIAL STATUS

Each PATIENT CLINICAL TRIAL STATUS

K	must be recorded during one and only one CANCER CARE SPELL
K	must be a status for one and only one CANCER CLINICAL TRIAL

PATIENT DIAGNOSIS

Attributes of this Class are:

		BASIS OF DIAGNOSIS
		for cancers only
		DEFINITIVE DIAGNOSIS
		for cancers only
	O	PATIENT DIAGNOSIS CODING SIGNIFICANCE
	O	PRIMARY DIAGNOSIS
		TUMOUR LATERALITY
		for cancers only

PATIENT PROCEDURE

Each PATIENT PROCEDURE

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

PERFORMANCE STATUS

PERFORMANCE STATUS

A type of CHARACTERISTIC.

A World Health Organisation classification indicating a PERSON's status relating to activity / disability.

National Codes:

0	Able to carry out all normal activity without restriction
1	Restricted in physically strenuous activity, but able to walk and do light work
2	Able to walk and capable of all self care, but unable to carry out any work. Up and about more than 50% of waking hours
3	Capable of only limited self care, confined to bed or chair more than 50% of waking hours
4	Completely disabled. Cannot carry on any self care. Totally confined to bed or chair

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	PERFORMANCE STATUSES

This class has no attributes.

This class has no relationships.

PERSON

Attributes of this Class are:

		BIRTH DATE
	O	DEATH DATE
	O	ENLISTMENT DATE
	O	LAST DISCHARGE DATE
		applies to certain patients see attribute description
	O	OVERSEAS VISITOR UK ARRIVAL DATE

PERSON

Each PERSON

K	must be allocated a primary identifier of one and only one PERSON IDENTIFIER
	may be located at one or more ADDRESS ASSOCIATION
	may be the subject of one or more CARE SPELL
	may be the receiver of one or more GMP CONSULTATION
	may be involved in one or more GMP CONTACT FOR PERSON
	may be related to one or more IMMUNISATION PROGRAMME FOR PERSON
	may be a member of one or more MENTAL HEALTH CARE TEAM MEMBER
	may be the person consenting to one or more ORGAN DONATION CONSENT
	may be associated with one or more PERSON CHARACTERISTIC
	may be the subject of one or more PERSON DEATH DETAILS
	may be associated with one or more PERSON GMP ASSOCIATION
	may be related to one or more PERSON IN A CONTACT TRACING PROGRAMME
	may be related to one or more PERSON IN ADVICE AND SUPPORT PROGRAMME
	may be related to one or more PERSON IN A SCREENING PROGRAMME
	may be related to one or more PERSON IN A SURVEILLANCE STAGE
	may be the person in one or more PERSON IN GMP PRACTICE POST
	may be related to one PERSON NAME
	may be related to one or more PERSON NATIONALITY OR RESIDENCY STATUS
	may be the observer of one or more PERSON OBSERVATION
	may be the subject of one or more PERSON OBSERVATION
	may be related to one PERSON RELATIONSHIP
	may be the observer of one or more PERSON OBSERVATION
	may be related to one or more PERSON RELATIONSHIP
	may be related to one PERSON RELATIONSHIP
	may be the holder of one or more PERSON ROLE IN ORGANISATION
	may be the instigator of one or more PERSON SMOKING CESSATION EPISODE
	may be listed on one or more PRIOR NOTIFICATION LIST ENTRY
	may be the subject of one or more REGISTRATION
	may be related to one or more SCREENING TEST
	may be contacted by one or more TELE-COMMUNICATION CONTACT STRING
	may be the originator of one or more WRITTEN COMPLAINT

PERSON CHARACTERISTIC

Each PERSON CHARACTERISTIC

K	must be classified by one and only one CHARACTERISTIC
K	must be of one and only one PERSON
	may be recorded in the context of one and only one CARE SPELL

PERSON DEATH DETAILS

PERSON DEATH DETAILS

Information relating to the death of a PERSON, including the date and cause of death.

This class is also known by these names:

Context	Alias
plural	PERSON DEATH DETAILS

Attributes of this Class are:

K		DEATH DATE
		DEATH CAUSE IDENTIFICATION METHOD
	O	DEATH CODE DISCREPANCY ORIGINATOR
		DEATH LOCATION TYPE
		for cancer deaths only

Each PERSON DEATH DETAILS

K	must be details relating to one and only one PERSON
	may be classified by one or more DEATH CAUSE

PERSON OBSERVATION

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

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

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

This class is also known by these names:

Context	Alias
plural	PERSON OBSERVATIONS

PERSON OBSERVATION

Each PERSON OBSERVATION

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

PRESCRIPTION

Each PRESCRIPTION

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

RADIOLOGY INVESTIGATION PLAN

Each RADIOLOGY INVESTIGATION PLAN

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

RADIOTHERAPY TREATMENT COURSE

Attributes of this Class are:

K		START DATE
	O	END DATE
		PRIMARY OR SUBSEQUENT COURSE
	O	RADIOTHERAPY ACTUAL DOSE
		RADIOTHERAPY ANAESTHETIC
		RADIOTHERAPY ANATOMICAL TREATMENT SITE
	O	RADIOTHERAPY PRESCRIBED DOSE
		RADIOTHERAPY PRESCRIBED DURATION
	O	TREATMENT COURSE STATUS

RADIOTHERAPY TREATMENT COURSE

Each RADIOTHERAPY TREATMENT COURSE

K	must be related to one and only one PATIENT
	must be provided by one and only one RADIOTHERAPY DEPARTMENT
	must be part of one and only one SERVICE PROVIDED
	may be the responsibility of one and only one CONSULTANT
	may be a set of one or more FRACTION

REFERRAL REQUEST

Attributes of this Class are:

K		REQUEST NUMBER
	O	CANCER SPECIALIST REFERRAL DATE
		for suspected cancer only
	O	COLPOSCOPY REFERRAL INDICATION
		colposcopy only
	O	COMMISSIONER REFERENCE NUMBER
	O	FIRST SEEN BY SPECIALIST DATE (CANCER)
		for suspected cancer only
	O	OUT-PATIENT CLINIC REFERRING INDICATOR
		if referral request from an out-patient clinic
		OUT-PATIENT REFERRAL INDICATOR
		PRIORITY TYPE
		REFERRAL DATE
	O	REFERRAL REQUEST CANCELLED DATE
		REFERRAL REQUEST RECEIVED DATE
		SERVICE TYPE REQUESTED
	O	SOURCE OF REFERRAL FOR A+E
		if request is for care by an ACCIDENT AND EMERGENCY DEPARTMENT
	O	SOURCE OF REFERRAL FOR CANCER
		if request is for care from specialist cancer care services
	O	SOURCE OF REFERRAL FOR COMMUNITY
		if request is for care by a COMMUNITY NURSE STAFF GROUP
	O	SOURCE OF REFERRAL FOR COMMUNITY DENTAL
		if request is for care by a Community Dental Service
	O	SOURCE OF REFERRAL FOR DRUG MISUSE
		if request is for care at a DRUG MISUSE FACILITY
	O	SOURCE OF REFERRAL FOR MENTAL HEALTH
		if request is for care from specialist mental care services
	O	SOURCE OF REFERRAL FOR OUT-PATIENTS
		if request is for care to be provided as an out-patient
	O	SOURCE OF REFERRAL FOR PROF STAFF GROUP
		if request is for care by a PROFESSIONAL STAFF GROUP SERVICE
	O	SUPRA SERVICE TYPE
	O	TWO WEEK WAIT EXCLUSION INDICATOR
		for suspected cancer only

REFERRAL REQUEST

Each REFERRAL REQUEST

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

RENAL FUNCTION

RENAL FUNCTION

A type of PERSON OBSERVATION.

A PATIENT's creatinine clearance. This is recorded when certain Chemotherapy drugs, for example, carboplatin, are administered.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	RENAL FUNCTIONS

Attributes of this Class are:

CREATININE CLEARANCE

This class has no relationships.

REQUEST FOR DIAGNOSTIC TEST

Each REQUEST FOR DIAGNOSTIC TEST

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

REQUEST FOR PATHOLOGY INVESTIGATION

Attributes of this Class are:

	O	BIOPSY REFERRAL OUTCOME
	O	CANCER HISTOLOGICAL TYPE
		breast cancer only
	O	CERVICAL SMEAR EXAMINED DATE
	O	CYTOLOGY RESULT TYPE
		cervical screening only
	O	CYTOLOGY SMEAR REASON
	O	INVASIVE CANCER SPECIAL TYPE INDICATOR
		breast cancer only
	O	INVASIVE LESION SIZE
		if applicable as a result of biopsy for invasive breast cancers
	O	LYMPH NODE STATUS
		breast cancer only
	O	PATHOLOGY INVESTIGATION TYPE
		for cancers only
		PATHOLOGY SPECIALTY
	O	SMEAR INFECTION TYPE
	O	SMEAR REFERRAL NATURE
		Cervical screening only
	O	SMEAR SOURCE TYPE

SERVICE PROVIDED

Attributes of this Class are:

K		SERVICE PROVIDED NUMBER
		CANCER TREATMENT INTENT
		for cancer treatment only
		SELF-REFERRAL OR OPEN ACCESS

SERVICE REPORT COPY

Each SERVICE REPORT COPY

K	must be related to one and only one SERVICE REPORT HEADER
	must be issued to one and only one HEALTH CARE PRACTITIONER
	must be issued to one and only one HEALTH CARE PROFESSIONAL
	or must be issued to one and only one ORGANISATION

SERVICE REPORT HEADER

Each SERVICE REPORT HEADER

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

TELETHERAPY TREATMENT COURSE

A type of RADIOTHERAPY TREATMENT COURSE.

A prescribed course of radiotherapy teletherapy treatment for a PATIENT. A course of radiotherapy teletherapy treatment for a PATIENT.

This class is also known by these names:

Context	Alias
plural	TELETHERAPY TREATMENT COURSES

TELETHERAPY TREATMENT COURSE

Attributes of this Class are:

		TELETHERAPY ACTUAL FRACTIONS
		TELETHERAPY BEAM TYPE
		TELETHERAPY COMPLEXITY GROUP
		TELETHERAPY ELECTRON ENERGY
		TELETHERAPY FIELDS
		TELETHERAPY MULTIPLE PLANNING
		TELETHERAPY PHOTON ENERGY
		TELETHERAPY PRESCRIBED FRACTIONS

TREATMENT RELATED MORBIDITY

TREATMENT RELATED MORBIDITY

Any morbidity, relevant to previous treatments provided to a PATIENT during a CANCER CARE SPELL, recorded during a CANCER CLINICAL STATUS ASSESSMENT.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	TREATMENT RELATED MORBIDITIES

Attributes of this Class are:

K		MORBIDITY CODE
K		TREATMENT TYPE

Each TREATMENT RELATED MORBIDITY

K	must be recorded in the context of one and only one CANCER CLINICAL STATUS ASSESSMENT

WEIGHT

A type of CHARACTERISTIC.

Identifies the weight of a person on a given date. The unit of measurement may be grams, Kilograms or pounds. The unit of measurement is Kilograms.

National Codes:

1	Grams
2	Kilograms
3	Pounds

This class is also known by these names:

Context	Alias
plural	WEIGHTS

ANATOMICAL EXAMINATION SITE

ANATOMICAL EXAMINATION SITE

A classification of the part of the body that is the subject of the IMAGING OR RADIODIAGNOSTIC EVENT.

The coding frame used is the OPCS 'Z' coding.

References:
National Cancer Data Set Version 1.3_ISB October 2002

BASIS OF DIAGNOSIS

BASIS OF DIAGNOSIS

A classification of how a PATIENT DIAGNOSIS relating to cancer was identified.

National Codes:

Non-microscopic
0 - Death Certificate	The only information available is from a death certificate
1 - Clinical	Diagnosis made before death but without the benefit of any of the following (2-7)
2 - Clinical Investigation	Includes all diagnostic techniques (e.g. X-rays, endoscopy, imaging, ultrasound, exploratory surgery and autopsy) without a tissue diagnosis
3 - Specific tumour markers	Includes biochemical and/or immunological markers which are specific for a tumour site
Microscopic
5 - Cytology	Examination of cells whether from a primary or secondary site, including fluids aspirated using endoscopes or needles. Also including microscopic examination of peripheral blood films and trephine bone marrow aspirates
6 - Histology of a mestastases	Histological examination of tissues from a metastasis, including autopsy specimens
7 - Histology of a primary tumour	Histological examination of tissue from the primary tumour, however obtained, including all cutting and bone marrow biopsies. Also includes autopsy specimens of a primary tumour
9 - Unknown	No information on how the diagnosis has been made (e.g. PAS or HISS record only)

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	BASIS OF DIAGNOSES

BRACHYTHERAPY DELIVERY TYPE

The prescribed type of delivery system of a BRACHYTHERAPY TREATMENT COURSE.

Classification: National Codes:

a.	Manual afterloading
1	Manual afterloading
b.	Mechanical afterloading
2	Mechanical afterloading
c.	Live source
3	Live source

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	BRACHYTHERAPY DELIVERY TYPES

BRACHYTHERAPY DOSE RATE

The prescribed dose rate of a BRACHYTHERAPY TREATMENT COURSE.

Classification: National Codes:

a.	High/medium
1	High/medium
b.	Low
2	Low

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	BRACHYTHERAPY DOSE RATES

BRACHYTHERAPY ISOTOPE TYPE

The prescribed type of isotope of a BRACHYTHERAPY TREATMENT COURSE.

Classification: National Codes:

a.	Caesium 137
B1	Caesium 137
b.	Iridium 192
B2	Iridium 192
c.	Strontium 90
B3	Strontium 90
d.	Iodine 125
B4	Iodine 125
e.	Colbalt 60
B5	Colbalt 60
f.	Gold grains Au 198
B6	Gold grains Au 198
g.	Other
B7	Brachytherapy other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	BRACHYTHERAPY ISOTOPE TYPES

CANCER CARE PLAN INTENT

CANCER CARE PLAN INTENT

A classification of the intention of a CANCER CARE PLAN developed within a CANCER CARE SPELL.

National Codes:

C	Curative
P	Palliative anti-cancer
S	Supportive
N	No specific cancer treatment

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER CARE PLAN INTENTS

CANCER CLINICAL TRIAL IDENTIFIER

CANCER CLINICAL TRIAL IDENTIFIER

The unique identifier for a CANCER CLINICAL TRIAL

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER CLINICAL TRIAL IDENTIFIERS

CANCER CLINICAL TRIAL TREATMENT TYPE

CANCER CLINICAL TRIAL TREATMENT TYPE

A classification that identifies the type of treatment covered by a CANCER CLINICAL TRIAL.

National Codes:

1	Surgery
2	Chemotherapy
3	Hormone therapy
4	Immunotherapy
5	Radiotherapy
6	Combination treatment

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER CLINICAL TRIAL TREATMENT TYPES

CANCER IMAGING MODALITY

CANCER IMAGING MODALITY

A classification used to identify the type of imaging procedure used in relation to a CANCER CARE SPELL.

National Codes:

1	Standard radiography
1A	Chest X-ray
1B	Sinus X-rays
1C	Mastoid views
1D	Orthopantomogram (OPG)
1E	Skull base X-rays
1F	Angiography
1G	Intravenous urography
1H	Retrograde urography
1J	Inferior vena cavography
1K	Bone angiography
1L	Soft tissue angiography
2A	CT scan with contrast
2B	CT scan without contrast
3A	MRI scan with contrast
3B	MRI scan without contrast
3C	MRI cholangiography
4	PET scan
5	Ultrasound
5A	Transabdominal ultrasound
5B	Transvaginal ultrasound
5C	Doppler ultrasound
5D	Transrectal ultrasound
5E	Endoscopic ultrasound
5F	Laparascopic ultrasound
6	Nuclear Medicine imaging
6A	Radio-isotope bone scan
6B	Other radio-isotope scan
6C	Ventilation/Perfusion scan
7	Mammography
8	Barium
8A	Barium enema
8B	Barium swallow
9	Lymphoscintigraphy
99	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER IMAGING MODALITIES

CANCER MARKER LYMPH NODE STATUS

CANCER MARKER LYMPH NODE STATUS

An indication of the presence or absence of metastases in a marker lymph node. Marker lymph nodes are identified within the cancer site and the presence or absence of metastases are a useful indication of the spread of the cancer, and inform both the treatment and the PATIENT's prognosis.

National Codes:

N	No, marker lymph node 1 negative
Y	Yes, marker lymph node 1 positive

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER MARKER LYMPH NODE STATUSES

CANCER STAGING TYPE

CANCER STAGING TYPE

A classification of the type of cancer staging for which tumour, node and metastasis (TNM) values are collected i.e. clinically determined prior to treatment, determined on histological evidence, or determined on the basis of all the clinical, imaging and pathological data available following the first surgical procedure.

National Codes:

1	Final pre-treatment stage
2	Pathological stage
3	Integrated stage

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER STAGING TYPES

CANCER TREATMENT INTENT

CANCER TREATMENT INTENT

A classification of the intention of the treatment provided given during a CANCER CARE SPELL.

National Codes:

A	Adjuvent
C	Curative
D	Diagnostic
N	Neoadjuvent
S	Staging
P	Palliative

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER TREATMENT INTENTS

CANCER VASCULAR OR LYMPHATIC INVASION

CANCER VASCULAR OR LYMPHATIC INVASION

An indication of the presence or absence of unequivocal tumour in vascular spaces.

National Codes:

N	No, vascular/lymphatic invasion not present
Y	Yes, vascular/lymphatic invasion present
U	Uncertain whether vascular invasion is present or not

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CANCER VASCULAR OR LYMPHATIC INVASIONS

CLAIMING GMP RELATIONSHIP

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

Classification:

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

This attribute is also known by these names:

Context	Alias
plural	CLAIMING GMP RELATIONSHIPS

CLINICAL STATUS ASSESSMENT DATE

CLINICAL STATUS ASSESSMENT DATE

The date on which a clinical status assessment was performed.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CLINICAL STATUS ASSESSMENT DATES

CREATININE CLEARANCE

CREATININE CLEARANCE

The measurement of a PERSON's renal function, in terms of expulsion of creatinine, measured in millilitres per minute.

This is recorded when certain Chemotherapy drugs, for example, carboplatin, are administered.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CREATININE CLEARANCES

DEATH CAUSE CANCER

DEATH CAUSE CANCER

The cause of death of the patient in relation to their diagnosis of cancer. It is left blank if the patient is still alive.

National Codes:

1	Death by first registered primary
2	Death by another primary
3	Death by other causes/ cancer known to be present
4	Death by other causes, cancer not mentioned
5	Indeterminate cause of death (more than one primary)
6	Death from metastatic disease where origin of primary is known
7	Death by metastatic disease where origin of primary is unknown

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DEATH CAUSES CANCER

DEATH CAUSE CODE

DEATH CAUSE CODE

A code indicating a cause of death, classified using ICD-10.

This attribute is also known by these names:

Context	Alias
plural	DEATH CAUSE CODES

DEATH CAUSE IDENTIFICATION METHOD

DEATH CAUSE IDENTIFICATION METHOD

The source of information from which the cause of death was established.

National Codes:

1	Death certificate
2	NHS Central Register Follow-up
3	Hospital records
4	Verbal communication
5	Post mortem

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DEATH CAUSE IDENTIFICATION METHODS

DEATH CAUSE TYPE

DEATH CAUSE TYPE

A classification of the types of cause of death, as specified on the death certificate.

National Codes:

1	Immediate cause of death
2	Condition giving rise to death
3	Underlying condition leading to death
4	Significant condition not directly related to death

This attribute is also known by these names:

Context	Alias
plural	DEATH CAUSE TYPES

DEATH CODE DISCREPANCY ORIGINATOR

DEATH CODE DISCREPANCY ORIGINATOR

The originator of the information that a death code discrepancy is present. This is a discrepancy between the cause of death presented on the death certificate and other evidence which is available, for example from patient case notes.

National Codes:

10	There is a discrepancy between the hospital evidence and the death certificate (information provided by the Trust)
11	There is a discrepancy between the hospital evidence and the death certificate (information provided by the Cancer Registry)

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DEATH CODE DISCREPANCY ORIGINATORS

DEATH LOCATION TYPE

DEATH LOCATION TYPE

A classification of the type of location at which a person suffering from cancer died.

National Codes:

1	Hospital
2	NHS hospice / specialist palliative care unit
3	Voluntary hospice / specialist palliative care unit
4	Patient's own home
5	Care home
6	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DEATH LOCATION TYPES

DEFINITIVE DIAGNOSIS

DEFINITIVE DIAGNOSIS

An indication of whether a PATIENT DIAGNOSIS is a DEFINITIVE DIAGNOSIS.

A DEFINITIVE DIAGNOSIS is an indication of the confirmation of the site, histology and stage of cancer by a PATIENT DIAGNOSIS. A definitive PATIENT DIAGNOSIS forms the basis on which action, in terms of care or treatment, was taken.

National Codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DEFINITIVE DIAGNOSES

DRUG PROGRAMME RESPONSE

DRUG PROGRAMME RESPONSE

The outcome of an ANTI-CANCER DRUG PROGRAMME in terms of the effect on the patient's cancer.

National Codes:

1	Complete response
2	Partial response
3	Static disease
4	Progressive disease
5	Not assessed
6	Unassessable

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DRUG PROGRAMME RESPONSES

DRUG TREATMENT INTENT

DRUG TREATMENT INTENT

A classification of the overall aim of the ANTI-CANCER DRUG PROGRAMME.

National Codes:

A	Adjuvent
N	Neoadjuvent
C	Curative
P	Palliative

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DRUG TREATMENT INTENTS

EXCISION MARGIN

EXCISION MARGIN

An indication of whether the excision margin was clear of the tumour and if so, by how much.

National Codes:

A	Margin involved
B	less than 1 mm clear
C	1-5 mm clear
D	>5 mm clear
U	Uncertain

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	EXCISION MARGINS

GRADE OF DIFFERENTIATION

GRADE OF DIFFERENTIATION

The assessment of the grade of differentiation of a tumour expressed as the extent to which the tumour resembles the normal tissue at that site.

National Codes:

GX	Grade of differentiation is not appropriate or cannot be assessed
G1	Well differentiated
G2	Moderately differentiated
G3	Poorly differentiated
G4	Undifferentiated / anaplastic

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	GRADES OF DIFFERENTIATION

HONOS SCORE DATE

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

This attribute is also known by these names:

Context	Alias
plural	HONOS SCORE DATES

INVASIVE LESION SIZE

The size in millimetres of the diameter of a lesion, largest if more than one, if the histology of a breast sample proves to be invasive. The size in millimetres of the diameter of a lesion, largest if more than one, if the histology of a sample proves to be invasive.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	INVASIVE LESION SIZES

MARKER RESPONSE STATUS

MARKER RESPONSE STATUS

A classification identifying whether a marker was used, and if so what the result was. Markers are chemicals produced by certain cancers that circulate in the blood and can be measured, for example CA125 for ovarian cancer. The marker level is measured by a blood test to see whether it is rising (disease worsening), static or falling (disease shrinking).

National Codes:

1	No marker
2	Progressive status
3	Static disease
4	Partial response
5	Complete response
6	Not assessed

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	MARKER RESPONSE STATUSES

METASTATIC STATUS

METASTATIC STATUS

The status of a PATIENT's distant metastases, determined during a CANCER CLINICAL STATUS ASSESSMENT.

National Codes:

1	Residual distant metastases
2	No evidence of metastases
3	New distant metastases
4	Not assessed
5	Uncertain

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	METASTATIC STATUSES

MORBIDITY CODE

MORBIDITY CODE

The code for morbidity recorded in the context of a TREATMENT RELATED MORBIDITY.

The coding frame used depends on the TREATMENT TYPE.

For Surgery - Primary Site Specific Surgical Complications - ICD-10 coding

National Codes:

For Chemotherapy and Combination treatment (only long-term adverse effects need to be recorded)
2	Mild toxicity
3	Moderate toxicity
4	Severe toxicity
5	Death due to toxicity
For Radiotherapy (only significant morbidity needs to be recorded):
3	Moderate toxicity
4	Severe toxicity
5	Death due to toxicity

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	MORBIDITY CODES

NO CANCER TREATMENT REASON

NO CANCER TREATMENT REASON

A classification of the reason why no specific cancer treatment is specified within a CANCER CARE PLAN.

National Codes:

01	Patient declined treatment
02	Unfit: poor performance status
03	Unfit: significant co-morbidity
04	Unfit: advanced stage cancer
05	Unknown primary site
06	Died before treatment
07	No anti-cancer treatment available
08	Other
09	Watchful waiting