STD009-1

Birth Notification

The trust MUST ensure Births registered to the Personal Demographics System

Birth Notification Application (BNA) Quick Reference Guide

MUST

STD019-1

All providers of Type 01, 02 and 03 Emergency Care Departments MUST submit ECDS 6.2.3 to SUS+ on a daily basis, using MESH, to allow collection and extraction in the required manner, from 1st April 2021.

This amendment takes effect from 1st April 2021.

Full details of data required and formats can be found here

MUST

STD024-1

Critical Care Dataset

The supplier system MUST allow following data must be recorded:

NHS NUMBER

LOCAL PATIENT IDENTIFIER

CRITICAL CARE LOCAL IDENTIFIER

SITE CODE (OF TREATMENT)

GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)

ACTIVITY TREATMENT FUNCTION CODE

PERSON BIRTH DATE

POSTCODE OF USUAL ADDRESS

CRITICAL CARE START DATE

CRITICAL CARE START TIME

CRITICAL CARE UNIT FUNCTION

CRITICAL CARE UNIT BED CONFIGURATION

CRITICAL CARE ADMISSION SOURCE

CRITICAL CARE SOURCE LOCATION

CRITICAL CARE ADMISSION TYPE

ADVANCED RESPIRATORY SUPPORT DAYS

BASIC RESPIRATORY SUPPORT DAYS

ADVANCED CARDIOVASCULAR SUPPORT DAYS

BASIC CARDIOVASCULAR SUPPORT DAYS

RENAL SUPPORT DAYS

NEUROLOGICAL SUPPORT DAYS

GASTRO-INTESTINAL SUPPORT DAYS

DERMATOLOGICAL SUPPORT DAYS

LIVER SUPPORT DAYS

ORGAN SUPPORT MAXIMUM

CRITICAL CARE LEVEL 2 DAYS

CRITICAL CARE LEVEL 3 DAYS

CRITICAL CARE DISCHARGE STATUS

CRITICAL CARE DISCHARGE DESTINATION

CRITICAL CARE DISCHARGE LOCATION

CRITICAL CARE DISCHARGE READY DATE

CRITICAL CARE DISCHARGE READY TIME

CRITICAL CARE DISCHARGE DATE

CRITICAL CARE DISCHARGE TIME

MUST

STD0036-1

FGM-Information Sharing (FGM-IS) - Local System Integration

This information standard requires in-scope NHS funded healthcare providers to update their local applicable IT system(s) to automatically display an alert message when a patient with female genitalia under 18 years old has a family history of FGM, as recorded in the FGM-IS core service (a national Spine application). The search undertaken to display the alert is made of all genders, to cater for any patient adopting a new gender identity, and all patient records that have this flag will be displayed. This ensures all are treated fairly and no additional risk is created, as is required by the Equality Act 2010

Specific data details are show here : NHS Data Model & Dictionary - FGM-IS Dataset

MAY

STD0039-1

Data Composition

This standard describes and governs reference data about the Organisations that comprise health and social care services, and the Sites they provide services from. This reference data is comprised of a number of core components, listed below:

Dates, Name,. Identifier, Geographic Location, Contacts, Roles, Relationship(s), Succession and Additional Attributes.

Full details of the data and structures is included at Health and Social Care Organisation Reference Data

MUST

STD0045-1

10 Data Security Standards 

https://digital.nhs.uk/cyber-and-data-security/guidance-and-assurance/data-security-and-protection-toolkit-assessment-guides

MUST

STD0062-1

The Supplier system MUST be capable of storing the NHS Number as described in the NHS Data Dictionary on patient/service user records.

MUST

STD0062-2

The Supplier system MAY record the verification status of each recorded NHS Number.

MAY

STD0062-3

The Supplier system MUST allow users to find a patient/service user record using the NHS Number as the only search criterion.

MUST

STD0062-4

The Supplier system MAY allow users to find a patient/service user record using the NHS Number as part of the search criteria in conjunction with other demographic information.

MAY

STD0062-5

The Supplier system MUST allow users to find a patient/service user record without using the NHS Number as part of the search criteria

MUST

STD0062-6

The supplier system MUST include the NHS Number in any patient identifiable data/service user information sent electronically, with the following exceptions:

• The NHS Number is not available at time of transmission.

• The use of the NHS Number is in conflict with other requirements, standards, legislation, common law duty of confidentiality or policies.

MAY

STD0062-7

The Supplier system MUST display the NHS Number on every screen showing patient identifiable data/service user information (if available). The verification status of the NHS Number SHOULD also be displayed if maintained.

MUST

STD0062-8

The Supplier system MUST include the NHS Number on all hard-copy outputs containing patient identifiable data/service user information (if appropriate and available at time of output).

MUST

STD0062-9

The Supplier system MUST display and print the NHS Number for people to read in 3 3 4 format (e.g. 123 456 7890).

MUST

STD0062-10

The Supplier system MUST allow the NHS Number to be input in into the appropriate data input field on the screen as 10 digits with or without spaces.

MUST

STD0062-11

The Supplier system MUST validate (both format and check-digit) the NHS Number when input.

MUST

STD0062-12

The Supplier system MUST be capable of reporting where the same NHS Number (verified or not) is recorded on more than one patient/service user record.

MUST

STD0062-13

The Supplier system SHOULD be capable of reporting all patient/service user records without an NHS Number recorded.

SHOULD

The following requirements apply to the use of Applicable Systems by commissioner and
provider organisations, and to their communications, processes and behaviours

STD0062-14

When a system user uses the NHS Number to retrieve an electronic record the system supplier must allow other demographic information supplied MUST be used to confirm the patient’s/service user’s identity and that the record retrieved belongs to that patient/service user.

MUST

STD0062-15

When supplied, the NHS Number SHOULD be used instead of demographic data as the
patient/service user identifier.

SHOULD

STD0062-16

Data quality processes SHOULD be in place to resolve electronic patient/service user
records where the same NHS Number (verified or not) is recorded on more than one record

SHOULD

STD0062-17

Organisations MUST ensure all staff are trained in the correct use of information management technology systems, human behaviours and business processes required to support this Standard.

MUST

STD0062-18

At the start of each new episode of care or contact, or at the earliest opportunity the patient’s/service user’s demographic data, including NHS Number SHOULD be confirmed with the patient/service user or his/her parent or carer or other organisations working with the patient/service user.

SHOULD

STD0062-19

The patient’s/service user’s NHS Number SHOULD be determined at the beginning of (or prior to) the episode of care, where possible and practical.

SHOULD

STD0062-20

The parent or guardian MUST be given written confirmation of the NHS Number of a newborn child following allocation via the statutory notification of birth (through NHS Number for Babies Service (NN4B)) or the Personal Demographics Service (PDS).

MUST

STD0062-21

The patient’s/service user’s NHS Number SHOULD always be included as part of all communications, correspondence and filing systems involving patient/service user identifiable data/service user information. Additional patient/service user demographic information MUST also be included with the NHS Number.

SHOULD

STD0062-22

Organisations MUST promote the importance and use of the NHS Number to all staff.

MUST

STD0062-23

Organisations MUST have processes in place to support patients/service users to know their NHS Numbers and to supply it to them when requested.

MUST

STD0064-1

Verification Status

Applicable 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 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.  

STD0021-1

The national data opt-out MUST be respected and applied if appropriate by health and adult social care organisations in England.

MUST

STD0021-2

Implementation guidance supporting the standard MUST be considered to ensure compliance with national data opt-out policy.

Organisations SHOULD read all relevant documentation but MUST read and adhere to the National Data Opt-out Operational Policy Guidance; Compliancy Implementation Guide; and if required to apply opt-outs the User Guidance (MESH Guidance for using the Check for National Data Opt-outs Service).

MUST

STD0021-3

Organisations MUST make sure any patients wishing to opt-out of the use of their confidential patient information for purposes beyond individual care are informed about the national data opt-out and signposted to the relevant information.

MUST

STD0021-4

Organisations MUST make sure relevant staff are informed and trained about the national data opt-out and are able to appropriately support and signpost patients wishing to opt-out of the use of their confidential patient information for purposes beyond individual care.

MUST

STD0021-5

Organisations handling confidential patient information MUST have in place appropriate procedures so that on an ongoing basis they can:

• identify any data disclosures where national data opt-outs need to be applied in line with the National Data Opt-out Operational Policy Guidance (it should be noted that procedures MUST be effective for pre-existing and any new data disclosures).

• apply the national data opt-out in line with the published information standard for compliance with the national data opt-out.

MUST

STD0021-6

Organisations MUST inform patients of their compliance with the national data opt-out policy and the standard in line with the agreed timelines for implementation.

MUST

STD0021-7

Organisations applying the national data opt-out MAY provide information to the data recipient on the number of records removed due to the application of national data opt-outs.

MAY