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| Note |
|---|
This page has been superseded and archived. |
Standards
ID | STD009 |
|---|---|
Standard Name | |
External ID | N/A |
Version | 1.0 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status | Alpha |
Effective Date | TBC |
Description
New births are registered on the Personal Demographics Service (PDS). The PDS is part of the NHS Spine. This ensures that babies are issued with an NHS Number that is immediately available to organisations involved in the ongoing provision and recording of their care.
Applicability
It is a legal requirement in the UK to register a birth within 36 hours, they will then be assigned an NHS number.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
STD009-1 | Birth Notification The trust MUST ensure Births registered to the Personal Demographics System | MUST |
ID | STD019 |
|---|---|
Standard Name | |
External ID | N/A |
Version | 0.1 |
Link to standard | |
Standard Type | Guidance |
Status |
Alpha | |
Effective Date | TBC |
|---|
Description
The Emergency Care Data Set (ECDS) collects information about why people attend emergency departments and the treatment they receive to
improve patient care through better and more consistent information
allow better planning of healthcare services
improve communication between health professionals
Applicability
All providers of Type 01, 02 and 03 Emergency Care Departments
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
ID | STD024 |
|---|---|
Standard Name | |
External ID | ISB0153 |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date |
|---|
Description
The Critical Care Minimum Data Set contains a subset of mandatory items for the generation of Critical Care Healthcare Resource Groups (HRGs). The Critical Care HRG subset replaced the Augmented Care Period data elements in the Commissioning Data Sets.
Applicability
The Critical Care Minimum Data Set has been developed to be used in all units where critical care is provided. That is where the CRITICAL CARE LEVEL is National Code:
...
Neonates are excluded from the data set. The recording of Critical Care Minimum Data Set for older babies (over 28 days) on Neonatal and Paediatric Intensive Care Units is optional. However, the activity for children treated on adult critical care units should be recorded.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
ID | STD036 |
|---|---|
Standard Name | |
External ID | DCB2112 |
Version | 0.1 |
Link to standard | DCB2112: FGM-Information Sharing (FGM-IS) - Local System Integration |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date |
|---|
Description
The Female Genital Mutilation - Information Service (FGM-IS) is a national IT system that supports the ongoing safeguarding of patients, under the age of 18, who have a family history of Female Genital Mutilation (FGM).
Applicability
This information standard makes provision for the data held within the FGM-IS to be made available to all relevant healthcare staff by allowing integration of a view only capability of the family history indicator within all applicable IT systems across all health care services.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
MAY
ID | STD039 |
|---|---|
Standard Name | |
External ID | DAPB0090 |
Version | 0.1 |
Link to standard |
Standard Type | Data Standard (NHS) |
|---|---|
Status |
Alpha | |
Effective Date |
|---|
Description
This information standard provides reference data about the Organisations that comprise the health and social care services, including non-direct-care Organisations, primarily in England but also in the other UK-constituent countries. The data is distributed and uploaded to health IT systems. It supports user security, access control, messaging and is used as reference data for both operations and reporting.
Applicability
All end-users of Organisation Reference Data. Including but not limited to: NHS Trusts, primary care & commissioning organisations, independent sector healthcare organisations, healthcare organisations in other UK-constituent countries, suppliers of systems, SUS/NTS & data set owners, social care, arms-length bodies, government departments & non-departmental public bodies, executive agencies, inspectorates, health and social care educational establishments, professional bodies, etc.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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 |
MUST |
ID | STD045 |
|---|---|
Standard Name | |
External ID | n/a |
Version | 0.1 |
Link to standard | |
Standard Type | Guidance |
Status |
Alpha | |
Effective Date |
|---|
Description
The Data Security and Protection Toolkit is an online self-assessment tool that enables organisations to measure and publish their performance against the National Data Guardian's ten data security standards.
Applicability
All organisations that have access to NHS patient data and systems must use this toolkit to provide assurance that they are practising good data security and that personal information is handled correctly.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
STD0045-1 | 10 Data Security Standards | MUST |
ID | STD056 |
|---|---|
Standard Name | |
External ID | DCB1567 |
Version | 0.1 |
Link to standard | |
Type | Mapped Standard |
Status |
Alpha | |
Effective Date |
|---|
Description
The National Joint Registry (NJR) has been in operation for 15 years and provides activity and outcome data about the orthopaedic sector.
...
The NJR provides a Bulk Upload service that enables units to upload data directly from a third party system (eg orthopaedic patient administration system) directly to the NJR, thus removing the need for double data entry. The transfer is enabled by the use of an XML messaging schema. The NJR has been in direct contact with the third party system suppliers since November 2017 and the new schema was provided to them in February 2018. The schema will be published on the NJR website following the publication of the Information Standards Notice (ISN) for any potential, new system providers. This Specification and the associated Change Specification relate only to changes to the data entry system and its underlying database.
Applicability
Surgeries for which data is collected:
Primary Ankle Replacement Surgery, Revision Ankle Replacement Surgery
Primary Elbow Replacement Surgery, Revision Elbow Replacement Surgery
Primary Hip Replacement Surgery, Revision Hip Replacement Surgery
Primary Knee Replacement Surgery, Revision Knee Replacement Surgery
Primary Shoulder Replacement Surgery, Revision Shoulder Replacement Surgery
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
STD0056-1 | National Joint Registry PATIENT CONSENT OBTAINED INDICATOR (NATIONAL JOINT REGISTRY RECORDING DATA) PERSON HEIGHT IN METRES And PERSON WEIGHT Or BODY MASS INDEX PERSON GIVEN NAME PERSON FAMILY NAME LOCAL PATIENT IDENTIFIER (NATIONAL JOINT REGISTRY) PERSON STATED GENDER CODE (NATIONAL JOINT REGISTRY) PERSON BIRTH DATE POSTCODE OF USUAL ADDRESS NHS NUMBER Or HEALTH AND CARE NUMBER ORGANISATION SITE IDENTIFIER (OF TREATMENT) PROCEDURE DATE ANAESTHETIC TYPE (JOINT REPLACEMENT) ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE (NATIONAL JOINT REGISTRY) OPERATION FUNDING (NATIONAL JOINT REGISTRY) CONSULTANT CODE (RESPONSIBLE CONSULTANT) CARE PROFESSIONAL CODE (OPERATING SURGEON) CARE PROFESSIONAL LEAD OPERATING SURGEON GRADE (JOINT REPLACEMENT) CARE PROFESSIONAL FIRST ASSISTANT GRADE (JOINT REPLACEMENT) | Various |
ID | STD062 |
|---|---|
Standard Name | |
External ID | ISB0149 |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date |
|---|
Description
This standard provides the specification for use of the NHS Number by NHS bodies and by other organisations providing health and care services in England in partnership with the NHS. It defines how the NHS Number must be used in identifying people receiving health and care services, and in locating and communicating their health and care records and other information pertaining to the planning and provision of their care. The standard sets out how information systems must accept, store, process, display and transmit the NHS Number, and what organisations must do to ensure that they use the NHS Number correctly.
Who this applies to
This standard applies to all bodies that commission or provide health and care services in England in partnership with the NHS including their relevant system suppliers.
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
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:
| 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 | ||
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 | SHOULD |
STD0062-16 | Data quality processes SHOULD be in place to resolve electronic patient/service user | 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 |
ID | STD064 |
|---|---|
Standard Name | |
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 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 |
ID | STD085 |
|---|---|
Standard Name | |
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 | STD021 |
|---|---|
Standard Name | |
External ID | DCB3058 |
Version | 0.1 |
Link to standard | |
Standard Type | Data Standard (NHS) |
Status |
Alpha | |
Effective Date |
|---|
Description
The national data opt-out policy enables patients to opt out from the use of their data for anything other than their individual care and treatment , for example research or planning purposes.
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 |
|---|---|---|
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 |
ID | STD080 |
|---|---|
Standard Name | |
External ID | SCCI0034 |
Version | 0.1 |
Link to standard |
Standard Type | Data Standard (NHS) |
|---|---|
Status |
Alpha | |
Effective Date |
|
|---|
Description
SNOMED CT is the fundamental standard for healthcare terminology. SNOMED CT provides the vocabulary for recording structured data in electronic records that relate to the health and care of an individual; it provides the clinical terms clinicians need to record to communicate key information to other clinicians.
The UK Edition of SNOMED CT must be used in the UK and not the International Edition. The UK Edition extends the International Edition with UK English descriptions (in preference to US English descriptions) and UK required components; for example clinical concepts such as PHE screening programmes are only provided by the UK Edition of SNOMED CT.
Applicability
This standard will be needed in all systems that are used in the direct management of the health and care of individuals.
Systems used within Secondary Care, Acute Care, Mental Health Services, Community Services, Dentistry and Optometry
Requirements
Requirement ID | Requirement Text | Level |
|---|---|---|
STD080-1 | Supplier systems used for the direct management of care of an individual - must use SNOMED CT as the clinical terminology standard within all electronic patient level recording and communications before 1 April 2020. | MUST |
STD080-2 | Systems used by all other providers of health related services where the flow of information for the direct management of patient care comes into the NHS must use SNOMED CT by 1 April 2020. | MUST |