Genitourinary Medicine Access Monthly Monitoring Data Set OverviewGenitourinary Medicine Access Monthly Monitoring Data Set Overview

The About the NHS Data Model and Dictionary Version 3About the NHS Data Model and Dictionary Version 3

Following the issue of DSCN 07/2004 'Data Standards: Meta Model' the NHS Data Model and Dictionary has been changed to reflect and be based upon a more generic logical data model which will better support the strategic way forward. This NHS Data Model and Dictionary will be published as the NHS Data Model and Dictionary Version 3.

There has been extensive quality assurance of Version 3 including involvement of the Data Definition Group. All Version 3 contents have been cross mapped and checked to ensure consistency with the current Version 2 contents. With the completion of the final quality assurance, Version 3 is now ready for live publication and will completely supersede the current Version 2 on 1st May 2005.

Version 3 supports all the messages, data sets and central returns supported by Version 2 but the underlying structure has been genericised. No changes have been made to business definitions.

Version 3 introduces a new UML (Unified Modelling Language) Generic Model which is 'person based' rather than 'organisation based'. The model has been developed around generic 'care activity' for a patient at 'service point' facility or location with each event transaction being recorded. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP.Version 3 introduces a new UML (Unified Modelling Language) Generic Model which is 'PERSON' based rather than 'ORGANISATION' based. The model has been developed around generic 'CARE ACTIVITY' for a PATIENT at 'SERVICE POINT' facility or location with each event transaction being recorded. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail or approved definitions or value sets in Version 2 has been lost although some of the old class definitions will now be found in the new 'NHS Business Definitions'.

The NHS Data Dictionary Version 2 will be frozen and made available for archive information purposes only and will be watermarked accordingly. All future changes to NHS data standards and the supporting DSCNs will be made or be consistent only with Version 3.

Summary of main changes and enhancements incorporated within Version 3

• Introduction of the capability of holding Retired Items
• Introduction of NHS Business Definitions, which allow specific business areas to be defined in a more flexible manner
• New ‘All Items Index’ which lists all the contents held within the NHS Data Model and Dictionary
• Reduction in the number of data model diagrams making them more comprehensible
• Introduction of Domains, which are conceptual logical modelling objects which identify the logical format, length and value set attributable to one or more attribute/s• Introduction of Domains, which are conceptual logical modelling objects which identify the logical format, length and value set attributable to one or more attribute(s)
• Where Used list expanded to include a description of usage column
• Creation of a separate Meta Model area within the publication

The introduction of Version 3 has no impact on current data standards or system suppliers.

About the Generic Model

We have been working on supporting the principles of RoWBI (Review of Waiting and Booking Information), the emerging Secondary Uses Service (SUS), the national data warehouse and the migration of the CDS messages.We have been working on supporting the principles of RoWBI (Review of Waiting and Booking Information), the emerging Secondary Uses Service (SUS), the national data warehouse and the migration of the Commissioning Data Set messages. This has included rationalising the existing data standards so that the NHS Data Model and Dictionary can support both the 'legacy' systems and data needs, as well as new and emerging systems and data needs.

It supports all the messages, data sets and central returns which the current model supports but the underlying structure has been genericised. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail has been lost and most of the old class definitions can be found in the new 'Business Definitions'. This has involved grouping many of the old classes into generic classes like ACTIVITY GROUP. However, none of the detail has been lost and most of the old class definitions can be found in the new 'NHS Business Definitions'. The number of diagrams has been greatly reduced and they now describe coherent areas of the model which is a far more useful approach for data modellers.

This has led to the creation of a new UML (Unified Modelling Language) Generic Model which is 'person based' rather than 'organisation based'. The model has been developed around generic 'care activity' for a patient at 'service point' facility or location with each event transaction being recorded.This has led to the creation of a new UML (Unified Modelling Language) Generic Model which is 'PERSON' based rather than 'ORGANISATION' based. The model has been developed around generic 'CARE ACTIVITY' for a PATIENT at 'SERVICE POINT' facility or location with each event transaction being recorded.

The Model will form the underpinning common structure which can be used by all future data sets related to patients and care activity, whether they be 'administrative', 'clinical', 'management' etc. The data elements specified within the model and within attached data set modules will form the basis for XML message exchanges.The Model will form the underpinning common structure which can be used by all future data sets related to patients and CARE ACTIVITY, whether they be 'administrative', 'clinical', 'management' etc. The data elements specified within the model and within attached data set modules will form the basis for XML message exchanges.

The model is aimed at enabling all 'care activities' related to the same condition for the same patient to be recorded and linked across organisations. The different states of the same 'care activity' are recorded as event transactions e.g. requested, intended, scheduled, provided, cancelled, etc. These different state events also drive the scheduling and capacity planning of resources (people, equipment, facilities, etc.) to deliver the care.

Contact us for more information: For more information contact the NHS Data Model and Dictionary ServiceContact us for more information: datastandards@nhs.net.

The Accident and Emergency Commissioning Data Set identified the need for a national set of codes to to be used in Accident And Emergency Departments  to reflect ACTIVITY relating to Diagnosis, Investigation and Treatment. These are presented in the following tables:

Accident and Emergency Diagnosis TablesThese are presented in the following tables:

Accident and Emergency Investigation Table

Accident and Emergency Treatment Tables

• Accident and Emergency Diagnosis Tables
• Accident and Emergency Investigation Table
• Accident and Emergency Treatment Tables

ACCIDENT AND EMERGENCY CLINICAL CODES

1. Accident and Emergency Diagnosis

   A broad classification of types of diagnoses which may be made as a result of Accident And Emergency Attendance. The full description is made up of codes from three tables - ACCIDENT AND EMERGENCY DIAGNOSIS, Accident And Emergency Attendance: ANATOMICAL AREAS and Accident And Emergency Attendance: ANATOMICAL SIDE. ANATOMICAL AREA (a classification of parts of the human body) and ANATOMICAL SIDE (an indication of the side of the human body) together give the Anatomical Site of clinical problems presented at an Accident And Emergency Attendance.

   
   
   • A broad classification of types of diagnoses which may be made as a result of Accident And Emergency Attendance. The full description is made up of codes from three tables - ACCIDENT AND EMERGENCY DIAGNOSIS, Accident And Emergency Attendance: ANATOMICAL AREAS and Accident And Emergency Attendance: ANATOMICAL SIDE. ANATOMICAL AREA (a classification of parts of the human body) and ANATOMICAL SIDE (an indication of the side of the human body) together give the Anatomical Site of clinical problems presented at an Accident And Emergency Attendance.
   • 
     

   • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

   • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
   • ACCIDENT AND EMERGENCY DIAGNOSIS is a six character code, comprising:

     Diagnosis Condition	n2
     Sub-Analysis	n1
     Accident And Emergency Attendance - ANATOMICAL AREA	n2
     Accident And Emergency Attendance - ANATOMICAL SIDE	an1

     Accident and Emergency Diagnosis - Diagnosis Condition

     Diagnosis Condition	Code
     Laceration	01
     Contusion/abrasion*	02
     Soft tissue inflammation	03
     Head injury*	04
     Dislocation/fracture/joint injury/amputation*	05
     Sprain/ligament injury	06
     Muscle/tendon injury	07
     Nerve injury	08
     Vascular injury	09
     Burns and scalds*	10
     Electric shock	11
     Foreign body	12
     Bites/stings	13
     Poisoning* (including overdose)	14
     Near drowning	15
     Visceral injury	16
     Infectious disease*	17
     Local infection	18
     Septicaemia	19
     Cardiac conditions*	20
     Cerebro-vascular conditions	21
     Other vascular conditions	22
     Haematological conditions	23
     Central Nervous System conditions* (excluding strokes)	24
     Respiratory conditions*	25
     Gastrointestinal conditions*	26
     Urological conditions (including cystitis)	27
     Obstetric conditions	28
     Gynaecological conditions	29
     Diabetes and other endocrinological conditions*	30
     Dermatological conditions	31
     Allergy (including anaphylaxis)	32
     Facio-maxillary conditions	33
     ENT conditions	34
     Psychiatric conditions	35
     Ophthalmological conditions	36
     Social problem (includes chronic alcoholism and homelessness)	37
     Diagnosis not classifiable	38
     Nothing abnormal detected	39

     *Item sub-analysed

     Accident and Emergency Diagnosis - Sub-analysis

     Sub-analysis		Code
     Contusion/abrasion	- contusion - abrasion	1 2
     Head Injury	- concussion - other head injury	1 2
     Dislocation/fracture/joint injury/amputation	- dislocation - open fracture - closed fracture - joint injury - amputation	1 2 3 4 5
     Burns and scalds	- electric - thermal - chemical - radiation	1 2 3 4
     Poisoning	- prescriptive drugs - proprietary drugs - controlled drugs - other, including alcohol	1 2 3 4
     Infectious disease	- notifiable disease - non-notifiable disease	1 2
     Cardiac conditions	- myocardial ischaemia & infarction - other non-ischaemia	1 2
     Respiratory conditions	- bronchial asthma - other non-asthma	1 2
     Central Nervous System conditions	- epilepsy - other non-epilepsy	1 2
     Gastrointestinal conditions	- haemorrhage - acute abdominal pain - other	1 2 3
     Diabetes and other endocrinological conditions	- diabetic - other non-diabetic	1 2

     Anatomical Site

     Accident And Emergency Anatomical Area - Area

     Anatomical Area	Code
     Head and Neck
     Brain	01
     Head	02
     Face	03
     Eye	04
     Ear	05
     Nose	06
     Mouth, Jaw, Teeth	07
     Throat	08
     Neck	09
     Upper Limb
     Shoulder	10
     Axilla	11
     Upper Arm	12
     Elbow	13
     Forearm	14
     Wrist	15
     Hand	16
     Digit	17
     Trunk
     Cervical spine	18
     Thoracic	19
     Lumbosacral spine	20
     Pelvis	21
     Chest	22
     Breast	23
     Abdomen	24
     Back/buttocks	25
     Ano/rectal	26
     Genitalia	27
     Lower Limb
     Hip	28
     Groin	29
     Thigh	30
     Knee	31
     Lower leg	32
     Ankle	33
     Foot	34
     Toe	35
     Multiple Site	36
     Accident and Emergency Anatomical Side
     Left	L
     Right	R
     Bilateral	B
     Not applicable	8

ACCIDENT AND EMERGENCY CLINICAL CODES

1. Accident and Emergency Investigation

   
   
   • A broad classification of types of investigation which may be requested to assist with diagnosis as a result of Accident And Emergency Attendance.
   • 
     
   • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.
   • 
     
   • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
   • 
     
   • ACCIDENT AND EMERGENCY INVESTIGATION is a six character code, comprising:

   Investigation	n2 (see Table below)
   Local sub-Analysis	up to an4

   A broad classification of types of investigation which may be requested to assist with diagnosis as a result of Accident And Emergency Attendance.Accident And Emergency Investigation Table

2. Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

3. It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

4. ACCIDENT AND EMERGENCY INVESTIGATION is a six character code, comprising:

   Investigation	n2 (see Table below)
   Local sub-Analysis	up to an4

   Accident And Emergency Investigation Table

   Investigation	Code
   X-ray plain film	01
   Electrocardiogram	02
   Haematology	03
   Cross match blood/group and save serum for later cross match	04
   Biochemistry	05
   Urinalysis	06
   Bacteriology	07
   Histology	08
   Computerised Tomography - Retired 2006-04-01	09
   Ultrasound	10
   Magnetic Resonance Imaging	11
   Computerised Tomography (excludes genitourinary contrast examination/tomography)	12
   Genitourinary contrast examination/tomography	13
   Clotting studies	14
   Immunology	15
   Cardiac enzymes	16
   Arterial/capillary blood gas	17
   Toxicology	18
   Blood culture	19
   Serology	20
   Pregnancy test	21
   Dental investigation	22
   Refraction, orthoptic tests and computerised visual fields	23
   None	24
   Other	99

   Items expected to be sub-analysed at discretion of individual Accident And Emergency Departments.

Items expected to be sub-analysed at discretion of individual Accident And Emergency Departments.

ACCIDENT AND EMERGENCY CLINICAL CODES

1. Accident and Emergency Treatment

   
   
   • A broad classification of types of treatment or guidance which may be provided to a PATIENT as a result of Accident And Emergency Attendance.
   • 
     
   • Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.
   • 
     
   • It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.
   • 
     
   • ACCIDENT AND EMERGENCY TREATMENT is a six character code, comprising:

   Condition	n2 (see Treatment Table below)
   Sub-Analysis	n1 (see Sub-analysis Table below)
   Local use	up to an3

   A broad classification of types of treatment or guidance which may be provided to a PATIENT as a result of Accident And Emergency Attendance.Accident and Emergency Treatment - Treatment

2. Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.

3. It is recommended that computerised systems provide a minimum of six character fields for each category in order to accommodate more detailed information if necessary. Where fewer than six characters are required for coding, such as for investigations and treatments, it is recommended that the codes are left-justified and the unused fields left blank.

4. ACCIDENT AND EMERGENCY TREATMENT is a six character code, comprising:

   Condition	n2 (see Treatment Table below)
   Sub-Analysis	n1 (see Sub-analysis Table below)
   Local use	up to an3

   Accident and Emergency Treatment - Treatment

   Treatment	Code
   Dressing*	01
   Bandage/support	02
   Sutures*	03
   Wound closure (excluding sutures)*	04
   Plaster of Paris*	05
   Splint	06
   Prescription - Retired 2006-04-01	07
   Removal foreign body	08
   Physiotherapy*	09
   Manipulation*	10
   Incision & drainage	11
   Intravenous cannula	12
   Central line	13
   Lavage/emesis/charcoal/eye irrigation	14
   Intubation & Endotracheal tubes/laryngeal mask airways/rapid sequence induction	15
   Chest drain	16
   Urinary catheter/suprapubic	17
   Defibrillation/pacing*	18
   Resuscitation/cardiopulmonary resuscitation	19
   Minor surgery	20
   Observation/electrocardiogram, pulse oximetry/head injury/trends	21
   Guidance/advice only*	22
   Anaesthesia*	23
   Tetanus*	24
   Nebuliser/spacer	25
   Parenteral thrombolysis*	28
   Other Parenteral drugs*	29
   Recording vital signs	30
   Burns review	31
   Recall/x-ray review	32
   Fracture review	33
   Wound cleaning	34
   Dressing/wound review	35
   Sling/collar cuff/broad arm sling	36
   Epistaxis control	37
   Nasal airway	38
   Oral airway	39
   Supplemental oxygen	40
   Continuous positive airways pressure/nasal intermittent positive pressure ventilation/bag valve mask	41
   Arterial line	42
   Infusion fluids	43
   Blood product transfusion	44
   Pericardiocentesis	45
   Lumbar puncture	46
   Joint aspiration	47
   Minor plastic procedure/split skin graft	48
   Active rewarming of the hypothermic patient	49
   Cooling - control body temperature	50
   Medication administered*	51
   Occupational Therapy*	52
   Loan of walking aid (crutches)	53
   Social work intervention	54
   Eye*	55
   Dental treatment	56
   Prescription\medicines prepared to take away	57
   Other (consider alternatives)	27
   None (consider guidance/advice option)	99

   Items sub-analysed in Table below

   Accident and Emergency Treatment - Sub-analysis

   Sub-analysis Treatment		Code
   Dressing	- dressing minor wound/burn/eye - dressing major wound/burn	1 2
   Sutures	- primary sutures - secondary/complex suture - removal of sutures/clips	1 2 3
   Wound closure (excluding sutures)	- steristrips - wound glue - other (e.g. clips)	1 2 3
   Plaster of Paris	- application Plaster of Paris - removal Plaster of Paris	1 2
   Physiotherapy	-strapping, ultra sound treatment, short wave diathermy, manipulation - gait re-education, falls prevention	1 2
   Manipulation	- manipulation of upper limb fracture - manipulation of lower limb fracture - manipulation of dislocation	1 2 3
   Defibrillation/pacing	- defibrillation - external pacing	1 2
   Guidance/advice only	- written - verbal	1 2
   Anaesthesia	- general anaesthetic - local anaesthetic - regional block - entonox - sedation - other	1 2 3 4 5 6
   Tetanus	- immune - tetanus toxoid course - tetanus toxoid booster - human immunoglobulin - combined tetanus/diphtheria course - combined tetanus/diphtheria booster	1 2 3 4 5 6
   Parenteral thrombolysis	- streptokinase parenteral thrombolysis - recombinant - plasminogen activator	1 2
   Other Parenteral drugs	- intravenous drug, e.g. stat/bolus - intravenous infusion	1 2
   Medication administered	- oral - intra-muscular - subcutaneous - per rectum - sublingual - intra-nasal - eye drops - ear drops - topical skin cream	1 2 3 4 5 6 7 8 9
   Occupational Therapy	- OT functional assessment - OT activities of daily living equipment provision	1 2
   Eye	- orthoptic exercises - laser of retina/iris or posterior capsule - retrobulbar injection - epilation of lashes - subconjunctival injection	1 2 3 4 5

Items sub-analysed in Table below

Accident and Emergency Treatment - Sub-analysis

Introduction

Administrative data sets are exchanged between Health Care Providers or between DEPARTMENTS or CARE PROFESSIONAL TEAMS in Health Care Providers.

Introduction

• 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)

Note: access to this address requires a Unify2 account and password. Any queries about the site can be addressed to the Unify2 helpdesk by emailing STEIS-Helpdesk@dh.gsi.gov.uk or calling 0113 254 5278

Introduction and Overview

The Department of Health uses the information gathered from Central Return Forms to monitor service provision at a high level and to support trend analysis for health service activity and health needs assessment.The Department of Health uses the information gathered from Central Returns to monitor service provision at a high level and to support trend analysis for health service activity and health needs assessment. In addition, the returns support the monitoring of progress in the achievement of overall objectives for the NHS and contribute towards the development of policy and the process of funding allocation.

Each Central Return Form contained within this publication has an image of the Central Return Form itself and provides guidance on its content and completion. The guidance also describes how data items held in the NHS Data Model and Dictionary are used to derive the information required for Central Return Forms.Each Central Return contained within this publication has an image of the Central Return form itself and provides guidance on its content and completion. The guidance also describes how data items held in the NHS Data Dictionary are used to derive the information required for Central Returns. Physical definitions of data items, such as the code values, are included.

Important Notes

1. Some of the Central Return Forms covered in this publication are under review. Changes arising from these reviews are not covered in this publication as they were not available in time for publishing. Users should therefore use this publication in conjunction with relevant change notifications as they are published. These were issued as Data Set Change Notices (DSCNs) at time of writing, but the Information Standards Board for Health and Social Care may use a different notification system.

2. Not all mandated Central Return Forms are contained within this publication. For those returns not yet covered, please consult the Notes for Completion provided with the form for detailed information requirements.

• International Classification of Diseases (ICD-10)
• Read Coded Clinical Terms
• OPCS Classification of Interventions and Procedures

• Accident and Emergency Coding Tables
• Accident and Emergency Diagnosis Tables
• Accident and Emergency Investigation Table
• Accident and Emergency Treatment Tables
• International Classification of Diseases (ICD-10)
• Read Coded Clinical Terms
• OPCS Classification of Interventions and Procedures
• 
  
  

A period of time within a Hospital Provider Spell during which a PATIENT receives care in a designated critical care bed.

Excluded from this is care provided to neonates, which is recorded elsewhere. Outreach activity and resuscitation conducted outside designated critical care areas should not be recorded as a Critical Care Period. Also excluded from this is care provided on general wards (except as an occasional non-standard location), A&E, Radiology Departments, labour wards and special care baby units.

A new Critical Care Period starts when the PATIENT is admitted to a critical care location regardless of CRITICAL CARE LEVEL. Repeated admissions to the same unit, transfers to a different critical care location and transfers from a non-standard location to a critical care unit within the same Hospital Provider Spell trigger a new Critical Care Period. A change of Consultant Episode (Hospital Provider) or brief transfers for investigation or treatment do not end the Critical Care Period.

A Critical Care Period ends when the PATIENT is discharged from the critical care location or dies.

Critical care locations are described by CRITICAL CARE UNIT FUNCTION and UNIT BED CONFIGURATION. Critical Care beds may include occasional non-standard locations using a ward area or operating department when conventional critical care beds are not available. Non standard locations may only be recorded if the CRITICAL CARE LEVEL is National Code 02 'Level 2' or 03 'Level 3' and the delivery of care is greater than four hours.

The type of ORGAN SYSTEM SUPPORTED is recorded and the duration of each organ system support is calculated from the ACTIVITY PROPERTY EFFECTIVE DATE and the ACTIVITY PROPERTY END DATE. The ORGAN SUPPORT MAXIMUM is the maximum number of different ORGAN SYSTEMS SUPPORTED on any one day in the Critical Care Period. Each organ system can only be counted once on any calendar day. Both basic and advanced categories cannot be counted at the same time. The range of values for ORGAN SUPPORT MAXIMUM is from 0 to 7.

CRITICAL CARE DISCHARGE READY DATE and CRITICAL CARE DISCHARGE READY TIME are recorded to identify and quantify significant problems in discharging patients from critical care units.

A subset of the BAD_REFERENCE is used to derive Adult Critical Care HRGs.A subset of the Critical Care Minimum Data Set is used to derive Adult Critical Care HRGs. The subset is sent in the following Commissioning Data Set messages:
ADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODEADMITTED PATIENT CARE CDS TYPE - BIRTH EPISODE
ADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODEADMITTED PATIENT CARE CDS TYPE - DELIVERY EPISODE
ADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODEADMITTED PATIENT CARE CDS TYPE - GENERAL EPISODE

A Critical Care Period does not include the following:
a. Surgical and anaesthetic intra-operative care
b. Post-operative care within an operating department except where level 2 or level 3 care are provided for more than 4 hours
c. Cardiac (coronary) Care
d. Imaging procedures
e. Endoscopy procedures

Information recorded for a Critical Care Period includes:

DEFAULT CODES SUMMARY

Default (or pseudo) codes may be used:

• to indicate an ORGANISATION TYPE, such as Commissioner Code for Ministry of Defence (MoD) Healthcare;
• to indicate that the code value is not known;
• to indicate that a code cannot be supplied (e.g. no referring doctor or dentist).

DEFINITIONS INTRODUCTION

All the classes that appear within the NHS data standards logical data model. Each class contains its nationally agreed definition, all of its attributes and all the relationships it has with other classes.

Attribute Definitions

All the attributes of the classes that appear within the NHS data standards logical data model. Each attribute contains its nationally agreed definition which may also include its agreed National Codes or classifications and a clickable 'data' tab, if a data element also exists for it.

Data Elements

Data elements which may be supported by an attribute definition i.e. the data element has the same name as an attribute, be a derived item which is derivable from attributes or only exists as a data element.

Where a data element is supported by an attribute definition, such as the national codes to be used in that data element exist in an attribute, then there will be a link to that attribute through a 'definition' tab.

Data elements are used in the completion of Datasets, CDS, Hospital Episode Statistics and Central Returns. The data element information comprises format and field length, Hospital Episode Statistics name if applicable, National Codes or classifications and useful notes clarifying the selected data element.

NHS Business Definitions

These contain the business rules for recording NHS activity and will be of particular relevance to NHS Information Professionals.

The data set provides definitions to support the national census on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment. This is a census reporting the diagnostic test waiting times.

The data set provides definitions to support the national data collections on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment.The Diagnostics Waiting Times Census Data Set provides definitions to support the national data collections on DIAGNOSTIC TESTS, a key element towards monitoring waits from referral to treatment. This is a census of DIAGNOSTIC TEST waiting times.

This data set is for the census covering 4 main areas of DIAGNOSTIC TESTS as below:

Part 1 - Endoscopy

Part 2 - Imaging

Part 3 - Pathology

Parts 4 to 11 - Physiological Measurement

Patient level information

How the data set is transmitted

Full guidance on Unify2 can be found at the following address:
Unify2 Guidance

Further guidance

Guidance on extracting the data sets, including OPCS Classification of Interventions and Procedures, can be found at:Guidance on extracting the data sets, including OPCS Classification of Interventions and Procedures, can be found at:
Department of Health - Monthly and Biannual Diagnostics statistics - Definitions

and

NHS 18 weeks - Guidance on Diagnostic Data Collections.NHS 18 weeks - Guidance on Diagnostic Data Collections.

Disclaimer

Copyright

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Every reasonable effort has been made to ensure that the information and data that is held on this web site is free from computer viruses or other contamination. However, it is recommended that content downloaded from this site, is additionally checked by your own anti-virus checking system prior to use.

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The Department of Health requires this dataset from NHS providers of specialised services, where the primary function of the specialist clinical multidisciplinary team is concerned with the provision of screening, diagnosis and management of sexually transmissible infections and related genital medical conditions.The Department of Health requires this data set from NHS providers of specialised services, where the primary function of the specialist clinical multidisciplinary team is concerned with the provision of screening, diagnosis and management of sexually transmissible infections and related genital medical conditions. In line with the national strategy for sexual health, Human Immunodeficiency Virus (HIV), genitourinary medicine services are represented as level three providers. This information is collected via the Genitourinary Medicine Access Monthly Monitoring Data Set. This information is collected via the Genitourinary Medicine Access Monthly Monitoring Data Set.

The Genitourinary Medicine Access Monthly Monitoring Data Set provides essential information for :-The Genitourinary Medicine Access Monthly Monitoring Data Set provides essential information for:

• monitoring the 48 hour access target
• assurance of validity and veracity of the achievement of the target
• support for local service modernisation, performance management and commissioning required to assure 48 hour access on an on-going basis

Collection and Submission of the Genitourinary Medicine Access Monthly Monitoring Data SetCollection and Submission of the Genitourinary Medicine Access Monthly Monitoring Data Set

• The Genitourinary Medicine Access Monthly Monitoring Data Set is a monthly provider based return.
• The Genitourinary Medicine Access Monthly Monitoring Data Set is a monthly provider based return.
• Provider returns must be submitted by the 18th (or next working day) for the previous calendar month. Commissioner returns are due by the 25th or nearest next working day.
• The data is submitted via Unify2, the Department of Health online data collection system. NHS providers enter their data onto Unify2 using an upload.
• The data is submitted via Unify2, the Department of Health online data collection system. NHS providers enter their data onto Unify2 using an upload.

1. REPORTING PERIOD, ORGANISATION CODE (CODE OF PROVIDER), ORGANISATION CODE (CODE OF COMMISSIONER) and SITE CODE (OF TREATMENT)
2. Attendances
3. First APPOINTMENTS Missed
4. First APPOINTMENTS offered within 2 days (excludes bank holidays & weekends)
5. PATIENTS reporting symptoms
6. FIRST ATTENDANCES seen after 2 days (excludes bank holidays & weekends)
7. Human immunodeficiency virus (HIV) clinic attendances
8. PATIENT perspective
9. PATIENTS registered but not seen

GLOSSARY OF TERMS

The Glossary lists commonly used terms in alphabetical order. These terms are not defined and therefore do not have a class or attribute. Each entry in the Glossary is shown with its related class and attribute where appropriate.

For example 'Booked Admission' is shown as relating to the class ELECTIVE ADMISSION LIST ENTRY. ELECTIVE ADMISSION LIST ENTRY has an attribute ELECTIVE ADMISSION TYPE and reference to the attribute definition will identify that 'Booked Admission' is one of the national code classifications of ELECTIVE ADMISSION TYPES.

The Health and Social Care Information Centre is an NHS Special Health Authority that collects, analyses and distributes national statistics on health and social care.

It also underpins regulation, health research, education and training. Health, social care, government and education bodies trust information from the Health and Social Care Information Centre, which is reliable, up-to-date, independent and trustworthy.

The Health and Social Care Information Centre collection systems make it quick and easy for frontline staff to provide data with minimum impact on the delivery of care.

NHS frontline management, clinicians, information and care professionals, policy makers, patients and the media rely on the Health and Social Care Information Centre for their information needs.

The Health and Social Care Information Centre is also referred to as the Information Centre for health and social care or the Information Centre (IC).

Further information on the Health and Social Care Information Centre can be found on their website.Further information on the Health and Social Care Information Centre can be found on their website.

The purpose of the Information Standards Board for Health and Social Care (ISB HaSC) is to provide assurance and approval that information standards, when implemented in the NHS and Social Care, are implementable, interoperable, fit for purpose (as described in the standard's scope and purpose) and safe.

Specifically, the role of the Information Standards Board for Health and Social Care is to:

• Approve standards based on the recommendations of independent Appraisal Panels, and decide on their approval status for implementation in the NHS and Social Care.
• Communicate details of its activities to the wider NHS, Social Care, system suppliers, and other partner organisations.
• Commission, manage, and respond to reviews of existing NHS and Social Care Information Standards and make recommendations on any action needed.
• With other parties, identify gaps and contribute to policy and strategy around information standards and make recommendations on the action needed.

For further information on the Information Standards Board for Health and Social Care, see the Information Standards Board for Health and Social Care website.For further information on the Information Standards Board for Health and Social Care, see the Information Standards Board for Health and Social Care website.

LOCATION TYPE CODES

1. The codes enable the classification of LOCATION TYPE. This is the type of physical location where PATIENTS are seen or where services are provided or from which requests for services are sent.



• The codes enable the classification of LOCATION TYPE. This is the type of physical location where PATIENTS are seen or where services are provided or from which requests for services are sent.
• 
  

• Each LOCATION must be classified by one, and only one, LOCATION TYPE, i.e. once a building (or department or unit within that building) has been allocated a specific LOCATION TYPE, that LOCATION TYPE should be used by all users regardless of the type of activity, specialty or client group involved. The LOCATION TYPE should only be altered if there is a complete change in use.

• Note that the term Professional Staff Group refers to health professional staff and covers Chiropody, Clinical Psychology, Dietetics, Occupational Therapy, Physiotherapy and Speech and Language Therapy.

• Please note that the following Central Return forms have been discontinued with effect from the 1st April 2004:
  KC56 - Patient Care in the Community: District Nursing
  KC57 - Patient Care in the Community: Community Psychiatric Nursing
  KC58 - Patient Care in the Community: Learning Disability Nursing

• Tables 1 to 3 gives the groupings used on the following Central Returns:

  KC56: Patient Care in the Community: District Nursing
  KC57: Patient Care in the Community: Community Psychiatric Nursing
  KC58: Patient Care in the Community: Learning Disability Nursing

• Note that the leading zero of Location Type Code should be omitted for use with the cdstab/CDS.

  Location Type Codes

  Code	Description
  001	Client's or Patient's Home
  002	Health Centre
  003	GP Practice premises other than Health Centre
  004	Ward on NHS Hospital Site
  006	Hospice
  007	Other Voluntary or Private Hospital or Nursing Home
  008	Group Home managed by the NHS
  009	Group Home managed by Local Authority
  010	Group Home managed by Voluntary or Private Agents
  011	Other Residential Care Homes managed by Local Authority
  012	Other Residential Care Homes managed by Voluntary or Private Agents
  013	NHS Day Care Facility on NHS Hospital Site
  014	NHS Day Care Facility on Other Sites
  015	Day Centre managed by Local Authority
  016	Day Centre managed by Voluntary or Private Agents
  017	NHS Consultant Clinic Premises on a NHS Hospital site
  018	NHS Consultant Clinic Premises off a NHS Hospital site
  019	Health Clinic managed by the NHS
  020	Health Clinic managed by Voluntary or Private Agents
  021	Resource Centre on NHS Hospital Site
  022	Resource Centre managed by the NHS off NHS Hospital Site
  023	Resource Centre managed by Local Authority
  024	Resource Centre managed by Voluntary or Private Agents
  025	Professional Staff Group Department on NHS Hospital Site
  026	Professional Staff Group Department managed by the NHS off NHS Hospital Site
  027	Professional Staff Group Department managed by Local Authority
  028	Professional Staff Group Department managed by Voluntary or Private Agents
  029	Educational Establishment Premises managed by Local Authority or Grant Maintained
  030	Educational Establishment Premises managed by Voluntary or Private Agents
  031	Other Health or Local Authority Facility on NHS Hospital Site
  032	Other Health or Local Authority Site managed by the NHS off NHS Hospital Site
  033	Other Health or Local Authority Site managed by Local Authority
  034	Other Health or Local Authority Site managed by Voluntary or Private Agents
  035	Prison Department Establishments
  036	Public Place or Street, or Police Station
  037	Other locations not classified elsewhere
  038	NHS Nursing Home
  039	Other Residential Care Homes managed by the NHS

TREATMENT FUNCTION, rather than the Royal College or Faculty specialty, is required on most activity returns and in the Commissioning Data Sets (CDS). It is based on specialty, but also includes approved sub-specialties and treatment specialties used by lead CARE PROFESSIONALS including hospital CONSULTANTS.

The appropriate TREATMENT FUNCTION CODE can be used by any lead CARE PROFESSIONAL eg Intermediate Care as the TREATMENT FUNCTION CODE for a Nursing Episode.

A full list of TREATMENT FUNCTION CODES (Table 2) follows the MAIN SPECIALTY CODES (Table 1).

MAIN SPECIALTY CODES are aligned with the specialties recognised in the European Specialist Medical Qualifications Order 1995 and European Primary and Specialist Dental Qualifications Regulations 1998. Pseudo codes should be used in Commissioning Data Set (CDS) messages for lead CARE PROFESSIONALS other than hospital CONSULTANTS eg Nursing Episode.

For further information, contact the NHS Data Model and Dictionary Service; see Contact Details.For further information, contact the NHS Data Model and Dictionary Service; see Contact Details.

Table 1 Main Specialty codes

MENTAL HEALTH ACT

The following table is effective from 3rd November 2008 onwards after the relevant section of the Mental Health Act 2007 comes into force, and sets out the relationship between Parts and Sections of the Mental Health Act 1983 (amended by the Crime (Sentences) Act 1997 and the Mental Health Act 2007), and specifies how the codes in Category of Patient, LEGAL STATUS CLASSIFICATION CODE, Status Of Patient Included in the Psychiatric Census and MENTAL HEALTH ACT 2007 MENTAL CATEGORY interrelate.

The underlying LEGAL STATUS CLASSIFICATION CODE of a Mental Health Care Spell will be carried through a period of Supervised Community Treatment although the LEGAL STATUS CLASSIFICATION will be suspended during that period.

The following table is effective prior to 3rd November 2008 when the relevant section of the Mental Health Act 2007 comes into force, and sets out the relationship between Parts and Sections of the Mental Health Act 1983 (amended by the Crime (Sentences) Act 1997), and specifies how the codes in Category of Patient, LEGAL STATUS CLASSIFICATION CODE, Status Of Patient Included in the Psychiatric Census and MENTAL CATEGORY interrelate.

Files Available

• Metadata files are used by the NHS to validate data. The files facilitate data consistency and quality. The files are:
  • Diagnosis (ICD-10)
  • OPCS Classification of Interventions and Procedures (OPCS-4)
  • NHS Postcode Directory
  • Frozen Postcode Directory
  • Country Pseudo Postcodes.
• Metadata files are used by the NHS to validate data. The files facilitate data consistency and quality. The files are:
  • Diagnosis (ICD-10)
  • OPCS Classification of Interventions and Procedures (OPCS-4)
  • NHS Postcode Directory
  • Frozen Postcode Directory
  • Country Pseudo Postcodes.

• The ICD-10 file is issued by NHS Connecting for Health, from whom a specification is available. It is intended to reissue this file in line with the ICD-10 updates.

• The Operation metadata file and specification is issued by the NHS Classifications Service of NHS Connecting for Health to support implementation of new releases; see Contact Details.

• The full and reduced versions of the NHS Postcode Directory are issued every quarter by the Organisation Data Service. Named recipients both inside the NHS and other recipients licensed to use this data in support of the NHS are able to access it through the online distribution service, TRUD (Terminology Reference Data Update Distribution Service) and through the Organisation Data Service pages on NHSnet; see Contact Details.

• A full description of the NHS Postcode Directory and the Organisation Data Service reduced postcode data files, can be found by browsing the Office for National Statistics Data section of the Organisation Data Service pages on NHSnet at http://nww.connectingforhealth.nhs.uk/ods/downloads/officenatstats/ (NHS Postcode Directory) and http://nww.connectingforhealth.nhs.uk/ods/downloads/postcode/ (reduced files). The same descriptions can also be accessed via TRUD (Terminology Reference Data Update Distribution Service). 

• The Operation metadata file and specification is issued by the NHS Classifications Service of NHS Connecting for Health to support implementation of new releases; see Contact Details.

• The full and reduced versions of the NHS Postcode Directory are issued every quarter by the Organisation Data Service. Named recipients both inside the NHS and other recipients licensed to use this data in support of the NHS are able to access it through the online distribution service, TRUD (Terminology Reference Data Update Distribution Service) and through the Organisation Data Service pages on NHSnet; see Contact Details.

• A full description of the NHS Postcode Directory and the Organisation Data Service reduced postcode data files, can be found by browsing the Office for National Statistics Data section of the Organisation Data Service pages on NHSnet at http://nww.connectingforhealth.nhs.uk/ods/downloads/officenatstats/ (NHS Postcode Directory) and http://nww.connectingforhealth.nhs.uk/ods/downloads/postcode/ (reduced files). The same descriptions can also be accessed via TRUD (Terminology Reference Data Update Distribution Service). 

• Any area within the NHS taking advantage of the supply of metadata by the Office for National Statistics will be expected to abide by any rules and conditions imposed by the Office for National Statistics Section supplying the metadata.

  Format of Metadata Files

• The following pages give the record layouts and data content for Country Pseudo Postcode metadata files.

Country Pseudo Postcode File Data Content

• This file contains about 130 records. The usual country of residence for short term overseas visitors is derived from the country pseudo postcode. The codes are  available in electronic format on the NHS Postcode Directory ("Gridlink version").

  For the Organisation Data Service contact details, see Contact Details.

• This file contains about 130 records. The usual country of residence for short term overseas visitors is derived from the country pseudo postcode. The codes are  available in electronic format on the NHS Postcode Directory ("Gridlink version").

  For the Organisation Data Service contact details, see Contact Details.

• The expanded area code field contains the country of birth code in characters 1-4 (a repeat of the characters 3-6 in the pseudo postcode). The remainder of the expanded area code is blank except for codes 993C (UK nos) and 993V (no fixed abode) where characters 5-7 are 9space9.

  COUNTRY PSEUDO FILE RECORD LAYOUT

  Start Pos	Size	Data Type	Field Description
  1	11	X	selection indicators
  12	6	X	6 digit postcode (POSTSIX)
  18	1	A	7th digit
  19	6	X	filler
  25	50	X	name of country
  75	5	X	filler
  80	19	X	area details
  99	154	X	filler

The National Direct Access Audiology Patient Tracking List Data Set collects performance information on a weekly basis, on the Referral To Treatment pathways of PATIENTS who are receiving NHS funded audiology treatment in England, who are not already included in the Referral to Treatment Summary Patient Tracking List Data Set.The National Direct Access Audiology Patient Tracking List Data Set collects performance information on a weekly basis, on the Referral To Treatment pathways of PATIENTS who are receiving NHS funded audiology treatment in England, who are not already included in the Referral to Treatment Summary Patient Tracking List Data Set. This includes:

• both analogue and digital hearing aid fittings
• services provided directly by NHS Healthcare Providers and also NHS funded PATIENTS treated via the Independent Sector and third sector providers (collected directly or via Primary Care Trusts)
• both new and existing PATIENTS
• any other PATIENTS attending Audiology services directly

For the purposes of the National Direct Access Audiology Patient Tracking List Data Set, "Direct Access" means PATIENTS who are not referred via Ear, Nose and Throat (ENT) or other hospital CONSULTANT.For the purposes of the National Direct Access Audiology Patient Tracking List Data Set, "Direct Access" means PATIENTS who are not referred via Ear, Nose and Throat (ENT) or other hospital CONSULTANT. Any pathways that are subject to the 18 weeks waiting time target for Referral to Treatment are out of scope. For this reason PATIENTS on Ear, Nose and Throat pathways (or pathways from other specialties) are excluded from this central return data set - information on these PATIENTS is available via the Referral To Treatment Summary Patient Tracking List Data Set data collection. For this reason PATIENTS on Ear, Nose and Throat pathways (or pathways from other specialties) are excluded from this central return data set - information on these PATIENTS is available via the Referral to Treatment Summary Patient Tracking List Data Set data collection.

The National Direct Access Audiology Patient Tracking List Data Set is in two parts, as follows:The National Direct Access Audiology Patient Tracking List Data Set is in two parts, as follows:

Parts 1A and 1B: Untreated Patients

Part 1A should be completed for PATIENTS who have not had an ACTIVITY which ends their REFERRAL TO TREATMENT PERIOD (such as first definitive treatment, or a decision not to treat)

AND

who do not have a future APPOINTMENT for an ACTIVITY with an anticipated REFERRAL TO TREATMENT PERIOD STATUS of 30 before the REFERRAL TO TREATMENT PERIOD EXCEEDS 18 WEEKS DATE.

Part 1B should be completed for PATIENTS who have not had an ACTIVITY which ends their REFERRAL TO TREATMENT PERIOD (such as first definitive treatment, or a decision not to treat)

AND

whose REFERRAL TO TREATMENT PERIOD EXCEEDS 18 WEEKS DATE has passed.

Part 2 should be completed for PATIENTS who have a REFERRAL TO TREATMENT PERIOD END DATE within the last 7 days

Full guidance on the completion and submission of the National Direct Access Audiology Waiting Times Data Set is available from the Department of Health website.Full guidance on the completion and submission of the National Direct Access Audiology Waiting Times Data Set is available from the Department of Health website.

The Department of Health document 'Improving Access to Audiology Service in England' can be found at the "Direct Access Audiology Waiting Times and PTL collections section" of the Department of Health website.

Navigating the NHS Data Model and Dictionary

The NHS Data Model and Dictionary has been developed as a web based publication, for presentation compatible with browsers upwards from Internet Explorer version 4.0 and Netscape Navigator version 4.0. The standard navigation buttons of both these browsers are active and work as normal.

Text which is displayed in blue indicates a clickable and active link.

Please note that for easy access to all of the contents of the NHS Data Model and Dictionary, we have created a new 'All Items Index', which lists alphabetically the whole contents of the dictionary.

In addition to the standard browser navigation buttons, certain screens will display with their own tabs. If these are used they will navigate you within the publication rather than the overall browser. For example, click on the relationships tab within a class window and this will display the relationship list for that class (if one is present). Click on the 'description' tab to navigate back to the class definition.

Recommended Screen Display Settings

If you use a 14 or 15 inch monitor the recommended display setting to view this web publication is 800 x 600. If you use a 17 monitor, or above, the recommended screen setting is 1024 x 768.

The NHS Data Dictionary and the NHS Data Manual were originally published separately. The elements of both these publications have been consolidated into one browsable integrated publication called the NHS Data Model and Dictionary.

NHS Data Standards

The NHS Data Model and Dictionary gives common definitions and guidance to support the sharing, exchange and comparison of information across the NHS. The common definitions, known as data standards, are used in commissioning and make up the base currency of Commissioning Data Sets. On the monitoring side, they support comparative data analysis, preparation of performance tables, and data returned to the Department of Health. NHS data standards also support clinical messages, such as those used for pathology and radiology. NHS data standards are presented as a logical data model, ensuring that the standards are consistent and integrated across all NHS business areas.

NHS data standards should not just be seen as supporting the collection of data on a consistent basis throughout the NHS. They also have an important role in supporting the flow and quality of information used in different parts of the NHS so that health care professionals are presented with the relevant information where and when it is required. An example of this is the linking of all records about a patient collected in different parts of the NHS, to be available to a health care professional wherever the patient attends to be seen for treatment, thus facilitating the Electronic Patient Record. Changes to NHS data standards are still being published as Data Set Change Notices at the time of publication. The Information Standards Board for Health and Social Care may eventually use a different form of change notification, but the principles of regulated changes will still apply.

See the Information Standards Board for Health and Social Care.

The NHS Data Model and Dictionary Elements

GUIDANCE ON NHS TRUST MERGERS AND THE CONCLUSION OF HOSPITAL PROVIDER SPELLS

Introduction

1. This guidance explains the circumstances under which Hospital Provider Spells should close and reopen as a result of a merger or demerger, in terms of NHS data standards. It specifies which codes should be used for those Hospital Provider Spells which must be closed and reopened,
   • for DISCHARGE DESTINATION etc, for the closing Hospital Provider Spell and
   • for SOURCE OF ADMISSION etc, for the new Hospital Provider Spell.

   Note that the NHS-wide Clearing Service (NWCS) has also issued Guidance Note NWCS/GN-003 which explains the use of NWCS Exchange Protocols when NHS Trusts merge.

When Hospital Provider Spells Should be Closed and Reopened

2. A Hospital Provider Spell is provided by one ORGANISATION acting as a Health Care Provider. This means that the spell is linked to the ORGANISATION CODE of the provider. If the ORGANISATION CODE changes, the spell must end and another begin with the new ORGANISATION CODE. If the spell does end, the Consultant Episode (Hospital Provider) within the spell must also end.

   The following scenarios explain what this means in terms of NHS Trust mergers or demergers. Note that these assume that nothing changes other than the fact that the NHS Trusts merge or demerge, e.g. the CONSULTANT stays the same, etc.

Mergers

Demergers

The Codes Used when Hospital Provider Spells are Closed and Reopened

3. If Hospital Provider Spells are to be closed and reopened only as a result of NHS Trust mergers or demergers, for most cases the codes below should be used.

The CLOSED Hospital Provider Spell

DISCHARGE DESTINATIONS

This depends on the type of WARD the PATIENT is in, but will be either:

51     NHS Hospital Provider - WARD for general PATIENTS or the younger physically disabled

52     NHS Hospital Provider - WARD for maternity PATIENTS or neonates

53     NHS Hospital Provider - WARD for PATIENTS who are mentally ill or have learning disabilities

DISCHARGE METHOD

1     PATIENT discharged on clinical advice or with clinical consent

The REOPENED Hospital Provider Spell

ADMISSION METHOD

81     Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency

Note that this ADMISSION METHOD is classed under "Other Admission". It is not elective and the PATIENT does therefore not have an entry on an Elective Admission List.

Again, this depends on the type of WARD the PATIENT is in, but will be either:

51     NHS Hospital Provider - WARD for general PATIENTS or the younger physically disabled or Accident And Emergency Department

52     NHS Hospital Provider - WARD for maternity PATIENTS or neonates

53     NHS Hospital Provider - WARD for PATIENTS who are mentally ill or have learning disabilities

REFERRER CODE

This will be the referrer to the Hospital Provider Spell within which the PATIENT was receiving care before the merger, i.e. the "original" Hospital Provider Spell.

Introduction

The OPCS Classification of Interventions and Procedures (OPCS-4) is a Fundamental Information Standard.The OPCS Classification of Interventions and Procedures (OPCS-4) is a Fundamental Information Standard.  The classification is used by Health Care Providers and Strategic Health Authorities.

 OPCS-4 is used to support operational and strategic planning, resource utilisation, performance management, reimbursement, research and epidemiology. OPCS-4 is used to support operational and strategic planning, resource utilisation, performance management, reimbursement, research and epidemiology.  It is used by NHS suppliers to build/update software to support NHS business functions and interoperability.

The OPCS-4 is subject to annual review and potential update to ensure that modern clinical practice is represented appropriately.The OPCS-4 is subject to annual review and potential update to ensure that modern clinical practice is represented appropriately.  This will be continued until further notice as shown below:

*Tables of Coding Equivalences are issued for mapping back to previous versions found at https://www.uktcregistration.nss.cfh.nhs.uk/trud/

The NHS Data Model and Dictionary contains a number of data collections that require OPCS-4 codes, such as Central Returns and Commissioning Data Sets.  All data collections should use the latest version of the  OPCS-4 classification as specified in the table above.The NHS Data Model and Dictionary contains a number of data collections that require OPCS-4 codes, such as Central Returns and Commissioning Data Sets.  All data collections should use the latest version of the  OPCS-4 classification as specified in the table above.

Background

The classification of Surgical Operations and Procedures was originally issued by the Office of Population Censuses and Surveys (OPCS). The 4th revision was first implemented in hospital information systems in 1987. This was subject to a significant number of amendments and a consolidated version was reproduced in 1990.

The OPCS Classification of Surgical Operations and Procedures (OPCS-4.2) was substantially enhanced to ensure that modern clinical practice was represented appropriately within the classification and a new version was implemented in 2006 titled OPCS Classification of Interventions and Procedures (OPCS-4.3) with a commitment to undertake annual review and potential update. The classification comprises a list of alphanumeric codes with mainly anatomically based chapters, most of which relate to the whole or part of a body system. Each chapter is designated alphabetically e.g. Chapter A covers the nervous system and Chapter K is assigned to the heart. The alphabetic character for each chapter forms the prefix of the 3 and 4 digit codes within it. The strict link between chapters and body systems with specific procedures being listed for individual organs was breached in OPCS-4.3 because of limited capacity.

There are instances where an existing category needs extension because all the available codes have been allocated. In such cases an extended category is created within the Tabular List chapter. These categories are referred to as principal category or extended category and identified by an accompanying note to ease navigation.

Chapters that have reached capacity are extended using alphanumeric categories which are assigned using the free alpha O. This has occurred within three chapters (Chapters L, W and Z). Codes created in this way still form part of an existing chapter even though they have a different alpha prefix to the rest of that chapter. Such new codes will, therefore, logically sit at the end of the body system chapter and are readily identified within the alphabetical index. There is an additional chapter (Chapter X) for operations on multiple systems using miscellaneous procedures.

The classification is published in two volumes. The Tabular List and Alphabetical Index are available from The Stationary office at www.tsoshop.co.uk

OPCS-4 Requests Portal

The OPCS-4 Requests Portal allows stakeholders to submit change requests to the NHS Classification Service all year round.The OPCS-4 Requests Portal allows stakeholders to submit change requests to the NHS Classification Service all year round. A cut-off date is necessary to support the annual review of requests and business case to proceed with an update to the classification.

More information about this classification and access to the OPCS-4 Requests Portal can be found at:
http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/44submissions

High Cost Drugs and Chemotherapy Regimens

The listings of High Cost Drugs and Chemotherapy Regimens which are mapped to OPCS-4 codes are provided as look-up tables downloadable either from:

• the NHS Classifications Service website
  http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/ or
• the Terminology Reference Data Update Distribution Service website (user registration required)
  https://www.uktcregistration.nss.cfh.nhs.uk/trud/

• Referenced Organisations:
• • Department of Health
  • Health and Social Care Information Centre
  • Health Protection Agency
  • Healthcare Commission
  • Information Standards Board for Health and Social Care
  • Organisation Data Service

Publication Version

Navigating the NHS Data Model and Dictionary

Link to DSCNs

NHS Data Model and Dictionary Elements

The NHS CDS Manual

Contact Details 

Disclaimer

Publication Feedback

CONTACT DETAILS

• General Enquiries about the NHS Data Model and Dictionary: 

  NHS Data Model and Dictionary Service
  NHS Connecting for Health
  Princes Exchange
  Princes Square
  Leeds
  LS1 4HY

  Email: datastandards@nhs.net

  NHS Data Model and Dictionary Service Website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/datamodeldictionary
• 
  
• Information Standards Board for Health and Social Care:

  Information Standards Board for Health and Social Care
  Princes Exchange 
  Princes Square
  Leeds
  LS1 4HY

• Internet: http://www.isb.nhs.uk/

• Hospital Episode Statistics (HES):

  Website: HES online

  Queries: HES queries

• Clinical Coding general enquiries:

  International Classification of Diseases (ICD-10);
  OPCS-4 Classification of Interventions and Procedures;
  Clinical Terms (The Read Codes);
  SNOMED CT (Systematised Nomenclature of Medicine Clinical Terms)

  For all general enquiries, contact:

  NHS Connecting for Health
  Data Standards and Products Help Desk
  E-mail: datastandards@nhs.net
  Website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/

  • Electronic copies of International Classification of Diseases (ICD-10) Volumes 1, 2 and 3
    • The ICD-10 metadata file and its specification;
    • The ICD-10 Codes and Titles (on diskette);
    • The ICD-10 Tables of Equivalence (on diskette);
  • OPCS-4 Classification of Interventions and Procedures;
    • OPCS-4 Codes and Titles;
    • OPCS-4 metadata file;
    • OPCS-4 Tables of Coding Equivalence;
    • Electronic format of Index and Tabular List of OPCS-4;
  • Clinical Terms (The Read Codes) and SNOMED CT® (Systematised Nomenclature of Medicine Clinical Terms) are released to licensees every six months (March and September) via the Terminology Reference Data Update Distribution Service (TRUD).

    Information on the Terminology Reference Data Update Distribution Service (TRUD) can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

    Hard copy versions of ICD-10 and the Tabular List of OPCS-4 are available from The Stationery Office (formerly HMSO).

• Organisation Data Service Queries:

  Organisation Data Service
  Hexagon House
  Pynes Hill
  Rydon Lane
  Exeter
  Devon EX2 5SE

  exeter.helpdesk@nhs.net
  Tel: 01392 251 289

  Organisation Data Service website pages:

  • NHSnet pages where data is published: http://nww.connectingforhealth.nhs.uk/ods/
  • Public domain pages: http://www.nhs.uk/ods/
  • Information pages on the NHS Connecting for Health website:
    http://www.connectingforhealth.nhs.uk/systemsandservices/data/standards/ods/index_html

  Information on the Terminology Reference Data Update Distribution Service can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

• Postcodes:

  Postcode and Geographic Area Queries
  All Fields Postcode Directory
  Areas of Residence Classification
  NHS Organisation Manual
  1991 Frozen Postcode File
  Communal Establishment File

  Office for National Statistics Geography Customer Services Unit
  Office for National Statistics
  Segensworth Road
  Titchfield
  Fareham
  Hants
  PO15 5RR

  1991 Frozen Postcode File
  Communal Establishment File

  Tel: 01329 813243 or 813477
  Fax: 01329 813383
  e-mail: ons.geography@ons.gov.uk
  Internet: http://www.statistics.gov.uk

PUBLICATION VERSION

The version number is held at the individual element level, which means that a Change Log can be held for each attribute, data element, central return form, CDS message etc.The version number is held at the individual element level, which means that a Change Log can be held for each Attribute, Data Element, Central Return Form, Commissioning Data Set message etc.

Classes have been treated slightly differently as they have been broken down into three separate sections, one each for its description, attribute and relationship list, and each will have its own Change Log and version number.

Version Number Structure

Each version number is composed of 3 numbers, e.g. Version 3.5.1.

The first number reflects the version number of the publication as a whole (currently version 3), and will only change when there is a major new release of whole Data Dictionary.The first number reflects the version number of the publication as a whole (currently version 3), and will only change when there is a major new release of whole NHS Data Model and Dictionary.

The second number changes whenever the individual element has been affected by a nationally approved change, currently published in DSCNs. In this example the element has been changed by three DSCNs, each of which will be listed in the Change Log.

The third number is incremented whenever a minor patch change is made to the element, for instance to make a simple typographical change to the text, which would not normally need to go through the usual standards approval mechanism. These minor changes will not appear in the Change Log.

Contextual Overview

The data set provides essential information for monitoring key targets and standards in the Cancelled Operations Guarantee.TheQuarterly Monitoring Cancelled Operations Data Set (QMCO) provides essential information for monitoring key targets and standards in the Cancelled Operations Guarantee.

The Department of Health requires information on services provided by Health Care Providers of Theatre services and this information is collected by the Department of Health via the Quarterly Monitoring Cancelled Operations Data Set (QMCO).The Department of Health requires information on services provided by Health Care Providers of Theatre services and this information is collected by the Department of Health via the Quarterly Monitoring Cancelled Operations Data Set (QMCO).

Reporting

The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a quarterly return with the first quarter starting on 1 April and the last quarter ending on 31 March.The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a quarterly return with the first quarter starting on 1 April and the last quarter ending on 31 March.

Any ACTIVITY where the outcome is not yet known should be reported in the following quarter. That is any ACTIVITY where it not known the outcome of subsequent OFFERS OF ADMISSION within the 28 day limit.

Data sets must be submitted by 15 working days after the end of the quarter.

The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a provider based return.The Quarterly Monitoring Cancelled Operations Data Set (QMCO) is a provider based return.

The data is entered via Unify2, an online data collection system. NHS providers enter their data onto Unify2 either directly or by uploading a spreadsheet.

Quarterly Monitoring Cancelled Operations Data Set (QMCO)Quarterly Monitoring Cancelled Operations Data Set (QMCO)

The Quarterly Monitoring Cancelled Operations Data Set (QMCO) requires the following for each ORGANISATION CODE (CODE OF PROVIDER), REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE:The Quarterly Monitoring Cancelled Operations Data Set (QMCO) requires the following for each ORGANISATION CODE (CODE OF PROVIDER), REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE:

• Number of OPERATING THEATRES.

• Number of OPERATING THEATRES that are dedicated to day cases.

• Number of last minute cancellations for non clinical reasons (LAST MINUTE CANCELLATIONS FOR NON CLINICAL REASONS TOTAL).

• Number of breaches of the standard for Cancelled Operations Guarantee (FAILURE TO TREAT WITHIN 28 DAYS TOTAL).

Cancellation at 'the last minute' or 'short notice' means on or after the day that the PATIENT was due to arrive in hospital.

Contextual Overview

• The Department of Health requires performance management information on ELECTIVE ADMISSION LIST and Out-Patient Waiting List events within a specified REPORTING PERIOD.

• The Department of Health uses the information to help monitor national WAITING LIST trends. These are used to develop policies and indicate changes which can enable the WAITING LISTS to be managed more effectively.

• This central information collection requirement is both:

• provider based and is submitted by provider NHS Trusts and provider Primary Care Trusts regardless of where PATIENTS live.

  and

  commissioner based and is the aggregation of commissioned PATIENT activity delivered by provider NHS Trusts and provider Primary Care Trusts.

• Each submission will be from one ORGANISATION in the role of provider or commissioner and should only contain data appropriate to that role i.e. must not contain a mixture of commissioning and provider role data.

• COMMISSIONER OR PROVIDER STATUS INDICATOR indicates whether it is a submission from the ORGANISATION in the role of commissioner of care or provider of care.

  Admitted Patient Flow Events Elective Admission List

• The collection data is sub grouped by totals for all MAIN SPECIALTY CODES and for MAIN SPECIALTY CODE 110 Trauma & Orthopaedics only.
• The collection is for:

• all PATIENTS admitted during the REPORTING PERIOD from the Elective Admission List subdivided into count of day case admissions and ordinary admissions

  and

  all PATIENTS admitted during the REPORTING PERIOD from the Elective Admission List as planned admission during the REPORTING PERIOD

  and

  all PATIENTS admitted during the REPORTING PERIOD from the Elective Admission List to a NHS Treatment Centre and Independent Sector Treatment Centre during the REPORTING PERIOD

• It includes private PATIENTS and PATIENTS from overseas.

• It excludes Suspended Patients.

  ELECTIVE ADMISSION TYPE records the classification of the admission.

• The collection is sub-divided into a count of day case admissions and ordinary admissions.

• INTENDED MANAGEMENT records whether a PATIENT is intended as an ordinary admission (to stay overnight) or a day case admission (not to stay overnight).

  Admitted Patient Flow Events non-Elective Admissions

• The collection data is grouped by totals for ADMISSION INTENDED PROCEDURE which indicates the required range of OPERATIVE PROCEDURES and by admission to NHS Hospitals and non-NHS Hospitals.
• The required grouping ranges of ADMISSION INTENDED PROCEDURE are:

• 0001 CABG - Coronary Artery Bypass Graft Code Range:
  or
  0002 PTCA - Percutaneous Transluminal Operations Coding Range:
  or
  0005 CHD - Coronary Heart Disease Coding Range

• ORGANISATION TYPE of ORGANISATION records whether the hospital provider is an NHS or non-NHS organisation.
• The collection is for all PATIENTS admitted non-electively during the REPORTING PERIOD.

  a

  all PATIENTS admitted during the REPORTING PERIOD from the Elective Admission List to a NHS Treatment Centre and Independent Sector during the REPORTING PERIOD

• For NHS hospital providers it includes private PATIENTS and PATIENTS from overseas.
• For NHS Hospital Providers it includes private PATIENTS and PATIENTS from overseas.

• It excludes Suspended Patients.

  ELECTIVE ADMISSION TYPE records the classification of the admission.

  Out-Patient Referral Flow Events

• The collection data is sub grouped by totals for all MAIN SPECIALTY CODE and for MAIN SPECIALTY CODE 110 Trauma & Orthopaedics only.
• The collection is for:

• all GENERAL PRACTITIONER written referrals, whether from doctor or dentists, received within the REPORTING PERIOD for a first Out-Patient Appointment Consultant

  and

  all FIRST ATTENDANCE APPOINTMENTS arising from GENERAL PRACTITIONER written referrals, whether from doctors or dentists, where the Out-Patient Attendance Consultant took place within the REPORTING PERIOD.

• It includes private PATIENTS and PATIENTS from overseas.

• Contextual Overview

• The Department of Health requires performance management information on ELECTIVE ADMISSION LIST stocks at the end of a specified REPORTING PERIOD.

• The Department of Health uses the information to help monitor national WAITING LIST trends. These are used to develop policies and indicate changes which can enable the WAITING LISTS to be managed more effectively.

• This central information collection requirement is both:

• provider based and is submitted by provider NHS Trusts and provider Primary Care Trusts regardless of where PATIENTS live.

  and

  commissioner based and is the aggregation of commissioned PATIENT activity delivered by provider NHS Trusts and provider Primary Care Trusts.

• Each submission will be from one ORGANISATION in the role of provider or commissioner and should only contain data appropriate to that role i.e. must not contain a mixture of commissioning and provider role data.

• COMMISSIONER OR PROVIDER STATUS INDICATOR indicates whether it is a submission from the ORGANISATION in the role of commissioner of care or provider of care.

  Admitted Patient Stock Group Main Specialty Code 110 Trauma & Orthopaedics

• The collection data is grouped by ordinary admissions and day case admissions for MAIN SPECIALTY CODE 110 Trauma & Orthopaedics only.
• The collection is for:

• all patients for who have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and are waiting to be admitted from the Elective Admission Listall PATIENTS for who have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and are waiting to be admitted from the Elective Admission List

  and

  all PATIENTS for who have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and are waiting to be admitted by specified waiting time band from the Elective Admission List

• It includes those PATIENTS who are classified as a booked admissions and waiting list admissions; and is inclusive of private PATIENTS and PATIENTS from overseas.

• It excludes those PATIENTS who are classified as a planned admissions and Suspended Patients.

  ELECTIVE ADMISSION TYPE records the classification of the admission.

  Summarised Admitted Patient Stock Group Intended Procedures for Ordinary Admissions

• The collection data is grouped by ADMISSION INTENDED PROCEDURE which indicates the required range of OPERATIVE PROCEDURE. Where the are no stocks present for a ADMISSION INTENDED PROCEDURE within the REPORTING PERIOD then no in-patient stocks group should be recorded for it. Only one group is permitted per ADMISSION INTENDED PROCEDURE.
• The required grouping ranges of ADMISSION INTENDED PROCEDURE are:

• 0001 CABG - Coronary Artery Bypass Graft Code Range:
  or
  0002 PTCA - Percutaneous Transluminal Operations Coding Range:
  or
  0003 Valves Coding Range
  or
  0004 - Angiography Coding Range

• Within the ADMISSION INTENDED PROCEDURE the collection only applies to PATIENTS waiting for admission as ordinary admissions as indicated by INTENDED MANAGEMENT.
• The collection is for:

• all PATIENTS for who have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and are waiting to be admitted from the Elective Admission List

  and

  all PATIENTS for who have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and are waiting to be admitted by specified waiting time band from the Elective Admission List

• It includes those PATIENTS who are classified as a booked admissions and waiting list admissions; and is inclusive of private PATIENTS and PATIENTS from overseas.

• It excludes those PATIENTS who are classified as a planned admissions and Suspended Patients.

  ELECTIVE ADMISSION TYPE records the classification of the admission.

  Out-Patient Stock Group Main Specialty Code 110 Trauma & Orthopaedics

• The collection data is for MAIN SPECIALTY CODE 110 Trauma & Orthopaedics only.
• The collection is for all PATIENTS referred by GENERAL PRACTITIONER written referral for a first Out-Patient Appointment Consultant where the appointment has not taken place by the REPORTING PERIOD END DATE by specified waiting time band.
• The collection is for all PATIENTS referred by GENERAL PRACTITIONER written referral for a first Out-Patient Appointment Consultant where the APPOINTMENT has not taken place by the REPORTING PERIOD END DATE by specified waiting time band.
• It includes private PATIENTS and PATIENTS from overseas.

SUPPORTING INFORMATION INTRODUCTION

Supporting information such as Clinical Coding, Meta Data etc, is provided to help users understand the Commissioning Data Sets (CDS), Data Sets (National Cancer Data Set, etc) and Central Return forms.

• NHS Trust Mergers
• Mental Health Act Table
• Default Codes Summary Table
• Clinical Coding
• Location Type Codes
• Administrative Codes
• NHS Postcode Directory
• Main Specialty and Treatment Function Codes
• NHS Trust Mergers
• Mental Health Act Table
• Default Codes Summary Table
• Clinical Coding
• Location Type Codes
• Administrative Codes
• NHS Postcode Directory
• Main Specialty and Treatment Function Codes
• Organisations
• Metadata Files
• Metadata Files
• 
  
• Publication Version
• Navigating the NHS Data Model and Dictionary
• The NHS Data Model and Dictionary Elements
• Contact Details
• Disclaimer
• Publication Version
• Navigating the NHS Data Model and Dictionary
• NHS Data Model and Dictionary Elements
• Contact Details
• Glossary of Terms
• Disclaimer
• Publication Feedback
• Link to Data Set Change Notices (DSCNs)