| Data Set Data Elements | |
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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: |
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| 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 | |
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| 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. | |
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| 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. | |
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| 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 ADULTS | Investigations 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. | |
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| 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. | |
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| 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' | |
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| 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. | |
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| 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 | |
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Radiotherapy (Teletherapy):
A course of teletherapy is defined as a string of prescriptions which are consecutive. | |
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| 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. | |
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| 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. |
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| 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 |
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| PATIENT TRIAL STATUS (CANCER) | |
| CANCER CLINICAL TRIAL TREATMENT TYPE | |
| DEATH DETAILS | |
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| 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) | |
