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DSC Notice: 12/2000 * Date of Issue: October 2000 Subject: NHS Information Standards Board Data Standards: Minor Changes and Corrections Implementation date: Immediate DATA SET CHANGE CONTROL PROCEDURE This paper gives notification of changes to be included in the NHS Data Dictionary, the NHS Data Manual and the NHS CDS Manual in due course. Summary of change: Correction and clarification of existing NHS data standards. Summary of impact: Minor changes and corrections to NHS data standards. Change Proposal Reference No: CP10/00 CP12/00 CP13/00 CP15/00 CP18/00 CP21/00 The NHS Information Standards Board (ISB), established by the NHS Information Authority, is responsible for approving information standards. The NHS ISB is supported by the Management Information Standards Board, Clinical Data Standards and Technical Standards sub-boards. *The DSCN Number Format has been changed to denote the new arrangements as follows: sequence number/year of issue (ccyy). The service identifier and service sequence number are redundant owing to changes in practice and have been removed. The packaging of standards documentation is under review. Any changes will be notified in due course. Please address enquiries about this DSCN to the Data Standards Team, NHS Information Authority, 15 Frederick Road, Birmingham B15 1JD Tel: 0121 335 4461 or to the nominated enquiry point. Data Set Change Notices are located on the Internet in the Electronic Library at http://www.standards.nhsia.nhs.uk/library/index.htm and on the NHSnet at http://nww.standards.nhsia.nhs.uk/library/index.htm DSCN 12/2000 Page 2 of 8 DATA SET CHANGE NOTICE 12/2000 Reference: CP10/00 - DG899/09/00 (v1.3) CP12/00 - DG903/09/00 (v1.2) CP13/00 - DG905/09/00 (v1.4) CP15/00 - DG912/09/00 (v1.1) CP18/00 – DG919/09/00 (v1.3) CP21/00 – DG923/09/00 (v1.1) Subject: Minor changes and corrections to NHS Data Standards Type of Change: Changes to NHS Data Dictionary Effective Date: Immediate Reason for Change: Corrections and revisions Background: ADMISSION METHOD The structure of the NHS Data Dictionary has changed over time, and the description of ADMISSION METHOD has been updated to reflect the current structure. ANAESTHETIC/ANALGESIC CATEGORY The Department of Health Maternity Statistics section wished to change the description of ANAESTHETIC/ANALGESIC CATEGORY in order to clarify which classification should be recorded when analgesics are given. FIRST ATTENDANCE The description of the attribute FIRST ATTENDANCE mentioned DAY CARE SPECIALTY FUNCTION which no longer exists. This was an error in updating from a previous DSCN and should read DAY CARE FUNCTION. MATERNITY MEDICAL SERVICE When the entity type MATERNITY MEDICAL SERVICE was created, published in DSCN 36/97/P23, the wording of the text of two of its relationships appeared incorrectly. All relationship text must either begin with ‘must be’ or ‘may be’, because of the constraints imposed by Oracle Designer2000, the NHS Data Dictionary repository. When the two relationships appeared in the DSCN they began with the text ‘may require’ and when these were updated in the repository this was changed to ‘may be require’. This is how the text subsequently appears in the NHS Data Dictionary and the relationships have therefore been reworded. OUT-PATIENT ATTENDANCE: CONSULTANT The definition of OUT-PATIENT ATTENDANCE: CONSULTANT has been changed to make it clearer that all consultant out-patient attendances may relate either to the CONSULTANT or any member of their firm or to a locum for such a member. DSCN 12/2000 Page 3 of 8 PATIENT CLASSIFICATION The description of the attribute PATIENT CLASSIFICATION contained information concerning its derivation. Such information is generally to be found in the Notes on Codes and Classifications section of the NHS Data Manual. The wording has been removed from the attribute description and included in the relevant section of NHS Data Manual text. Still Births The description of the attribute LIVE OR STILL BIRTH contained a note relating to changes that occurred in 1992. This information is old, and has been removed. Source of Dental Referral The attribute name SOURCE OF DENTAL REFERRAL was out of line with other sources of referral in the NHS Data Dictionary. It has been changed to SOURCE OF REFERRAL: COMMUNITY DENTAL to bring it in line with other sources of referral and to clarify that it applies to the Community Dental Service. THEATRE SESSION CANCELLATION REASON The description of the entity type THEATRE SESSION CANCELLATION REASON included a reference to additional guidance that was to be provided in the NHS Data Manual. However, the guidance is no longer published in the NHS Data Manual so it is proposed that this reference be removed. In addition, the attribute CANCELLATION SEQUENCE NUMBER of THEATRE SESSION CANCELLATION REASON was intended to allow the recording of more than one reason why a theatre session was cancelled. It was felt that one reason is sufficient and therefore CANCELLATION SEQUENCE NUMBER has been removed and the relationship between THEATRE SESSION CANCELLATION REASON and OPERATING THEATRE SESSION has been revised. Summary of Changes: DENTAL EPISODE MATERNITY MEDICAL SERVICE OPERATING THEATRE SESSION OUT-PATIENT ATTENDANCE: CONSULTANT THEATRE SESSION CANCELLATION REASON ADMISSION METHOD ANAESTHETIC/ANALGESIC CATEGORY CANCELLATION SEQUENCE NUMBER FIRST ATTENDANCE LIVE OR STILL BIRTH PATIENT CLASSIFICATION SOURCE OF DENTAL REFERRAL DSCN 12/2000 Page 4 of 8 Change entity type attributes Change entity type relationships Change entity type relationships Change entity type description Change entity type description, attributes and relationships Change attribute description Change attribute description Delete attribute Change attribute description Change attribute description Change attribute description Change attribute name CHANGES Change Type: Change entity type attributes DENTAL EPISODE The description is unchanged Attributes of this entity type are: SOURCE OF DENTAL REFERRAL SOURCE OF REFERRAL: COMMUNITY DENTAL The remaining attributes are unchanged The relationships are unchanged Change Type: Change entity type relationships MATERNITY MEDICAL SERVICE The description and attributes are unchanged Each MATERNITY MEDICAL SERVICE may require attendances to be provided during one or more CLINIC ATTENDANCES: NON-CONSULTANT may require consultation within be provided during one or more GMP CONSULTATIONS The remaining relationships are unchanged Change Type: Change entity type relationships OPERATING THEATRE SESSION The description and attributes are unchanged Each OPERATING THEATRE SESSION K must be related to one and only one OPERATING THEATRE may be the actual responsibility of one and only one CONSULTANT may be planned for one and only one CONSULTANT may be related to one and only one SPECIALTY FUNCTION may be related to one or more THEATRE CASES DSCN 12/2000 Page 5 of 8 may be related to one or more THEATRE SESSION CANCELLATION REASONS may be cancelled due to one and only one THEATRE SESSION CANCELLATION REASON Change Type: Change entity type description OUT-PATIENT ATTENDANCE: CONSULTANT An attendance at which a PATIENT is seen by a CONSULTANT, a member of the consultant firm or locum for such a member, in respect of one referral, that is not a visit to the home of a PATIENT for which a fee is payable under paragraph 140 of the Terms and Conditions of Service. For the purposes of this definition ‘CONSULTANT’ includes a member of the CONSULTANT’s firm or locum for such a member. The remaining description is unchanged Change Type: Change entity type description and attributes and relationships THEATRE SESSION CANCELLATION REASON A reason for cancelling an OPERATING THEATRE SESSION. If there is more than one reason for the cancellation all the reasons may be recorded. No national standard is provided for the classification of the reasons at present but guidance will be given in the Data Manual. Attributes of this entity type are: K CANCELLATION SEQUENCE NUMBER K CANCELLATION REASON Each THEATRE SESSION CANCELLATION REASON K must be related to one and only one OPERATING THEATRE SESSION may be the reason for cancellation of one or more OPERATING THEATRE SESSION Change Type: Change attribute description ADMISSION METHOD The method of admission to a HOSPITAL PROVIDER SPELL. The coded classification A detailed definition of elective admission is given in ELECTIVE ADMISSION TYPE. National Codes: Elective admission, when the decision to admit could be separated in time from the actual admission: 11 Waiting list 12 Booked DSCN 12/2000 Page 6 of 8 13 Planned The remaining description is unchanged Change Type: Change attribute description ANAESTHETIC/ANALGESIC CATEGORY The coded type of anaesthetic and/or analgesic administered to the mother during or after LABOUR AND DELIVERY. Where an analgesic is administered in addition to an anaesthetic, only the anaesthetic or combination of anaesthetics should be recorded. National Codes: 1 General anaesthetic, the administration by a doctor of an agent intended to produce unconsciousness 2 Epidural or caudal anaesthetic, the injection of a local anaesthetic agent into the epidural space 3 Spinal anaesthetic, the injection of a local anaesthetic agent into the subarachnoid space 4 General anaesthetic and epidural or caudal anaesthetic 5 General anaesthetic and spinal anaesthetic 6 Epidural or caudal and spinal anaesthetic 7 Other than 1 to 6 Anaesthetic other than in 1 to 6, or analgesic only 8 No analgesic or anaesthetic administered Change Type: Delete attribute CANCELLATION SEQUENCE NUMBER Change Type: Change attribute description FIRST ATTENDANCE This indicates whether a patient is making a first or follow-up attendance. For DAY CARE ATTENDANCES, FIRST ATTENDANCE is the first of a series, or only attendance, within one DAY CARE FUNCTION at DAY CARE FACILITIES of an ORGANISATION by either a PATIENT using a hospital bed or a regular day attender. A re-attendance is any subsequent attendance at a DAY CARE SESSION of the same DAY CARE FUNCTION and same HEALTH CARE PROVIDER by a PATIENT whose attender status has not changed since the previous attendance. DSCN 12/2000 Page 7 of 8 It should be noted that: a. If a PATIENT attends a DAY CARE SESSION of the same DAY CARE SPECIALTY FUNCTION at another site of the ORGANISATION, the initial attendance at the second facility is a re-attendance b. If a PATIENT attends a DAY CARE SESSION which is not of the same DAY CARE FUNCTION as one previously attended within the ORGANISATION, the initial attendance at the second facility is a FIRST ATTENDANCE c. If a PATIENT changes attender status from hospital bed to regular attender or vice-versa, the initial attendance after the change is a FIRST ATTENDANCE The remaining description is unchanged Change Type: Change attribute description LIVE OR STILL BIRTH An indicator of whether the birth was a live or still birth. A still birth is a birth after a gestation of 24 weeks (168 days) where the baby shows no identifiable signs of life at delivery. Note: Up to, and including, 30/9/92 the criteria was 28 weeks and not 24 weeks as above. The remaining description is unchanged Change Type: Change attribute description PATIENT CLASSIFICATION A code for classifying patients. The classification is derived from the method of admission, intended management and the duration of stay of the PATIENT. The duration of stay is derived by subtracting the date of admission from the date of discharge. In the case of maternity patients, the use being made of the delivery facilities is also used in the derivation. A coded classification of PATIENTS who have been admitted to a HOSPITAL PROVIDER SPELL. The remaining description is unchanged DSCN 12/2000 Page 8 of 8 Change Type: Change attribute name SOURCE OF DENTAL REFERRAL SOURCE OF REFERRAL: COMMUNITY DENTAL The description is unchanged DSCN 12/2000 Page 9 of 8