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| Note |
|---|
This page has been superseded and archived. |
ID | STD064 |
|---|---|
Name | NHS Number |
External ID | ISB0149-02 |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date |
|
|---|
Description
The aim of the NHS Number for Secondary Care standard is to increase NHS Number usage within Trusts, ensuring that the patient is correctly associated with their unique NHS Number.
Applicability
All information systems supporting the commissioning or provision of NHS Services that hold patient/service user demographic data.
All information systems supporting the commissioning or provision of health and care services that are used to transfer or otherwise communicate patient/service user information with other bodies that commission or provide health and care services in England in partnership with the NHS.
All new information systems procured after this standard comes into force. • All existing information systems where it is reasonably practicable, given cost and other constraints, to upgrade it to comply with this standard.
All existing or new information systems where the use of the NHS Number would not compromise patient/service user care nor provide a barrier to the uptake of care services – this to be determined by a local clinical risk assessment
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
ID | STD085 |
|---|---|
Name | Core Information Standard |
External ID | N/A |
Version | 0.1 |
Link to standard | |
Standard Type | Guidance |
Status |
Alpha | |
Effective Date |
|
|---|
Description
The Core information standard defines a set of information that can potentially be shared between systems in different sites and settings, among professionals and people using services.
Applicability
This guidance is intended for anyone implementing the core information standard. This will include project teams (including clinicians, other care professionals and people who use services) involved in building systems that will use the core information standard and system suppliers.
Requirements
Requirement ID | Requirement Text | Level | |
|---|---|---|---|
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:
| ||
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:
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. | ||
ID | STD091 |
|---|---|
Name | Acute Inpatient Discharge Standard |
External ID | DAPB4042 |
Version | 0.1 |
Link to standard | |
Standard Type | Mapped Standard |
Status |
Alpha | |
Effective Date | TBC |
|---|
Description
An information standard to establish consistency in the creation and issue of transfer of care acute inpatient discharge documents.
Applicability
The Transfer of Care - Acute Inpatient Discharge is applicable for all ordinary admission and day case admissions. It should be considered for adoption by the specialty using the patient classification “regular day admission” or “regular night admission” based on the value and frequency of GP correspondence currently being generated at the end of each treatment session, and as agreed with the commissioning organisation.
Requirements
These requirements are intended for Supplier Implementation and must be assured via an ITK3 test harness.
See further implementation guidance here- DAPB4042:Implementation guidance
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
ID | STD097 |
|---|---|
External ID | PRSB Outpatient Letter |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date | TBC |
|---|
Description
PRSB standards for digital outpatient letters allow clinical information to be recorded, exchanged and accessed consistently across care settings. Best practice for most outpatient letters is writing directly to patients.
Applicability
The PRSB standard for outpatient letters is designed to improve and standardise the content of outpatient letters so that professionals, patients and carers receive consistent, reliable, high-quality information between clinicians and patients.
Requirements
These requirements are professional, and patient endorsed, and evidence based clinical record standards. These provide the basis for technical (FHIR) specifications produced to enable suppliers to implement technical solutions.
...
Service Suppliers should include the following data set in implementation of an automatically generated Outpatient letter.
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
ID | STD098 |
|---|---|
External ID | PRSB Mental Health Inpatient Discharge |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date | TBC |
|---|
Description
The mental health discharge summary will improve professional communication between the patient’s secondary care providers to their GP. It is very important to recognise the different nature of mental illness to physical illness and disease including the different methods of treatments and imperative follow-up care after discharge.
Applicability
The Professional Record Standards Body (PRSB) provides professional, and patient endorsed, and evidence based clinical record standards. These provide the basis for technical (FHIR) specifications produced to enable industry to implement technical solutions.
Requirements
These requirements list the data collected for the patient demographic details and the Patient discharge details. For the full specification Suppliers should refer to this document Mental health discharge summary
Service Suppliers should include the following data set in implementation of an automatically generated Mental health discharge summary.
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
Requirement ID | Requirement Text | Level |
|---|---|---|
STD097-12 | Discharging consultant | SHOULD |
STD097-13 | Discharging specialty/department | SHOULD |
STD097-14 | Discharge location | SHOULD |
STD097-15 | Date/time of discharge | MUST |
STD097-16 | Legal Status on discharge | SHOULD |
STD097-17 | Discharge method | SHOULD |
STD097-18 | Discharge destination cluster | SHOULD |
STD097-19 | Discharge type | SHOULD |
STD097-20 | Discharge address | SHOULD |
ID | STD099 |
|---|---|
External ID | Emergency care discharge v2.1 – PRSB |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date | TBC |
|---|
Description
The Emergency Care discharge data standard will improve professional communication between the patient’s secondary care providers and their GP. Sharing discharge information between Emergency Care and GP practices is essential for ensuring patient safety and good ongoing treatment.
Applicability
The Professional Record Standards Body (PRSB) provides professional, and patient endorsed and evidence based clinical record standards. These provide the basis for technical (FHIR) specifications produced to enable industry to implement technical solutions.
Requirements
These requirements list the data collected for the Patient discharge details and their GP details. For the full specification Suppliers should refer to this document: Emergency care discharge summary standard
Service Suppliers should include the following data set in implementation of an automatically generated emergency care discharge summary.
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |