[Archived] Standard Implementation - Care Record Coordination

[Archived] Standard Implementation - Care Record Coordination

This page has been superseded and archived.

Standards

ID

STD009

Standard Name

Birth Notifications (Personal Demographics Service)

External ID

N/A

Version

1.0

Link to standard

Personal Demographic Service - Birth Notifications

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

Requirement ID

Requirement Text

Level

STD009-1

Birth Notification

The trust MUST ensure Births registered to the Personal Demographics System

Birth Notification Application (BNA) Quick Reference Guide

MUST

ID

STD019

Standard Name

Emergency Care Dataset

External ID

N/A

Version

0.1

Link to standard

Emergency Care Data Set

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

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

Critical Care Minimum Data Set

External ID

ISB0153

Version

0.1

Link to standard

ISB0153 Critical Care Minimum Dataset

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:

(02) Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care

or

(03) Patients requiring advanced respiratory support alone or monitoring and support for two or more organ systems. This level includes all complex patients requiring support for multi-organ failure.

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

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

Information Sharing (FGM-IS) Local System Integration

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

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

Health and Social Care Organisation Reference Data

External ID

DAPB0090

Version

0.1

Link to standard

Health and Social Care Organisation Reference Data

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

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 at Health and Social Care Organisation Reference Data

MUST

ID

STD045

Standard Name

Data Security and Protection Toolkit

External ID

n/a

Version

0.1

Link to standard

Data Security and Protection Toolkit

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

Description

The National Joint Registry (NJR) has been in operation for 15 years and provides activity and outcome data about the orthopaedic sector.

Hip, knee, ankle, elbow and shoulder joint replacements have become common operations, using a wide range of implants. The NJR helps to monitor the performance of these implants and the effectiveness of different types of surgery, improving clinical standards and benefiting patients, clinicians and the orthopaedic sector as a whole.

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

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

NHS Number

External ID

ISB0149

Version

0.1

Link to standard

ISB 0149 NHS Number

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

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:

  • 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.