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					Dietetic Diabetes Extension
NCDDP Formal Name            Common Name(s)       Definition of NCDDP data Standard
Address (BS7666)             Structured Address   Definition:
                                                  A collection of data describing the
                                                  addressing of locations.




Alcohol Intake per Average   Alcohol Intake       Definition:
Week                                              The amount of alcohol consumed by a
                                                  patient, measured in units, per average
                                                  week.




Appointment Type                                  Definition:
                                                  Indicates whether the person's
                                                  appointment is a first (new)
                                                  appointment or review (return/ follow-
                                                  up) appointment.
Associated Person        Other person   Definition:
                                        People who have a significant
                                        involvement or relationship with the
                                        client/patient (e.g. main carer, next of
                                        kin, key holder, emergency contact,
                                        etc). This includes professionals who
                                        are not involved in the care of the
                                        client/patient e.g. accountant, lawyer.




Associated Person Role   Person Role    Definition:
                                        A description of the particular
                                        involvement(s) with/ function(s) fulfilled
                                        by an associated person towards the
                                        client/ patient.
Associated Professional       Associated Care      Definition:
                              Professional, Care   Associated Professionals are those
                              Professional         individuals who are involved with the
                                                   client/ patient in a professional capacity
                                                   e.g. consultant, social worker,
                                                   occupational therapist, etc.
Associated Professional Group Associated Care      Definition: The recognised
                              Professional Group   professional group to which the care
                                                   professional belongs and in which they
                                                   are employed.
Associated Proffesional   Associated Care            Definition: The unique identifier
Identifier                Professional Identifier,   issued to all health and social care
                          Professional               professionals by their professional
                          Registration               regulatory body.
                          Number/Identifier




Basal Metabolic Rate      BMR                        Definition:
(Schofield Equation)                                 Basal Metabolic Rate (BMR) is the
                                                     amount of energy which is needed to
                                                     maintain physiological equilibrium
                                                     while lying at rest in a fasted state
                                                     (kcal/day).
Body Mass Index              BMI                 Definition:
                                                 Body Mass Index (BMI) =
                                                 weight/height² (kg/m²)




Carbohydrate Value of Meal   CHO Value of Meal   Definition:
                                                 The total carbohydrate value of the
                                                 food items in a meal.
CHI Number                       Definition:
                                 The Community Health Index (CHI) is
                                 a population register, which is used in
                                 Scotland for health care purposes.
                                 The CHI number uniquely identifies a
                                 person on the index.




Clinic Code                      Definition:
                                 A code assigned locally to identify a
                                 clinic session or group of clinic
                                 sessions




Combined Activity and Diet-      Definition:
induced Thermogenesis Factor     A factor by which the basal metabolic
                                 rate can be adjusted to take into
                                 consideration patient mobility and
                                 physical activity, combined with diet-
                                 induced thermogenesis.

Compliance-influencing Factors   Definition:
                                 Records any factors that may influence
                                 the achievement of the agreed goals
Confidence in Ability to Change   Definition:
                                  An assessment of the confidence in
                                  the ability to change using the
                                  confidence ruler which is on a scale of
                                  1 to 10, 10 being very confident.

Contact Category                  Definition:
                                  A description of whether the care
                                  professional contact occurs with the
                                  client/patient(s) themselves or another
                                  person on behalf of the client/ patient.




Contact Mode                      Definition:
                                  A record of the manner and/or setting
                                  of the contact.




Contact Status                    Definition:
                                  A record of whether or not the patient/
                                  client attended for their appointment or
                                  was present for a planned home visit.
Contact Type            Definition:
                        An indication of whether a contact for
                        the purpose of care and/or assessment
                        is with an individual client/ patient or
                        more than one person.




Correction Bolus Dose   Definition:
                        An insulin dose taken to reduce a high
                        blood glucose level (units).
Current Alcohol Drinking Status Alcohol Status,   Definition:
                                Alcohol Intake    Record of the individual's current
                                                  alcohol consumption in relation to
                                                  prevailing guidelines, with reference to
                                                  any past excessive alcohol
                                                  consumption.
Current or Recommended Food                          Definition:
Intake                                               Records whether the dietary record is
                                                     current or recommended.




Current Physical Activity Status Physical Activity   Definition:
                                                     All movements in everyday life,
                                                     including work, recreation, exercise,
                                                     and sporting activities (World Health
                                                     Organization definition of physical
                                                     activity).
                                                     http://www.who.int/topics/physical_acti
                                                     vity/en/).
Current Tobacco and Nicotine   Tobacco           Definition:
Consumption Status             Consumption,      Tobacco consumption at date of
                               Tobacco Status,   contact including smoking, chewing
                               Smoking Status    and use of other nicotine substances
Date                             Definition:
                                 The day, month, year and century, or
                                 truncated combination of these
                                 elements, of an
                                 event.




Date of Contact   Contact Date   Definition:
                                 The date on which a contact took place
                                 between a patient/client and an
                                 individual care professional for the
                                 purpose of care. A contact can take
                                 place when the Health Care
                                 Professional (HCP) is on care
                                 premises or visiting the patient and
                                 may be in person, by telephone, e-
                                 mail, letter, text message or
                                 telemedicine.
Date of Referral   Referral Date, Date of Definition:
                   Patient Referral       The date on which a referral
                                          communication to a care professional,
                                          team, service or organisation is
                                          completed by the referral
                                          source/referrer
Date Referral Received   Referral Request          Definition:
                         Received Date, Date       The date on which a referral
                         of Receipt of Referral,   communication is first received by the
                         Date Referral             organisation, service, team or care
                         Received by               professional, either via letter, electronic
                         Department                communication or verbally
Diabetes Mellitus Type   Type of Diabetes   Definition: Classifies the type of
                         Mellitus           diabetes mellitus according to the
                                            World Health Organisation (WHO).
Dietary Education Topics   Definition:
                           Topics of dietary education discussed.




Dietary Target Met         Definition:
                           Records that the dietary target has
                           been met.




Dietary Target Set         Definition:
                           Records whether or not a dietary target
                           has been set.
Education Literature Medium                           Definition:
                                                      The medium used to give the
                                                      educational literature.




Education Topic (Literature)                          Definition:
                                                      The topics of education delivered




Estimated Total Energy           Estimated TEE,       Definition:
Expenditure                      Estimated Total EE   The amount of energy spent, on
                                                      average, in a typical day (kcal/day).




Estimated Total Energy of Food                        Definition:
Portions                                              Records the estimated total energy
                                                      from the food portions for various food
                                                      groups.
Ethnic Group (Self Assigned)   Definition:
                               A statement made by the service user
                               about their current ethnic group.
Follow-up Type            Definition:
                          The type of follow-up.




Food Components of Meal   Definition:
                          The name of the food items in a meal.




Food Diary Given          Definition:
                          Records whether or not the patient has
                          been given a food diary.




Food Group - Number of    Definition:
Portions                  Records the number of portions for the
                          various food groups.
General Practice Registration   Practice Registration   Definition:
Status of Patient               Status                  The registration status of the patient
                                                        with the general practice from which
                                                        they are receiving care.
Glycaemic Index Assessment                     Definition:
                                               A ranking system of carbohydrate
                                               foods based on their overall effect on
                                               blood glucose levels.




Glycated Haemoglobin         HbA1c             Definition: Glycated haemoglobin
                                               refers to the measurement of HbA1c
                                               (not HbA1) and recorded as a
                                               percentage.

GP General Medical Council   GP GMC Number     Definition:
Number                                         The GMC (General Medical Council)
                                               number is the personal identification
                                               number issued to each doctor in the
                                               UK by the General Medical Council.




Health Record Identifier     Case Reference    Definition:
                             Number, CRN,      A Patient Health Record Identifier is a
                             Hospital Number   code (set of characters) used to
                                               uniquely identify a patient within a
                                               health register or a HEALTH
                                               RECORDS SYSTEM, e.g. PAS.
Height                              Definition:
                                    Height in metres (to the nearest
                                    centimetre) - measured without shoes




Impairment   Impairment Indicator   Definition:
                                    An indicator of whether the
                                    client/patient has any impairment,
                                    which may affect the ability of
                                    professionals to communicate with the
                                    client/patient, or may impact on the
                                    assessment process or the delivery of
                                    services.
Importance of Change                             Definition:
                                                 An assessment of the importance to
                                                 change using the importance ruler,
                                                 which is on a scale of 1 to 10, 10 being
                                                 very important.


Index of Deprivation Score   Deprivation Index   Definition:
{Diabetes Dietetic}          Score               Records the Index of Deprivation
                                                 Score obtained for the patient using
                                                 either the Carstairs 2001 Index or the
                                                 Scottish Index of Multiple Deprivation
                                                 (SIMD 2004).
Index of Deprivation Type    Deprivation Index   Definition:
{Diabetes Dietetic}          Type                Type of 'area-based' index used to
                                                 measure deprivation.
Insulin:Carbohydrate Ratio                   Definition:
                                             A ratio that shows how many units of
                                             insulin a person needs to take to cover
                                             a specified number of carbohydrate
                                             grams (units/g).




Internet Email Address       Email Address   Definition: The string of characters
                                             that identifies an addressee's post box
                                             on the Internet.




Internet Email Address
Location Code         Location, Location of   Definition:
                      Contact                 This is the reference number of any
                                              building or set of buildings where
                                              events pertinent to NHS Scotland take
                                              place. Locations include hospitals,
                                              health centres, GP surgeries, clinics,
                                              NHS board offices, nursing homes,
                                              schools and patient/client's home.




Location of Contact                           Definition:
                                              Records the type of location where the
                                              contact with the person took place.
Non-specialist Tobacco and    Smoking Cessation   Definition:
Nicotine Consumption Advice   Advice              Record of the tobacco and nicotine
                                                  consumption advice given by a health
                                                  care professional (who is not part of a
                                                  Smoking Cessation Service).




Number of Days Per Average                        Definition:
Week Alcohol Consumed                             Records the number of days a week
                                                  that the person consumes alcohol.
Nutritional Screening Score   Definition:
                              Records a score using a nutritional
                              screening tool for identifying clinical
                              characteristics known to be associated
                              with malnutrition.




Nutritional Screening Tool    Definition:
                              Records the specific nutritional
                              screening tool used for deriving the
                              score.




Occupation                    Definition:
                              The current and/ or previous relevant
                              occupation(s) of the patient/client, as
                              described by them.
Patient Agreed Goals                   Definition:
                                       Specific, measurable, achievable and
                                       realistic goals agreed during
                                       consultation between patient and HCP.
                                       These may relate to aspects such as
                                       lifestyle and disease management.

Person Birth Date      Date of Birth   Definition:
                                       The date on which a person was born
                                       or is officially deemed to have been
                                       born, as recorded on the Birth
                                       Certificate




Person Birth Date
Person Current Gender   Current Gender   Definition:
                                         A statement by the individual about the
                                         gender they currently identify
                                         themselves to be (i.e. self-assigned).
Person Death Date                      Definition:
                                       The date on which a person died or is
                                       officially deemed to have died, as
                                       recorded on the Death Certificate.




Person Family Name   Surname, Family   Definition:
                     name              That part of a person's name which is
                                       used to describe family, clan, tribal
                                       group, or marital association
Person Full Name        Full Name         Definition:
(Unstructured)                            The full name of a person. This is an
                                          unstructured concatenation of some or
                                          all of the Person Title, Person Given
                                          Name, Person Family Name and
                                          Person Name Suffix elements, or other
                                          elements that make up a person's full
                                          name.




Person Given Name       Forename, Given   Definition:
                        Name, Personal    The forename or given name of a
                        Name              person




Person Marital Status   Marital Status    Definition:
                                          An indicator to identify the legal marital
                                          status of a person.
Person Preferred Forename   Preferred Forename, Definition:
                            Known as (Forename) The forename by which a person
                                                prefers to be called if different from first
                                                forename.




Person Title                Title                  Definition:
                                                   Standard form of address used to
                                                   precede a person's name.
Postcode   Definition:
           The code allocated by the Post Office
           to identify a group of postal delivery
           points.
Preferred Language   Definition:
                     The person's language of preference
                     and may differ from first language and
                     is required for effective communication
                     with the person.
Previous Person Family Name     Previous Surname,    Definition:
                                Family Name          That part of a person's name used to
                                                     describe family, clan, tribal group, or
                                                     marital association, and by which a
                                                     person was previously known.




Pubertal Status                                      Definition:
                                                     A record of the stage of puberty
                                                     reached by the patient.




Reason for Referral {Diabetes   Reason for Contact   Definition:
Dietetic}                                            The reason(s) for the patient/ client
                                                     requiring involvement with care
                                                     professionals. These may include any
                                                     problem, issue or event affecting the
                                                     patient/ client's health and/ or well
                                                     being.
Recorded Period of Food                         Definition:
Portion Intake                                  The period over which the food intake
                                                portions are recorded.




Referral Source           Referred by, Source   Definition:
                          of Referral           The type of organisation, service, care
                                                professional or other individual making
                                                a referral.
Registered GP Practice Code   Registered GP   Definition:
                              Practice        General Medical Practitioners provide
                                              general medical services to the
                                              population either in partnership with
                                              other GMPs or on a single handed
                                              basis. Each GP practice in Scotland is
                                              identified by a unique GP practice
                                              code.




Religion                                      Definition:
                                              A statement made by the service user
                                              about their current religious affiliation /
                                              faith community.
Stress Factor   Definition:
                A factor by which the basal metabolic
                rate can be adjusted to take into
                consideration patient stress from injury,
                wound, disease or weight gain/ loss.
Structured Name          Person Title         Definition:
                         Person Family Name   An ordered sequence of person name
                         Person Given Name    elements such as title, forename(s)
                                              and family name




Target Weight                                 Definition:
                                              The weight target level set for the
                                              patient as part of the care plan (kg).



Telephone Contact Type




Time of Meal                                  Definition:
                                              The time of day that the meal is
                                              consumed.



Type of Meal                                  Definition:
                                              Records the type of meal.
Type of Specific Dietary Advice   Definition:
Given {Diabetes}                  Specific topics of dietary advice
                                  discussed.
UK Postal Address   Unstructured Address/ Definition:
                    Simple address        The address of a postal delivery point.
                                          This is usually a building and usually
                                          comprises a name/number, street,
                                          town and county/state/province and
                                          sometimes country. This is not the
                                          preferred e-GIF standard.
UK Telephone number   Telephone Number   Definition:
                                         A number, including any exchange or
                                         location code, at which a person or
                                         organisation can be contacted in the
                                         UK by telephonic means.




Waist Circumference                      Definition:
                                         Waist circumference measured half
                                         way between costal margin and iliac
                                         crest (cm).




Weight                                   Definition:
                                         Weight in kilograms taken without
                                         shoes or outdoor clothing
Weight Change                  Definition:
                               Percentage weight change since last
                               record (%).



Year Patient Stopped Smoking   Definition:
{Diabetes}                     The actual or estimated year in which
                               the patient stopped smoking.
                         Hyperlink to NCDDP item on Data
Format & Field Length                                          Codes & Values
                         Dictionary
Format                   http://www.datadictionaryadmin.scot.n 00 None
Address (BS7666) - see   hs.uk/isddd/11214.html                01 Normal domicile address
Government Data                                                02 Alternative contact address
                                                               03 Non-domicile address
                                                               04 Invoiced address
                                                               05 Employer¿s address
                                                               06 Temporary domicile address
                                                               07 Professional contact address
                                                               08 No fixed abode
                                                               97 Not disclosed
                                                               98 Not known
Format: Numeric (nnn)    http://www.datadictionaryadmin.scot.n
Field Length: 3          hs.uk/isddd/12157.html




Format: Characters       http://www.datadictionaryadmin.scot.n 01 First e.g. new appointment
                         hs.uk/isddd/14226.html
Field Length: 2


                                                               02 Review e.g. return or follow-up
                                                               appointment
Format: N/A          http://www.datadictionaryadmin.scot.n
Field Length: N/A    hs.uk/isddd/11744.html




Format: Characters   http://www.datadictionaryadmin.scot.n 00 - No role The person does not
Field Length: 3      hs.uk/isddd/11746.html                carry out any particular role for the
                                                           client/patient.




                                                             01 - Carer
                                                             01A Main carer The main carer of the
                                                             client/patient.
                                                             01B Secondary carer Any carer of the
                                                             client/patient other than the main
                                                             carer.
                                                             02 - Key holder
02A Main key holder - A person
holding keys which allow admittance
to the client/patient's normal place of
residence, and who would usually be
the first to be contacted by anyone
requiring legitimate admittance.

02B Additional key holder Any person
holding keys which allow admittance
to the client/patient's normal place of
residence, other than the main key
holder.
03 - Appointed representative
03A Advocate - A person who can
communicate on behalf of a
client/patient who has difficulty in
doing so, to ensure that their
opinions, wishes and needs are taken
into account. An advocate cannot
make decisions on behalf of the
client/patient for whom they speak.

03B Proxy - A person with the power
to take decisions or act on behalf of a
client/patient who does not have the
capacity to do so for him/herself. The
power may have been granted by the
incapable client/patient when they still
had the power to do so, as in
Continuing Power of Attorney or
Welfare Power of Attorney, or the
proxy may have been appointed by
the courts as a financial Guardian or
a Welfare Guardian under the Adults
with Incapacity Act 2000. A
client/patient with mental health
problems subject to a statutory order
may appoint a 'named person' as
their proxy.

04 - Emergency contact - A person
who may be contacted in the event of
an accident, emergency or crisis
befalling the client/patient.
05 - Person with parental
responsibility - Parental
responsibility involves:· safeguarding
and promoting the child's health,
development and welfare;· providing
direction and guidance;· acting as the
child's legal representative;· if the
child is not living with the parent,
maintaining personal relations and
direct contact with the child on a
regular basis A person with parental
responsibility, in order to enable him
to fulfil his parental responsibilities,
has the right:· to have the child living
with him or otherwise to regulate the
child's residence;· to control, direct or
guide the child's upbringing Parental
responsibilities are held automatically
by the following:· a mother· a father if
married to the mother at the time of
the child's conception or
subsequently· an unmarried father
who by agreement with the mother
has been registered in the Books of
Council and Session as the child's
father· a guardian who is a person
appointed by a parent to act in the
parent's place in the event of his or
her death



06 - Relevant person - The term
"relevant person" is used for the
purposes of legal proceedings,
particularly children's hearings, and
includes:· any person who has
parental responsibilities under Part 1
of the Children (Scotland) Act 1995·
any other adult with parental
responsibilities and rights· any person
who appears to be a person who
ordinarily has charge of, or control
over, the child other than by reason
only of his or her employment ·
following the outcome of a case in the
Court of Session, foster parents who
have looked after a child for a period
of approximately seven months or
longer
                                                             07 - Next of kin - The next of kin
                                                             should be nominated by the person
                                                             (patient/client). Where no nomination
                                                             has been made, a next of kin default
                                                             can be identified, which is likely to be
                                                             the person most closely related to the
                                                             patient/client.

                                                             98 - Other specific role - Any other
                                                             role not covered by the above
                                                             categories.
                                                             99 - Not known
Format: N/A          http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/11750.html
Field Length: N/A



Format: Characters   http://www.datadictionaryadmin.scot.n 01 - Medical Doctor
                     hs.uk/isddd/11754.html
Field Length: 3




                                                             02 - Dentist
                                                             03 - Registered Nurse
                                                             04 - Registered Midwife
                                                             05 - Biomedical Scientist
                                                             06 - Chiropodist/Podiatrist
                                                             07 - Clinical Scientist
                                                             08 - Dietician
                                                             09 - Occupational Therapist
                                                             10 - Operating Department
                                                             Practitioner
11 - Orthoptist
12 - Orthotist
13 - Paramedic
14 - Pharmacist
15 - Pharmacy Technician
16 - Physiotherapist
17 - Prosthetist
18 - Psychologist
18A Psychologist - Clinical
18B Psychologist - Educational
19 - Public Health Practitioner
20 Radiographer
20A Radiographer - Diagnostic
20B Radiographer - Therapeutic
21 - Specialty Community Public
Health Nurse
22 - Speech & Language Therapist
23 - Other Healthcare Professionals
who have direct patient contact
24 - Arts Therapist
25 Complementary and Alternative
Medicine Therapist
26 - Social Care Professional
27 - Teacher
98 - Other
99 - Not Known
Format: Characters (right   http://www.datadictionaryadmin.scot.n
justified)                  hs.uk/isddd/11752.html

Field Length: 8




Format: Numeric             http://www.datadictionaryadmin.scot.n
                            hs.uk/isddd/14786.html
Field Length: 5
Format: nn.n         http://www.datadictionaryadmin.scot.n
Field Length: 3      hs.uk/isddd/11186.html




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14334.html
Field Length: 198
Format: Characters   http://www.datadictionaryadmin.scot.n
Field Length: 10     hs.uk/isddd/11203.html




Format characters    http://www.datadictionaryadmin.scot.n
Field Length; 15     hs.uk/isddd/12579.html




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14802.html
Field Length: 198




Format: Characters   http://www.datadictionaryadmin.scot.n 01 Caring Issues
                     hs.uk/isddd/14877.html
Field Length: 2



                                                             02 Lives Alone
                                                             03 Shift Worker
                                                             04 Language Barriers
                                                             05 Financial Barriers
                                                             06 Cannot Read
                                                             07 Poor Motivation
                                                             08 Learning Difficulties
                                                             09 Cognitive Difficulties
                                                             10 Sensory Impairment
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14870.html
Field Length: 2



Format: Characters   http://www.datadictionaryadmin.scot.n 01 Direct contact A contact between a
                     hs.uk/isddd/11861.html                care professional and a client/patient
Field Length: 2



                                                           02 Indirect contact A contact between
                                                           a care professional and another
                                                           person on behalf of a client/patient,
                                                           e.g. parent, carer.
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Face to face A meeting between a
                     hs.uk/isddd/11863.html                healthcare profession and a client/
Field Length: 2                                            patient or their carer



                                                             02 Email A communication sent via
                                                             email to a client/ patient or carer (this
                                                             does not include issuing appointment
                                                             cards)
                                                             03 Letter A letter is written to a client/
                                                             patient or carer (this does not include
                                                             issuing appointment cards)

                                                             04 Telephone Contact is by means of
                                                             a telephone conversation (this does
                                                             not include arranging appointments)

                                                           05 Video link Contact is by means of
                                                           a video link (e.g. telemedicine)
                                                           06 Text message Contact is by
                                                           means of a SMS text message
                                                           07 2-way radio e.g. ship-to-shore
                                                           communication
Format Characters    http://www.datadictionaryadmin.scot.n 01 Attended
Field Length 2       hs.uk/isddd/33670.html



                                                             02 Could not wait (CNW) Patient
                                                             attended but could not wait and was
                                                             not seen
                                                             03 Attended without appointment
                                                             Patient attended without an
                                                             appointment and was seen
                                                             04 Did not attend (DNA) Patient did
                                                             not attend and gave no prior warning

                                                             05 Could not attend and cancelled
                                                             appointment (CNA) Patient could not
                                                             attend the appointment offered.
                                                             Appointment cancelled by, or on
                                                             behalf of, the patient in advance
                                                             06 Appointment cancelled or
                                                             postponed by the service
                                                             07 Failed access/Waste visit Patient
                                                             was not present/ not available at their
                                                             home at time of contact

Format: Characters   http://www.datadictionaryadmin.scot.n 01 Individual A contact with a client/
                     hs.uk/isddd/16750.html                patient and/ or representative, alone
Field Length: 2




                                                             02 Group A contact as part of an
                                                             arranged group session with other
                                                             clients/ patients and/ or carers
                                                             03 Family A contact with a client/
                                                             patient, carer or other family
                                                             member(s) as part of a specific family
                                                             session
                     http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14341.html
Format: Characters   http://www.datadictionaryadmin.scot.n 00 Non drinker Teetotal - individual
Field Length: 2      hs.uk/isddd/11269.html                does not currently and has never
                                                           drunk alcohol




                                                           01 Ex-drinker Has not drunk alcohol
                                                           for at least 12 months
                                                           02 Current non-drinker Has stopped
                                                           drinking alcohol within the past 12
                                                           months
                                                           03 Currently within recommended
                                                           daily and weekly limits Alcohol
                                                           consumption is within the bounds of
                                                           current national recommendations.

                                                           04 Currently exceeds daily
                                                           recommended limits Alcohol
                                                           consumption is in excess of current
                                                           national daily recommendations, but
                                                           is within weekly recommended limits.

                                                           05 Currently exceeds weekly
                                                           recommended limits Alcohol
                                                           consumption is in excess of current
                                                           national weekly recommendations,
                                                           but is within daily recommended
                                                           limits.
                                                           06 Currently exceeds both weekly
                                                           and daily recommended limits Alcohol
                                                           consumption exceeds both current
                                                           daily and weekly national
                                                           recommendations.
                                                           97 Not disclosed Patient chose not to
                                                           disclose this information
                                                           99 Not known
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Current
                     hs.uk/isddd/14321.html
Field Length: 2



                                                           02 Recommended
Format: Characters   http://www.datadictionaryadmin.scot.n 00 Incapable of physical exercise e.g.
Field Length: 2      hs.uk/isddd/22873.html                bed-bound




                                                           01 Sedentary No leisure time or
                                                           occupational physical activity
                                                           02 Insufficiently active Some leisure
                                                           time or occupational physical activity

                                                           03 Moderately active Meeting
                                                           moderate physical activity guidelines
                                                           04 Vigorously active Meeting vigorous
                                                           physical activity guidelines
                                                           97 Not disclosed Patient refused to
                                                           disclose this information
                                                           99 Not known
Format: Characters   http://www.datadictionaryadmin.scot.n 00 No use Never used tobacco or any
Field Length: 2      hs.uk/isddd/26508.html                nicotine containing substances of any
                                                           kind - may have tried once or twice




                                                          97 - Patient declined
                                                          99 - Not known
                                                          Chewing - Chewing tobacco possibly
                                                          together with other substances

                                                          20 Never chewed May have tried
                                                          chewing once or twice
                                                          21 Ex-chewer Has not chewed for at
                                                          least 12 months
                                                          22 Current non-chewer Has not
                                                          chewed within the past 12 months
                                                          23 Current chewer
                                                          Other nicotine containing substances -
                                                          e.g. chewing gum or nicotine patches
                                                          (non therapeutic use)

                                                          40 Never used other nicotine
                                                          containing substances May have tried
                                                          once or twice
41 Ex-user of other nicotine
containing substances Has not used
for at least 12 months
42 Current non-user of other nicotine
containing substances Has not used
within the past 12 months
43 Current user of other nicotine
containing substances
Smoking - Includes cigarettes, cigars
and pipes, possibly together with
other substances
10 Never smoked May have tried
smoking once or twice
11 Ex-smoker Has not smoked for at
least 12 months
12 Current non-smoker Has stopped
smoking within the past 12 months

13 Current smoker
Snuff
30 Never used snuff May have tried
once or twice
31 Ex-user of snuff Has not used for
at least 12 months
32 Current non-user of snuff Has not
used within the past 12 months
33 Current user of snuff
Format: Characters (CCYY- http://www.datadictionaryadmin.scot.n
MM-DD, CCYY-MM or         hs.uk/isddd/11952.html
CCYY)

Field Length: 10




Format;                   http://www.datadictionaryadmin.scot.n
Characters (CCYY-MM-      hs.uk/isddd/11841.html
DD)
Field Length; 10
Format: characters (CCYY- http://www.datadictionaryadmin.scot.n
MM-DD)                    hs.uk/isddd/12581.html

Field Length: 10
Format: characters (CCYY- http://www.datadictionaryadmin.scot.n
MM-DD)                    hs.uk/isddd/12583.html

Field Length: 10
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Type 1 Diabetes Mellitus Type 1
                     hs.uk/isddd/13332.html                diabetes includes all diabetes due to
Field Length: 3                                            absolute insulin deficiency caused by
                                                           a) autoimmune pancreatic destruction
                                                           and b) idiopathic where there is no
                                                           evidence of autoimmunity or other
                                                           identifiable cause.




                                                           02 Type 2 Diabetes Mellitus Type 2
                                                           diabetes includes those forms of
                                                           diabetes with insulin resistance and
                                                           an insulin secretary defect.
                                                           03 Gestational Diabetes first
                                                           recognised during pregnancy.
                                                           Diagnostic criteria differ from non-
                                                           pregnant state: venous plasma
                                                           glucose >5.5mmol/l fasting OR
                                                           >9.0mmol/l 2 hours after 75g OGTT -
                                                           SIGN Guideline 55, 2001. (Note: this
                                                           differs from current WHO diagnostic
                                                           criteria for GDM).
04 Maturity Onset Diabetes of Youth
MODY refers to forms of diabetes
associated with mono-genic defects
in pancreatic beta cell function,
characterised by onset of
hyperglycaemia at a young age
(typically less than 25 years), and an
autosomal dominant inheritance
pattern. Mutations at a number of
discrete genetic loci on different
chromosomes have been identified.

04A HNF4a Insulin secretory defect
due to a mutation within the HNF4a
gene.
04B Glucokinase deficiency Blood
glucose sensing defect due to a
mutation in the glucokinase gene.
Causes mild non progressive
hyperglycaemia that is present from
birth.
04C HNF1a Insulin secretory defect
due to a mutation within the HNF1a
gene.
04D IPF1 Insulin secretory defect due
to a mutation within the IPF1 gene.

04E HNF1b Insulin secretory defect
due to a mutation within the HNF1b
gene.
04F NeuroD1 Insulin secretory defect
due to a mutation within the NeuroD1
gene.
05 - Other Specific Diabetes Mellitus

05A Pancreatic Pathology Diabetes
caused by primary pancreatic disease
e.g. chronic pancreatitis, pancreatic
carcinoma.
05B Secondary - Drug Induced
Diabetes secondary to specific drug
therapies.
05C Secondary - Disease Includes
diabetes secondary to specific
diseases, e.g. cystic fibrosis,
Cushing's syndrome,
haemochromatosis.
98 Other Includes diabetes
associated with recognised genetic
syndromes.
99 Not Known Includes where the
patient's diabetes mellitus has not yet
been classified.
Format: Characters   http://www.datadictionaryadmin.scot.n 01 - Current Dietary Guidlines
                     hs.uk/isddd/14826.html
Field Length: 3



                                                           01A Carbohydrate management
                                                           01B Fats
                                                           01C Protein
                                                           01D Vitamins and minerals
                                                           01E Fruits and vegetables
                                                           01F Alcohol
                                                           02 - Weight Management
                                                           02A Prescriptive
                                                           02B General
                                                           03 - Pregnancy
                                                           03A Pre-conceptional counselling
                                                           03B General pregnancy advice
                                                           04 - Lipid Lowering
                                                           04A Cholesterol lowering
                                                           04B Triglyceride lowering
                                                           05 - Renal
                                                           05A Renal impairment
                                                           05B Conservative management
                                                           05C Haemodialysis
                                                           05D Peritoneal Dialysis
                                                           06 - Nutritional Support
                                                           06A Supplemented intake
                                                           06B Complete nutrition
                                                           06C Texture modification
                                                           07 - Disordered Eating
                                                           07A Anorexia nervosa
                                                           07B Bulimia nervosa
                                                           07C Binge eating disorder
                                                           08 - Food Allergy/Intolerance
                                                           08A Food allergy
                                                           08B Food intolerance
                                                           08C Food sensitivity
                                                           09 Sport and Activity
Format: Characters   http://www.datadictionaryadmin.scot.n 00 No
                     hs.uk/isddd/14845.html
Field Length: 2



                                                           01 Yes
Format: Characters   http://www.datadictionaryadmin.scot.n 00 No
                     hs.uk/isddd/14841.html
Field Length: 2



                                                           01 Yes
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Paper Includes leaflets, booklets
                     hs.uk/isddd/14822.html                and charts
Field Length: 2



                                                           02 Video
                                                           03 Cassette Tape
                                                           04 CD
                                                           05 DVD
                                                           06 Website Details
                                                           07 Foreign Language
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Healthy Eating
                     hs.uk/isddd/14812.html
Field Length: 2



                                                             02 Carbohydrate Information
                                                             03 Lipids
                                                             04 Salt
                                                             05 Illness
                                                             06 Renal
                                                             07 Hypoclycaemia
                                                             08 Activity
                                                             09 Food Labelling
                                                             10 Pregnancy
                                                             11 Weight Reduction
                                                             12 Nutritional Support
                                                             13 Gluten Free
                                                             14 Food Diary
                                                             98 Other
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14805.html
Field Length: 198




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14313.html
Field Length: 2
Format: Characters           http://www.datadictionaryadmin.scot.n 01 - White
Field Length: Up to 6 (2 +   hs.uk/isddd/11139.html
4)




                                                                  01E002 Irish
                                                                  01E004 Scottish
                                                                  01E039 Any other White background
                                                                  See recording guidance

                                                                  01E070 Other British
                                                                  02 - Mixed
                                                                  02E029 Any Mixed background See
                                                                  recording guidance
                                                                  03 - Asian, Asian Scottish or Asian
                                                                  British
                                                                  03E041 Indian
                                                                  03E042 Pakistani
                                                                  03E043 Bangladeshi
                                                                  03E059 Any other Asian background
                                                                  See recording guidance

                                                                  03E081 Chinese
                                                                  04 - Black, Black Scottish or Black
                                                                  British
                                                                  04E061 Caribbean
                                                                  04E062 African
                                                             04E069 Any other Black background
                                                             See recording guidance

                                                             05 - Other Ethnic Background
                                                             05E089 Any other ethnic background
                                                             See recording guidance

                                                           97 - Not disclosed
                                                           99 - Not known
Format               http://www.datadictionaryadmin.scot.n 01 - Telephone
Characters           hs.uk/isddd/14904.html
Field Length
2




                                                             02 - Diabetic Clinic
                                                             02A Diabetic Clinic (Hospital)
                                                             02B Diabetic Clinic (GP)
                                                             03 - Diabetes Centre
                                                             04 - Diabetes/ Obstetrics Clinic
                                                             05 - Diabetes/ Renal Clinic
                                                             06 - Inpatient Review
                                                             07 - Home Visit
                                                             08 - Care Home Visit
                                                             09 - School Visit
                                                             10 - Video Link
                                                             98 - Other
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14332.html
Field Length: 198



Format: Characters   http://www.datadictionaryadmin.scot.n 00 No
                     hs.uk/isddd/14849.html
Field Length: 2



                                                           01 Yes
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Bread/ Cereal/ Potatoes
                     hs.uk/isddd/14310.html
Field Length: 2



                                                             02 Milk/ Dairy
                                                             03 Fruit
                                                             04 Added Sugars
                                                             05 Meats
                                                             06 Poultry
                                                             07 Fish
                                                           08 Fats - Saturated
                                                           09 Fats - Poly, Mono, Hidden
                                                           10 Vegetable/ Salads
                                                           11 Salts
                                                           12 Alcohol Units
Format: Characters   http://www.datadictionaryadmin.scot.n 01 - Permanently registered
Field Length: 3      hs.uk/isddd/11742.html




                                                          02 - Permanent registration
                                                          discontinued
                                                          02A - Permanent registration
                                                          discontinued Transferred to another
                                                          GP Includes patients moving
                                                          elsewhere in the UK or abroad
                                                          02B - Permanent registration
                                                          discontinued Patient died
                                                          03 - Temporarily registered
                                                          03A - Temporarily registered
                                                          Temporary resident Includes patients
                                                          on holiday
                                                          03B - Temporarily registered
                                                          Immediate necessary treatment e.g.
                                                          emergency patient
                                                          03C - Temporarily registered
                                                          Maternity services
                                                          03D - Temporarily registered
                                                          Contraceptive services
                                                          03E - Temporarily registered Child
                                                          health surveillance
                                                          03F - Temporarily registered Health
                                                          promotion clinic
                                                          03G - Temporarily registered Travel
                                                          vaccination
                                                          03H - Temporarily registered Other
                                                          enhanced services
                                                          99 - Not known
Format: Characters          http://www.datadictionaryadmin.scot.n 01 High
                            hs.uk/isddd/14316.html
Field Length: 2




                                                                    02 Medium
                                                                    03 Low
Format: Numeric (nn.n)      http://www.datadictionaryadmin.scot.n
                            hs.uk/isddd/14314.html
Field Length: 3


Format: Characters (right   http://www.datadictionaryadmin.scot.n
justified)                  hs.uk/isddd/11293.html
Field Length: 8




Format: Characters          http://www.datadictionaryadmin.scot.n
Field Length;14             hs.uk/isddd/11299.html
Format: n.nn        http://www.datadictionaryadmin.scot.n
Field Length: 3     hs.uk/isddd/11182.html




Format:Characters   http://www.datadictionaryadmin.scot.n 00 None
                    hs.uk/isddd/11943.html
Field Length: 2




                                                            01 Specific learning difficulties
                                                            02 Hearing impairment
                                                            03 Language and communication
                                                            disorder
                                                            04 Physical or motor impairment
                                                            05 Visual Impairment
                                                            06 Cognitive impairment
                                                            07 Combined sight and hearing loss
                                                            (see further information)
                                                            98 Other impairment (specify
                                                            separately)
                                                             99 Not known
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14866.html
Field Length: 2




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14072.html
Field Length: 4



Format: Characters   http://www.datadictionaryadmin.scot.n 01 Carstairs 2001 index The Carstairs
                     hs.uk/isddd/14066.html                and Morris index was originally
Field Length: 2                                            developed in the 1980s using 1981
                                                           census data. It is composed of 4
                                                           indicators at postcode sector level
                                                           that were judged to represent material
                                                           disadvantage in the population (lack
                                                           of car ownership, Registrar General
                                                           social class, overcrowded households
                                                           and male unemployment). The index
                                                           has also been calculated based on
                                                           1991, and subsequently, 2001 census
                                                           data. However, the 1981 and 1991
                                                           Carstairs indices are only available
                                                           for postcode sector, whereas the
                                                           2001 index is available for postcode
                                                           sector, data zone and output areas.
                                                           Further information can be found at
                                                           http://www.msoc-
                                                           mrc.gla.ac.uk/Publications/pub/Carsta
                                                           irs_MAIN.html


                                                             02 Scottish Index of Multiple
                                                             Deprivation (SIMD 2004) It has six
                                                             domains (income, employment,
                                                             education, housing, health, and
                                                             geographical access) at datazone
                                                             level, which have been combined into
                                                             an overall index. Full information on
                                                             the SIMD 2004 can be found in the
                                                             report at
                                                             http://www.scotland.gov.uk/library5/so
                                                             ciety/siomd.pdf and the full dataset at
                                                             http://www.scotland.gov.uk/library5/so
                                                             ciety/simd04-00.asp
Format: n:nn          http://www.datadictionaryadmin.scot.n
                      hs.uk/isddd/14337.html
Field Length: 3




Format : Characters   http://www.datadictionaryadmin.scot.n
                      hs.uk/isddd/11192.html
Field Length : 255
Format: Characters   http://www.datadictionaryadmin.scot.n
Field Length: 5      hs.uk/isddd/11839.html




Format: Characters   http://www.datadictionaryadmin.scot.n 01 Diabetes Centre
                     hs.uk/isddd/14212.html
Field Length: 2



                                                             02 Hospital Diabetes Clinic
                                                             03 Hospital Outpatient Department
                                                             04 Ward
                                                             05 Outreach Diabetes Clinic
                                                             06 Health Centre Diabetes Clinic
                                                             Includes GP Practice
                                                             07 Health Centre General Clinic
                                                             Includes GP Practice
                                                             08 Patient's Home
                                                             09 School
                                                             10 Care Home
                                                             11 Prison
                                                             12 Nurse-led Clinic
                                                             13 Dietetic-led Clinic
                                                             14 Patient's Workplace
                                                             98 Other
Format: Characters   http://www.datadictionaryadmin.scot.n 00 No advice given
Field Length: 2      hs.uk/isddd/11263.html




                                                             01 Oral advice
                                                             02 Written advice
                                                             03 Referral to/attending NHS
                                                             Smoking Cessation Service A referral
                                                             is made to a specialist smoking
                                                             cessation service, or the person is
                                                             already attending such a service

                                                             04 Exempted/ not appropriate e.g.
                                                             patient too frail/ ill
                                                             05 Not indicated Individual is a non-
                                                             smoker
                                                             06 Patient declined
                                                             99 Not known
Format: Numeric      http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/15956.html
Field Length: 1
Format; Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14281.html
Field Length: 50




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14286.html
Field Length: 75




Format: Characters   http://www.datadictionaryadmin.scot.n
Field Length: 75     hs.uk/isddd/11956.html
Format: Characters        http://www.datadictionaryadmin.scot.n
                          hs.uk/isddd/14862.html
Field Length: 198




Format: Characters (CCYY- http://www.datadictionaryadmin.scot.n
MM-DD)                    hs.uk/isddd/11140.html

Field Length: 10
Format: Character              http://www.datadictionaryadmin.scot.n
                               hs.uk/isddd/11253.html
Field Length : 1

Codes and Values: (Code
order)
0 Not known
1 Male
2 Female
8 Other specific The
person has a clear idea of
what their gender is, but it
is neither discretely male
nor female, e.g. 'intersex',
'transgender', 'third
gender'.
9 Not specified The
person is unable to specify
their current gender or
does not have a clear idea
of what their current
gender is.
Format: Characters (CCYY- http://www.datadictionaryadmin.scot.n
MM-DD)                    hs.uk/isddd/11143.html

Field Length: 10




Format : Characters       http://www.datadictionaryadmin.scot.n
Field Length :35          hs.uk/isddd/11130.html
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/11206.html
Field Length: 70




Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/11224.html
Field Length: 35




Format: Character    http://www.datadictionaryadmin.scot.n D Divorced/Dissolved Civil
                     hs.uk/isddd/11205.html                Partnership
Field Length :1




                                                             M Married/Civil Partner
                                                             N Not disclosed/Not known
                                                             P Separated
                                                             S Single
                                                             W Widowed/Surviving Civil Partner
Format : Characters   http://www.datadictionaryadmin.scot.n
                      hs.uk/isddd/11244.html
Field Length: 35




Format : Characters   http://www.datadictionaryadmin.scot.n Mr
                      hs.uk/isddd/11125.html
Field Length :35




                                                              Mrs
                                                              Ms
                                                              Dr
                                                              Rev
                                                              Sir
                                                              Lady
                                                              Lord
                                                              Dame
                                                              Miss
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/11287.html
Field Length: 8
Format: Characters      http://www.datadictionaryadmin.scot.n 097 - Not disclosed
Field Length: Up to 6   hs.uk/isddd/11281.html




                                                              ara - Arabic
                                                              ben - Bengali
                                                              chi - Chinese
                                                              eng - English
                                                              fre - French
                                                              ger - German
                                                              gla - Gaelic; Scottish Gaelic
                                                              gre - Greek
                                                              guj - Gujarati
                                                              hin - Hindi
                                                              ita - Italian
                                                              nor - Norwegian
                                                              pan - Panjabi; Punjabi
                                                              per - Persian
                                                              sgn - Sign Language
                                                              sgn-GB British Sign Language
                                                              spa - Spanish; Castilian
                                                              tur - Turkish
                                                              und - Undetermined (Not Known)
                                                              urd - Urdu
                                                              XXX - Other (choose from ISO 639-2
                                                              list)
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/11223.html
Field Length: 35




Format: Characters   http://www.datadictionaryadmin.scot.n 01 Pre-pubertal
                     hs.uk/isddd/14232.html
Field Length: 2



                                                           02 Pubertal
                                                           03 Adult
                                                           99 Not Known
Format: Characters   http://www.datadictionaryadmin.scot.n 01 - Education
                     hs.uk/isddd/14188.html
Field Length: 3




                                                             01A New Patient Education
                                                             01B Established Patient Education
                                                             02 - Annual Review
                                                             03 - Progress Monitoring
                                                             04 - Medication Review
                                                             05 - Compliance Issues
                                                             06 - Glycaemic Control
                                                             06A Blood Glucose Review
                                                             06B Hypoglycaemia
                                                             07 Altered Biochemistry
                                                             08 General Diabetes Care
                                                             09 - General Health Advice
                                                             10 - Impaired Glucose Tolerance
                                                             11 - Pre-Conceptual Counselling
                                                             12 - Pregnancy
                                                             13 - Dietary Advice
                                                           13A Weight Management
                                                           13B Dietary Management of a New
                                                           Disease State
                                                           13C Dietary Review of a Co-existing
                                                           Disease State
                                                           14 - School Related Issues
                                                           15 - Illness
                                                           16 - Equipment Problem
                                                           17 - Family Request
                                                           18 - Insulin Dosage Error/ Omission
                                                           98 - Other
                                                           99 - Not Known
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Daily
                     hs.uk/isddd/14306.html
Field Length: 2



                                                           02 Week
Format: characters   http://www.datadictionaryadmin.scot.n 01 - Non-professional
                     hs.uk/isddd/12587.html
Field Length: 3
01A Self referral Includes any person
not acting in an official professional
capacity. e.g. includes relatives who
are healthcare professionals but are
not making the referral as part of their
employment, rather in their capacity
as a relative.

01B Associated person Includes any
person not acting in an official
professional capacity. e.g. includes
relatives who are healthcare
professionals but are not making the
referral as part of their employment,
rather in their capacity as a relative
Includes family, friends, employer,
neighbour, Good Samaritan

02 - Healthcare professional, service
or organisation
02A GP Referral from usual GP
practice / practice providing
temporary general medical services
02B Specified other common
healthcare referrers Determined as
appropriate to specific clinical data
standards/datasets
02Z Other healthcare professional
Another person acting in their official
healthcare professional capacity but
out with the groups specified above

03 - Local authority
03A Education
03B Social services
03C Police
03D Other local authority department
e.g. Housing department

04 - Private agency / organisation -
e.g. Nursing home, care agency,
hospice
05 - Other agency
05A Prison / penal establishment
05B Judicial
05C Voluntary agency
05D Armed forces
98 - Other - The true value to be
recorded is not covered by any of the
specific given categories
99 Not known
Format: Characters (right    http://www.datadictionaryadmin.scot.n
justified)                   hs.uk/isddd/11292.html
Field Length: 6




Format: Characters           http://www.datadictionaryadmin.scot.n 00 - Atheist, agnostic or no religious
Field Length: Up to 6 (2 +   hs.uk/isddd/11251.html                affiliation
4)




                                                                     00R003 Agnostic
                                                                     00R012 Atheist
                                                                     00R121 None
                                                                     01 - Christian - Church of Scotland
                                                                     02 - Christian - Roman Catholic
                                                             03 - Other Christian
                                                             03R014 Baptist
                                                             03R043 Church of England
                                                             03R083 Free Church of Scotland
                                                             03R109 Methodist
                                                             03R131 Pentecostal
                                                             03R137 Protestant
                                                             03R148 Salvation Army
                                                             03R153 Scottish Episcopal Church
                                                             03R170 United Free Church of
                                                             Scotland
                                                             03R171 United Reformed Church
                                                             03RXXX For other Christian religions
                                                             see Religion Subsidiary Codes

                                                             04 - Buddhist
                                                             05 - Hindu
                                                             06 - Muslim
                                                             07 - Jewish
                                                             08 - Sikh
                                                             97 - Not disclosed
                                                             98 - Any other religion
                                                             98RXXX see Religion Subsidiary
                                                             Codes
                                                             99 - Not known
Format: Characters   http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14799.html
Field Length: 198
                  http://www.datadictionaryadmin.scot.n
                  hs.uk/isddd/11145.html




Format: nnn.nn    http://www.datadictionaryadmin.scot.n
                  hs.uk/isddd/14273.html
Field Length: 5



                  http://www.datadictionaryadmin.scot.n
                  hs.uk/isddd/15144.html



Format: hh:mm     http://www.datadictionaryadmin.scot.n
                  hs.uk/isddd/14328.html
Field Length: 4



                  http://www.datadictionaryadmin.scot.n 01 Breakfast
                  hs.uk/isddd/14326.html



                                                          02 Mid-morning
                                                          03 Lunch
                                                          04 Mid-afternoon Snack
                                                          05 Dinner
                                                          06 Evening Snack
                                                          07 Supper
Format: Characters   http://www.datadictionaryadmin.scot.n 01 Achieve 500kcal/ day Deficit
                     hs.uk/isddd/14837.html
Field Length: 2



                                                           02 Achieve Prescribed Calorie
                                                           Increase
                                                           03 Achieve Prescribed Calorie
                                                           Restriction
                                                           04 Additive Free Advice
                                                           05 Advice on Diabetic Products
                                                           06 Advice on Sweeteners
                                                           07 Alcohol (current) Guidelines
                                                           08 Alcohol (general) Advice
                                                           09 Breastfeeding Advice
                                                           10 Carbohydrate Counting
                                                           11 DAFNE Research Education
                                                           Programme
                                                           12 Decrease Alcohol Intake
                                                           13 Decrease Calories
                                                           14 Decrease Fruit Intake
                                                           15 Decrease Overall Portion Sizes
                                                           16 Decrease Phosphate
                                                           17 Decrease Phosphate Intake
                                                           18 Decrease Potassium Intake
                                                           19 Decrease Saturated Fat
                                                           20 Decrease Sodium Intake
                                                           21 Decrease Sugar Intake
                                                           22 Decrease Total Carbohydrate
                                                           23 Decrease Total Fat
                                                           24 Decrease Total Protein
                                                           25 Decrease Use of Polyunsaturated
                                                           Fats
                                                           26 Decrease Vegetables
                                                           27 Decrease/ Stop Phosphate
                                                           Binders
                                                           28 DESMOND Research Education
                                                           Programme
                                                           29 Egg-free Advice
                                                           30 Fluid Restriction Advice
                                                           31 Food Fortification Recommended

                                                           32 Food Labelling Advice
                                                           33 Food Safety Advice
                                                           34 General Nut Allergy Advice
                                                           35 Glycaemic Index Advice
                                                           36 Gluten-free Advice
                                                           37 Heartburn Advice
                                                           38 Increase ACE Vitamins
                                                           39 Increase Calcium Intake
                                                           40 Increase Calories
                                                           41 Increase Carbohydrate
                                                           42 Increase Folic Acid Intake
                                                           43 Increase Fruit Intake
                                                           44 Increase Insoluble Fibre
45 Increase Intake of Oily Fish
46 Increase Iron Intake
47 Increase Low Glycaemic Index
Foods
48 Increase Overall Portion Sizes
49 Increase Phosphate Binders
50 Increase Phosphate Intake
51 Increase Potassium Intake
52 Increase Sodium Intake
53 Increase Soluble Fibre
54 Increase Total Fat
55 Increase Total Protein
56 Increase Use of Monounsaturated
Fats
57 Increase Use of Polyunsaturated
Fats
58 Increase Vegetables
59 Insulin:Carbohydrate Ratio
60 JEJ Feed
61 Maintain Weight
62 Mashed Diet
63 Minced Diet
64 Mineral Supplementation
65 Nausea Advice Given
66 NG Feed
67 Nil by Mouth
68 No Added Salt Advice
69 No Change in Dietary Habits
Required
70 Normal Fluids
71 Optimal Calorie Advice
72 Optimal Protein Advice Given
73 Oral Nutritional Supplements
Recommended
74 Peanut Allergy Advice
75 PEG Feed
76 PN
77 Prescribable Product Advice
78 Preservative Free Advice
79 Pureed Diet
80 Regulate Carbohydrate
Distribution
81 Regulate Meals
82 Salicylate Free Advice
83 Soft Diet
84 Thickened Fluids
85 Vitamin Supplementation Advice
86 Wheat-free Advice
Format                       http://www.datadictionaryadmin.scot.n 00 None
Characters. Minimum 2        hs.uk/isddd/11286.html
address lines, no
maximum although a de
facto standard exists of 5
lines exists for
presentation purposes.

Field Length
Maximum 35 per address
line




                                                                 01 Normal domicile address

                                                                 02 Alternative contact address

                                                                 03 Non-domicile address
                                                                 04 Invoiced address
                                                                 05 Employer's address
                                                                 06 Temporary domicile address
                                                                 07 Professional contact address
                                                                 08 No fixed abode
                                                                 97 Not disclosed
                                                                 98 Not known
Format: Characters        http://www.datadictionaryadmin.scot.n
                          hs.uk/isddd/11288.html
Field Length: 35




Format: Numeric (nnn.n)   http://www.datadictionaryadmin.scot.n
                          hs.uk/isddd/12155.html
Field Length: 4




Format: nnn.n             http://www.datadictionaryadmin.scot.n
Field Length: 4           hs.uk/isddd/11184.html
Format: nnn.n        http://www.datadictionaryadmin.scot.n
                     hs.uk/isddd/14269.html
Field Length: 4



Format: Characters   http://www.datadictionaryadmin.scot.n
(CCYY)               hs.uk/isddd/13705.html
Field Length: 4
Additional or related Information            Additional Information
Further Information;                         Related Data Items
Main source of standard: Government          UK Postal Address, Postcode
Data Standards Catalogue




Further Information:
A unit of alcohol
1 unit = 8g of alcohol e.g. a half pint of
3.5% beer or lager, or one 25ml
measure of spirits. A small (125ml)
glass of average strength (12%) wine
contains 1.5 units.
Refer to Sign 74 Annex 1: Alcohol
content of some beverages
Living in Britain 2002, published 2004
http://www.statistics.gov.uk/cci/nugget.
asp?id=829
Whilst the number of units consumed
per week should usually be regarded
as an estimate (often an under-
estimate), recording of a numerical
value has a number of uses: to assess
whether a person's consumption is
within prevailing recommended
consumption limits and to measure
changes in consumption over time.
Related Data Items:
Current Alcohol Drinking Status
Further Information:                        Related Data Items:
Where an associated person's age is         Structured Name
of relevance to the client/patient's care   Title
e.g. where the associated person is a       35 characters
child or an elderly person, it is           Surname/Family name
recommended that their date of birth        35 characters
be recorded. The full or precise birth      First Forename
date may not be required e.g. the birth     35 characters
year may suffice. Where necessary a         Preferred Forename (if different)
derived age may be calculated.              35 characters
Personal information about a third          Second Forename
party should be recorded with their         35 characters
knowledge and consent.                      Other Forename(s)
                                            35 characters
Recording Guidance:                         Previous Surname
Data about multiple associated              35 characters
persons may need to be recorded.            Name Suffix
Where a client/patient has an               35 characters
associated person not fulfilling a          Name Status
specific role, e.g. other household         2 characters
members, IT systems should allow            Name Element Position
for an entry of 'none'. Data can be         2 characters
entered for all people significantly        Unstructured Name
associated with the person,                 70 characters
                                            Address
including all members of the
                                            Address (BS7666) or
person's household.
                                            Gazetteer
                                            UK Postal Address
                                            5x35 characters
                                            Postcode
                                            8 characters
                                            Telephone Number
Further Information:                        35 characters
Other specific role can refer to an
associated person involved in a
professional (but not a care
professional) capacity such as the
person's lawyer, business partner, etc.
For household members who do not
carry out any particular role in relation
to the client/patient, record "00 No
Role".
Recording Guidance:
Multiple relevant roles may be
recorded for each associated person.
No GCS definition for this item, only
the item name as listed.
Sub Data Items

Start and End dates



Further Information:
The specialist capacity in which a
professional is employed is not
necessarily the same as the specialist
registration status of that person with
their professional body. Other aspects
such as the grade of the professional
should be taken into account. For
example, a doctor in a training grade or
Staff and Associated Specialist (SAS)
grade may legitimately be employed to
work in a specialist area without being
registered on the GMC Specialist
Register for that specialty. However, a
consultant employed in that specialist
area would probably be expected to
have appropriate specialist registration.
It is the responsibility of the employing
body to ensure that the professional is
suitably qualified for the post to which
they are appointed.
Recording Guidance:
Each clinical working group may
augment this data model by defining
their own sub-specialty code list
suitable for local use.
Further Information:                        Regulatory body / Professional group
An electronic health record should          Identifier format
record the professional identifier of the
professional responsible for care.          Further information
In the future, the NHS Staff Directory
will accurately identify care               General Medical Council
professionals by a unique professional       Doctors
identifier, issued by their professional     9999999(9)
body. Currently, there are a small           http://www.gmc-
number of professionals who do not          uk.org/register/default.htm
have a unique professional identifier.       General Dental Council
Where a care professional has multiple       Dentists
registrations for different professions,     99999 or XX999 or XX9999
the professional identifier and the          http://www.gdc-uk.org/contact.html
associated professional group to be          Nursing and Midwifery Council
recorded should be that which relates        Nurses, midwives
to the professional role in the episode      99X9999X
or contact being recorded.                   http://www.nmc-
                                            uk.org/nmc/main/splash.html
                                             Health Professions Council
                                             Allied Health Professionals
                                             XX99999(9)
                                             http://www.hpc-uk.org
                                            Royal Pharmaceutical Society of Great
                                            Britain
                                             Pharmacists
                                             7 alphanumeric
                                             http://www.rpsgb.org.uk/
                                             British Psychological Society
                                             Psychologists
                                             999999
                                             http://www.bps.org.uk/index.cfm
Further Information:                        Related Social Services Council
                                            Scottish Data Items:
Basal Metabolic Rate (BMR) is               Stress Factor, Combined Activity and
calculated by first determining the         Diet-induced Thermogenesis Factor,
gender, age and body weight of the          Estimated Total Energy Expenditure
individual. The Schofield equation is
used in clinical situations to estimate
BMR from weight (in kilogrammes) for
either sex.
Schofield WN (1985) Predicting Basal
Metabolic Rate: New Standards &
Review of Previous Work. Hum Nutr:
Clin Nutr 39C (Suppl 1.5), 41
Schofield WN, Schofield C & James
WPT (1985) Basal Metabolic Rate -
review and prediction, together with
annotated bibliography of source
material. Hum Nutr: Clin Nutr 39C
(Suppl 1), 5-96.
A Pocket Guide to Clinical Nutrition,
3rd Edition, V. Todorovic and A.
Micklewright (eds.) on behalf of the
PEN Group of the British Dietetic
Association. 2004
Further Information:
IT systems should calculate BMI
automatically from height and weight
as weight/height² (kg/m²)
BMI should ideally be calculated from
measurements taken on the same
date. This should be recorded as the
date of the BMI.
In certain patients, calculation of BMI
may not be straightforward, e.g.
amputees. Guidance for such specific
circumstances will be included in
specialist data standards as
appropriate.
Interpretation of BMI results using
standard charts can be used to assign
values to the categories Normal,
Underweight, Overweight and Obese.
To interpret a child's BMI and assign
values to the categories: Normal;
Underweight; Overweight; Obese, refer
to standard age specific UK Children's
Growth Reference Charts: Cole TJ,
Freeman JV and Preece MA. Body
mass reference curves for the UK
1990. Arch Dis Child 1995; 73: 25-29

Related Data Items:
Type of Meal, Time of Meal, Food
Components of Meal,
Insulin:Carbohydrate Ratio, Correction
Bolus Dose
Further Information
The Community Health Index (CHI) is a
computer based population index
whose main function at present is to
support primary care services. CHI
contains details of all Scottish residents
registered with a General Practitioner
and was originally envisaged and
implemented as a population-based
index to help assess the success of
immunisation and screening
programmes. It is therefore closely
integrated with systems for child health,
cervical cytology and breast screening
call and recall¿It is intended that this
number, the Scottish equivalent of the
new NHS number in England and
Wales, should become the Unique
Patient Identifier throughout the NHS in
Scotland.
From Designed to Care - Scottish
Office
The CHI number is a unique numeric
identifier, allocated to each patient on
first registration with the system. The
CHI number is a 10-character code
consisting of the 6-digit date of birth
(DDMMYY), two digits, a 9th digit which
is always even for females and odd for
males and an arithmetical check digit.
(ISD, Information Services, NHS
National Services Scotland)
Further Information
This code is used locally for a variety of
purposes, such as: distinguishing
between a Health Care Professional's
morning and afternoon clinics;
identifying new only clinics; and
identifying a specialist sub-section of a
specialty (e.g. foot clinic, obesity clinic,
communication clinic etc.)

Related Data Items:
Basal Metabolic Rate (Schofield
Equation), Stress Factor, Estimated
Total Energy Expenditure



Related Data Items:
Patient Agreed Goals, Importance of
Change, Confidence in Ability to
Change
Further Information:
Question asked - 'How confident are
you that you can change?'
Further Information:
Two or more client/patients may have
contact with a care profession at the
same time, e.g. in a group session. A
client/patient may also have contact
with two or more care professions at
the same time, e.g. in a multi-discipline
team setting.
An attendance (e.g. a day patient
attendance) may comprise contacts
with more than one care profession.




Further Information:                          Related Data Items
The Correction Bolus Dose is based on
the duration of insulin action, total daily   Type of Meal, Time of Meal, Food
dose of insulin, insulin correction           Components of Meal, Carbohydrate
factor, and the correction bolus target.      Value of Meal, Insulin:Carbohydrate
                                              Ratio
Further Information:
Ref. SIGN Guideline 74: "Management
of harmful drinking and alcohol
dependence in primary care
http://www.sign.ac.uk/pdf/sign74.pdf
A unit of alcohol
1 unit = 8g of alcohol e.g. a half pint of
3.5% beer or lager, or one 25ml
measure of spirits. A small (125ml)
glass of average strength (12%) wine
contains 1.5 units.
Refer to Sign 74 Annex 1: Alcohol
content of some beverages
Living in Britain 2002, published 2004
http://www.statistics.gov.uk/cci/nugget.
asp?id=829
Current daily recommended alcohol
limits
Men: Consistently drinking four or more
units a day is not advised.
Women: Consistently drinking three or
more units a day is not advised.
(Refs. http://www.healthscotland.com/
http://www.hebs.com/services/pubs/pdf
/Alcofacts.pdf)
Current weekly recommended alcohol
limits
Men: 21 units
Women: 14 units
(Ref. SIGN Guideline 74:
"Management of harmful drinking and
alcohol dependence in primary care
Further Information:
Main Source of Standard: Let's Make
Scotland More Active; a strategy for
physical activity, Scottish Executive,
2003
This document describes the values for
physical activity. A patient administered
General Practice Physical Activity
Questionnaire (GPPAQ) can be used
and a computerised algorithm used to
automatically calculate the individual's
current physical activity level.
Moderate intensity activity
For general public health benefit, the
most appropriate activities are those of
moderate intensity. A person who is
doing moderate intensity activity will
usually experience:
· an increase in breathing rate
· an increase in heart rate, to the level
where the pulse can be felt, and
· a feeling of increased warmth,
possibly accompanied by sweating on
hot or humid days.
Also, a bout of moderate intensity
activity can be continued for many
minutes, and does not cause
exhaustion or extreme fatigue when
continued for an extended period.
(Recommendations for active living
throughout the life-course
http://www.dh.gov.uk/assetRoot/04/08/
Further Information:
In 1996, The World Health
Organization defined former smokers
as those who have not smoked in the
last year - this can be interpreted to
mean a minimum of 1 year should be
used to define abstinence.
Ramstrom LM. 1987. The WHO
guidelines for standardization of
smoking surveys.
In: Aoki M, (ed) Smoking and Health.
Elsevier Science Publishers, 715-717.
Recording Guidance
More than one option can be chosen,
for example Ex-smoker and Current
chewer.
Subsets of the codes and values may
be implemented where it is not
appropriate or necessary to implement
the full standard, e.g. only the section
relating to smoking. In this situation,
the data item name is still current
tobacco and nicotine consumption, but
a common name of ¿ Smoking Status¿
may be implemented.
00 No use
10 Never smoked
11 Ex-smoker
12 Current non-smoker
13 Current smoker
 97 Patient declined
 99 Not known
Further Information:                           Sub Data Items /Verification level
This may be a date extracted from a            Code & Values / Explanatory notes
Date and Time data item.                       Level 0 Actual All of the elements of
On each occasion when a date is to be          the date, to the level of completeness
recorded, consideration should be              required, are actual.
given as to whether the complete date          Level 1 Estimated Some or all of the
(CCYY-MM-DD) or a truncated date               elements of the date, to the level of
(CCYY-MM or CCYY) is required.                 completeness required, are estimated,
In some circumstances only an actual           that is the person/ source providing the
date may be acceptable, whilst in              date information cannot guarantee
others an estimated date may be                accuracy.
allowed. In the latter situation, it will be   Level 2 Not known A date has been
often be necessary to identify whether         recorded but it is not known whether it
the date recorded is actual or                 is an actual or estimated date.
estimated. Dates identified as actual          Acknowledging that some components
may be used in calculations and                of an estimated date may be actual
analyses. Dates marked as estimated            and others estimated, where detail
should be treated with caution and the         regarding the level of accuracy of an
implications of undertaking any                estimated date is required, the
calculations or analyses should be             following verification levels are
considered in the particular context           recommended:
within which the date is recorded or to        1. Complete dates (CCYY-MM-DD):
be made subsequent use of. Where an            Code & Value / Sub-Code / Sub-value
estimated date is allowed, the                 / Explanatory notes
appropriate degree of verification detail      Level 0 Actual Year, month and day
required should be decided, again              actual.
dependent on the context in which it is        Level 1 Estimated A Day estimated
recorded and how the date is to be             Year and month actual, but day is
used.                                          estimated
Recording Guidance:                            B Month and day estimated Year
Government Data Standards                      actual, but month and day estimated
Catalogue                                      C Year, month and day estimated
Further Information:                           Level 2 Date not required e.g. the
Telephone and Telemedicine contacts
should be recorded where
communication is between a HCP and
a patient, or a HCP and another HCP
in the presence of a patient, for the
purpose of consultation or treatment.
Further Information:                         Sub Data Items
Referral letters sent by electronic
communication:                               Verification Level:
For electronic referrals, this is the date   Code & Value
on which the referral document is
completed, not the date on which it was      Level 0   Actual
started. In some instances, the referrer     Level 1   Estimated
may start the referral and then ¿park¿       Level 2   Date not required
it for completion at a later stage, for      Level 3   Not known
example where the result of an
investigation is awaited. The referral
email should have a delivery receipt
and a read receipt. It is expected that
once an electronic referral has been
completed it will usually be sent on the
same date. The Date of Referral, and
time if desired, should be the same as,
or close to the date and time when the
electronic communication is sent/
delivered. For electronic referrals the
Date of Referral may be the same as
the Date Referral Received.
Referral letters sent via internal mail or
postal services:
The Date of Referral should be the
date on which the letter was dictated by
the referrer. It is not the date on which
the letter was typed or the date on
which it was sent.
Verbal referrals (includes telephone):
In some circumstances, only a verbal
referral may be made, for example for
Further Information:                         Sub Data Items
Referral letters sent by electronic          Verification Level:
communication:                               Code & Value
For electronic referrals, this is the date
on which the referral document is            Level 0 Actual
completed, not the date on which it was      Level 1 Estimated
started. In some instances, the referrer     Level 2 Not known
may start the referral and then ¿park¿
it for completion at a later stage, for
example where the result of an
investigation is awaited. The referral
email should have a delivery receipt
and a read receipt. It is expected that
once an electronic referral has been
completed it will usually be sent on the
same date. The Date of Referral, and
time if desired, should be the same as,
or close to the date and time when the
electronic communication is sent/
delivered. For electronic referrals the
Date of Referral may be the same as
the Date Referral Received.
Referral letters sent via internal mail or
postal services:
The Date of Referral should be the
date on which the letter was dictated by
the referrer. It is not the date on which
the letter was typed or the date on
which it was sent.
Verbal referrals (includes telephone):
In some circumstances, only a verbal
referral may be made, for example for
Further Information:                       Related Data Items:
                                           Structured Name
See WHO 1999 report for
                                            Title
comprehensive list of Diabetes Mellitus     35 characters
Types and definitions:                     Surname/Family name
http://www.staff.ncl.ac.uk/philip.home/w    35 characters
ho_dmg.pdf.                                First Forename
                                            35 characters
Details about the specific drug or         Preferred Forename (if different)
disease involved in 'Other Specific         35 characters
Diabetes Mellitus' or of any other type    Second Forename
of diabetes may be recorded in an           35 characters
                                           Other Forename(s)
associated textbox.
                                            35 characters
Related Data Items: Date of Diagnosis      Previous Surname
{Diabetes}                                  35 characters
                                           Name Suffix
                                            35 characters
                                           Name Status
                                            2 characters
                                           Name Element Position
                                            2 characters
                                           Unstructured Name
                                            70 characters
                                           Address
                                            Address (BS7666) or
                                            Gazetteer
                                           UK Postal Address
                                            5x35 characters
                                           Postcode
                                            8 characters
                                           Telephone Number
                                            35 characters
                                           Internet Email Address
                                            255 characters
                                           Current Gender
                                            1 character
                                           Person Birth Date
                                            10 characters (CCYY-MM-DD)
                                           Associated Person Role
Recording Guidance:
Where '98 - Other' is recorded,
systems may be configured to include
a text box to allow specification of the
education topic.




Further Information:
It is not the exact amount of energy
spent each and every day.
It is calculated by adjusting the Basal
Metabolic Rate for stress or weight
gain/ loss, physical activity level and
diet-induced thermogenesis.
FAO (2004) Human Energy
Requirements: Report of a Joint
FAO/WHO/UNU Expert Consultation.
Food and Nutrition Technical Report
Series 1. Rome

Further Information:                        Related Data Items:
The estimated total energy of food          Recorded Period of Food Portion
portions is calculated by multiplying the   Intake, Food Group - Number of
number of portions by the energy per        Portions, Glycaemic Index Assessment
portion for each food group and adding
them all together.
Scottish Nutrition and Diet Resources
Initiatives (SNDRI):
http://www.sndri.gcal.ac.uk
Further Information:                    Ethnic Group - Recording Guidance -
Ethnic Group - Order to display codes   General:
and values                              Ethnic group of a child or young
Ethnic Group - Further Information      person:
Recording Guidance:                     For babies and very young children it is
Ethnic Group - Recording Guidance       anticipated that the parent/ guardian
Ethnic Group Specific Codes             will assign the child’s ethnic group.
                                        Once the child develops their own
                                        concept of their ethnicity, this should
                                        be recorded in preference to that
                                        determined by the parent/ guardian.
                                        Code 97 in the main list “Not disclosed”
                                        means that the person has been asked
                                        what his/her ethnic group is, and has
                                        chosen not to disclose it.
                                        Code 99 in the main list “Not known”
                                        means the information is not available
                                        for a reason OTHER than non-
                                        disclosure.
                                        NHS Information Systems (issued by
                                        the National Clinical Datasets
                                        Development Programme)
                                        There are 3 recommended ways of
                                        implementing this standard depending
                                        on the level of detail required:
                                        1 Use the codes and values as given in
                                        the main list, with the following codes
                                        for the “Any other” and “Any Mixed”
                                        values.
                                        E039 – Any other White background
                                        E029 – Any Mixed background
                                        E059 – Any other Asian background
                                        E069 – Any other Black background
Related Data Items:
Follow-up Arrangements, Date of Next
Apointment, Time of Next Appointment,
Location of Next Appointment
Recording Guidance:
Where '98 - Other' is recorded,
systems may be configured to include
a text box to allow specification of the
follow-up type.




Related Data Items:
Type of Meal, Time of Meal,
Carbohydrate Value of Meal,
Insulin:Carbohydrate Ratio, Correction
Bolus Dose




Related Data Items:
Recorded Period of Food Portion
Intake, Estimated Total Energy of Food
Portions, Glycaemic Index Assessment
Further Information:
Most care will be provided by the GP
practice with which the patient is
currently permanently registered;
however, under the enhanced services
component of the new GMS contract,
patients can be temporarily registered
with a different practice for provision of
specific services such as child health
surveillance or warfarin management.
Multiple registration status entries may
be recorded where applicable.
Start and end dates should be
associated with registration status to
facilitate tracing a patient/client's
registration history.
Recording Guidance:
 IT systems should allow for the
recording of more than one registration
status.
Sub Data Items:
Start Date, End Date
Further Information:                        Related Data Items:
Slowly absorbed foods have a low GI         Recorded Period of Food Portion
rating, whilst foods that are more          Intake, Food Group - Number of
quickly absorbed will have a higher         Portions, Estimated Total Energy of
rating. This is important because           Food Portions
choosing slowly absorbed
carbohydrates can help even out blood
glucose levels when you have
diabetes.
For Glycaemic Index assessment, the
GI can be ranked as low (55 or less),
medium (55-69) and high (70 or more).
http://www.diabetes.org.uk and
http://www.glycemicindex.com




Further Information
The GMC/GDC number is the personal
identification number issued to each
doctor/dentist by the General Medical
Council/General Dental Council (SMR
Definitions and codes)
Patients are no longer registered with
an individual GP, but with a practice
however 'registered GP' is still required
for historical reasons, and it will be
important to identify the registered
practice of a patient, especially where
they are being seen by another
practice e.g. whilst on holiday.




Further Information:
The CHI number should always be
used to identify a patient if available.
However, health record identifiers,
such as hospital numbers in patient
administration systems (PAS), may be
used locally until universal
implementation of CHI has been
achieved.
Further Information:                      Sub Data Items:
If height cannot be measured, record      Verification level
recently documented or self-reported      0 Unverified
height (if reliable and realistic) as     1 Verified
'unverified'.
In certain groups or diseases,
measurement of height may not be
straightforward, e.g. infants, wheel
chair/ bed bound, scoliosis, kyphosis.
Guidance for such specific
circumstances will be included in
specialist data standards as
appropriate.
Further Information:
1) A cognitive impairment (06) can be
either acquired (e.g. head injury) or
internally developed (e.g. dementia).
2) Definition of "Combined Sight &
Hearing Loss" (also known as:
Deafblindness, Dual Sensory Loss)
Persons can be regarded as having
combined sight and hearing loss
(deafblindness) if they have a severe
degree of combined visual and auditory
impairment resulting in problems of
communication, access to information
and mobility. There are many routes to
deafblindness which can occur at
different stages of people's lives, as
follows:
· both of the impairments resulting in
deafblindness have been present from
birth. A person who is deafblind from
birth is likely to have other problems
such as a Learning Disability, physical
disability etc.
OR
· only one of the impairments has been
present from birth and the second
impairment develops later in life (eg.
certain forms of Usher Syndrome).
OR
· neither impairment has been present
from birth; they both develop later in
life.
Further Information:                       Related Data Items:
Question asked - 'How important is it      Confidence in Ability to Change,
for you to make a change?'                 Patient Agreed Goals, Compliance-
                                           influencing Factors



Recording Guidance:                   Related Data Items
The above data item will be derived   Index of Deprivation Type {Diabetes
from postcode sector and generated by Dietetic}
the system.


Further Information:
Ideally, material deprivation would be
measured on an individual basis using
information on income, education or
occupation. In practice, however, this
information is often not available, so
deprivation for individuals is estimated
from aggregate data derived from the
census and other routine sources.
These are used to estimate the
deprivation of individuals in small
geographical areas. Two area-based
measures of deprivation are the
Carstairs index and the Scottish Index
of Multiple Deprivation.
Further Information:                   Related Data Items
For example if the ratio is 1:12, the
person will need 1 unit of insulin for Type of Meal, Time of Meal, Food
every 12 grams of carbohydrate eaten. Components of Meal, Carbohydrate
                                       Value of Meal, Correction Bolus Dose




Further Information:                         Sub Data Items
Main Source of Standard: Government          Email Address Type:
Data Standards Catalogue                     01 Preferred
From Government Data Standard                02 Alternative
Catalogue
From IETF RFC2822: An email
address is a specific Internet identifier
that contains a locally interpreted string
followed by the at-sign character ("@",
ASCII value 64) followed by an Internet
domain. The locally interpreted string is
either a quoted-string or a dot-atom
Comments and enfolding white space
SHOULD NOT be used around the "@"
in the email address (i.e. no space
characters either side of the @
character). The domain portion
identifies the point to which the mail is
delivered. The local-part portion is a
domain dependent string. In
addresses, it is simply interpreted on
the particular host as a name of a
particular mailbox.
For example: fredbloggs@hotmail.com
or
hector.mcsporran@scotland.gsi.gov.uk
Further Information:
Each location has a location code,
which is maintained jointly by ISD and
General Register Office (Scotland).
http://www.show.scot.nhs.uk/smrfiles/in
formation.html - datafiles
Location must be viewed as an
address and not a code. If any new
locations arise where NHS healthcare
is delivered/administered, please
ensure that the Reference Files Team
at ISD is informed using form LOC-
NEW (which can be downloaded from
the website below) so that a new code
may be issued as appropriate.
http://www.show.scot.nhs.uk/smrfiles
Recording Guidance:
Information about location should be
electronically stored, managed and
transferred using the relevant location
code. IT systems should allow the
recording and display of locations on
the user interface as the relevant
location name and associated address,
etc.



Recording Guidance:
Where '98 - Other' is recorded,
systems may be configured to include
a text box to allow specification of the
location of contact.
Further Information:
Oral and written advice may include
direction to health promotion resources
services such as
http://www.ashscotland.org.uk,
Smokeline on 0800 84 84 84;
http://www.hebs.scot.nhs.uk/topics/smo
king/.
Current recommended guidance:
Ref: NHS Health Scotland and ASH
Scotland (2004) Smoking Cessation
Guidelines for Scotland: 2004 Update
http://www.hebs.scot.nhs.uk/services/p
ubs/pdf/smokingCES2004.pdf
"GPs should ensure that they have
discussed smoking with known
smokers at least once a year, and
advised them to stop and offered
treatment (in the form of a referral to an
NHS Scotland Smoking Cessation
Service as the preferred option) to help
them do so."
"Hospital doctors, dentists, midwives,
health visitors and other health
professionals should advise patients to
stop on initially determining their
smoking status, offer treatment to help
them do so and possibly repeat this at
appropriate opportunities thereafter."
"All records held in General Practice
and hospitals should contain
information on
Further Information:
The screening process is intended for
use prior to a more detailed nutritional
assessment. The tool should contain
the following criteria - weight loss in
last 3 months, BMI, ability to
eat/absorb food, appetite, stress
factors, physical condition and mental
condition.
Examples of scoring tools are
Malnutrition Universal Screening Tool,
Burton score, Birmingham Heartlands
Hospital Nutritional Screening Tool,
and Falkirk & District Royal Infirmary
Nutritional Assessment Form.

Further Information:                     Related Data Items
It is recognised that there are a number Nutritional Screening Score
of well-developed nutritional screening
tools that when used in their entirety
are reliable and client group specific.
The tool can identify patients who are
low risk, moderate risk and high risk.
The tool should contain the following
criteria - weight loss in last 3 months,
BMI, ability to eat/ absorb food,
appetite, stress factors, physical
condition and mental condition.
Examples of scoring tools are
Malnutrition Universal Screening Tool,
Burton score, Birmingham Heartlands
Hospital Nutritional Screening Tool,
and Falkirk & District Royal Infirmary
Nutritional Assessment Form.


Further Information:                     Attributes:
 A person may have had more than         Status
one occupation during their lifetime, or Current
may have more than one occupation at Previous
the same time. It is important to
enquire about any occupation(s)
relevant to the particular health
situation.
 The patient/ client's current or most
recent occupation should be recorded
as a minimum.
Recording Guidance
 Systems should allow for recording of
multiple options.
 In future, Read or SNOMED-CT
terminologies will be implemented
within IT systems and occupation could
be recorded using these so that
relevant analyses may be made.
Related Data Items:
Confidence in Ability to Change,
Importance of Change, Compliance-
influencing Factors



Further Information:                          Sub Data Items
Main Source of Standard: Government           Code & Values
Data Standards Catalogue                      Level 0 Not Verified
The Government Data Catalogue                 Level 1 One or more of the following
Standards recommends that                     Secondary certificates:
verification of a birth date should           Certificate of Baptism.
always be carried out if feasible.            Marriage Certificate
Recording Guidance:                           National Health Service Medical Card
A notional birth date may be recorded         Child's Certificate of Vaccination
where an informant has reported an            Child's Health Record Card
approximate age for a person whose            A certificate of Service in HM Forces or
actual date of birth is unknown. This         other employment under the Crown or
should be identified using verification       in the Mercantile Marine.
level ¿0¿. Work is currently being            A certificate of membership of a Trade
done on a recording convention for            Union Friendly Society or any cards or
dates where only the month and year,          papers relating to membership of an
or only the year, is available.               Approved Society or Unemployment
If Birth Verification Type is level 1 or 2,   Insurance Apprenticeship indentures.
then the Person Birth Date cannot be          Early certificate or testimonial from
amended.                                      employer.
                                              Aliens registration card, certificate of
                                              naturalisation, Home Office travel
                                              document or a passport.
                                              Life insurance policy.
                                              Certificate of confirmation.
                                              School certificate or report.
                                              A birthday book or old family record.
                                              Family Bible containing a record of
                                              birth.
                                              Level 2 One of the following:
                                              Full birth certificate.
                                              Birth certificate short form.
                                              Certificate of registry showing given
Further Information                        Related Data Items :Person Sex at
Since current gender is self-assigned      Birth
and can change, it should not be
presumed by care professionals.

Where an individual is unable to
provide information on their current
gender, it may be provided by a
suitable delegate, but should be
confirmed by the person themselves in
due course.
In the majority of cases, the "Person
Current Gender" and "Person Sex at
Birth" will be the same.
If a patient /client is or has undergone
gender reassignment, they may record
"male", "female" or "other specific
gender" as they wish to indicate their
perceived gender at that time.
Recording Guidance
In some circumstances, it may be
considered acceptable to populate the
"Person Current Gender" field from
"Person Sex at Birth", e.g. for young
children. Otherwise, the default "0 =
Not known" should be used until the
information can be confirmed by the
individual.
Further Information:                      Sub Data Items
Government Data Standards                 Code & Value s
Catalogue                                 Level 0 Not Verified / Interim Death
                                          certificate.
The Government Data Catalogue             Level 1 One of the following:
Standards recommend use of                Notification from Hospital
verification of date of death.            Police Statement
Interim Death Certificates. There is a    Level 2 One of the following:
distinction between an interim death      Documented Coroners Verdict
certificate and a death certificate       Presumption of death by a court of Law
showing the cause of death. The           in England, Scotland or Wales.
Registrars Office confirmed that all      Level 3 One of the following:
death certificates show a cause of        Death Certificate BD8
death except where a case is referred Notification from General Registrars
to the Coroner for the cause of death to Office (system or clerical).
be determined. In these cases, an         Certificate of Registry showing given
interim death certificate is issued. An   names and family name.
interim death certificate is issued as a GRO copy.
courtesy to the relatives/ friends of the Notification of death issued by Forces
deceased. It has no legal standing and Department of the Ministry of Defence
is not deemed as verification of a        (MOD).
cause/ date of death.                     Notification of death issued by the
Recording Guidance:                       Registrar General of the Shipping and
Interim Death Certificates should be      Seamen
identified using verification level '0'.  (Mercantile Marine).
If Death Verification Type is level 1, 2
or 3, then the Person Death Date
cannot be amended.

Further Information                           Sub Data Items: Name Element
                                              Position. Start and End dates
Main Source of Standard:Government
Data Standards Catalogue

The surname of a person represents
that part of the name of a person
indicating the family group of which the
person is part.

It should be noted that in Western
culture this is normally the latter part of
the name of a person. However, this is
not necessarily true of all cultures.
This will, of course, give rise to some
problems in the representation of the
name. This is resolved by including
the data item Name Element Position
in the structured name indicating the
order of the name elements.
From SMR Definitions and Codes
Further Information:                   Related Data Items
Main Source of Standard: Government Person Requested Name
Data Standards Catalogue               (Unstructured)
Person Full Name should only be used
where the structured name format
cannot be used.
Recording Guidance:
Government Data Standards
Catalogue requirements:
1. Each element of the name must be
separated by a space.
2. Consecutive spaces are not allowed.


Further Information                     Sub Data Items: Start and End dates.
Main Source of Standard:Government Name Element Position
Data Standards Catalogue
The first forename of a person
represents that part of the name of a
person which after the surname, is the
principal identifier of a person.
Recording Guidance
A person can have multiple
occurrences of a given name, the order
of which is identified by the sub data
item 'Name Element Position'.
Where the person's preferred
forename is not the first forename, the
related data item 'Preferred Forename'
should be used to indicate this.




Sub Data Items:                            Order to display codes and values
If verification of the marital status is
recorded, then the government eGIF         Codes and values:
standard recommendations should be
used. Link attached:                    S = Single
                                        M = Married/Civil Partner
http://www.govtalk.gov.uk/gdsc/html/fra D = Divorced/ Dissolved Civil
mes/default.htm                         Partnership
Further Information                     W = Widowed/Surviving Civil Partner
Order to display codes and values       N = Not disclosed/Not known
                                        P = Separated
Further Information:                      Sub Data Items: Start and End dates
The preferred forename of a person
represents the forename by which a
person prefers to be known. This may
be the first forename, another
forename, or any other name, e.g.
Elizabeth Mary Smith may prefer to be
known as either Elizabeth, Mary or
Betty.
From SMR Definitions and Codes
Further Information:
The title of a person is a series of
characters representing the way of
addressing a person. It may imply a
combination of gender and marital
status: e.g. Mr, Mrs, and Miss. It may
reflect social or professional status:
e.g. Dr; Rev; Lady, Lt.Col.
From SMR Definitions and Codes
Recording Guidance:
The full range of generally recognised
titles is permitted. The Government
data standards catalogue recommends
that if any of these listed values are
used, the value input must conform
exactly to the given format, e.g. "Mr" is
uppercase M, lower case r and no full
stop. (The value "Miss" has been
added to the Government Data
Standard Catalogue values for this
standard.)
An appropriate list of values for a drop-
down list can be agreed for local
system implementations, providing
they conform to the above format.
Additional titles can be added as
required.
Further Information:                     Related Data Items
Main source of standard: Government Address (BS7666), UK Postal Address
Data Standards Catalogue
1) Postcode is included in Address
(BS7666) (GDSC) but there also is
also a separate postcode standard
which will be populated from Address
(BS7666) Postcode.
2) The UK Postal Address might be
recorded only, in which case a
separate standard to record Postcode
is required.
3) A postcode has two component
parts. Part one of the postcode is
known as the outcode, and part two is
known as the incode.
Outcode
The outcode identifies the postal area
and the postal district. The postal area
is represented by 1 or 2 alpha
characters and the postal district is
represented by 1 or 2 digits. Therefore,
part 1 contains 2, 3 or 4 characters.
Incode
The incode is 3 characters. The
postcode sector is represented by the
outcode plus the first digit of the
incode. The complete postcode
represents the postman's walk.
SMR Definitions and Codes
Further Information:                    Related Data Items:First Language,
It is important that agencies establish Interpretation Assistance Indicator
clearly at the earliest opportunity
whether there are likely to be any
difficulties in communicating or
understanding terms and/or service
descriptions etc. (e.g. concepts such
as 'special needs' which may not be
clear even to native speakers are
unlikely to be understood by those from
other cultures).
Recording Guidance:
The codes and values list provided is
an extract from ISO 639-2 and reflects
prevalent languages spoken in
Scotland. Other languages, including
other sign languages, should be
recorded from the full ISO 639-2 list.
The primary purpose of ISO 639 is to
classify WRITTEN language. Care
professionals may need to know a
person's preferred written language
and/ or preferred SPOKEN language,
e.g. a person's preferred written
language may be Chinese, but their
preferred spoken language may be
Cantonese or Mandarin. A method of
recording the spoken variants of a
language will be developed in the near
future. The Government Data
Standards Catalogue codes for the
Chinese dialects: Cantonese, Mandarin
and Hakka have not been adopted due
Further Information                         Sub Data Items: Start and End dates
The surname of a person represents
that part of the name of a person
indicating the family group of which the
person is or has been part.
It should be noted that in Western
culture this is normally the latter part of
the name of a person. However, this is
not necessarily true of all cultures.
This will, of course, give rise to some
problems in the representation of the
name. This is resolved by including
the data item Name Element Position
in the structured name indicating the
order of the name elements.
From SMR Definitions and Codes
Recording Guidance:
The Previous Person Family Name
may be derived from the Person Family
Name entries through the use of start
and end dates.




Recording Guidance:
Where '98 - Other' is recorded,
systems may be configured to include
a text box to allow specification of the
reason for referral.
Systems should allow for the recording
of more than one Reason for Referral.
Related Data Items:
Food Group - Number of Portions,
Estimated Total Energy of Food
Portions, Glycaemic Index Assessment



Further Information:                         Referral Source Table:
A referral may be verbal or written by
letter, fax or e-mail.
A referral can be made either with or        Data Item - Definition - Format & Field
without advance notification. For            length
example, in most secondary and
tertiary settings, a referral will usually   Referral Source
be received before a patient presents        For Consultation
whilst in emergency circumstances, a         3 characters
referral will often be received at the
same time as a patient presents.             Structured Name
Where more detail about the actual
referrer is needed this should be            - Referral Source Title
recorded in related fields based on the      - Referral Source Family Name
appropriate data standards, for              - Referral Source Given name
example Associated Professional               An ordered sequence of person name
details (identifier, role, employing         elements such as title, forename(s)
organisation, etc.) or Associated            and family name.
Person details (relationship, role, etc.)
                                             35 characters
                                             35 characters
                                             35 characters
                                              Person Full Name (Unstructured)
                                              This alternative to recording structured
                                             name involves the whole name being
                                             recorded as a single character string
                                             with no separately identified elements.
                                              70 characters

                                             Address (BS7666)
                                              A collection of data describing the
                                             addressing of locations
                                              see Government Data Standards
Further Information: It should be noted
that patients are no longer registered
with an individual GP, but with a
practice.
In NHS Scotland, the practice code is a
four-digit code plus a check digit with
ranges of codes allocated to each
Health Board. ISD maintains a GP
Practice code reference file which
contains up to date details of address,
postcode, telephone number for each
GP Practice in Scotland.
In England and Wales, the field is 6
digits therefore to accommodate cross
border patient flows, this should be
taken into account.



Further Information:                        Order to display codes and values
Order to display codes and values
Research indicates that for many            Codes and values:
people, their identity is defined more by   00 Atheist, agnostic or no religious
their religion than their nationality.      affiliation
The data recorded against this data         Ø R012 – Atheist
item should be current religion as          Ø R003 – Agnostic
declared by the person and NOT the          Ø R121 – None
religion he/she was brought up in.
                                            01 Christian - Church of Scotland
The classification provided here is         02 Christian - Roman Catholic
based on the Scottish Census 2001           03 Other Christian
classification with the addition of "Not    Ø R137 - Protestant
disclosed" and "Not known" options.         Ø R170 – United Free Church of
Recording Guidance:                         Scotland
Where a person embraces aspects of          Ø R083 - Free Church of Scotland
more than one religion, record the          Ø R014 – Baptist
person's MAIN current religion.             Ø R153 - Scottish Episcopal Church
There are three ways to implement this      Ø R043 - Church of England
standard depending on the detail            Ø R109 – Methodist
appropriate to the environment in which     Ø R171 - United Reformed Church
the data will be used:                      Ø R131 – Pentecostal
1. Record a person's religion using only    Ø R148 Salvation Army
the 2 digit codes listed under Codes        Ø For other Christian religions see
and values.                                 Religion Subsidiary Codes
2. Where required, the subsidiary 4         04 Buddhist
character codes for the common sub-         05 Hindu
values within values "00" or "03" can       06 Muslim
be used, making 6 characters (see           07 Jewish
Religion Subsidiary Codes).                 08 Sikh
3. Where the full range of possible         97 Not disclosed
religions is required, a detailed code      98 Any other religion (see Religion
                                            Subsidiary Codes)
Further Information:                        Related Data Items:
Can be derived from charts in A Pocket      Basal Metabolic Rate (Schofield
Guide to Clinical Nutrition, 3rd Edition,   Equation), Combined Activity and Diet-
V. Todorovic and A. Micklewright (eds.)     induced Thermogenesis Factor,
on behalf of the PEN Group of the           Estimated Total Energy Expenditure
British Dietetic Association. 2004.
Recording guidance:

The structured name approach breaks
names down into specific elements,
with start and end dates for each one
(with the exception of Preferred Name),
and facilitates electronic inter-agency
sharing and exchange of name
information. There are also start and
end dates associated with name status
so that data users can track changes to
name status (e.g. when a name is
changed by deed poll, when name
changes through marriage or divorce
etc.). Name Element Position is helpful
in identifying particular name elements
within the entire word string (e.g. family
name in Asian names does not
necessarily come at the end - Asian
names can be presented in different
sequences according to the person
being addressed).


Related Data Items:
Weight Change




Recording Guidance:                          Related Data Items
Complete only for telephone contact.         Contact Mode



Related Data Items:
Type of Meal, Food Components of
Meal, Carbohydrate Value of Meal,
Insulin:Carbohydrate Ratio, Correction
Bolus Dose

Related Data Items:
Time of Meal, Food Components of
Meal, Carbohydrate Value of Meal,
Insulin:Carbohydrate Ratio, Correction
Bolus Dose
Further Information:                       Related Data Items:
Main source of standard: Government        Address (BS7666), Postcode
Data Standards Catalogue                   Sub Data Items:
1) The flat reference (e.g. 2F3 - 2nd      Address Type
floor, Flat 3) should always be included
where applicable.
2) The address should be recorded as
`No fixed abode' or 'Address unknown'
where this is the case.
3) It is recommended that at least the
Normal domicile address is recorded. If
the patient /client has more than one
address then the patient/ client should
select one address to be recorded as
the Normal Domicile address. Students
may use either their home address or
term time address as their normal
domicile.
4) This format should be used to record
international addresses until the
Government Data Standard Catalogue
International Address data item is
defined.
Further Information:                      Recording Guidance:
Main source of standard: Government       Telephone number could be a
Data Standards Catalogue                  repeating field in order to store as
Care needs to be exercised to avoid       many numbers as are required or may
the inappropriate sharing of telephone    be useful.
number e.g. where a number is ex-         A telephone number type should be
directory.                                recorded for each recorded UK
                                          Telephone Number.
The complete telephone number             There is an option to select more than
should always be transferred for          one e.g. where a number is both a
international operation and clarity as to home telephone number and a fax
which country (in this case UK) the       number.
number belongs e.g. +447710287657. Sub Data Items:
Note no leading zero after country        Telephone Number Type
code."                                    Codes Values
(From Government Data Standards           01 Home
Catalogue)                                02 Mobile
                                          03 Work
                                          04 Fax
                                          05 Textphone
Further Information:
Waist circumference is a convenient
and simple measure which is unrelated
to height, correlates closely with BMI
and the ratio of waist to hip
circumference, and is an approximate
index of intra-abdominal fat mass and
total body fat. Furthermore, changes in
waist circumference reflect changes in
risk factors for cardiovascular disease.
There is an increased risk of metabolic
complications for men with a waist
circumference of 102cm or more and
women with a waist circumference of
88cm or more.
(WHO Diet, nutrition and the
prevention of Chronic Diseases' 2003)
This data item may be subject to
change following consultation on a
generic basis.


Further Information:                       Sub Data Items:
If weight cannot be measured, record       Verification level
recently documented or self-reported       0 Unverified
weight (if reliable and realistic) as      1 Verified
'unverified'.
In certain groups or diseases,
measurement of weight may not be
straightforward, e.g. infants, amputees,
patients undergoing dialysis. Guidance
for specific circumstances will be
included in specialist data sets as
appropriate.
Recording Guidance:                            Related Data Items
The above data item will be derived            Target Weight
from the system.



Further Information:                           Sub Data Items:
This may be a date extracted from a            Verification level
Date and Time data item.                       Codes & Value Explanatory notes
On each occasion when a date is to be          Level 0 Actual Year actual, month and
recorded, consideration should be              day not relevant/required.
given as to whether the complete date          Level 1 Estimated Year estimated,
(CCYY-MM-DD) or a truncated date               month and day not relevant/required.
(CCYY-MM or CCYY) is required.                 Level 2 Date not Required e.g. the
In some circumstances only an actual           event to which the date refers did not
date may be acceptable, whilst in              happen and therefore no entry is
others an estimated date may be                required.
allowed. In the latter situation, it will be   Level 3 Not Known A date has been
often be necessary to identify whether         recorded but it is not known whether it
the date recorded is actual or                 is an actual or estimated date.
estimated. Dates identified as actual
may be used in calculations and
analyses. Dates marked as estimated
should be treated with caution and the
implications of undertaking any
calculations or analyses should be
considered in the particular context
within which the date is recorded or to
be made subsequent use of. Where an
estimated date is allowed, the
appropriate degree of verification detail
required should be decided, again
dependent on the context in which it is
recorded and how the date is to be
used.
Recording Guidance:
Government Data Standards
Catalogue
                                                                 Sub-Section
    Sub-Headings            Specialty        Clinical Domain
                                                                  Heading




  Patient Admin &
                         Dietetic Diabetes      Diabetes
   Demographics




   Lifestyle & Risk
                         Dietetic Diabetes      Diabetes
     Assessment




   Care Episode                                                Care Journey and
                         Dietetic Diabetes      Diabetes
Administration Details                                            Encounter
                                                             Carer(s), Care
                                                            Professional(s),
                                                               Team(s),
Associated Person Details   Dietetic Diabetes   Diabetes
                                                              Service(s),
                                                           Organisation(s) or
                                                               Sector(s)
                                                             Carer(s), Care
                                                            Professional(s),
                                                               Team(s),
Associated Person Details   Dietetic Diabetes   Diabetes
                                                              Service(s),
                                                           Organisation(s) or
                                                               Sector(s)
                                                             Carer(s), Care
                                                            Professional(s),
                                                               Team(s),
Associated Person Details   Dietetic Diabetes   Diabetes
                                                              Service(s),
                                                           Organisation(s) or
                                                               Sector(s)
                                                           Carer(s), Care
                                                          Professional(s),
Associated Professional                                      Team(s),
                          Dietetic Diabetes   Diabetes
        Details                                             Service(s),
                                                         Organisation(s) or
                                                             Sector(s)




                                                           Carer(s), Care
                                                          Professional(s),
Associated Professional                                      Team(s),
                          Dietetic Diabetes   Diabetes
        Details                                             Service(s),
                                                         Organisation(s) or
                                                             Sector(s)
Associated Professional                                      Team(s),
                          Dietetic Diabetes   Diabetes
        Details                                             Service(s),
                                                         Organisation(s) or
                                                             Sector(s)
                                                           Carer(s), Care
                                                          Professional(s),
Associated Professional                                      Team(s),
                          Dietetic Diabetes   Diabetes
        Details                                             Service(s),
                                                         Organisation(s) or
                                                             Sector(s)




Assessment - Schofield                                    Finding(s) and
                          Dietetic Diabetes   Diabetes
      Equation                                               Result(s)
    Assessment and                                         Finding(s) and
                           Dietetic Diabetes   Diabetes
     Management                                               Result(s)




                                                           Care Planning,
Assessment - Dietary and
                           Dietetic Diabetes   Diabetes   Management and
        Carb
                                                            Outcome(s)
   Patient Admin &                                           Person
                         Dietetic Diabetes   Diabetes
    Demographics                                          Identification




   Care Episode                                         Care Journey and
                         Dietetic Diabetes   Diabetes
Administration Details                                     Encounter




                                                         Assessment(s),
Assessment - Schofield                                   Examination(s)
                         Dietetic Diabetes   Diabetes
      Equation                                                 and
                                                         Investigation(s)




   Goals Assessing                                       Problem(s) and
                         Dietetic Diabetes   Diabetes
 Readiness to Change                                        Issue(s)
  Goals Assessing                                        Problem(s) and
                         Dietetic Diabetes   Diabetes
Readiness to Change                                         Issue(s)




  Goals Assessing                                        Finding(s) and
                         Dietetic Diabetes   Diabetes
Readiness to Change                                         Result(s)




   Care Episode                                         Care Journey and
                         Dietetic Diabetes   Diabetes
Administration Details                                     Encounter




   Care Episode                                         Care Journey and
                         Dietetic Diabetes   Diabetes
Administration Details                                     Encounter




   Care Episode                                         Care Journey and
                         Dietetic Diabetes   Diabetes
Administration Details                                     Encounter
    Care Episode                                          Care Journey and
                           Dietetic Diabetes   Diabetes
 Administration Details                                      Encounter




    Care Episode                                          Care Journey and
                           Dietetic Diabetes   Diabetes
 Administration Details                                      Encounter




Assessment - Dietary and                                  Treatment(s) and
                           Dietetic Diabetes   Diabetes
        Carb                                               Intervention(s)
Lifestyle & Risk
                   Dietetic Diabetes   Diabetes   Lifestyle
  Assessment
                                                           Care Planning,
Assessment - Dietary and
                           Dietetic Diabetes   Diabetes   Management and
        Carb
                                                            Outcome(s)




    Lifestyle & Risk
                           Dietetic Diabetes   Diabetes      Lifestyle
      Assessment
Lifestyle & Risk
                   Dietetic Diabetes   Diabetes   Lifestyle
  Assessment
        Date             Dietetic Diabetes   Diabetes




   Care Episode
                         Dietetic Diabetes   Diabetes
Administration Details
Referral Administration
                          Dietetic Diabetes   Diabetes
        Details
Referral Administration
                          Dietetic Diabetes   Diabetes
        Details
Diagnosis Details   Dietetic Diabetes   Diabetes   Diagnosis
Diagnosis Details   Dietetic Diabetes   Diabetes   Diagnosis
                                                       Care Planning,
Dietary Intervention   Dietetic Diabetes   Diabetes   Management and
                                                        Outcome(s)




                                                       Care Planning,
Dietary Intervention   Dietetic Diabetes   Diabetes   Management and
                                                        Outcome(s)




                                                       Care Planning,
Dietary Intervention   Dietetic Diabetes   Diabetes   Management and
                                                        Outcome(s)
                                                         Care Planning,
 Dietary Intervention    Dietetic Diabetes   Diabetes   Management and
                                                          Outcome(s)




                                                         Care Planning,
 Dietary Intervention    Dietetic Diabetes   Diabetes   Management and
                                                          Outcome(s)




Assessment - Schofield                                   Finding(s) and
                         Dietetic Diabetes   Diabetes
      Equation                                              Result(s)




                                                         Care Planning,
  Assessment - Food
                         Dietetic Diabetes   Diabetes   Management and
     Frequency
                                                          Outcome(s)
Ethnic Cultural & Diversity   Dietetic Diabetes   Diabetes   Diversity
                                                           Care Planning,
                           Dietetic Diabetes
       Follow-Up                               Diabetes   Management and
                              Extension
                                                            Outcome(s)




                                                           Care Planning,
Assessment - Dietary and
                           Dietetic Diabetes   Diabetes   Management and
        Carb
                                                            Outcome(s)




                                                           Care Planning,
  Dietary Intervention     Dietetic Diabetes   Diabetes   Management and
                                                            Outcome(s)




                                                           Care Planning,
  Assessment - Food
                           Dietetic Diabetes   Diabetes   Management and
     Frequency
                                                            Outcome(s)
                                                    Care Planning,
Assessment - Food
                    Dietetic Diabetes   Diabetes   Management and
   Frequency
                                                     Outcome(s)




   GP Details       Dietetic Diabetes   Diabetes
                                                        Assessment(s),
 Assessment - Food                                      Examination(s)
                         Dietetic Diabetes   Diabetes
    Frequency                                                 and
                                                        Investigation(s)




    Investigations       Dietetic Diabetes   Diabetes




     GP Details          Dietetic Diabetes   Diabetes




   Care Episode
                         Dietetic Diabetes   Diabetes
Administration Details
 Assessment and                                    Finding(s) and
                    Dietetic Diabetes   Diabetes
  Management                                          Result(s)




Background Health                                  Problem(s) and
                    Dietetic Diabetes   Diabetes
   Information                                        Issue(s)
  Goals Assessing                                     Finding(s) and
                      Dietetic Diabetes   Diabetes
Readiness to Change                                      Result(s)




                                                      Care Planning,
Socio-Environmental
                      Dietetic Diabetes   Diabetes   Management and
      Details
                                                       Outcome(s)




                                                      Care Planning,
Socio-Environmental
                      Dietetic Diabetes   Diabetes   Management and
      Details
                                                       Outcome(s)
                                                            Care Planning,
Assessment - Dietary and
                            Dietetic Diabetes   Diabetes   Management and
        Carb
                                                             Outcome(s)




    Patient Admin &
                            Dietetic Diabetes   Diabetes
     Demographics




Associated Person Details   Dietetic Diabetes   Diabetes
   Care Episode
                         Dietetic Diabetes   Diabetes
Administration Details




   Care Episode
                         Dietetic Diabetes   Diabetes
Administration Details
Lifestyle & Risk                                  Treatment(s) and
                   Dietetic Diabetes   Diabetes
  Assessment                                       Intervention(s)




Lifestyle & Risk
                   Dietetic Diabetes   Diabetes
  Assessment
 Assessment and                                      Finding(s) and
                      Dietetic Diabetes   Diabetes
  Management                                            Result(s)




                                                     Assessment(s),
 Assessment and                                      Examination(s)
                      Dietetic Diabetes   Diabetes
  Management                                               and
                                                     Investigation(s)




                                                       Social and
Socio-Environmental
                      Dietetic Diabetes   Diabetes      Personal
      Details
                                                     Circumstances
                                                            Care Planning,
    Goals Assessing
                            Dietetic Diabetes   Diabetes   Management and
  Readiness to Change
                                                             Outcome(s)




    Patient Admin &
                            Dietetic Diabetes   Diabetes
     Demographics




Associated Person Details   Dietetic Diabetes   Diabetes
Patient Admin &
                  Dietetic Diabetes   Diabetes   Diversity
 Demographics
  Outcomes        Dietetic Diabetes   Diabetes




Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics
Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics




Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics




                                                   Social and
Patient Admin &
                  Dietetic Diabetes   Diabetes      Personal
 Demographics
                                                 Circumstances
Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics




Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics
Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics
Ethnic Cultural & Diversity   Dietetic Diabetes   Diabetes
  Patient Admin &
                         Dietetic Diabetes   Diabetes
   Demographics




  Assessment and                                         Finding(s) and
                         Dietetic Diabetes   Diabetes
   Management                                               Result(s)




   Care Episode                                         Care Journey and
                         Dietetic Diabetes   Diabetes
Administration Details                                     Encounter
                             Dietetic Diabetes   Diabetes
 Administration Details                                        Encounter




   Assessment - Food
                             Dietetic Diabetes   Diabetes
      Frequency




                                                            Care Journey and
Source of Referral Details   Dietetic Diabetes   Diabetes
                                                               Encounter
                                                            Care Journey and
Source of Referral Details   Dietetic Diabetes   Diabetes
                                                               Encounter
                                                               Carer(s), Care
                                                              Professional(s),
                                                                 Team(s),
        GP Details            Dietetic Diabetes   Diabetes
                                                                Service(s),
                                                             Organisation(s) or
                                                                 Sector(s)




Ethnic Cultural & Diversity   Dietetic Diabetes   Diabetes
Ethnic Cultural & Diversity   Dietetic Diabetes   Diabetes




 Assessment - Schofield                                      Problem(s) and
                              Dietetic Diabetes   Diabetes
       Equation                                                 Issue(s)
       GP Details          Dietetic Diabetes   Diabetes




                                                           Care Planning,
    Assessment and
                           Dietetic Diabetes   Diabetes   Management and
     Management
                                                            Outcome(s)



    Care Episode
                           Dietetic Diabetes   Diabetes
 Administration Details



                                                           Care Planning,
Assessment - Dietary and
                           Dietetic Diabetes   Diabetes   Management and
        Carb
                                                            Outcome(s)




                                                           Care Planning,
Assessment - Dietary and
                           Dietetic Diabetes   Diabetes   Management and
        Carb
                                                            Outcome(s)
                                                       Care Planning,
Dietary Intervention   Dietetic Diabetes   Diabetes   Management and
                                                        Outcome(s)
                                                       Care Planning,
Dietary Intervention   Dietetic Diabetes   Diabetes   Management and
                                                        Outcome(s)
    Patient Admin &
                            Dietetic Diabetes   Diabetes
     Demographics




       GP Details           Dietetic Diabetes   Diabetes




Associated Person Details   Dietetic Diabetes   Diabetes
Patient Admin &
                  Dietetic Diabetes   Diabetes
 Demographics




Assessment and                                   Finding(s) and
                  Dietetic Diabetes   Diabetes
 Management                                         Result(s)




Assessment and                                   Finding(s) and
                  Dietetic Diabetes   Diabetes
 Management                                         Result(s)
Assessment and                                    Finding(s) and
                   Dietetic Diabetes   Diabetes
 Management                                          Result(s)




Lifestyle & Risk
                   Dietetic Diabetes   Diabetes
  Assessment
Section Heading




   Person
Demographic(s)




 Clinical / Care
    Process
   Person
Demographic(s)
   Person
Demographic(s)
   Person
Demographic(s)
   Person
Demographic(s)




   Person
Demographic(s)
   Person
Demographic(s)
   Person
Demographic(s)




Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
   Process
   Person
Demographic(s)




Clinical / Care
   Process




Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
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Clinical / Care
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Clinical / Care
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Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
   Process




Clinical / Care
   Process
   Socio-
Environmental
Clinical / Care
   Process




   Socio-
Environmental
   Socio-
Environmental
Date(s) and
 Time(s)
Date(s) and
 Time(s)
Clinical / Care
   Process
Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
   Process




Clinical / Care
   Process
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   Person
Demographic(s)
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Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process




   Person
Demographic(s)
Clinical / Care
   Process




   Person
Demographic(s)




   Person
Demographic(s)
Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process




   Person
Demographic(s)




   Person
Demographic(s)
   Person
Demographic(s)
Clinical / Care
   Process
Clinical / Care
   Process




Clinical / Care
   Process




   Socio-
Environmental
Clinical / Care
   Process




   Person
Demographic(s)




   Person
Demographic(s)
   Person
Demographic(s)
  Date(s) and
   Time(s)




   Person
Demographic(s)
   Person
Demographic(s)




   Person
Demographic(s)




   Socio-
Environmental
   Person
Demographic(s)




   Person
Demographic(s)
   Person
Demographic(s)
  Personal
Preference(s)
Clinical / Care
   Process




Clinical / Care
   Process
   Process




 Date(s) and
  Time(s)




Clinical / Care
   Process
Clinical / Care
   Process
   Person
Demographic(s)
Clinical / Care
   Process
   Person
Demographic(s)




Clinical / Care
   Process




   Person
Demographic(s)




Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process
Clinical / Care
   Process
   Person
Demographic(s)




   Person
Demographic(s)




   Person
Demographic(s)
   Person
Demographic(s)




Clinical / Care
   Process




Clinical / Care
   Process
Clinical / Care
   Process




 Date(s) and
  Time(s)
v1.1   Hyperlinks amended
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v1.2   Codes and Values put into separate cells and removed comment boxes
       New Data Dictionary Headings added
       Changes to Data Standards                                 Date
                                                                 Date Referral Received

				
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