An Arts Therapist is a CARE PROFESSIONAL who is registered with the Health Professions Council.

An Arts Therapist, which includes art, music or drama, encourages people to express their feelings and emotions through art, such as painting and drawing, music or drama.Arts Therapists include art therapists, music therapists and drama therapists. They encourage people to express their feelings and emotions through art, such as painting and drawing, music or drama.

• information requirements of national and local performance management, planning and clinical governance
• assurance of the quality of health and social care services
• the monitoring of National Service Frameworks (NSFs)

Clinic Attendance Sexual and Reproductive Health Service is a CARE CONTACT.

A Clinic Attendance Non-Consultant.

An attendance or contact by a PATIENT at a Sexual and Reproductive Health Clinic.

Information recorded for a Clinic Attendance Sexual and Reproductive Health Service includes:

Consultant Upgrade Date is an ACTIVITY DATE TIME TYPE. 

It is the DATE  that the CONSULTANT responsible for the care of the PATIENT (or an authorised member of the CONSULTANT team as defined by local policy) decided that the PATIENT should be upgraded onto an urgent Cancer PATIENT PATHWAY.

The Consultant Upgrade Date should only be recorded when the PRIORITY TYPE of the original SERVICE REQUEST was not National Code 3 - Two Week Wait.The Consultant Upgrade Date should only be recorded when the PRIORITY TYPE of the original SERVICE REQUEST was not National Code 3 - 'Two Week Wait'.

Consultant upgrades are not allowed for PATIENTS who were urgently referred with suspected cancer from an NHS Cancer Screening Programme (where the SOURCE OF REFERRAL FOR OUT-PATIENTS was National Code 17 - referral from a National Screening Programme, and the PRIORITY TYPE of the SERVICE REQUEST was National Code 2 -Urgent).  Therefore a Consultant Upgrade Date cannot be recorded in these circumstances.

The Consultant Upgrade Date must be on or before the DECISION TO TREAT DATE (if recorded). 

The Consultant Upgrade Date must also be on or before the MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) (if recorded).

A Data Dictionary Change Notice (DDCN) is a notice of a change to the NHS Data Model and Dictionary which is not suitable for  Information Standards Board for Health and Social Care board publication as an Information Standards Notice, as the change does not relate to an individual standard.

Further information on Data Dictionary Change Notices can be found on the NHS Data Model and Dictionary Service website at:

• Policy and Publications page
• Data Dictionary Change Notices page.

This supporting information is also known by these names:

Context	Alias
shortname	DDCN
plural	Data Dictionary Change Notices

FEV1 Absolute Amount is a MEASURED PERSON OBSERVATION,FEV1 Absolute Amount is a MEASURED PERSON OBSERVATION.

The forced expiratory volume of the lungs in 1 second measured in litres.FEV1 Absolute Amount is the forced expiratory volume of the lungs in 1 second measured in litres.

References:
National Cancer Dataset Version 1.3_ISB October 2002

The Department of Health requires summary details from Primary Care Trusts to monitor the implementation and effectiveness of the Human Papillomavirus (HPV) Immunisation Programme.

The Human Papillomavirus Vaccination Programme for England will commence in September 2008, the first TARGET POPULATION being for females born between 1st September 1995 and 31st August 1996. This will be the first HEALTH PROGRAMME STAGE for what will then be a routine annual Immunisation Programme for all 12-13 year old females.

There will be catch-up HEALTH PROGRAMME STAGES in 2008/09 for 17-18 year olds, 2009/10 for 16-18 year old females and one in 2010/11 for 15-17 year old females.

It is recommended for the vaccine delivery to be in Schools/Colleges but Primary Care Trusts are responsible for implementing the programme according to their local needs.

Each Primary Care Trust will collect and return data on the females in a particular TARGET POPULATION. Primary Care Trusts are recommended to run a Schools-based programme, but some may choose not to. The ANNUAL TARGET DENOMINATOR (HUMAN PAPILLOMAVIRUS VACCINE) will either be Schools based or non-Schools based.

The Human Papillomavirus vaccine requires 3 separate doses to complete a full course. It is recommended that this full course is given within a 6 month period, but it may be given in a period of up to a 12 months. It is recommended that this full course is given within a 6 month period, but it may be given in a period of up to 12 months. However, to allow for those that missed one or more doses in their TARGET POPULATION year, summary data will be collected every year for each TARGET POPULATION until those PERSONS reach 18 years old. This is because the Human Papillomavirus vaccine is most effective before an individual becomes sexually active.

Although data is collected monthly in the HPV Immunisation Programme Vaccine Monitoring Monthly Minimum Data Set, it is recognised that Primary Care Trusts may not be aware of the number of other females they are responsible for at the start of the HPV Immunisation Programme Vaccine Monitoring Monthly Minimum Data Set campaign year. However by the end of the School Year, Primary Care Trusts will have had opportunity to complete vaccinations for any others they are responsible for and these will be included in the HPV Immunisation Programme Vaccine Monitoring Annual Minimum Data Set together with the HPV Immunisation Programme Vaccine Monitoring Monthly Minimum Data Sets.

The HPV Immunisation Programme Vaccine Monitoring Annual Minimum Data Set requires information on number of doses administered as well as the administration LOCATION TYPES.

Collection and Submission of the HPV Immunisation Programme Vaccine Monitoring Annual Minimum Data Set

• The HPV Immunisation Programme Vaccine Monitoring Annual Minimum Data Set is the School Year end annual return from Primary Care Trusts.
• The return must be submitted within 20 working days after the previous School Year end of 31st August.
• The data is submitted via a web form on the Health Protection Informatics website

1. Primary Care Trust, HEALTH PROGRAMME STAGE NUMBER (HUMAN PAPILLOMAVIRUS VACCINE), REPORTING PERIOD and ANNUAL TARGET DENOMINATOR (HUMAN PAPILLOMAVIRUS VACCINE)
2. Doses administered (by each of the three doses)
3. Doses administered by LOCATION TYPE.

NHS DATA MODEL AND DICTIONARY

Version 3

What's New: September 2010

	Welcome to the NHS Data Model and Dictionary for England If you would like to know more about us or need help using the NHS Data Model and Dictionary, see the Help pages The NHS Data Model and Dictionary is maintained and published by the NHS Data Model and Dictionary Service and all changes are assured by the Information Standards Board for Health and Social Care and published as Information Standards Notices (ISNs). The NHS Data Model and Dictionary provides a reference point for assured information standards to support health care activities within the NHS in England. It has been developed for everyone who is actively involved in the collection of data and the management of information in the NHS.
	Welcome to the NHS Data Model and Dictionary for England If you would like to know more about us or need help using the NHS Data Model and Dictionary, see the Help pages The NHS Data Model and Dictionary provides a reference point for assured information standards to support health care activities within the NHS in England. It has been developed for everyone who is actively involved in the collection of data and the management of information in the NHS. The NHS Data Model and Dictionary is maintained and published by the NHS Data Model and Dictionary Service and all changes are assured by the Information Standards Board for Health and Social Care. Changes are published as Information Standards Notices (ISN) by the Information Standards Board for Health and Social Care and Data Dictionary Change Notices (DDCN) by the NHS Data Model and Dictionary Service.
	Related Links Frequently Asked Questions Useful Links Department of Health website The NHS Information Centre for health and social care website Information Catalogue Secondary Uses Service website

ORGANISATIONS such as The NHS Information Centre for health and social care, General Medical Council etc which are included in the NHS Data Model and Dictionary.

Screening Programme is a HEALTH PROGRAMME.

A programme directed towards the detection of a specific disease or condition in a target group: for example, cervical cancer in women of a particular age group, hypertension in adults of a particular age group, or hearing impairment in school children. Screening makes the use of tests which can be applied rapidly to apparently well PERSONS as a means of distinguishing those who probably have the condition from those who probably do not.A programme directed towards the detection of a specific disease or condition in a target group: for example:

Screening makes the use of tests which can be applied rapidly to apparently well PERSONS as a means of distinguishing those who probably have the condition from those who probably do not.

An Out-Patient Clinic.

A clinic specifically to provide Sexual and Reproductive Health Services.A clinic specifically to provide Sexual and Reproductive Health Services. This includes non-NHS organisation clinics from which these services are commissioned by the NHS. Clinics run by CONSULTANTS are included under Consultant Clinic.

Clinics run by CONSULTANTS are included under Consultant Clinic.

It should be noted that work in GENERAL MEDICAL PRACTITIONER surgeries or GENERAL MEDICAL PRACTITIONER work on hospital premises is excluded.

A subtype of ACTIVITY.

Subtypes of ACTIVITY GROUP are:

A continuous period of care or assessment for a PATIENT by one or more CARE PROFESSIONAL. ACTIVITY GROUPS mainly consist of episodes, spells, stays or care periods.

An ACTIVITY GROUP may include one or more CARE ACTIVITIES.

ACTIVITY GROUPS include:

• Accident And Emergency Episode
• Acute Myocardial Infarction Care Spell
• Adult Mental Health Care Spell
• Breast Cancer Care Spell
• Cancer Care Spell
• Cancer Treatment Period
• Care Home Stay (Consultant Care)
• Care Home Stay (Midwife Care)
• Care Home Stay (Nursing Care)
• Care Home Stay (Residential)
• Care Programme Approach Episode
• Care Spell
• Colorectal Cancer Care Spell
• Community Episode
• Consultant Episode (Acute Home-Based)
• Consultant Episode (Hospital Provider)
• Consultant Out-Patient Episode
• Dental Episode
• Drug Misuse Episode
• Genitourinary Episode
• Gynaecological Cancer Care Spell
• Head And Neck Cancer Care Spell
• Home Dialysis Episode
• Hospital Provider Spell
• Hospital Stay
• Lung Cancer Care Spell
• Mental Health Care Spell
• Mental Health Care Without Patient Consent
• Midwife Episode
• Neonatal Level Of Care Period
• Nursing Episode
• Palliative Care Episode
• PERSON STOP SMOKING EPISODE
• Pregnancy Episode
• Professional Staff Group Episode
• Regular Attender Episode
• Sarcoma Care Spell
• Skin Cancer Care Spell
• Supervised Discharge Episode
• Supervised Community Treatment
• Supervised Community Treatment Recall
• Supervision Register Episode
• Upper GI Cancer Care Spell
• Urological Cancer Care Spell
• Ward Stay

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

A subtype of CARE ACTIVITY.

Information about medical or surgical actions performed on or planned to be performed on a PATIENT.

• Anaesthetic Service
• Anti-Cancer Drug Cycle
• Anti-Cancer Drug Fraction
• Anti-Cancer Drug Programme
• Anti-Cancer Drug Regimen
• Newborn Blood Spot Test
• Brachytherapy Treatment Course
• Clinical Investigation
• Contraceptive Service
• Dental Haemorrhage Service
• Dental Treatment
• Drug Dosage And Administration
• Drug Treatment
• Emergency Treatment Service
• Endocrine Therapy
• Fraction
• Hip Replacement Surgery
• Imaging Or Radiodiagnostic Event
• Immunisation Dose Given
• Joint Replacement Surgery
• Knee Replacement Surgery
• Labour And Delivery
• Lithotripsy Course Attendance
• Maternity Medical Service
• Minor Surgery Procedure
• Newborn Blood Spot Test
• Pathology Laboratory Investigation
• Patient Procedure
• Post Mortem
• Radiotherapy Treatment Course
• Screening Test
• Teletherapy Treatment Course
• Test Of Immunity
• Therapy After Discharge
• Thrombo Prophylaxis Regime
• Unsealed Source Treatment Course
• Vaccination Service
• Vasectomy Performed

The date of an APPOINTMENT. In the case of a PATIENT attending an Out-Patient Clinic without prior notice or APPOINTMENT, the PATIENT will be given an Out-Patient Appointment.

The date on which the decision was made to urgently refer a PATIENT with suspected cancer. This should be the first point of referral from one of the following:

This should be the first point of referral from one of the following:

A classification of the type of treatment or care which was delivered in a Cancer Treatment Period.

National 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.

The level of Care Programme Approach which has been determined as applicable for a PATIENT's Care Programme Approach Episode. Health Care Providers may develop expanded local classifications to meet local requirements.

Health Care Providers may develop expanded local classifications to meet local requirements. However, local classifications must map back to the national classifications and only National Codes should be used for central reporting.

National Codes:

An indication of a PATIENT's route to diagnosis of cancer for a Cancer Care Spell.

National Codes:

References:
National Cancer Dataset Version 1.3_ISB October 2002

This is the site of the metastatic disease.  It is used to identify metastatic disease relating to the PRIMARY DIAGNOSIS (ICD).The site of the metastatic disease. 

It is used to identify metastatic disease relating to the PRIMARY DIAGNOSIS (ICD). 

National Codes:

The status of a PATIENT's distant metastases, determined during a Cancer Clinical Status Assessment.

National Codes:

References:
National Cancer Dataset Version 1.3_ISB October 2002

A classification of the reason why no specific cancer treatment is specified within a Cancer Care Plan.

National Codes:

References:
National Cancer Dataset Version 1.3_ISB October 2002

Identifies the physical status of the PATIENT as recorded by an anaesthetist for an operative procedure. This is an abbreviated version of the American Society of Anesthesiologists Physical Status grading.

This is an abbreviated version of the American Society of Anesthesiologists Physical Status grading.

National Codes:

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

The final pre-treatment measure of the stage based on the serum tumour marker for testis cancer only. This is coded according to the UICC (Union Internationale Contre le Cancer) coding (5th Edition, 1997) guidelines. Further information can be found in the Urology Appendix on: http://www.

Further information can be found at:http://www.ic.nhs.uk/datasets/downloads/cancer/canceruk/services/national-clinical-audit-support-programme-ncasp/cancer.

References:
National Cancer Dataset Version 1.3_ISB October 2002

The prime reason for an adjustment to waiting time in the National Cancer Waiting Times Monitoring Data Set. Where there is more than one adjustment applicable, this should be the reason for the longest adjustment.

Where there is more than one adjustment applicable, this should be the reason for the longest adjustment. This item can be derived and the following values are to be used:

National Codes:

Where there has been no adjustment to waiting time, default code 9 - no adjustment to waiting time should be used.

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:
A and E ARRIVAL MODE CODE is the same as attribute A AND E ARRIVAL MODE.

A and E ARRIVAL MODE CODE replaces A and E ARRIVAL MODE and should be used for all new and developing data sets and for XML messages.

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: 
A and E ATTENDANCE CATEGORY CODE is the same as attribute A AND E ATTENDANCE CATEGORY.

A FIRST ATTENDANCE is the first or only attendance for the same incident, which may be an injury or occurrence of a condition; a follow-up attendance is a visit to the same department for the same incident as the first visit within the episode. If a PATIENT has a recurring condition, such as epilepsy, or a tendency for joints to dislocate, there would be a new FIRST ATTENDANCE each time that the PATIENT presents with the condition.

A subsequent attendance may not always be a follow-up attendance. It could qualify as an attendance at a consultant out-patient clinic and if so, it needs to be recorded appropriately.

A and E ATTENDANCE CATEGORY CODE replaces A and E ATTENDANCE CATEGORY and should be used for all new and developing data sets and for XML messages

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:
ADMINISTRATIVE CATEGORY CODE is the same as ADMINISTRATIVE CATEGORY CODE.

A PATIENT who is an Overseas Visitor does not qualify for free NHS healthcare can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS.

The PATIENT's ADMINISTRATIVE CATEGORY CODE may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded.

If the ADMINISTRATIVE CATEGORY CODE changes during a Hospital Provider Spell the ADMINISTRATIVE CATEGORY (ON ADMISSION) is used to derive the 'Category of PATIENT' for Hospital Episode Statistics (HES).

ADMINISTRATIVE CATEGORY CODE replaces ADMINISTRATIVE CATEGORY and should be used for all new and developing data sets and for XML messages.

Hospital Provider Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.

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:
ADMISSION OFFER OUTCOME CODE is the same as attribute ADMISSION OFFER OUTCOME.

PATIENTS are taken off the ELECTIVE ADMISSION LIST once they are admitted into hospital.

If treatment is then deferred because of lack of facilities, or for medical reasons, e.g. the PATIENT may have a cold or unacceptably high blood pressure, the PATIENT is discharged with the ADMISSION OFFER OUTCOME CODE recorded as 'Patient admitted - treatment deferred'. A new DECISION TO ADMIT and a new ELECTIVE ADMISSION LIST ENTRY will then be made for the PATIENT.

Note that the ORIGINAL DECIDED TO ADMIT DATE will still be used for the PATIENT's waiting time calculation. However, if the PATIENT fails to arrive or if the Admission is cancelled by, or on behalf of, the PATIENT then the waiting time is re-set from the missed admission date.

ADMISSION OFFER OUTCOME CODE replaces ADMISSION OFFER OUTCOME and should be used for all new and developing data sets and for XML messages.

Notes:

A classification of part of the body to which the RADIOTHERAPY ACTUAL DOSE is administered.

See Radiotherapy Data Set Manual for the Office of Population Censuses ans Surveys (OPCS-4) code to be used.See the Radiotherapy Data Set Manual for the Office of Population Censuses and Surveys (OPCS-4) code to be used.

Notes:
This is the same as attribute CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS.CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS is the same as attribute CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS.

Notes:

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.

Notes:
CANCER REFERRAL PRIORITY TYPE is the same as attribute CANCER REFERRAL PRIORITY TYPE.

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.  

Notes:
CANCER SPECIALIST REFERRAL DATE may be the same date as CANCER REFERRAL DECISION DATE if the initial referral was direct to an appropriate specialist for the cancer.

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.

Notes:

This is the same as attribute CANCER TREATMENT MODALITY.

Notes:
CARE PLAN AGREED DATE is the same as attribute CARE PLAN AGREED DATE.

CLINICAL EXAMINATION FINDINGS (BREAST CANCER) is the same as attribute CLINICAL EXAMINATION FINDINGS.

CONSULTANT CODE (PATHOLOGIST) is the same as data element CONSULTANT CODE.

Notes:

See Consultant Upgrade Date.

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

This is the ICD code of the condition giving rise to death as recorded on the death certificate.

DEATH CAUSE CODE (IMMEDIATE) is the same as attribute DEATH CAUSE CODE. It is the ICD code of the immediate cause of death as recorded on the death certificate.This is the ICD code of the immediate cause of death as recorded on the death certificate.

Notes:
DEATH CAUSE CODE (SIGNIFICANT) is the same as attribute DEATH CAUSE CODE. It is the ICD code of a significant condition not directly related to death as recorded on the death certificate.

This is the ICD code of a significant condition not directly related to death as recorded on the death certificate.

Notes:
DEATH CAUSE CODE (UNDERLYING) is the same as attribute DEATH CAUSE CODE. It is the ICD code of the underlying condition leading to death as recorded on the death certificate.

This is the ICD code of the underlying condition leading to death as recorded on the death certificate.

Notes:
DEATH CAUSE IDENTIFICATION METHOD is the same as attribute DEATH CAUSE IDENTIFICATION METHOD.

Notes:
DELIVERY PLACE CHANGE REASON is the same as attribute DELIVERY PLACE CHANGE REASON.

DELIVERY PLACE CHANGE REASON will replace DELIVERY PLACE CHANGE REASON CODE, which should be used for all new and developing data sets and for XML messages.

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:
DELIVERY PLACE CHANGE REASON CODE is the same as attribute DELIVERY PLACE CHANGE REASON.

DELIVERY PLACE CHANGE REASON CODE replaces DELIVERY PLACE CHANGE REASON and should be used for all new and developing data sets and for XML messages.

Notes:

References:
Department of Health: Monthly and Quarterly/Biannual Diagnostics statisticsDepartment of Health: Diagnostics website.

Notes:Notes:
This is the date that the PATIENT is first seen by the appropriate specialist for cancer care within a Cancer Care Spell. This is the PERSON or PERSONS who are most able to progress the diagnosis of the primary tumour. The date will be one of the following, whichever is the earlier ACTIVITY related to the Cancer Care Spell where the PATIENT saw an appropriate specialist for cancer care:

This date may be the same as DATE FIRST SEEN if the initial consultation was with an appropriate cancer specialist in the Trust that receives the first referral.

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. 

This is the PATIENT DIAGNOSIS for the cell type of the malignant disease recorded as part of a Cancer Care Spell.

Cancer Care Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 05 'Cancer Care Spell'.

INVASIVE LESION SIZE (RADIOLOGICAL DETERMINATION) is the same as attribute INVASIVE LESION SIZE.

This is the estimate of the size of the tumour from the image.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence of distant metastases where the TNM TYPE is 3. Metastasis component and the CANCER TNM STAGING TYPE is 1. Final pre-treatment stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence of distant metastases where the TNM TYPE is 3. Metastasis component and the CANCER TNM STAGING TYPE is 3. Integrated stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence of distant metastases where the TNM TYPE is 3. Metastasis component and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE together with the CANCER TNM EXTENDED STAGE which classifies the presence of metastatic deposits of the primary tumour at distant metastatic sites where the TNM TYPE is 3. Metastasis component and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:

For the National Cancer Waiting Times Monitoring Data Set, this is the DATE of the Multidisciplinary Team Meeting where a Cancer Care Plan (which was subsequently agreed with the PATIENT) was discussed.

Notes:

When used in the National Cancer Waiting Times Monitoring Data Set, this records whether the Cancer Care Plan (that was subsequently agreed with the PATIENT) was discussed at a Multidisciplinary Team Meeting. 

The MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR should be recorded as follows:

Y is recorded if the Cancer Care Plan was drawn up at a Multidisciplinary Team Meeting

N is recorded if the Cancer Care Plan was NOT discussed at a Multidisciplinary Team Meeting

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence and extent of regional lymph node metastases where the TNM TYPE is 2. Node component and the CANCER TNM STAGING TYPE is 1. Final pre-treatment stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence and extent of regional lymph node metastases where the TNM TYPE is 2. Node component and the CANCER TNM STAGING TYPE is 3. Integrated stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the absence or presence and extent of regional lymph node metastases where the TNM TYPE is 2. Node component and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

References:Notes:
National Joint Registry Dataset: v.1: 24th March 2003PATIENT PHYSICAL STATUS is the same as attribute PATIENT PHYSICAL STATUS.

Notes:
PATIENT TRIAL STATUS (CANCER) is the same as attribute PATIENT TRIAL STATUS.

If PATIENTS usually resident elsewhere are staying in hotels, hostels or other residential establishments for a short term, say a week, they should be recorded as staying at their usual place of residence. However if long term, such as at boarding school, the school address must be recorded. University students may nominate either their home address or the address of their university accommodation.

Where PATIENTS are not capable of supplying this information, because of age or mental illness, for example, then the person responsible for the PATIENT, such as a parent or guardian, should nominate the usual address.

PATIENTS not able to provide an address should be asked for their most recent address. If this cannot be established, record the address as `No fixed abode' or 'Address unknown'. These PATIENTS are regarded as resident in the local geographical district for commissioning purposes.

For birth episodes this should refer to the mother's usual place of residence.

The format of 5 lines of an35 conforms to ADDRESS FORMAT TYPE 'Unstructured Format'. The format refers to the physical layout of the address, not the logical layout, and does not require intelligent intervention when splitting the text string into lines. For example:

The patient's name and address should be withheld from any commissioning record which contains a valid NHS NUMBER.The PATIENT's name and address should be withheld from any commissioning record which contains a valid NHS NUMBER.

PERFORMANCE STATUS (ADULT) is the same as class PERFORMANCE STATUS CODE.

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:
PERSON DEATH TIME is the same as attribute PERSON DEATH TIME.

References:
The e-GIF version approved for use in NHS England is:
Government Data Standards Catalogue: (GDSC), Version 2.0, Agreed 1 January 2002.
GDSC: http://www.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards.aspx.

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:
PRESCRIPTION DATE is the same as attribute PRESCRIPTION DATE.

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:
PRIORITY TYPE CODES can be defined more precisely if this is needed for local purposes, as long as the classifications can be mapped back to the National Codes.

PRIORITY TYPE CODE replaces PRIORITY TYPE and should be used for all new and developing data sets and for XML messages.

This is a CLINICAL CLASSIFICATION CODE.

See OPCS Classification of Interventions and Procedures for Classification of Surgical Operations and Procedures (OPCS-4) and Read Coded Clinical Terms.

Record any operative procedures carried out, such as an endoscopy or electro-convulsive therapy (ECT), as part of the current consultant episode.

Clinical Terms (The Read Codes) (an7) may be used as an optional addition to OPCS-4.

Where a procedure is carried out and required for reporting using the OPCS-4 classification every effort must be made to report the appropriate OPCS-4 code in the Out-Patient Attendance Commissioning Data Set.

Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.

The default codes 'X998' and 'X999' and their descriptions have been retired as at 1st July 2010.The default codes 'X998' and 'X999' and their descriptions have been retired as at 1st October 2010. Although these bespoke Data Set default codes do not currently exist in the OPCS Classification of Interventions and Procedures, it has been agreed that these codes will never be assigned within the OPCS Classification so as to avoid any confusion in the future.

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:
See DIAGNOSTIC CODING for details on coding and PROVISIONAL DIAGNOSIS for the standardised definition of PROVISIONAL DIAGNOSIS.

Notes:
This is the ORGANISATION CODE of the ORGANISATION from which the referral is made, such as GP Practice or NHS Trust.REFERRING ORGANISATION CODE is the ORGANISATION CODE of the ORGANISATION from which the referral is made, such as a GP Practice or NHS Trust. This information is essential for managing service agreements which are based on patterns of referral.

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.

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

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:
SERVICE REQUEST DATE is the same as attribute SERVICE REQUEST DATE.

The date on which the referral was made, as recorded on the REFERRAL REQUEST.

This item is being used for development purposes. Codes "4" and "Z" have not yet been assured by the Information Standards Board for Health and Social Care.  

Notes:
SEXUAL ORIENTATION (CURRENT) is the same as attribute SEXUAL ORIENTATION CODE.

The current SEXUAL ORIENTATION of a PERSON.

For the purposes of the Genitourinary Medicine Clinic Activity Data Set, there is no requirement to report National Codes 4 'PERSON asked and does not know or is not sure' and 'Z Not Stated (PERSON asked but declined to provide a response)'.  National Codes 4 and Z should be mapped to '9 Unknown' for central reporting purposes.

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

The ORGANISATION SITE CODE of the ORGANISATION SITE of the ORGANISATION at which the brachytherapy took place.

Notes:
SITE CODE (OF CANCER DRUG TREATMENT) is the same as attribute ORGANISATION SITE CODE.

The ORGANISATION SITE CODE of the ORGANISATION SITE of the ORGANISATION at which the Drug Treatment took place.

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

The ORGANISATION SITE CODE of the ORGANISATION SITE of the ORGANISATION at which the imaging took place.

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

The ORGANISATION SITE CODE of the ORGANISATION SITE of the ORGANISATION at which the surgery took place.

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

The ORGANISATION SITE CODE of the ORGANISATION SITE of the ORGANISATION at which the teletherapy took place.

Notes:
SITE CODE (OF TREATMENT) is the ORGANISATION SITE CODE for the ORGANISATION SITE where the PATIENT was treated.

Note that the SITE CODE (OF TREATMENT) should always identify an ORGANISATION SITE where ACTIVITY managed by the treating ORGANISATION takes place, i.e. it should enable the treating ORGANISATION to be identified.

This identifies the site within the ORGANISATION on which the PATIENT was treated, since facilities may vary on different hospital sites. The code recorded should always be the national code; if the treatment is sub-commissioned to another provider, the site code used should be that of the provider actually carrying out the work.

Each ORGANISATION has a unique ORGANISATION CODE. However, where an ORGANISATION has more than one site from which it provides services then each site is uniquely identified. These sites are ORGANISATION SITES and are uniquely identified by ORGANISATION SITE CODE. The ORGANISATION SITE CODE contains the first 3 digits of the ORGANISATION CODE with the last two digits being the site identifier.

Example:

Where treatment for an NHS PATIENT is sub-commissioned to an independent UK provider the appropriate ORGANISATION SITE CODE should be used. Where treatment is sub-commissioned to an overseas provider the default code 89997 is applicable.

For out-patients, ACTIVITY may take place outside the hospital, such as in the PATIENT's home; in such cases, raising a site code is impractical. LOCATION CLASS is used in the Commissioning Data Set (CDS) message to indicate the classification of the physical LOCATION within which the ACTIVITY occurred.

Use in the Future Outpatient CDS:
If the INTENDED SITE CODE (OF TREATMENT) is not known, this data element should be omitted.

Notes:
STAGING CERTAINTY FACTOR (M CATEGORY) is the same as attribute STAGING CERTAINTY FACTOR where the TNM TYPE is National Code 3. 'Metastasis component'.

Notes:
STAGING CERTAINTY FACTOR (N CATEGORY) is the same as attribute STAGING CERTAINTY FACTOR where the TNM TYPE is classification 2. 'Node component'.

Notes:
STAGING CERTAINTY FACTOR (T CATEGORY) is the same as attribute STAGING CERTAINTY FACTOR where the TNM TYPE is National Code 1. 'Tumour component'.

Notes:
STAGING CERTAINTY FACTOR (TNM CATEGORY) is the same as attribute STAGING CERTAINTY FACTOR where the TNM TYPE is National Code 4. 'Overall TNM stage'.

Notes:
STATUS OF PERSON CONDUCTING DELIVERY is the same as the attribute STATUS OF PERSON CONDUCTING DELIVERY.

STATUS OF PERSON CONDUCTING DELIVERY will be replaced with STATUS OF PERSON CONDUCTING DELIVERY CODE, which should be used for all new and developing data sets and for XML messages.

Notes:
The SURGICAL URGENCY for each of the recorded operative PROCEDURE (OPCS). An operative Patient Procedure is identified by the OPERATIVE PROCEDURE INDICATOR Y 'yes'.

Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.

This is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1.
Notes:
T CATEGORY (FINAL PRETREATMENT) is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1. Tumour component and the CANCER TNM STAGING TYPE is 1. Final pre-treatment stage.

UICC (Union Internationale Contre Cancer) coding is used.

This is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1.
Notes:
T CATEGORY (INTEGRATED STAGE) is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1. Tumour component and the CANCER TNM STAGING TYPE is 3. Integrated stage.

UICC (Union Internationale Contre Cancer) coding is used.

This is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1.
Notes:
T CATEGORY (PATHOLOGICAL) is the CLINICAL CLASSIFICATION CODE which classifies the size and extent of the primary tumour where the TNM TYPE is 1. Tumour component and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE together with the CANCER TNM EXTENDED STAGE which classifies the extent of the invasion of the tumour where the TNM TYPE is 1.T CATEGORY EXTENDED (PATHOLOGICAL) is the CLINICAL CLASSIFICATION CODE together with the CANCER TNM EXTENDED STAGE which classifies the extent of the invasion of the tumour where the TNM TYPE is 1. Tumour component and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the combination of tumour, node and metastases into stage groupings where the TNM TYPE is 4. Overall TNM stage and the CANCER TNM STAGING TYPE is 1. Final pre-treatment stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the combination of tumour, node and metastases into stage groupings where the TNM TYPE is 4. Overall TNM stage and the CANCER TNM STAGING TYPE is 3. Integrated stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the CLINICAL CLASSIFICATION CODE which classifies the combination of tumour, node and metastases into stage groupings where the TNM TYPE is 4. Overall TNM stage and the CANCER TNM STAGING TYPE is 2. Pathological stage.

UICC (Union Internationale Contre Cancer) coding is used.

Notes:
This is the same as attribute TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE.TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE is the same as attribute TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE.

Notes:

This records the number of days that should be removed from the derived waiting time between CANCER TREATMENT PERIOD START DATE and TREATMENT START DATE (CANCER).

The recording of this data item is mandatory for all tumours, regardless of whether a national service standard is in place.

Adjustments are allowed in the following circumstances:

• When a patient pause is initiated because the PATIENT is unavailable for treatment for a specified period because of family commitments, holidays, or other (non-clinical) reasons

- When a patient pause is initiated because the PATIENT is unavailable for treatment for a specified period because of family commitments, holidays, or other (non-clinical) reasonsWAITING TIME ADJUSTMENT (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).

WAITING TIME ADJUSTMENT (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). 

Guidance on calculating the number of days which may be removed from the waiting time is available in Department of Health guidance at Cancer Waiting Times Documentation and Links.

Notes:
WAITING TIME ADJUSTMENT REASON (DECISION TO TREAT) 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 REASON (DECISION TO TREAT)). 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.

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.

Notes:
WAITING TIME ADJUSTMENT REASON (FIRST SEEN) 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 (FIRST SEEN). 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.

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).