STD064 - NHS Number

STD085 - Core Information Standard

STD091 - Acute Inpatient Discharge Standard

STD097 - Outpatient Letter

STD098 - Mental Health Inpatient Discharge

STD099 - Emergency care discharge v2.1

STD0064-1

Verification Status

Supplier systems must record the verification status of each recorded NHS Number.

A verified NHS number has been cross-checked using demographic details on the Personal Demographics Service (PDS)

MUST

STD0064-2

Electronic Communication

Only verified NHS numbers should be sent electronically

SHOULD

STD0064-3

Hard Copy Output

Only verified NHS numbers should be used when sending a hard copy output

SHOULD

STD0085-1

Information Components 

 Model Description 

SHOULD

Section 

A section groups together all the information related to a specific topic e.g. ‘Medications and medical devices’ and ‘Person demographics’.  

It is the highest level to logically group data elements that may be independent or related. For example: 

• ‘Legal information’ includes a set of independent elements or information items, grouped in a logical section.  

• ‘Medications and medical devices’ includes sets of related elements with dependencies between the elements.  

Record entry 

A record entry within a section is used where a set of information is repeated for a particular item, and there can be multiple items. For example, for each medication there is a set of information associated with that medication. Other examples are allergies or adverse reactions and procedures.   

Cluster 

This is a set of elements put together as a group and which relate to each other; e.g. medication course details cluster which is the set of elements describing the course of the medication.   

Element  

The data item.  

An element can appear in one or more sections e.g. name, date.  

Information model rules and instructions 

Explanations 

Description   

This is the description of the section, record entry, cluster or element.  For an element, it describes the information that the element should contain in as plain English as possible.   

Cardinality  

Each section, record entry, cluster and element will have a statement of cardinality. This clarifies how many entries can be made i.e. zero, one or many entries. The number of records expected and allowed are displayed as: 

0……* = zero to many record entries are allowed 

0……1 = zero to one record entry is allowed 

1……1 = one record is expected   

1……* = one to many records are expected 

For example, the ‘Medications and medical devices’ section may have zero to many medication item records in it and is displayed as 0…… *.   

Conformance  

Conformance defines what information is ‘mandatory’, ‘required’ or ‘optional’ and applies to sections, record entries, clusters and elements. 

The IT system must be developed to handle all the information elements that are defined in the Standard but not all the information is required for every individual record or information transfer.  

The following set of rules apply to enable implementers to cater for the end users (senders and receivers) requirements:  

• Mandatory – the information must be included  

• Required – if it exists, the information must be included  

• Optional – a local decision is made as to whether the information is included 

These rules apply at all levels and give the flexibility to allow local clinical or professional decisions on some information that is included, while being clear on what is important information to include.   

For example, a person subject to a referral may have many assessments, but not all of these will be relevant to the referral.  The conformance can be used to allow just relevant assessments to be included.  

Assessment Section – Required – i.e. its important information you must include if you have it. 

Record entry level – Optional – allows a local decision on what assessments are included, so only relevant ones are included based on clinical or professional needs.   

Assessment elements – Conformance set on the normal basis of which elements for an assessment are mandatory, required or optional.   

NB: It is permitted to upgrade a conformance rule but not to down grade one. For instance, a section that is classed as optional in the standard can be upgraded to required or mandatory in local implementations. However, one that is classed mandatory or required cannot be downgraded to required or optional.  

Valuesets  

Valuesets describe precisely how the information is recorded in the system and communicated between systems. This is required for interoperability (for information to flow between one IT system and another). 

The information can be text, multi-media or in a coded format. If coded it can be constrained to SNOMED CT and specific SNOMED CT reference sets, NHS Data Dictionary values or other code sets.  

STD091-1

The service Supplier MUST ensure the system has the ability to send an Inpatient and Day Case Discharge Summary - an ITK3 FHIR document containing Transfer of Care information supporting an inpatient and day case discharge. The document would need to be sent by any secondary care provider (NHS or independent sector) contracted under the terms of the NHS Standard Contract. The recipient would be the registered General Medical Practice of the patient

Test message examples are shown here

MUST

STD097-1

Patient name

MUST

STD097-2

Patient preferred name

SHOULD

STD097-3

Date of birth

MUST

STD097-4

Gender

SHOULD

STD097-5

NHS number

SHOULD

STD097-6

Other identifier

SHOULD

STD097-7

Patient address

MUST

STD097-8

Patient email address

MAY

STD097-9

Patient telephone number

MAY

STD097-10

Relevant contacts

MAY

STD097-11

Educational establishment 

MAY

STD097-1

Patient Name

MUST

STD097-2

Patient preferred name

SHOULD

STD097-3

Date of birth

MUST

STD097-4

Gender

SHOULD

STD097-5

NHS number

SHOULD

STD097-6

Other identifier

SHOULD

STD097-7

Patient address

MUST

STD097-8

Patient email address

MAY

STD097-9

Patient telephone number

MAY

STD097-10

Relevant contacts

MAY

STD097-11

Educational establishment 

MAY

STD099-1

Discharge status

MUST

STD099-2

Date/time of discharge

MUST

STD099-3

Discharge destination

MUST

STD099-4

GP practice

SHOULD

STD099-5

GP practice identifier

MUST

STD099-6

GP name

SHOULD

STD099-7

GP practice details

SHOULD