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Unscheduled Care Com.. - isd.scot.nhs.uk

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					Unscheduled Care Communications
                                     Definition of NCDDP
NCDDP Formal Name   Common Name(s)                             Format and Field Length
                                     data Standard
Accommodation                        Definition:               Format
Permanence Status                    The permanency of the     Characters
                                     person's current living
                                     arrangements/ place of    Field Length
                                     residence.                2
Accommodation Type   Definition:              Format: Characters
                     The type of
                     accommodation in which   Field Length: Up to 6
                     the person is normally   (2+4)
                     resident.
Address (BS7666)     Structured Address   Definition:               Sub Data Items
                                          A collection of data
                                          describing the addressing Address Type
                                          of locations.             Codes & Values

                                                                      00 None
                                                                       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




Ambulance Incident                        Definition:                 Format
Number                                    A record of the ambulance   Character
                                          incident number as per
                                          the Scottish Ambulance      Field Length
                                          Service Patient Record      12
                                          Form (PRF).
Ancestry- Related Health   Definition:                   Format
Risk                       A statement made by the       Read code term, where
                           individual about the          implemented (in future
                           geographic area(s) in         SCT code / term)
                           which they have their
                           ancestral origin. This
                           information may assist
                           Health Care Professionals
                           in providing health care to
                           an individual where there
                           may be altered health risk
                           associated with ancestral
                           origin.
Arrival Date & Time   Date & Time of Arrival at Definition:                Format: characters (CCYY-
                      A&E, Date & Time of A&E The date & time of arrival MM-DDThh:mm:ssTZD)
                      attendance                of a patient at an A&E
                                                department. If the patient Field Length: 25
                                                arrives by ambulance this
                                                will be taken from the
                                                ambulance data,
                                                otherwise this is when the
                                                patient arrives at A&E
                                                reception.
Arrival Mode        Mode of arrival at A&E,   Definition:                Format: Characters
{Unscheduled Care   Arrival transport mode,   The substantive means by Field Length: 2
Communications}     Arrived by                which a patient arrived at
                                              an A&E department.
Associated Person   Other person   Definition:                  Format
                                   People who have a            N/A
                                   significant involvement or
                                   relationship with the        Field Length
                                   client/patient (e.g. main    N/A
                                   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         Definition:                Format
Relationship to Client/   The relationship of an     Characters
Patient                   Associated Person to the
                          client/patient.            Field Length
                                                     3
Associated Person Role   Person Role   Definition:                      Format
                                       A description of the             Characters
                                       particular involvement(s)
                                       with/ function(s) fulfilled by   Field Length
                                       an associated person             3
                                       towards the client/ patient.
Associated Professional   Associated Care      Definition:
                          Professional, Care   Associated Professionals
                          Professional         are those individuals who
                                               are involved with the
                                               client/ patient in a
                                               professional capacity e.g.
                                               consultant, social worker,
                                               occupational therapist,
                                               etc.
Associated Professional   Employing Organisation   Definition:                    Format
Employing Organisation    Name, Employer Name      The organisation, body or      Characters
Name                                               agency, which employs
                                                   the associated                 Field Length
                                                   professional in relation to    255
                                                   the role they are fulfilling
                                                   with regard to a particular
                                                   client/patient. This is
                                                   either the name by which
                                                   the organisation wishes to
                                                   be known, or the official
                                                   name given to the
                                                   organisation.




Associated Professional   Type of Employer         Definition:                    Format
Employing Organisation                             The type of organisation,      Characters
Type                                               body or agency, which
                                                   currently employs the          Field Length
                                                   associated professional in     2
                                                   relation to the role they
                                                   are fulfilling.
Associated Professional Associated Care      Definition:                Format
Group {Unscheduled Care Professional Group   The recognised             Characters
Communications)                              professional group to
                                             which the care             Field Length
                                             professional belongs and   3
                                             in which they are
                                             employed.
Associated Professional   Main Source of Standard      Definition:                 Format
Identifier                General Medical Council,     The unique identifier       Characters (right justified)
                          General Dental Council,      issued to all health and
                          Royal Pharmaceutical         social care professionals   Field Length
                          Society of Great Britain,    by their professional       8
                          Health Professions           regulatory body.
                          Council, The Nursing and
                          Midwifery Council, British
                          Psychological Society,
                          Scottish S
Associated Professional   Associated Care     Definition:                   Format
Role                      Professional Role   Professionals are those       Characters
                                              individuals who are
                                              involved with the             Field Length
                                              client/patient in a           35
                                              professional capacity (e.g.
                                              Consultant, Social
                                              Worker, Occupational
                                              Therapist etc). The
                                              particular role(s) carried
                                              out by each professional
                                              is (are) indicated by this
                                              data item.
Body Mass Index   BMI   Definition:             Format
                        Body Mass Index (BMI) = nn.n
                        weight/height² (kg/m²)
                                                Field Length
                                                3
CHI Number   Definition:                Format: Characters
             The Community Health       Field Length: 10
             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.
Child Protection Register   Main Source of Standard Definition:                     Format
Status                      Scottish Social Care Data A CHILD PROTECTION            Characters
                            Standards                 REGISTRATION is the
                                                      inclusion of a specific       Field Length
                                                      Child on the Child            3
                                                      Protection Register. This
                                                      entity can include
                                                      registrations made by
                                                      other Social Work
                                                      Departments. Child
                                                      Protection Registrations
                                                      are used as an indicator to
                                                      highlight that a child has
                                                      been assessed as being
                                                      at risk from their
                                                      environment or another
                                                      person. Child protection
                                                      registration categories
                                                      describe the risk factors
                                                      associated with that child.
                                                      A CHILD PROTECTION
                                                      REGISTRATION
                                                      CATEGORY is the
                                                      classification of the
                                                      reason or category of
                                                      abuse for which a specific
                                                      child is placed on the
                                                      Child Protection Register.
Child Protection Register   Main Source of Standard     Definition:                   Format
Status - Child at Same      Based on, Children's        Where the patient/client is   Characters
Address on Register         Social Services Core        a child, an indication of
                            Information requirements.   whether or not another        Field Length
                            Logical Data Model. V3.1    child, who resides at the     2
                            DfES                        same address as the
                                                        patient/client, is included
                                                        in the Child Protection
                                                        Register.




Conscious Level             Level of consciousness      Definition:                   Format
                                                        A record of the patient's     Characters
                                                        level of consciousness.
                                                                                      Field Length
                                                                                      2
Cultural Diet Preference                             Definition:                 Format: Characters
                                                     Diet preference expressed
                                                     by a patient/ client, which Field Length: 2
                                                     may be related to religion
                                                     or other cultural issues.
                                                     This does not include food
                                                     intolerances or allergies.




Current Alcohol Drinking   Alcohol Status, Alcohol   Definition:                   Format
Status                     Intake                    Record of the individual's    Characters
                                                     current alcohol
                                                     consumption in relation to    Field Length
                                                     prevailing guidelines, with   2
                                                     reference to any past
                                                     excessive alcohol
                                                     consumption.
Current Location of   Location of casualty,   Definition:                   Format
Patient               Patient Location        A record of the type of       Character
                                              location of the
                                              patient/client to which the   Field Length
                                              healthcare professional is    Up to 3
                                              directed to attend.
Current Substance Misuse Drug Abuse, Substance   Definition:                   Format
Status                   Misuse                  Misuse of drugs (including    Characters
                                                 illicit substances,
                                                 prescription drugs, over      Field Length
                                                 the counter medications,      2
                                                 solvents, etc), which leads
                                                 a person to experience
                                                 physical, psychological or
                                                 social (including legal)
                                                 problems. (Excludes
                                                 alcohol or tobacco
                                                 consumption).
Current Tobacco and    Tobacco Consumption,    Definition:                 Format
Nicotine Consumption   Tobacco Status, Smoking Tobacco consumption at      Characters
Status                 Status                  date of contact including
                                               smoking, chewing and use    Field Length
                                               of other nicotine           2
                                               substances
Date and Time Call   Time Call Answered   Definition:                   Format
Answered                                  A record of the date and      (CCYY-MM-
                                          time the organisation first   DDThh:mm:ssTZD)
                                          responds to a call from the
                                          patient/client.               Field Length
                                                                        25
Date and Time Call     Definition:                   Format
Connected to Network   A record of the date and      25
                       time a call from the
                       patient/client is initially   Field Length
                       connected to the              (CCYY-MM-
                       healthcare provider's         DDThh:mm:ssTZD)
                       automated system.
Date and Time Contact   Date & Time Visit Ended   Definition:               Format
Ended                                             A record of the date &    (CCYY-MM-
                                                  time the contact the      DDThh:mm:ssTZD)
                                                  contact between a
                                                  healthcare professional   Field Length
                                                  and the patient/client    25
                                                  ended.
Date and Time Contact      Date & Time of Visit, Date Definition:                 Format
Started                    & Time of Contact, Date & A record of the date &       (CCYY-MM-
                           Time Visit Started         time the contact between    DDThh:mm:ssTZD)
                                                      a healthcare professional
                                                      and the patient/client      Field Length
                                                      began.                      25




Date of Last Discharge     Date of Last Discharge     Definition:                 Format
from Secondary Care        from Hospital/Hospice      The date on which the       Date
                                                      patient was most recently
                                                      discharged from a period    Field Length
                                                      of Secondary Care           10 (CCYY-MM-DD)


Date of Last Encounter     Date of Most Recent       Definition:
with Healthcare Provider   Encounter with Healthcare The date on which the
                           Provider                  patient/representative of
                                                     the patient most recently
                                                     contacted a first-line
                                                     Healthcare Provider for
                                                     advice/treatment.
Dependency upon Patient/ Dependency upon Person Definition:                  Format
Client                                          A record of whether the      Characters
                                                patient/client has
                                                dependant(s) relying upon    Field Length
                                                him/her for essential        2
                                                support on an ongoing
                                                basis, such that if this
                                                support were removed the
                                                dependant(s) would be left
                                                in a vulnerable position.
                                                This may include animals.




Diastolic Blood Pressure   DBP, Diastolic BP     Definition:                 Format
                                                 Diastolic Blood Pressure    nnn mmHg
                                                 measured using a
                                                 technique and equipment     Field Length
                                                 approved by the British     3
                                                 Hypertension Society.
Duration of Contact   Length of Contact, Length Definition:                   Format
                      of Visit                  The length of the             hh:mm
                                                healthcare professionals'
                                                contact with the              Field Length
                                                patient/client.               5




Dwelling Type                                   Definition:                   Format
                                                Dwelling Type is a            Characters
                                                description of the physical   Field Length
                                                structure in which            3
                                                someone lives.
End Date   Main Source of Standard   Definition:            Format
           Government Data           The date on which a    Characters (CCYY-MM-
           Standards Catalogue       process or period of   DD)
                                     validity terminates.
                                                            Field Length
                                                            10




End Date   Main Source of Standard
           Government Data
           Standards Catalogue
Ethnic Group (Self   Definition:                Format: Characters
Assigned)            A statement made by the    Field Length: Up to 6 (2 +
                     service user about their   4)
                     current ethnic group.
General Practice         Practice Registration   Definition:                  Format
Registration Status of   Status                  The registration status of   Characters
Patient                                          the patient with the
                                                 general practice from        Field Length
                                                 which they are receiving     3
                                                 care.
Glasgow Coma Scale -   Definition:                 Format
Best Motor Response    A record of the patient's   Characters
                       motor response assessed
                       using the Glasgow Coma      Field Length
                       Scale tool.                 2
Glasgow Coma Scale -   GCS   Definition:                 Format
Eye Opening                  A record of the patient's   Characters
                             eye response assessed
                             using the Glasgow Coma      Field Length
                             Scale tool.                 2




Glasgow Coma Scale -   GCS   Definition:                 Format
Verbal Response              A record of the patient's   Characters
                             verbal response assessed
                             using the Glasgow Coma      Field Length
                             Scale tool.                 2
GP General Medical   GP GMC Number   Definition:                 Format
Council Number                       The GMC (General            Characters (right justified)
                                     Medical Council) number
                                     is the personal             Field Length
                                     identification number       8
                                     issued to each doctor in
                                     the UK by the General
                                     Medical Council.




Heart Rate           Cardiac Rate    Definition:                 Format
                                     A record of the patient's   Numeric
                                     heart rate measured from
                                     heart sounds or an          Field Length
                                     electrocardiogram           3
                                     measured in beats per
                                     minute (bpm).
Height          Definition:                Format
                Height in metres (to the   n.nn
                nearest centimetre) -
                measured without shoes     Field Length
                                           3




Home Support    Definition:                 Format
Circumstances   A summary of any support Characters
                available to the patient or
                the support the patient
                provides to others when in
                their own home.
Impairment   Impairment Indicator   Definition:                  Format
                                    An indicator of whether      Characters
                                    the client/patient has any
                                    impairment, which may        Field Length
                                    affect the ability of        2
                                    professionals to
                                    communicate with the
                                    client/patient, or may
                                    impact on the assessment
                                    process or the delivery of
                                    services.
Initial Assessment Triage Triage Category   Definition:                   Format
Category {Unscheduled                       The category assigned to      Characters
Care Communications}                        a patient as a result of an
                                            initial assessment,           Field Length
                                            whether by telephone          2
                                            triage or face-to-face
                                            triage.
Internet Email Address      Email Address   Definition:                 Format
                                            The string of characters    Characters
                                            that identifies an
                                            addressee's post box on     Field Length
                                            the Internet.               255




Interpretation Assistance                   Definition:                 Format; Characters
Indicator                                   Indication of requirement
                                            for assistance to           Field Length: 2
                                            communicate in English.
Location Code     Location, Location of   Definition:                     Format
                  Contact                 This is the reference           Characters
                                          number of any building or
                                          set of buildings where          Field Length
                                          events pertinent to NHS         5
                                          Scotland take place.
                                          Locations include
                                          hospitals, health centres,
                                          GP surgeries, clinics,
                                          NHS board offices,
                                          nursing homes, schools
                                          and patient/client's home.




Mobility Status                           Definition:                     Format
                                          The degree to which the         Characters
                                          patient is mobile and what
                                          aids, if any, they require to   Field Length
                                          achieve this level of           3
                                          mobility.
Name Element Position   Element Position   Definition:                   Format
                                           Indicates the position        Digits
                                           each name word holds
                                           within the entirety of the    Field Length
                                           record; particularly          Up to 2
                                           relevant for people from
                                           Asian communities where
                                           naming conventions may
                                           differ from the British
                                           norm.




Outcome of Contact                         Definition:                   Format
                                           The result of the             Characters
                                           encounter with the patient,
                                           whether it be face-to-face    Field Length
                                           contact, by telephone or      3
                                           by questionnaire.
Oxygen Saturation   Definition:                 Format
                    A record of the patient's   Numeric
                    oxygen saturation
                    percentage (SpO2)           Field Length
                    measured using a pulse      3
                    oximeter.
Patient/ Client           Main Source of Standard    Definition:                     Format
Representative Required   Assessment Review Co-      An adult who represents         Characters
                          ordinating Group           or communicates on
                                                     behalf of the patient/ client   Field Length
                                                     and who is required to          2
                                                     ensure that the
                                                     patient/client's views,
                                                     wishes and needs are
                                                     appropriately
                                                     communicated and taken
                                                     into account.



Patient/Client Risk       Risk Factors, Identified   Definition:                     Format
Summary                   Risk, Risk Concerns        A high level summary of         Characters
                                                     the patient/client's risk
                                                     status identified through a     Field Length
                                                     specific risk assessment.       up to 3
Person Birth Date   Date of Birth   Definition:               Format: Characters
                                    The date on which a       (CCYY-MM-DD)
                                    person was born or is
                                    officially deemed to have Field Length: 10
                                    been born, as recorded on
                                    the Birth Certificate
Person Current Gender   Current Gender   Definition:                 Format: Character
                                         A statement by the
                                         individual about the        Field Length : 1
                                         gender they currently
                                         identify themselves to be   Codes and Values: (Code
                                         (i.e. self-assigned).       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.
Person Family Name   Surname, Family name   Definition:                     Format
                                            That part of a person's         Characters
                                            name which is used to
                                            describe family, clan, tribal   Field Length
                                            group, or marital               35
                                            association.
Person Given Name   Forename, Given Name,   Definition:             Format
                    Personal Name           The forename or given   Characters
                                            name of a person.
                                                                    Field Length
                                                                    35
Person Initials   Initials   Definition:            Format
                             A person's initials.   Characters free text with a
                                                    space between each
                                                    initial.

                                                    Field Length
                                                    35
Person Legal Status   Legal Status   Definition:                 Format
                                     A particular status usually Characters
                                     sanctioned by the courts
                                     or by the children's        Field Length
                                     hearing system in relation
                                     to the client/patient in
                                     order to ensure their
                                     protection and/or the
                                     protection of others.
Person Name Status   Name Status   Definition:                  Format
                                   Person Name Status           Characters
                                   identifies whether the
                                   name is the name the         Field Length
                                   person was registered        2
                                   with at birth, or has been
                                   subsequently changed by
                                   preference, customary
                                   use, marriage, or deed
                                   poll.
Person Name Suffix   Name Suffix   Definition:                 Format
                                   A textual suffix that may   Characters
                                   be added to the end of a
                                   person's name, for          Field Length
                                   example, OBE, MBE,          35
                                   BSc, JP, GM.
Person Preferred   Preferred Forename,   Definition:                      Format
Forename           Known as (Forename)   The forename by which a          Characters
                                         person prefers to be
                                         called if different from first   Field Length
                                         forename.                        35
Person Title   Title   Definition:              Format
                       Standard form of address Characters
                       used to precede a
                       person's name.           Field Length
                                                35
Postcode                  Main Source of Standard   Definition:                 Format
                          Government Data           The code allocated by the   Characters
                          Standards Catalogue       Post Office to identify a
                                                    group of postal delivery    Field Length
                                                    points.                     8




Preferred Communication                             Definition:                 Format: Characters
Method                                              The method of
                                                    communication preferred     Field Length; 3
                                                    by the person to make
                                                    themselves understood.
Preferred Language   Definition:                Format: Characters
                     This data item is defined
                     as the person's language Field Length: Up to 6
                     of preference and may
                     differ from first language
                     (as defined as the
                     language spoken at
                     home) and is required for
                     effective communication
                     with the person.
Preferred Name   Definition:                Format
                 Indicates whether or not   Characters
                 an instance of Name
                 (structured or             Field Length
                 unstructured) is the       2
                 person's preferred name.
Previous Person Family   Previous Surname, Family Definition:                   Format
Name                     Name                     That part of a person's       Characters
                                                  name used to describe
                                                  family, clan, tribal group,   Field Length
                                                  or marital association, and   35
                                                  by which a person was
                                                  previously known.
Pulse Rate Arterial                            Definition:                  Format
                                               The frequency of the         Numeric
                                               pulse measured in a
                                               peripheral artery recorded   Field Length
                                               as beats per minute          3
                                               (bpm).




Pulse Volume          Pulse character, Pulse   Definition:               Format
                      Strength                 A record of the amplitude Characters
                                               of the pulse.
                                                                         Field Length
                                                                         2
Pupil Reaction                                 Definition:                  Format
                                               A high level assessment      Characters
                                               of the reactivity of the
                                               pupil.                       Field Length
                                                                            2




Pupil Size                                     Definition:                  Format
                                               A high level assessment      Characters
                                               of the size of the pupil
                                                                            Field Length
                                                                            2




Recent Encounter(s) with Recent Contact with   Definition:                  Format
Healthcare Provider      Healthcare Provider   A record of whether the      Characters
{Unscheduled Care                              patient/client (or a
Communications}                                representative of the        Field Length
                                               patient/client) has          up to 3
                                               previously contacted a
                                               Healthcare Provider within
                                               the previous 30 days.
Referral Source     Source of referral,     Definition:                  Format
{Unscheduled Care   Referred by, Referral   The type of organisation,    Characters
Communications}     Type                    service, care professional
                                            or other individual making   Field Length
                                            a referral.                  3
Registered GP Practice   Registered GP Practice   Definition:                   Format
Code                                              General Medical               Characters (right justified)
                                                  Practitioners provide
                                                  general medical services      Field Length
                                                  to the population either in   6
                                                  partnership with other
                                                  GMPs or on a single-
                                                  handed basis. The term
                                                  GP practice covers both
                                                  partnerships and single-
                                                  handed practices. Each
                                                  GP practice in Scotland is
                                                  identified by a unique GP
                                                  practice code. The
                                                  practice code is a four-
                                                  digit code plus a check
                                                  digit with ranges of codes
                                                  allocated to each Health
                                                  Board.
                                                  (Scottish Morbidity Record
                                                  - NHS Information
                                                  Services)
Religion   Definition:                   Format: Characters
           A statement made by the
           service user about their      Field Length: Up to 6 (2 +
           current religious affiliation 4)
           / faith community.
Specified General Medical Specified GP   Definition:
Practitioner                             A doctor who has a
                                         certificate of satisfactory
                                         completion of GP training
                                         or equivalent. The
                                         specified GP is an
                                         individual GP within the
                                         patient/client's registered
                                         practice who needs to be
                                         identified for a particular
                                         role they fulfil.
Specified General Medical Specified GP Role   Definition:                   Format
Practitioner Role                             The function carried out      Characters
                                              by an individual GP in
                                              relation to the               Field Length
                                              patient/client, who may or    2
                                              may not be within the
                                              patient/client's registered
                                              practice.
Spiritual Care Preferences   Definition:               Format: Characters
                             Spiritual Care is person
                             centred care which,       Field Length: 2
                             through affirmation,
                             enables a person to make
                             the best use of all their
                             personal and spiritual
                             resources in facing and
                             coping with the doubts,
                             anxieties and questions
                             which arise in a health
                             care setting and often
                             accompany ill health and
                             suffering.
Staff/Carer's        Definition:                 Format
Environmental Risk   A summary of                Characters
Summary              risks/hazards to
                     staff/carer(s) in the       Field Length
                     patient/client's place of   3
                     residence or current
                     surroundings identified
                     through a specific risk
                     assessment.
Start Date        Main Source of Standard   Definition:                  Format
                  Government Data           The date on which a          Characters (CCYY-MM-
                  Standards Catalogue       process or period of         DD)
                                            validity commences.
                                                                         Field Length
                                                                         10




Structured Name                             Definition:                  Person Family Name
                                            An ordered sequence of       Person Title
                                            person name elements         Name Element Position
                                            such as title, forename(s)   Person Name Status
                                            and family name.             Preferred Name
                                                                         Previous Person Family
                                                                         Name
                                                                         Person Given Name
                                                                         Person Initials
                                                                         Person Preferred
                                                                         Forename
                                                                         Person Name Suffix
Systolic Blood Pressure   SBP, Systolic BP   Definition:                 Format
                                             Systolic Blood Pressure     nnn (mmHg)
                                             measured using a
                                             technique and equipment     Field Length
                                             approved by the British     3
                                             Hypertension Society.




Temperature (General                         Definition:
Body)                                        A record of the patient's
                                             general body temperature
                                             measured in degrees
                                             centigrade (°C).
UK Postal Address   Unstructured Address/   Definition:                  Format
                    Simple address          The address of a postal      Characters. Minimum 2
                                            delivery point. This is      address lines, no
                                            usually a building and       maximum although a de
                                            usually comprises a          facto standard exists of 5
                                            name/number, street,         lines exists for
                                            town and                     presentation purposes.
                                            county/state/province and
                                            sometimes country. This      Field Length
                                            is not the preferred e-GIF   Maximum 35 per address
                                            standard.                    line
UK Telephone number   Telephone Number   Definition:                  Format
                                         A number, including any      Characters
                                         exchange or location
                                         code, at which a person or   Field Length
                                         organisation can be          35
                                         contacted in the UK by
                                         telephonic means.




Unscheduled Care                         Definition:                  Format
Delivery Location                        A record of the location     Characters
                                         from where care is being
                                         delivered during a           Field Length
                                         particular episode of        Up to 3
                                         unscheduled care.
Unstructured Name     Main Source of            Definition:                  Format
                      Standard                  A single unstructured        Characters
                      Derived from I&DeA        concatenation of some or
                      naming standard           all of the elements that     Field Length
                                                make up a person's full      70
                                                name.




Urgency of Referral   Referral Priority, Urgency Definition:
{Unscheduled Care     Category                   A judgement made by the
Communications}                                  referring agent or agency
                                                 regarding how quickly a
                                                 patient needs to be seen
                                                 when referring onwards.
                                                 Is not applicable when a
                                                 self-referral is made.
Weight   Definition:               Format
         Weight in kilograms taken nnn.n
         without shoes or outdoor
         clothing                  Field Length
                                   4
Hyperlink to NCDDP                                      Additional or related         Further Additional
                        Codes and Values
item on Data Dictionary                                 Information                   Information
http://www.datadictionarya 01 Permanent The             Further Information: This
dmin.scot.nhs.uk/isddd/11 person's current              will help service providers
960.html                   accommodation is where       to ensure that they have
                           they expect to remain        the most up-to-date
                           living for the foreseeable   information on where the
                           future.                      person is living and the
                                                        length of time that they
                                                        are expecting to remain
                                                        there.
                                                        Recording Guidance:
                                                        Where accommodation is
                                                        temporary, this should be
                                                        associated with start and
                                                        end dates.

                           02 Temporary The
                           person's current
                           accommodation is
                           expected to be for a time-
                           limited period.
                           98 Other
                           99 Not known
http://www.datadictionarya 01 - Homeless            Further Information:
dmin.scot.nhs.uk/isddd/11                           Main source of standard:
226.html                                            Scottish Social Care Data
                                                    Standards
                                                    Detailed definitions for
                                                    each of the data items
                                                    featuring in the
                                                    subcategories under the
                                                    main codes are available
                                                    from Supporting People
                                                    documentation at
                                                    http://www.scotland.gov.u
                                                    k/Topics/Housing/Housing
                                                    /supportpeople/intro
                                                    Recording Guidance:
                                                    The code for Registered
                                                    Adult Care Homes (07)
                                                    also has sub-codes:
                                                    AC03 - Nursing Homes
                                                    AC04 - Residential Care
                                                    Homes
                                                    These are not featured in
                                                    the codes and values
                                                    table above as they are
                                                    valid only for historical
                                                    data for 'Residential' and
                                                    'Nursing' Homes prior to
                                                    their re-designation as
                                                    'Care Homes. Certain
                                                    national information
                                                    systems such as
                                                    "Supporting People" hold
                          01HM01 Homelessness       this sort of historical data.
                          Type unspecified
                          01HM02 Rough Sleepers
                          01HM03 Other Roofless
                          01HM04 Squatting
                          01HM05
                          Emergency/Temporary
                          Accommodation
                          01HM06 Women's
                          refuges
                          01HM07 Bed & Breakfast

                          01HM08 Young People
                          asked to leave
                          01HM09 Unable to secure
                          entry
                          02 - Mainstream
                          02MA01 Unspecified
                          02MA02 No adaptations
                          02MA03 With adaptations

                          02MA04 Barrier Free
                          Housing/Lifetime Homes
                          03 - Special Housing
03SP01 Unspecified
03SP02 Amenity Housing

03SP03 Wheelchair
Accessible Housing
03SP04 Ambulant
Disabled Housing
03SP05 Other specially
adapted housing
04 - Sheltered Housing
04SH01 Unspecified
04SH02 Extra Care
Housing
04SH03 Very Sheltered
Housing
04SH04 Integrated Very
Sheltered Housing/Shared
Housing Plus

04SH05 Other Sheltered
Housing
05 - Supported
Accommodation
05SU01 Unspecified
05SU02 Hostels
05SU03 Staffed Group
Hostels
05SU04 Core and Cluster

05SU05 Foyers
05SU06 Supported
tenancies
05SU07 Supported
landlady/resident
caretaker schemes
05SU08 Specialist
Facilities
05SU09 Other Supported
Accommodation

06 - Specialist
Rehabilitation Units
06RU01 Unspecified
06RU02 Addiction
Rehabilitation Units
06RU03 Mental Health
Rehabilitation Facilities
07 - Registered Adult
Care HomesSee
Recording Guidance.
07AC01 Unspecified
07AC02 Registered Care
Homes (single status
homes)
08 - Registered Child
Care Accommodation
08CC01 Unspecified
08CC02 Residential
Homes for children
08CC03 Residential
Schools
08CC04 Secure
Accommodation
09 - NHS Facilities/
Hospitals
09NH01 Unspecified
09NH02 Long Stay NHS
Facility/Hospital - Learning
Disability
09NH03 Long Stay NHS
Facility/Hospital - General
Psychiatry
09NH04 Long Stay NHS
Facility/Hospital -
Psychiatry of Old Age
09NH05 Long Stay NHS
Facility/Hospital - Geriatric
Medicine
10 - Penal Institutions
10PE01 Unspecified
10PE02 Prison
10PE03 Young Offenders
Institution
10PE04 Secure (forensic)
locked psychiatric facility.

11 - Independent
Hospitals and Clinics
12 - Independent
Hospices
13 - Mobile
Accommodation
99 - Not Known
http://www.datadictionarya   Further Information: Main
dmin.scot.nhs.uk/isddd/11    source of standard:
214.html                     Government Data
                             Standards Catalogue
                             1) It is recommended that
                             the Address (BS7666)
                             should be populated using
                             a BS7666 compatible
                             address system such as
                             ¿Quick Address¿ or the
                             Corporate Address
                             Gazetteer provided by the
                             DNA-Scotland
                             Programme.
                             2) The flat reference (e.g.
                             2F3 - 2nd floor, Flat 3)
                             should always be included
                             where applicable.
                             3) The address should be
                             recorded as `No fixed
                             abode' or 'Address
                             unknown' where this is the
                             case.
                             4) 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
http://www.datadictionarya   address. Students may
                             Further Information: The
dmin.scot.nhs.uk/isddd/15    ambulance incident
782.html                     number is comprised of 2
                             letters - 7 digits - 3 digits.
http://www.datadictionarya   Further Information: Some
dmin.scot.nhs.uk/isddd/11    health risks (e.g. specific
275.html                     genetic risks) may be
                             associated with the
                             geographic area in which
                             an individual has their
                             ancestral origin, with
                             certain diseases being
                             more or less common in
                             people with an ancestral
                             origin in a particular area.
                             In diseases where such
                             differences in prevalence
                             have been identified,
                             knowledge of a person's
                             ancestral origin can be
                             informative for the
                             provision of health care.
                             Patterns of health and
                             disease are influenced by
                             a wide range of genetic,
                             cultural, socio-economic
                             and environmental factors
                             and lifestyle. Therefore,
                             this data item should only
                             be used where there is a
                             recognised difference in
                             disease prevalence,
                             where this is known to
                             relate specifically to the
                             area of ancestral origin
                             rather than to any lifestyle,
                             social or environmental
http://www.datadictionarya   Further Information:
dmin.scot.nhs.uk/isddd/22    Where reference is made
844.html                     to A&E, this includes all
                             patients who attend for
                             emergency care in an
                             A&E department, minor
                             injuries unit or medical
                             assessment unit.
                             This is the start date and
                             time which will be used in
                             measuring the waiting
                             time between arriving at a
                             unit and subsequent
                             admission, discharge or
                             transfer as required for the
                             Scottish Executive
                             national waiting times
                             target (Reference: 'Fair to
                             All, Personal To Each:
                             The next steps for
                             Scotland' (Scottish
                             Executive Edinburgh
                             December 2004)
                             http://www.scotland.gov.u
                             k/Publications/2004/12/20
                             400/48699)
                             For patients arriving by
                             ambulance, the date and
                             time at which the
                             ambulance arrives at the
                             A&E facility is used and
                             not the (later) time when
                             the patient is then brought
http://www.datadictionarya 01 Ambulance (road)           Further Information:         Ethnic Group (Self
dmin.scot.nhs.uk/isddd/22 Excludes involvement of        Where reference is made      Assigned) - Recording
845.html                   an A&E retrieval team.        to A&E, this includes all    Guidance
                                                         patients who attend for
                                                         emergency care in an         General:
                                                         A&E department, minor
                                                         injuries unit or medical     Code 97 in the main list
                                                         assessment unit.             “Not disclosed” means
                                                         Recording Guidance:          that the person has been
                                                         Only one route should be     asked what his/her ethnic
                                                         recorded. For journeys       group is, and has chosen
                                                         using more than one          not to disclose it.
                                                         transport mode, select the
                                                         main mode used.              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
                         02 Ambulance (air) Travel                                    values as given in the
                         for all or any part of
                         journey by an aircraft
                         operating as an
                         ambulance. Includes
                         helicopter. Excludes
                         involvement of an A&E
                         retrieval team.
                         03 Ambulance and A&E
                         retrieval team Clinical staff
                         go to the patient to
                         provide on site immediate
                         care to stabilise the
                         patient in order to bring
                         them to a healthcare
                         facility. Includes both road
                         and air ambulance modes
                         of transport.
04 Out of Hours transport
OOH has arranged
transport (includes PTS
transport but not
emergency ambulance).

05 Private transport
Includes car, taxi,
motorbike, bicycle, etc
06 Public transport
Includes bus, train, etc.
07 Walking On foot.
08 Police/prison transport
Patient is brought to A&E
in a police or prison
vehicle.
98 Other The true value to
be recorded is not
covered by any of the
specific given categories.
For example, a visitor
within the hospital brought
by trolley. Includes
mortuary van.

99 Not known
http://www.datadictionarya   Further Information:
dmin.scot.nhs.uk/isddd/11    Where an associated
744.html                     person's age is of
                             relevance to the
                             client/patient's care e.g.
                             where the associated
                             person is a child or an
                             elderly person, it is
                             recommended that their
                             date of birth be recorded.
                             The full or precise birth
                             date may not be required
                             e.g. the birth year may
                             suffice. Where necessary
                             a derived age may be
                             calculated.
                             Personal information
                             about a third party should
                             be recorded with their
                             knowledge and consent.
                             Recording Guidance: Data
                             about multiple associated
                             persons may need to be
                             recorded.
                             Where a client/patient has
                             an associated person not
                             fulfilling a specific role,
                             e.g. other household
                             members, IT systems
                             should allow for an entry
                             of 'none'. Data can be
                             entered for all people
                             significantly associated
http://www.datadictionarya 01 - Spouse/ Civil Partner     Further Information: The      Sub Data Items
dmin.scot.nhs.uk/isddd/11 EITHER: A person of the         GDSC item 'Person
748.html                   opposite sex who is legally    Relationship Type' is         1. Start Dates
                           married to the                 under review.                    End Dates
                           client/patient, ORA person     Legislation on Civil
                           with whom the                  Partnerships will be          2. Dependency flag (Y/N).
                           client/patient has a           introduced by the Scottish    See definition below under
                           committed same-sex             Executive from the 5th        Further Information.
                           relationship which has         December 2005 following
                           been granted legal             the agreement of the          3. Relationship
                           recognition as a civil         Scottish Parliament to the    Verification
                           partnership (see Further       inclusion of Scottish         00 Level 0
                           Information).                  provisions in the UK           01 Level 1
                                                          Government's Civil             02 Level 2
                                                          Partnership Act. The          03 Level 3
                                                          purpose of the Act is to      04 Level 4
                                                          enable committed same-
                                                          sex couples to obtain legal   The verification levels as
                                                          recognition of their          defined by the GDSC are:
                                                          relationship by forming a
                                                          civil partnership.            If Value is Spouse/Civil
                                                          If verification of            Partner:
                                                          Associated Person             Level 0 - Not Verified
                                                          Relationship to               Level 1 - One or more of
                                                          Client/Patient is recorded,   the following:
                                                          then the government eGIF      · Sworn Affidavit.
                                                          standard                      · Passport.
                                                          recommendations should        Level 2 - Documented
                                                          be used. Ref:                 confirmation of Marriage
                                                          http://www.govtalk.gov.uk/    by Validity of Marriage
                                                          gdsc/html/frames/default.h    Unit
                                                          tm                            Level 3 - One of the
                           02 Code 02 is currently        Definition of                 following:
                           inactive.
                           03 - Partner A person who
                           has a relationship with the
                           client/patient having the
                           characteristics of a
                           marriage, but is not legally
                           married to the
                           client/patient, includes
                           cohabiters; excludes civil
                           partners.

                           04 - Polygamous partner
                           A person who is accepted
                           as another spouse/civil
                           partner of the
                           client/patient under the
                           law of another country.

                           05 - Parent
                           05A Biological parent A
                           person who gave birth to
                           or fathered the
                           client/patient.
05B Foster parent A
person approved by a
Local Authority to look
after the client/patient in
the capacity of parent.
05C Step parent A person
who is married to or the
partner of the person with
parental responsibility
over the client/patient.

05D Adoptive parent A
person who has legally
adopted the client/patient.

06 - Guardian A person
appointed by a parent to
act in the parent's place in
the event of his or her
death.
07 - Child (under 18) A
person under the age of
18 over whom the
client/patient exercises
appropriate parental
responsibility as per the
Children (Scotland) Act
1995.
08 - Sibling A person who
has at least one common
parent with the
client/patient.
08A Multiple birth sibling
For example twin, triplet
etc.
09 - Other blood relative
09A Son/Daughter (over
18)
09B Grandparent
09C Aunt/Uncle
09D Aunt/Uncle
09E Grandchild
09F Nephew/Niece
09Z Other
10 - Relative-in-law A
person related to the
client/patient by ties of
marriage, other than
spouse and civil partner.
11 - Neighbour
12 - Friend
                           13 - Volunteer A volunteer
                           may be associated with a
                           voluntary agency, informal
                           community group, support
                           group or religious
                           organisation.

                           98 - Other relationship not
                           otherwise specified
                           99 - Not known
http://www.datadictionarya 00 - No role The person        Further Information: Other
dmin.scot.nhs.uk/isddd/11 does not carry out any          specific role can refer to
746.html                   particular role for the        an associated person
                           client/patient.                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.
                           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
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
http://www.datadictionarya   Further Information:
dmin.scot.nhs.uk/isddd/11    Involvement includes
750.html                     contacts in relation to a
                             particular episode of care.
                             Data Item Sub Data Item
                             Format

                             Associated Professional
                             Identifier - 8
                             characters(right justified)
                              Structured Name
                              Title 35 characters
                              Surname/Family name 35
                             characters
                              First Forename 35
                             characters
                              Preferred Forename (if
                             different) 35 characters
                              Second Forename 35
                             characters
                             Other Forename(s) 35
                             characters
                              Previous Surname 35
                             characters
                              Name Suffix 35
                             characters
                             Name Status 2 characters
                              Name Element Position 2
                             characters
                              Start Date 10 characters
                             (CCYY-MM-DD)
                              End Date 10 characters
                             (CCYY-MM-DD)
http://www.datadictionarya                         Related Data Items: See
dmin.scot.nhs.uk/isddd/11                          Associated Professional
758.html                                           Table
                                                   Further Information:
                                                   Where a care professional
                                                   has multiple employing
                                                   organisations, e.g. an OT
                                                   jointly employed by health
                                                   and social care, the
                                                   employer to be recorded
                                                   should be that which
                                                   relates to the professional
                                                   role in the episode or
                                                   contact being recorded.
                                                   In due course, for NHS
                                                   Scotland staff, this should
                                                   be populated through the
                                                   planned NHS Scotland
                                                   Staff Directory.
                                                   Where appropriate, the
                                                   name of a private health
                                                   care provider could be
                                                   recorded.
                                                   Recording Guidance
                                                   The name of the
                                                   organisation can be
                                                   supplied either as free text
                                                   or via a locally devised
                                                   pick list e.g. NHS
                                                   Grampian, Aberdeenshire
                                                   CHP, Falkirk Housing and
                                                   Social Work Department.
http://www.datadictionarya 01 NHS                  Related Data Items: See
dmin.scot.nhs.uk/isddd/11                          Associated Professional
760.html                                           table




                             02 Local Authority
                             03 Private Dental
                             Services
                             04 Prison/Penal
                             Establishments
                             05 Judicial
                             06 Voluntary Agency
                             07 Armed Forces
                             08 Private Sector
                             96 Not applicable
                             98 Other
                             99 Not known
http://www.datadictionarya 01 Medical Doctor            Further Information: The
dmin.scot.nhs.uk/isddd/11                               specialist capacity in
754.html                                                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 is
                                                        the responsibility of the
                                                        employing body to ensure
                                                        that the professional is
                                                        suitably GMC Specialist
                                                        Register for that specialty.
                                                        However, a consultant
                                                        employed in that specialist
                                                        area would probably be
                                                        expected to have
                                                        appropriate specialist
                                                        registration. It qualified for
                                                        the post to which they are
                                                        appointed.
                          02 - Dentist                  Recording Guidance
                          03 - Registered Nurse
                          03A Specialist Community
                          Public Health Nurse

                          03B Community Nurse
                          04 - Registered Midwife
                          05 - Arts Therapist
                          06 - Biomedical Scientist

                          07 - Chiropodist/Podiatrist

                          08 - Clinical Scientist
                          09 - Dietitian
                          10 - Occupational
                          Therapist
                          11 - Operating
                          Department Practitioner
                          12 - Orthoptist
                          13 - Orthotist
                          14 Paramedic
                          15 - Ambulance
                          Technician
                          16 - Pharmacist
17 - Pharmacy Technician

18 - Physiotherapist
19 - Prosthetist
20 - Psychologist
20A Clinical
20B Educational
21 - Public Health
Practitioner
20 Public Health
Practitioner
22 - Radiographer
22A Diagnostic
22B Therapeutic
23 - Speech and
Language Therapist
24 - Other Healthcare
Professionals who have
direct patient contact
25 - Complementary and
Alternative Medicine
Therapist
26 - Social Care
Professional
27 - Teacher
98 - Other
99 - Not known
http://www.datadictionarya   Further Information: An
dmin.scot.nhs.uk/isddd/11    electronic health record
752.html                     should record the
                             professional identifier of
                             the professional
                             responsible for care.
                             In the future, the NHS
                             Staff Directory will
                             accurately identify care
                             professionals by a unique
                             professional identifier,
                             issued by their
                             professional body.
                             Currently, there are a
                             small number of
                             professionals who do not
                             have a unique
                             professional identifier.
                             Where a care professional
                             has multiple registrations
                             for different professions,
                             the professional identifier
                             and the associated
                             professional group to be
                             recorded should be that
                             which relates to the
                             professional role in the
                             episode or contact being
                             recorded.
                             Regulatory body
                             Professional group
                             Identifier format Further
                             information
http://www.datadictionarya   Related Data Items: See
dmin.scot.nhs.uk/isddd/11    Associated Professional
756.html                     Table
                             Further Information: This
                             item indicates the role(s)
                             carried out by the people
                             who are involved with the
                             person in a professional
                             capacity, recorded as free
                             text. It is important to note
                             the distinction between a
                             professional's designation
                             within an agency (i.e. job
                             role - e.g. Social Worker,
                             District Nurse) and their
                             role with regard to a
                             particular client (e.g. Key
                             Worker, Lead Assessor,
                             Named nurse, Lead
                             clinician, Operating
                             surgeon, Case manager,
                             Care Team Manager,
                             Locum GP).
                             Appropriate codes and
                             values will be developed
                             for specific NCDDP
                             clinical data
                             standards/datasets.
                             Recording Guidance
                             The most appropriate role
                             should be recorded in
                             relation to the contact with
                             the patient/client.
http://www.datadictionarya   Further Information: IT
dmin.scot.nhs.uk/isddd/11    systems should calculate
186.html                     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
http://www.datadictionarya   Further Information
dmin.scot.nhs.uk/isddd/11    The Community Health
203.html                     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
http://www.datadictionarya 00 - Not currently on         Further Information: Once
dmin.scot.nhs.uk/isddd/19 register                       a child has been assessed
231.html                                                 as being at risk, a Child
                                                         Protection Case
                                                         Conference should be
                                                         held. This multi agency
                                                         meeting will look at the
                                                         risk factors and will make
                                                         a formal decision as to
                                                         whether or not a child's
                                                         name should be placed on
                                                         the Child Protection
                                                         Register and under what
                                                         category. These are the
                                                         details that need to be
                                                         recorded and only when
                                                         the above procedure has
                                                         been followed.
                                                         A review Conference is
                                                         held at three months after
                                                         the initial Conference and
                                                         every three months until
                                                         the child's name is
                                                         removed from the register.
                                                         After each Review
                                                         Conference, details will be
                                                         updated to reflect the
                                                         decisions of the
                                                         conference and child
                                                         protection categories
                                                         changed if required.
                                                         Recording Guidance:
                           01 - Currently on register    Child Protection Register
                           01A Currently on register -
                           Failure to thrive
                           01B Currently on register -
                           Physical neglect
                           01C Currently on register -
                           Physical injury
                           01D Currently on register -
                           Sexual abuse
                           01E Currently on register -
                           Emotional abuse
http://www.datadictionarya 00 No                        Further Information: The
dmin.scot.nhs.uk/isddd/22                               'other child' may not
846.html                                                necessarily be a relative
                                                        of the patient/client, but
                                                        will reside at the same
                                                        address as the
                                                        patient/client. This data
                                                        item is designed to alert
                                                        healthcare professionals
                                                        to possible concern
                                                        factors - the patient/client
                                                        being treated may not
                                                        necessarily be included on
                                                        the register him/herself.
                                                        A CHILD PROTECTION
                                                        REGISTRATION
                                                        CATEGORY is the
                                                        classification of the
                                                        reason or category of
                                                        abuse for which a specific
                                                        child is placed on the
                                                        Child Protection Register.
                                                        For Child Protection
                                                        issues a child is classed
                                                        as a child or young person
                                                        who is 17 years old or
                                                        younger. The child's
                                                        name will automatically be
                                                        removed from the register
                                                        when they are18 years old
                                                        or if they leave the UK
                                                        permanently.
                           01 Yes                       Child Protection
                           96 Not Applicable
                           99 Not known
http://www.datadictionarya 01 Alert Fully alert and
dmin.scot.nhs.uk/isddd/17 keenly responsive
121.html




                            02 Drowsy Can be
                            aroused with minor
                            stimulation
                            03 Stuporous Requires
                            repeated stimulation to
                            attend
                            04 Coma Comatose and
                            responds only with reflex
                            motor or automatic
                            responses
                            99 Not known
http://www.datadictionarya 00 No specific preference Further Information:
dmin.scot.nhs.uk/isddd/11                             Refer to local policies for
242.html                                              advice on meeting dietary
                                                      preferences.
                                                      For further information
                                                      refer to:
                                                      www.ethnicityonline.net
                                                      Recording Guidance:
                                                      For 'Other specific', further
                                                      information about the
                                                      specific preference can be
                                                      recorded using a free text
                                                      field.
                           01 Halal
                           02 Kosher
                           03 Vegetarian
                           04 Vegan
                           98 Other specific
                           99 Not known
http://www.datadictionarya 00 Non drinker Teetotal - Related Data Items: Non-
dmin.scot.nhs.uk/isddd/11 individual does not         specialist Alcohol
269.html                   currently and has never    Consumption Advice
                           drunk alcohol              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.u
                                                      k/cci/nugget.asp?id=829
                                                      Current daily
                                                      recommended alcohol
                                                      limits
                                                      Men: Consistently drinking
                                                      four or more units a day is
                                                      not advised.
                           01 Ex-drinker Has not      Women: Consistently
                           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
http://www.datadictionarya 01 - Place of residence       Sub Data Items:
dmin.scot.nhs.uk/isddd/19                                Additional Information (e.g
105.html                                                 access information)
                                                         Format: 98 characters
                                                         Free text
                                                         Related Data Items:
                                                         Address (BS7666),
                                                         Accommodation Type,
                                                         Location Code
                                                         Further Information: The
                                                         Current Location of
                                                         Patient will not necessarily
                                                         be their recorded address.
                                                         The use of the Current
                                                         Location of Patient data
                                                         item along with the related
                                                         data items.
                                                         The sub-data item
                                                         'Additional Information'
                                                         should be used for
                                                         recording information
                                                         which would further qualify
                                                         the location e.g. 'use back
                                                         door' or 'lift not working'.
                                                         Recording Guidance: Only
                                                         one current location
                                                         should be recorded.



                           01A Home The person's
                           own home or the home of
                           a third party. Home
                           includes the main dwelling
                           and any associated
                           garden, driveway to home,
                           garage, path (walk) to
                           home, swimming pool in
                           private house or garden,
                           farmhouse, home
                           premises, house, non-
                           institutional place of
                           residence, apartment,
                           boarding house, private
                           caravan park (residential).


                           01B Residential institution
                           An institute with
                           residential
                           accommodation, e.g.
                           home for the elderly,
                           nursing home, prison,
                           children's home, hospice,
                           military institution, etc
02 - Transport area
02A Public highway, street
or road Publicly owned
and maintained highway,
street, road, pavements or
cycle path.

02B Other transport area
Places where transport
out-with a public highway,
street or road takes place,
e.g. private road, aircraft,
ferry terminal, Parking
area, Public transport
area/facility such as bus
terminal, railway station,
underground station,
airport etc. pedestrian
mall, railway line etc.

03 - Business area
(excluding recreational &
sports areas)
03A Industrial or
construction area A place
primarily intended for
industrial or construction
purposes. Refers to
buildings, other structures,
excavations and adjacent
grounds. Demolition sites,
mines quarries,
factory/plant, oil and gas
extraction facility, power
station etc.

03B Farm or other place
of primary production
Excludes injuries
occurring in the residential
area of a farm, where the
farm is the injured
person's home.

03C Commercial area-
non recreational A
commercial area not
primarily intended for
recreational purposes,
e.g. shop, store,
commercial garage, office
building, café, hotel,
restaurant, casino, bar,
dance/ night club,
swimming pool of hotel,
etc.
04 - School, educational
area Includes any
educational
establishment, e.g.
nursery, college,
university. Includes actual
educational building and
associated grounds, e.g.
school playground.

05 - Sports & Recreational
area
05A Sports and athletic
area Any place
specifically intended for
formal sporting purposes,
e.g. leisure centre.
Excludes places where
informal sporting
recreation may take place.

05B Recreational area,
cultural area or public
building A place primarily
intended for recreational
or cultural purposes
(whether public or
commercially owned) or
any other public building.
Includes public park/
playground, amusement/
theme park, holiday park,
campsite, public religious
place.

05C Countryside / open
nature area Refers to
open nature area not
classified elsewhere eg.
beach, cave, forest.
Includes injuries occurring
in water or the sea, where
not part of a formal
transport area e.g. marsh/
swamp, river, loch.

06 - Medical service
area/Health care area Any
formal healthcare
establishment, including
hospital, heath centre,
screening mobile van, etc.

98 - Other specified
99 - Not known
http://www.datadictionarya 00 Never misused May         Related Data Items: Non-
dmin.scot.nhs.uk/isddd/11 have tried once or twice      specialist Substance
271.html                                                Misuse Advice
                                                        Further Information: This
                                                        includes misuse of
                                                        prescribed and over the
                                                        counter medication e.g.
                                                        painkillers, and other
                                                        substances such as
                                                        solvents e.g. glue sniffing.
                                                        More detailed information
                                                        may be recorded
                                                        elsewhere in the person's
                                                        health records.
                                                        Confidentiality issues
                                                        should be considered
                                                        when recording this data
                                                        item.


                          01 Ex drug misuser Has
                          not misused for at least 12
                          months
                          02 Current non-misuser of
                          drugs Has not misused
                          within the past 12 months

                          03 Current drug misuser
                          97 Patient declined
                          99 Not known
http://www.datadictionarya 00 No use Never used        Further Information: In
dmin.scot.nhs.uk/isddd/26 tobacco or any nicotine      1996, The World Health
508.html                   containing substances of    Organization defined
                           any kind - may have tried   former smokers as those
                           once or twice               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
                           97 - Patient declined       current tobacco and
                           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
http://www.datadictionarya   Related Data Items: Date
dmin.scot.nhs.uk/isddd/19    and Time Call Connected
070.html                     to Network
                             Further Information: The
                             Date & Time Call
                             Connected to Network will
                             not necessarily be the
                             same as the Date & Time
                             Call Answered and thus it
                             is expected that both
                             items should be recorded.
                             The Date & Time Call
                             Answered will be the time
                             the patient/client's call is
                             actually responded to by a
                             healthcare provider i.e. if
                             an organisation has a
                             queuing system in
                             operation, the Date &
                             Time Call Answered will
                             not include any time spent
                             in the queue.
                             Recording Guidance:
                             (Government Data
                             Standards Catalogue)
                             1. It is expected that this
                             data item will be
                             automatically generated
                             from contact centre
                             systems.
                             2. All times must be
                             expressed in the 24 hour
                             clock format, e.g. one
http://www.datadictionarya   Related Data Items: Date
dmin.scot.nhs.uk/isddd/19    and Time Call Answered
066.html                     Further Information: The
                             Date & Time Call
                             Connected to Network will
                             not necessarily the same
                             as the Date & Time Call
                             Answered and thus it is
                             expected that both items
                             should be recorded.
                             The Date & Time Call
                             Connected to Network will
                             be the time the
                             patient/client's call is
                             initially connected to the
                             system, not the time they
                             actually spoke to the
                             healthcare provider which
                             is likely to be a later time.
                             It is likely this data item
                             will be used where an
                             organisation has a
                             queuing system in
                             operation.
                             The Healthcare provider
                             may be any other care
                             provider who provides
                             unscheduled care.
                             Recording guidance:
                             1. It is expected that this
                             data item will be
                             automatically generated
                             from contact centre
http://www.datadictionarya   Related Data Items: Date
dmin.scot.nhs.uk/isddd/19    and Time Contact Started,
088.html                     Duration of Contact
                             Further Information: The
                             Date & Time Contact
                             Ended is the time when a
                             healthcare professional
                             finished actively dealing
                             with the patient/client. In
                             a telephone triage
                             situation, it is likely the
                             Date & Time Contact
                             Ended will be either when
                             the call is terminated or
                             when the patient/client is
                             referred onwards. In other
                             situations, for example, it
                             may be when a nurse
                             leaves the patient/client's
                             home following a home
                             visit.
                             Recording Guidance
                             (Government Data
                             Standards Catalogue)
                             1. All times must be
                             expressed in the 24 hour
                             clock format, e.g. one
                             minute past midnight is
                             00:01:00.
                             2. Values of any element
                             less than 10 should be
                             entered with a zero in the
                             first position.
http://www.datadictionarya   Related Data Items: Date
dmin.scot.nhs.uk/isddd/19    and Time Call Answered ,
073.html                     Date and Time Contact
                             Ended, Duration of
                             Contact
                             Further Information: The
                             Date & Time Contact
                             Started is the time when a
                             healthcare professional
                             started to actively deal
                             with the patient/client. In
                             a telephone triage
                             situation, it is likely the
                             Date & Time Contact
                             Started will be the same
                             as the Date & Time Call
                             Answered. In other
                             situations it may be, for
                             example, when a patient is
                             seen by a healthcare
                             professional in a minor
                             injuries unit or when a
                             nurse provides a home
                             visit.
                             Recording Guidance
                             (Government Data
                             Standards Catalogue)
                             1. All times must be
                             expressed in the 24 hour
                             clock format, e.g. one
                             minute past midnight is
                             00:01:00.
http://www.datadictionarya   2. Values of any element
                             Recording Guidance: This      Sub Data Items
dmin.scot.nhs.uk/isddd/22    item may be acquired          Verification Level
924.html                     from existing data, in        Code       Value
                             which case the                Level 0 Actual
                             Verification Level should     Level 1 Estimated
                             be recorded as 'Level 0 -     Level 2 Not known
                             Actual'.
http://www.datadictionarya   Recording Guidance: This      Sub Data Items
dmin.scot.nhs.uk/isddd/22    item may be acquired          Verification Level
924.html                     from existing data, in        Code       Value
                             which case the                Level 0 Actual
                             Verification Level should     Level 1      Estimated
                             be recorded as 'Level 0 -     Level 2 Not known
                             Actual'.
http://www.datadictionarya 00 No            Further Information: There
dmin.scot.nhs.uk/isddd/11                   are many circumstances
954.html                                    on which a patient/client
                                            may fulfil an essential
                                            dependency role, which, if
                                            removed, would have an
                                            adverse impact upon the
                                            dependant, for whom
                                            alternative arrangements/
                                            contingency plan may
                                            have to be put in place.
                                            Where details are needed
                                            about person(s)
                                            dependent upon the
                                            patient/ client, these
                                            should be recorded using
                                            the Associated Person
                                            group of data standards,
                                            including their Associated
                                            Person Relationship to the
                                            patient and utilising the
                                            'dependency flag' sub-
                                            data item.



                             01 Yes
                             99 Not known
http://www.datadictionarya                  Further Information: Main
dmin.scot.nhs.uk/isddd/11                   Source of Standard:
190.html                                    British Hypertension
                                            society
                                            Unless specified, DBP is
                                            generally understood to
                                            be measured at rest with
                                            the patient sitting. IT
                                            systems could use 'sitting'
                                            as the default posture
                                            where appropriate.
                                            In certain clinical
                                            conditions, it may be
                                            necessary to record
                                            laterality and/ or limb e.g.
                                            coarctation of the aorta.
http://www.datadictionarya                              Further Information: The      Attributes
dmin.scot.nhs.uk/isddd/22                               Duration of Contact is the
949.html                                                length of time the            Posture
                                                        healthcare professional       · Lying
                                                        actively deals with the       · Standing
                                                        patient/client.               · Sitting
                                                        Recording Guidance:           Laterality
                                                        (Government Data              · Left
                                                        Standards Catalogue)          · Right
                                                        1. The Duration of Contact    · Bilateral
                                                        may be derived from the       Limbs
                                                        items Date & Time             · Upper
                                                        Contact Started and Date      · Lower
                                                        & Time Contact Ended.
                                                        2. All times must be
                                                        expressed in the 24 hour
                                                        clock format, e.g. one
                                                        minute past midnight is
                                                        00:01:00.
                                                        3. Values of any element
                                                        less than 10 should be
                                                        entered with a zero in the
                                                        first position.
                                                        4. All times for UK
                                                        transactions/events will be
                                                        assumed to be GMT.


http://www.datadictionarya 01 Detached                  Further Information: Main
dmin.scot.nhs.uk/isddd/11                               Source of Standard:
228.html                                                Scottish Social Care Data
                                                        Standards


                             01A Multi Storey
                             01B Single Storey
                             02 Semi-detached House

                             02A Multi Storey
                             02B Single Storey
                             03 Terraced House
                             03A Multi Storey
                             03B Single Storey
                             04 Flat
                             04A Multi Storey -
                             entrance on ground floor
                             04B Multi Storey -
                             entrance on upper floor
                             (stairs only)
                             04C Multi Storey -
                             entrance on upper floor
                             (lift access)
                             04D Single Storey -
                             entrance on ground floor
                             04E Single Storey -
                             entrance on upper floor
                             (stairs only)
                             04F Single Storey -
                             entrance on upper floor
                             (lift access)
                             05 Caravan/ Travelling
                             Trailer /Portakabin/ Tent
                             05A Static
                             05B Mobile
                             06 Water-borne craft
                             98 Other
                             99 Not Known
http://www.datadictionarya                               Further Information: This
dmin.scot.nhs.uk/isddd/11                                data format, which is
947.html                                                 taken from the
                                                         Government Data
                                                         Standards Catalogue,
                                                         should be used for
                                                         storage, management and
                                                         transmission of dates by
                                                         IT systems, but the way in
                                                         which a date is recorded &
                                                         displayed on a user
                                                         interface may be decided
                                                         according to local user
                                                         preference.
http://www.datadictionarya 01 - White                  Further Information        Further Information:
dmin.scot.nhs.uk/isddd/11                              Ethnic Group - Order to    Ethnic Group - Order to
139.html                                               display codes and values   display codes and values
                                                       Ethnic Group - Further     Ethnic Group - Further
                                                       Information                Information
                                                       Recording Guidance         Recording Guidance:
                                                       Ethnic Group - Recording   Ethnic Group Specific
                                                       Guidance                   Codes
                                                       Ethnic Group Specific      Ethnic Group (Self
                                                       Codes                      Assigned) - Recording
                                                                                  Guidance
                                                                                  Ethnic Group -
                                                                                  Recording Guidance -
                                                                                  General:
                                                                                  Ethnic group of a child or
                                                                                  young person:
                                                                                  For babies and very
                                                                                  young children it is
                                                                                  anticipated that the
                                                                                  parent/ guardian 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
                          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
http://www.datadictionarya 01 - Permanently         Further Information: Most
dmin.scot.nhs.uk/isddd/11 registered                care will be provided by
742.html                                            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

                            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
http://www.datadictionarya 01 Obey Commands For Related Data Items:
dmin.scot.nhs.uk/isddd/17 movement. Score of 6.       Conscious Level
127.html                                              Further Information: The
                                                      Glasgow Coma Scale
                                                      provides a framework for
                                                      describing the state of a
                                                      patient in terms of three
                                                      aspects of
                                                      responsiveness: eye
                                                      opening, verbal response
                                                      and best motor response,
                                                      each stratified according
                                                      to increasing impairment
                                                      (Ref SIGN 46).

                          02 Localise Pain
                          Purposeful movement to
                          painful stimuli. Score of 5.

                          03 Flexion Normal
                          Withdraws in response to
                          pain. Score of 4.
                          04 Flexion Abnormal
                          Score of 3.
                          05 Extend Extension
                          response in response to
                          pain. Score of 2.
                          06 None Score of 1.
                           07 Unassessable For
                           example, patient is
                           paralysed for ventilation.
http://www.datadictionarya 01 Spontaneous Open          Related Data Items:       Attributes
dmin.scot.nhs.uk/isddd/17 with blinking at baseline.    Conscious Level
123.html                   Score of 4.                  Further Information: The Laterality:
                                                        Glasgow Coma Scale        Left
                                                        provides a framework for Right
                                                        describing the state of a Bilateral
                                                        patient in terms of three
                                                        aspects of
                                                        responsiveness: eye
                                                        opening, verbal response
                                                        and best motor response,
                                                        each stratified according
                                                        to increasing impairment
                                                        (Ref SIGN 46).

                            02 To speech Score of 3.

                           03 To pain Not applied to
                           face. Score of 2.
                           04 None Score of 1.
                           05 Unassessable For
                           example, patient does not
                           have eyes
http://www.datadictionarya 01 Oriented Score of 5.   Related Data Items:
dmin.scot.nhs.uk/isddd/17                            Conscious Level
125.html                                             Further Information: The
                                                     Glasgow Coma Scale
                                                     provides a framework for
                                                     describing the state of a
                                                     patient in terms of three
                                                     aspects of
                                                     responsiveness: eye
                                                     opening, verbal response
                                                     and best motor response,
                                                     each stratified according
                                                     to increasing impairment
                                                     (Ref SIGN 46).

                            02 Confused conversation
                            Able to answer questions.
                            Score of 4.

                            03 Inappropriate words
                            Score of 3.
                            04 Incomprehensible
                            speech or noises Score of
                            2.
                            05 None Score of 1.
                            06 Unassessable For
                            example, patient is
                            intubated.
http://www.datadictionarya   Further Information: The
dmin.scot.nhs.uk/isddd/11    GMC/GDC number is the
293.html                     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.


http://www.datadictionarya   Further Information:           Attributes
dmin.scot.nhs.uk/isddd/19    Normal values for adult's
122.html                     resting heart rate are 60 to   Posture
                             100 beats per minute.          · Sitting
                             Normal values for children     · Lying
                             are dependent on age.          · Standing
                             Reference: Goldberger:         Activity
                             Clinical                       · Resting
                             Electrocardiography: A         · Exercise
                             Simplified Approach, 6th       Measurement device used
                             ed., Copyright C 1999          · Stethoscope
                             Mosby, Inc.                    · ECG
http://www.datadictionarya                                  Further Information: If        Sub Data Items
dmin.scot.nhs.uk/isddd/11                                   height cannot be               Verification level
182.html                                                    measured, record recently      0 Unverified
                                                            documented or self-            1 Verified
                                                            reported height (if reliable
                                                            and realistic) as
                                                            '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.

http://www.datadictionarya 00 - No support - Patient
dmin.scot.nhs.uk/isddd/23 lives alone
192.html




                             01 - Live-in carer - Patient
                             lives with someone who is
                             able to care for them

                             02 - Carer for other -
                             Patient lives with person
                             who relies on them for
                             care
                             03 - External support
                             03A External support -
                             Social Care Patient has
                             help from an outside
                             agency
                             03B External support -
                             Meals on Wheels
                             03C External support -
                             Home help
                             03D External support -
                             Other
                             98 - Other
                             99 - Not known
http://www.datadictionarya 00 None                   Further Information:
dmin.scot.nhs.uk/isddd/11                            1) A cognitive impairment
943.html                                             (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
                         01 Specific learning        problems such as a
                         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
http://www.datadictionarya 00 Not triaged               Related Data Items:
dmin.scot.nhs.uk/isddd/19                               Urgency of Referral
195.html                                                {Unscheduled Care
                                                        Communications}
                                                        Further Information: An
                                                        unscheduled care setting
                                                        refers to any location
                                                        where a care episode
                                                        occurs - it may refer to
                                                        NSH24, minor injures unit,
                                                        A&E etc.

                           01 Immediate
                           resuscitation Patients in
                           need of immediate
                           treatment for preservation
                           of life
                           02 Very urgent Seriously
                           ill or injured patients
                           whose lives are not in
                           immediate danger amend
                           notes
                           03 Urgent Patients with
                           serious problems, but
                           apparently stable
                           condition
                           04 Standard Patients who
                           are not in immediate
                           danger or distress

                           05 Non-urgent Patients
                           whose conditions are non-
                           urgent
http://www.datadictionarya                              Further Information: Main      Sub Data Items
dmin.scot.nhs.uk/isddd/11                               Source of Standard:
192.html                                                Government Data                Email Address Type:
                                                        Standards Catalogue            01 Preferred
                                                        From Government Data           02 Alternative
                                                        Standard 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



http://www.datadictionarya 00 No help needed Fluent Related Data Items:
dmin.scot.nhs.uk/isddd/11 in English                Preferred Language ,
282.html                                            Preferred Communication
                                                    Method

                             01 Need help only with
                             complex language Usually
                             conversant in English

                             02 Help needed at all
                             times Interpretation in
                             Preferred language or
                             Preferred Communication
                             Method required

                             97 Not disclosed
                             99 Not known
http://www.datadictionarya                    Further Information:
dmin.scot.nhs.uk/isddd/11                     Each location has a
839.html                                      location code, which is
                                              maintained jointly by ISD
                                              and General Register
                                              Office (Scotland).
                                              http://www.show.scot.nhs.
                                              uk/smrfiles/information.ht
                                              ml - 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
http://www.datadictionarya 00 - Independent   recording and display of
                                              Further Information:
dmin.scot.nhs.uk/isddd/11                     Walking aids include
999.html                                      walking stick, zimmer
                                              frame, rollator, etc.
                                              Wheelchair includes
                                              manual and electrically
                                              operated wheelchairs.
                                              Assessment should be
                                              based upon the best level
                                              of mobility that the person
                                              can usually achieve. For
                                              example, whilst a person
                                              may choose to use an
                                              electric wheelchair in
                                              certain circumstances but
                                              they are generally able to
                                              be independently mobile
                                              with a walking aid, then
                                              record their mobility status
                                              as the latter.
00A Independent - Walks
without walking aids

00B Independent - Walks
with walking aids
00C Independent - In
wheelchair
01 - Supervision required
01A Supervision required -
Walks without walking
aids
01B Supervision required -
Walks with walking aids

01C Supervision required -
In wheelchair
02 - Requires Physical
Assistance
02A Requires physical
assistance - Walks
without walking aids
Patient requires physical
assistance for example,
transfer from a chair
02B Requires physical
assistance - Walks with
walking aids
02C Requires physical
assistance - In wheelchair

03 - Not mobile
99 Not known
http://www.datadictionarya                             Further Information: A       This Data Item can also
dmin.scot.nhs.uk/isddd/11                              person's name has            constitute an element of
195.html                                               several components           the Structured Name:
                                                       (elements). A set of
                                                       component parts is           Person Family Name
                                                       defined to be used as a      Person Title
                                                       minimum standard for         Name Element Position
                                                       data interchange. An         Person Name Status
                                                       extended set of              Preferred Name
                                                       component parts is also      Previous Person Family
                                                       defined to allow a system    Name
                                                       to hold more data on the     Person Given Name
                                                       person's name and also to    Person Initials
                                                       allow the person to be       Person Preferred
                                                       addressed in his preferred   Forename
                                                       name format. This is         Person Name Suffix
                                                       particularly useful for
                                                       correct addressing of        Definition:
                                                       persons who are not of       An ordered sequence of
                                                       Western culture. See         person name elements
                                                       Examples                     such as title, forename(s)
                                                                                    and family name.

                                                                                    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-
http://www.datadictionarya 01 - Advice Given           Related Data Items:          agency sharing and
dmin.scot.nhs.uk/isddd/23                              Duration of Contact,
219.html                                               Current Location of
                                                       Patient
                                                       Recording Guidance: Only
                                                       one option should be
                                                       selected.

                             01A Advice Given
                             01B to Contact Pharmacy

                             01C to attend A&E
                             Includes Minor Injuries
                             Unit
                             01D to contact their
                             registered GP Practice
                             01E to contact a social
                             care professional
                             01F to contact Dental
                             Health Services
                             01G to Contact Mental
                             Health Services
                             01Z Other
                             02 - Treatment Given
                             03 - Patient
                             transferred/forwarded
                             03A to Ambulance
                             Service
                             03B to Primary Care Out
                             of Hours Service
                             03C to A&E Includes
                             Minor Injuries Unit
                             03D Admitted to Hospital
                             Not A&E
                             04 - Contact Incomplete
                             04A Patient left/terminated
                             call before assessment
                             completed

                             04B Patient left/
                             terminated call before
                             being treated
                             04C Patient declined
                             treatment
                             04D Patient left/
                             terminated call after
                             treatment started
                             04E Patient removed by
                             police e.g. into police
                             custody
                             05 - Died
                             05A Died in department
                             05B Dead on arrival
                             05C Died at scene This
                             may apply to Ambulance
                             Service personnel,
                             Clinicians providing a
                             home visit or an A&E
                             retrieval team.
                             06 - No Further Action
                             Required
                             98 - Other
                             99 - Not known
http://www.datadictionarya                                 Further Information:       Attributes
dmin.scot.nhs.uk/isddd/22                                  Oxygen saturation may
883.html                                                   also be measured using     Measurement method
                                                           an arterial blood sample   · Pulse oximeter
                                                           but is less commonly       · Arterial blood sample
                                                           used.
http://www.datadictionarya 00 No
dmin.scot.nhs.uk/isddd/23
119.html




                           01 Yes
                           99 Not known
http://www.datadictionarya 00 - No risk identified     Further Information: This
dmin.scot.nhs.uk/isddd/23                              data item is intended to
126.html                                               act to indicate whether or
                                                       not the patient/client is a
                                                       current risk to themselves
                                                       and/or another person.
                                                       This information is only as
                                                       up-to-date as the most
                                                       recent risk assessment.
                                                       Recording Guidance: This
                                                       risk status summary
                                                       should be populated from
                                                       information identified
                                                       during the formal risk
                                                       assessment. It is not
                                                       intended to replace a
                                                       formal risk assessment,
                                                       but to provide electronic
                                                       access to key risk
                                                       summary information.
                                                       Such information is
                                                       particularly important if a
                                                       crisis situation occurs out-
                                                       of-hours when detailed
                                                       risk assessment
                                                       information often cannot
                                                       be accessed. Information
                                                       on risk should be updated
                                                       when a subsequent formal
                                                       risk assessment is
                                                       undertaken with the
                                                       patient/client.
                            01 - Patient/ client       IT Systems should allow
                            01A Violent behaviour
                            01B Aggressive/ abusive
                            behaviour
                            01C Attempted suicide
                            01D Deliberate self harm
                            01E Self neglect
01F Non concordance e.g.
Not able to follow
treatment regime, whether
this is deliberate/ not.

01F Other (specify)
01G Disengagement from
services
02 - Patient/ client
02A Violent behaviour
Violent behaviour includes
with/ without
weapons.Risk to others
could include risk to care
providers, family
members/ public, etc.
02B Aggressive/ abusive
behaviour
02C Non concordance
02D Disengagement from
services
02E Hostage taking
02F Sexually
inappropriate behaviour
02G Fire raising
02Z Other (specify)
03 - Patient/ client
03A Violent behaviour
03B Aggressive/ abusive
behaviour
03C Neglect
03D Non concordance
03E Hostage taking
03F Disengagement from
services
03G Sexually
inappropriate behaviour
03H Fire raising
03Z Other (specify)
98 Other (specify)
http://www.datadictionarya   Further Information:            Sub Data Items
dmin.scot.nhs.uk/isddd/11    Main Source of Standard:        Code & Values
140.html                     Government Data                 Level 0 Not Verified
                             Standards Catalogue             Level 1 One or more of
                             The Government Data             the following Secondary
                             Catalogue Standards             certificates:
                             recommends that                 Certificate of Baptism.
                             verification of a birth date    Marriage Certificate
                             should always be carried        National Health Service
                             out if feasible.                Medical Card
                             Recording Guidance:             Child's Certificate of
                             A notional birth date may       Vaccination
                             be recorded where an            Child's Health Record
                             informant has reported an       Card
                             approximate age for a           A certificate of Service in
                             person whose actual date        HM Forces or other
                             of birth is unknown. This       employment under the
                             should be identified using      Crown or in the Mercantile
                             verification level ¿0¿.         Marine.
                             Work is currently being         A certificate of
                             done on a recording             membership of a Trade
                             convention for dates            Union Friendly Society or
                             where only the month and        any cards or papers
                             year, or only the year, is      relating to membership of
                             available.                      an Approved Society or
                             If Birth Verification Type is   Unemployment Insurance
                             level 1 or 2, then the          Apprenticeship
                             Person Birth Date cannot        indentures.
                             be amended.                     Early certificate or
                                                             testimonial from employer.
                                                             Aliens registration card,
                                                             certificate of
                                                             naturalisation, Home
http://www.datadictionarya   Further Information: Since
dmin.scot.nhs.uk/isddd/11    current gender is self-
253.html                     assigned 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
http://www.datadictionarya   Further Information: Main     This Data Item can also
dmin.scot.nhs.uk/isddd/11    Source of                     constitute an element of
130.html                     Standard:Government           the Structured Name:
                             Data Standards Catalogue
                             The surname of a person       Person Family Name
                             represents that part of the   Person Title
                             name of a person              Name Element Position
                             indicating the family group   Person Name Status
                             of which the person is        Preferred Name
                             part.                         Previous Person Family
                             It should be noted that in    Name
                             Western culture this is       Person Given Name
                             normally the latter part of   Person Initials
                             the name of a person.         Person Preferred
                             However, this is not          Forename
                             necessarily true of all       Person Name Suffix
                             cultures. This will, of
                             course, give rise to some     Definition:
                             problems in the               An ordered sequence of
                             representation of the         person name elements
                             name. This is resolved by     such as title, forename(s)
                             including the data item       and family name.
                             Name Element Position in
                             the structured name           Recording guidance:
                             indicating the order of the   The structured name
                             name elements.                approach breaks names
                             From SMR Definitions and      down into specific
                             Codes                         elements, with start and
                                                           end dates for each one
                                                           (with the exception of
                                                           Preferred Name), and
                                                           facilitates electronic inter-
                                                           agency sharing and
http://www.datadictionarya   Further Information: Main    This Data Item can also
dmin.scot.nhs.uk/isddd/11    Source of                    constitute an element of
224.html                     Standard:Government          the Structured Name:
                             Data Standards Catalogue
                             The first forename of a      Person Family Name
                             person represents that       Person Title
                             part of the name of a        Name Element Position
                             person which after the       Person Name Status
                             surname, is the principal    Preferred Name
                             identifier of a person.      Previous Person Family
                             Recording Guidance: A        Name
                             person can have multiple     Person Given Name
                             occurrences of a given       Person Initials
                             name, the order of which     Person Preferred
                             is identified by the sub     Forename
                             data item 'Name Element      Person Name Suffix
                             Position'.
                             Where the person's           Definition:
                             preferred forename is not    An ordered sequence of
                             the first forename, the      person name elements
                             related data item            such as title, forename(s)
                             'Preferred Forename'         and family name.
                             should be used to indicate
                             this.                        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
http://www.datadictionarya   Recording Guidance: This        This Data Item can also
dmin.scot.nhs.uk/isddd/11    can be used to record a         constitute an element of
243.html                     person's full set of initials   the Structured Name:
                             or used in conjunction with
                             and in addition to a            Person Family Name
                             Person Given Name. The          Person Title
                             general practice of central     Name Element Position
                             departments is to record        Person Name Status
                             the first Given Name in full    Preferred Name
                             and then use initials for       Previous Person Family
                             other Given Names               Name
                             From Government Data            Person Given Name
                             Standards Catalogue             Person Initials
                                                             Person Preferred
                                                             Forename
                                                             Person Name Suffix

                                                             Definition:
                                                             An ordered sequence of
                                                             person name elements
                                                             such as title, forename(s)
                                                             and family name.

                                                             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
http://www.datadictionarya 00 - No/ informal               Further Information: A link
dmin.scot.nhs.uk/isddd/11                                  will exist to an appropriate
970.html                                                   section of the Act, with
                                                           accompanying
                                                           documents, Named
                                                           Person, Advanced
                                                           Statements, etc.
                                                           Recording Guidance:
                                                           More than one status can
                                                           apply at any one time and
                                                           all relevant categories
                                                           should be recorded.
                                                           A person's circumstances
                                                           may change over time
                                                           and, as such, each legal
                                                           status should be
                                                           associated with a start,
                                                           end and review date.
                                                           It is recommended that
                                                           the 2 character codes and
                                                           values should be used as
                                                           the minimum, but ideally
                                                           the relevant sub-values
                                                           should also be
                                                           implemented (full 3
                                                           character codes).



                           01 - Looked after child As
                           defined by the Children
                           (Scotland) Act 1995, a
                           child is looked after if they
                           are:· Provided with
                           accommodation by local
                           authorities under section
                           25 of the Act· Subject to
                           supervision requirements
                           following a children's
                           hearing· Subject to an
                           order, warrant or
                           authorization under which
                           the local authority has
                           responsibilities as
                           respects the child

                           01A The child is looked
                           after at home
                           01B The child is
                           accommodated by the
                           Local Authority
                           01C Parental
                           responsibilities order
                           01D Other
02 - Mental Health
(Scotland) Act 1984 The
1984 Mental Health
(Scotland) Act allows for a
person's detention in
hospital if it is thought
necessary for the person's
own health or safety, or
for the protection of other
people.

02A Emergency detention

02B Short term detention

02C Compulsory
treatment order
03 - Mental Health Care
and Treatment (Scotland)
Act 2003 Ensures service
provision and safeguards
relating to the care
andTreatment of people
with mental health
problems

03A Emergency detention

03B Short term detention

03C Compulsory
treatment order
04 - Adults with Incapacity
Act (2000) The 2000 Act
changes the system for
safeguarding the welfare,
andmanaging the finances
and property of adults
(aged 16+) who lack
thecapacity to take some
or all decisions for
themselves because of
mental disorder or inability
to communicate by any
means. It allows other
people to make decisions
on behalf of these adults
subject to safeguards.All
decisions made on behalf
of an adult with impaired
capacity mustbenefit the
adult; take account of the
adults wishes and the
wishes ofthe nearest
relative or primary carer,
and any guardian or
attorney;restrict the adults
freedom as little as
possible while still
achieving thedesired
benefit; encourage the
adult to use existing skills
or developnew skills.

04A Power of welfare
attorney
04B Power of continuing
attorney (financial)
04C Intervention order
(property/ financial
powers)
04D Intervention order
(power of welfare)
04E Authority to intromit
with funds (access to
funds)
04F Management of funds
of residents in care
establishments
04G Medical treatment
04H Guardianship order
(property/ financial
powers)
04I Guardianship order
(power of welfare)
                           05 - Criminal Procedure
                           (Scotland) Act 1995 The
                           1995 Act consolidates
                           certain enactments
                           relating to criminal
                           procedure in Scotland
                           05A Supervised
                           attendance order
                           05B Probation order
                           05C Community service
                           order
                           05D Serving a custodial
                           sentence
                           05E In custody awaiting
                           trial (on remand)
                           05F Appropriate adult
                           requirement
                           98 - Other (specify)
                           Specified legal status not
                           listed elsewhere
                           99 - Not known
http://www.datadictionarya 01 Registered name           Related Data Items           This Data Item can also
dmin.scot.nhs.uk/isddd/11 Registered name refers to     Person Full Name             constitute an element of
200.html                   the name officially          (Unstructured) , Person      the Structured Name:
                           registered on the birth      Requested Name
                           certificate.                 (Unstructured)               Person Family Name
                                                        Further Information          Person Title
                                                        'Person Name Status'         Name Element Position
                                                        applies at the level of an   Person Name Status
                                                        entire structured or         Preferred Name
                                                        unstructured name            Previous Person Family
                                                        Sub Data Items               Name
                                                        Start and End dates          Person Given Name
                                                                                     Person Initials
                                                                                     Person Preferred
                                                                                     Forename
                                                                                     Person Name Suffix

                                                                                     Definition:
                                                                                     An ordered sequence of
                                                                                     person name elements
                                                                                     such as title, forename(s)
                                                                                     and family name.

                                                                                     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
02 Alternative name
Alternative name is a
name adopted by the
person him/herself but not
legally changed, or name
by which a person is
customarily known, (where
this name is always or
mostly used or is relevant
to the recording purpose).
Includes: aliases, also
known as (aka), preferred
names, nick names, pen
names,stage names.


03 Married name Married
name is the name
adopted at marriage.
04 Maiden name Maiden
name is the name before
it is changed through
marriage or cohabitation.
05 Name changed by
deed poll Name changed
by deed poll is the name
as legally changed to by
deed poll.
06 Electoral registration
name Electoral
registration name is the
name on the electoral
register where this differs
from any of the above.
99 Not known
http://www.datadictionarya   Further Information: The     This Data Item can also
dmin.scot.nhs.uk/isddd/11    association memberships      constitute an element of
245.html                     of a person are              the Structured Name:
                             represented by the initial
                             letters of associations,     Person Family Name
                             professional bodies or       Person Title
                             other organisations of       Name Element Position
                             which the person is a        Person Name Status
                             member.                      Preferred Name
                                                          Previous Person Family
                                                          Name
                                                          Person Given Name
                                                          Person Initials
                                                          Person Preferred
                                                          Forename
                                                          Person Name Suffix

                                                          Definition:
                                                          An ordered sequence of
                                                          person name elements
                                                          such as title, forename(s)
                                                          and family name.

                                                          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
http://www.datadictionarya   Further Information: The     This Data Item can also
dmin.scot.nhs.uk/isddd/11    preferred forename of a      constitute an element of
244.html                     person represents the        the Structured Name:
                             forename by which a
                             person prefers to be         Person Family Name
                             known. This may be the       Person Title
                             first forename, another      Name Element Position
                             forename, or any other       Person Name Status
                             name, e.g. Elizabeth Mary    Preferred Name
                             Smith may prefer to be       Previous Person Family
                             known as either Elizabeth,   Name
                             Mary or Betty.               Person Given Name
                             From SMR Definitions and     Person Initials
                             Codes                        Person Preferred
                                                          Forename
                                                          Person Name Suffix

                                                          Definition:
                                                          An ordered sequence of
                                                          person name elements
                                                          such as title, forename(s)
                                                          and family name.

                                                          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
http://www.datadictionarya Mr    Further Information: The        This Data Item can also
dmin.scot.nhs.uk/isddd/11        title of a person is a series   constitute an element of
125.html                         of characters representing      the Structured Name:
                                 the way of addressing a
                                 person. It may imply a          Person Family Name
                                 combination of gender           Person Title
                                 and marital status: e.g.        Name Element Position
                                 Mr, Mrs, and Miss. It may       Person Name Status
                                 reflect social or               Preferred Name
                                 professional status: e.g.       Previous Person Family
                                 Dr; Rev; Lady, Lt.Col.          Name
                                 From SMR Definitions and        Person Given Name
                                 Codes                           Person Initials
                                 Recording Guidance: The         Person Preferred
                                 full range of generally         Forename
                                 recognised titles is            Person Name Suffix
                                 permitted. The
                                 Government data                 Definition:
                                 standards catalogue             An ordered sequence of
                                 recommends that if any of       person name elements
                                 these listed values are         such as title, forename(s)
                                 used, the value input must      and family name.
                                 conform exactly to the
                                 given format, e.g. "Mr" is      Recording guidance:
                                 uppercase M, lower case r       The structured name
                                 and no full stop. (The          approach breaks names
                                 value "Miss" has been           down into specific
                                 added to the Government         elements, with start and
                                 Data Standard Catalogue         end dates for each one
                                 values for this standard.)      (with the exception of
                                 An appropriate list of          Preferred Name), and
                                 values for a drop-down list     facilitates electronic inter-
                          Mrs    can be agreed for local         agency sharing and

                          Ms

                          Dr

                          Rev
                          Sir
                          Lady
                          Lord
                          Dame
                          Miss
http://www.datadictionarya                         Further Information: Main Sub Data Items:
dmin.scot.nhs.uk/isddd/11                          source of standard:          Start and End dates
287.html                                           Government 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
http://www.datadictionarya 01 Verbal Communication characters.
                                                   Further Information:
dmin.scot.nhs.uk/isddd/11                          Where a person does not
180.html                                           rely on speech as their
                                                   main method of making
                                                   themselves understood,
                                                   and/or understanding
                                                   others, it is important to
                                                   record the other methods
                                                   of communication that
                                                   may be used.

                             01A Generally intelligible
                             speech (i.e. person can be
                             understood by all)
                             01B Speech of limited
                             intelligibility (i.e. only
                             some of what a person
                             says can be understood
                             by all, OR person can be
                             understood only by people
                             familiar with their mode of
                             speech)
01C Other verbal
communication (i.e.
Person uses grunts or
other utterances to
communicate)
02 Communication based
on the alphabet
02A Finger spelling
02B Deaf/Blind manual
alphabet
02C Block
03 Communication based
on sign language
03A British Sign
Language (BSL)
03B Visual frame
signing/Close signing
03C Hands on signing
03D Makaton
03E Sign supported
English
03F Signed English
03G Other sign language
04 Communication using
text
04A Large print
04B Braille and/ or Moon
05 Communication using
objects and symbols
05A Objects of reference
05B Blissymbols
05C Rebus symbols
06 Communication based
on body language and
touch
06A Body language
06B Tadoma
98 Other preferred
communication method
(specify separately)
99 Preferred
communication method
not known
http://www.datadictionarya This short list is an extract   Further Information:          Related Data Items:
dmin.scot.nhs.uk/isddd/11 from ISO 639-2 and               It is important that          First Language,
281.html                   reflects prevalent              agencies establish clearly    Interpretation Assistance
                           languages spoken in             at the earliest opportunity   Indicator
                           Scotland. Other                 whether there are likely to
                           languages can be                be any difficulties in
                           recorded from the full ISO      communicating or
                           639-2 list. (Code order)        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
                            097 - Not disclosed            and/ or preferred
                            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)
http://www.datadictionarya 00 No                    Related Data Items:           This Data Item can also
dmin.scot.nhs.uk/isddd/11                           Person Full Name              constitute an element of
201.html                                            (Unstructured) , Person       the Structured Name:
                                                    Requested Name
                                                    (Unstructured)                Person Family Name
                                                    Further Information           Person Title
                                                    Recording Guidance: Only      Name Element Position
                                                    one name should be            Person Name Status
                                                    recorded as the Preferred     Preferred Name
                                                    Name.                         Previous Person Family
                                                    Where a new instance of       Name
                                                    a name (structured or         Person Given Name
                                                    unstructured) is recorded,    Person Initials
                                                    this is not necessarily the   Person Preferred
                                                    person's preferred name -     Forename
                                                    the person should confirm     Person Name Suffix
                                                    their preferred name.
                                                                                  Definition:
                                                                                  An ordered sequence of
                                                                                  person name elements
                                                                                  such as title, forename(s)
                                                                                  and family name.

                                                                                  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-
                          01 Yes                                                  agency sharing and
http://www.datadictionarya   Further Information: The      This Data Item can also
dmin.scot.nhs.uk/isddd/11    surname of a person           constitute an element of
223.html                     represents that part of the   the Structured Name:
                             name of a person
                             indicating the family group   Person Family Name
                             of which the person is or     Person Title
                             has been part.                Name Element Position
                             It should be noted that in    Person Name Status
                             Western culture this is       Preferred Name
                             normally the latter part of   Previous Person Family
                             the name of a person.         Name
                             However, this is not          Person Given Name
                             necessarily true of all       Person Initials
                             cultures. This will, of       Person Preferred
                             course, give rise to some     Forename
                             problems in the               Person Name Suffix
                             representation of the
                             name. This is resolved by     Definition:
                             including the data item       An ordered sequence of
                             Name Element Position in      person name elements
                             the structured name           such as title, forename(s)
                             indicating the order of the   and family name.
                             name elements.
                             From SMR Definitions and      Recording guidance:
                             Codes                         The structured name
                             Recording Guidance: The       approach breaks names
                             Previous Person Family        down into specific
                             Name may be derived           elements, with start and
                             from the Person Family        end dates for each one
                             Name entries through the      (with the exception of
                             use of start and end          Preferred Name), and
                             dates.                        facilitates electronic inter-
                                                           agency sharing and
http://www.datadictionarya                                Further Information:           Attributes
dmin.scot.nhs.uk/isddd/22                                 Arterial pulse is defined as
713.html                                                  the rhythmic expansion         Posture
                                                          and contraction of an          · Lying
                                                          artery caused by the           · Standing
                                                          impact of blood pumped         · Sitting
                                                          by the heart and is            Activity
                                                          obtained by palpation at       · Rest
                                                          various locations in the       · Exercise
                                                          body.                          Laterality
                                                          Pulse rate may also be         · Left
                                                          obtained using monitors        · Right
                                                          such as pulse oximeters,       · Bilateral
                                                          electronic BP.monitors         Limb
                                                          etc.                           · Upper
                                                          Recording Guidance: In         · Lower
                                                          certain clinical conditions,   Anatomical site
                                                          it may be necessary to         · Radial artery
                                                          record laterality and/ or      · Ulnar artery
                                                          limb e.g. in coarctation of    · Carotid artery
                                                          the aorta but pulse rate is    · Brachial artery
                                                          generally measured by          · Femoral artery
                                                          palpation of radial pulse at   · Popliteal artery
                                                          rest.                          · Dorsalis pedis artery
                                                                                         · Posterior tibial artery
                                                                                         · Superficial temporal
                                                                                         artery


http://www.datadictionarya 00 Not palpable                Further Information: "The
dmin.scot.nhs.uk/isddd/22                                 terms 'good', 'bad',
880.html                                                  'strong', and 'weak' in
                                                          relation to the pulse lack
                                                          precision and should be
                                                          avoided."- (Hutchison's
                                                          Clinical Methods).
                             01 Normal (or average)
                             volume
                             02 Small volume(Thready)
                             Due to reduced cardiac
                             outpute.g. major
                             haemorrhage, pulmonary
                             embolism,valvular
                             obstruction.

                             03 Large volume Also
                             called collapsing pulse,
                             bounding pulsee.g . fever,
                             hyperthyroidism, aortic
                             regurgitation.May also
                             accompany bradycardia
                             as in complete heart
                             block.
                             04 Pulsus paradoxus
                             Variation with
                             breathing.Exaggerated in
                             asthma, constrictive
                             pericarditis, pericardial
                             tamponade
                             05 Pulsus alternans
                             Amplitude is alternately
                             larger and smallerEg. Left
                             ventricular failure
                             06 Pulsus bisferience
                             Slow rising with a vibratory
                             feel on the upstroke.

                           99 Not known
http://www.datadictionarya 00 Normal                        Related Data Items: Pupil Attributes
dmin.scot.nhs.uk/isddd/22                                   Size
878.html                                                    Further Information: This Laterality
                                                            data item is intended for  Left
                                                            use in the recording of    Right
                                                            basic vital signs, not for
                                                            specialised measurement
                                                            of pupil reactivity.

                           01 Fixed
                           02 Abnormal
                           96 Not applicable e.g.
                           enucleation, prosthesis
                           99 Not Known
http://www.datadictionarya 00 Normal                        Further Information: This Attributes
dmin.scot.nhs.uk/isddd/22                                   data item is intended for
876.html                                                    use in the recording of    Laterality
                                                            basic vital signs, not for  Left
                                                            specialised measurement Right
                                                            of pupil size.


                             01 Constricted
                             02 Dilated
                             96 Not applicable e.g.
                             enucleation, prosthesis
                             99 Not Known
http://www.datadictionarya                                  Related Data Items:        Sub Data Items
dmin.scot.nhs.uk/isddd/22                                   Location Code              Number of Encounters
948.html                                                    Recording Guidance:        Code    Value
                                                            More than one option may   01       One
                                                            be selected within the     02      Two
                                                            "Yes" sub-values.          03      Three
                                                                                       04      Four +
http://www.datadictionarya 01 - Self referral            Further Information: Each
dmin.scot.nhs.uk/isddd/22                                organisation/healthcare
849.html                                                 provider will record a
                                                         distinct referral source for
                                                         each contact - for
                                                         example, 'code 01 - self-
                                                         referral' may be when a
                                                         patient calls NHS 24 for
                                                         advice. The NHS 24
                                                         Nurse Advisor may then
                                                         recommend the patient
                                                         attends their local A&E
                                                         department - therefore the
                                                         Referral Source recorded
                                                         by the A&E department
                                                         will be ' Code 02D -
                                                         Healthcare professional/
                                                         service/ organisation -
                                                         NHS 24'.
                                                         Where a clinician is
                                                         employed to attend to
                                                         patients within an A&E
                                                         department, the
                                                         attendance is classified as
                                                         an A&E attendance.
                                                         Since patients usually
                                                         present at an A&E
                                                         department without
                                                         advance notification, a
                                                         referral is often received
                                                         at the same time as a
                                                         patient presents.
                            01A Patient                  However, in certain
                            01B Associated person
                            eg. parent, friend,
                            employer, neighbour.
                            02 - Healthcare
                            professional/ service/
                            organisation Excludes
                            where the patient is
                            employed by one of these
                            agencies but the referral
                            relates to an injury
                            occurring in the course of
                            their work, which should
                            be recorded under '01 -
                            self referral'.
02A Primary Care - in
hours Referral from usual
Primary Medical Services
Practices / Primary
Healthcare Team practice
providing temporary
primary medical services.
Usually referrals within
working hours, but may be
out-with hours where
usual GP practice
performs out of hours
care.

02B Primary Care - Out of
Hours Referral from
clinician within a service
providing OOH cover
through local Primary care
emergency centre.
02C 999 Emergency
Services Includes SAS
Paramedic Practitioner
02D NHS24
02E Minor injuries unit
02F Secondary Care and
A&E
02G Specialist Palliative
Care Services
02H Same hospital
Excludes minor injuries
units
02J Other hospital
Excludes minor injuries
units
02K Other healthcare
professional Another
person acting in their
healthcare professional
capacity but out-with a
hospital or minor injuries
unit, e.g. dentist, private
healthcare professional.
03 - Local authority
03A Education
03B Social services
03C Police
03D Other local authority
department
04 - Private professional
/agency /organisation eg.
Nursing home, care
agency, etc
                             05 - Other agency
                             Excludes where the
                             patient is employed by
                             another agency but the
                             referral relates to an injury
                             occurring in the course of
                             their work, which should
                             be recorded under '01 -
                             self referral'.

                             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
http://www.datadictionarya                                   Further Information: It
dmin.scot.nhs.uk/isddd/11                                    should be noted that
292.html                                                     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.
http://www.datadictionarya 00 - Atheist, agnostic or    Further Information:
dmin.scot.nhs.uk/isddd/11 no religious affiliation      Research indicates that
251.html                                                for many people, their
                                                        identity is defined more by
                                                        their religion than their
                                                        nationality.
                                                        The data recorded against
                                                        this data item should be
                                                        current religion as
                                                        declared by the person
                                                        and NOT the religion
                                                        he/she was brought up in.
                                                        The classification
                                                        provided here is based on
                                                        the Scottish Census 2001
                                                        classification with the
                                                        addition of "Not disclosed"
                                                        and "Not known" options.
                                                        Recording Guidance:
                                                        Where a person
                                                        embraces aspects of more
                                                        than one religion, record
                                                        the person's MAIN current
                                                        religion.
                                                        There are three ways to
                                                        implement this standard
                                                        depending on the detail
                                                        appropriate to the
                                                        environment in which the
                                                        data will be used:
                                                        1. Record a person's
                                                        religion using only the 2
                           00R003 Agnostic              digit codes listed under
                           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
http://www.datadictionarya                               Further Information:
dmin.scot.nhs.uk/isddd/11                                Commencing April 2005,
713.html                                                 patients are registered
                                                         with a GP practice, not
                                                         with an individual GP. The
                                                         registered GP practice
                                                         code is the primary
                                                         identifier for this purpose.
                                                         The details of the
                                                         individual GPs working
                                                         within a practice are
                                                         recorded against the GP
                                                         practice code. There may
                                                         be an individual GP within
                                                         the practice who fulfils a
                                                         specific purpose, e.g.
                                                         patients may have a GP
                                                         whom they prefer to
                                                         provide their care where
                                                         possible. The GP role
                                                         data standard should be
                                                         used to identify these
                                                         roles.
                                                         The reason for having the
                                                         GP standard is based on
                                                         the assumption that there
                                                         will still be a need to
                                                         contact the GP who is
                                                         involved with a patient's
                                                         health and primary care
                                                         provision even though
                                                         patients are registered
                                                         with a practice rather than
http://www.datadictionarya 01 Usual GP Preferred        Further Information:
dmin.scot.nhs.uk/isddd/11 GP at registered practice.    Locums should be
735.html                   This is relevant for the     recorded using Associated
                           GMS contract                 Professional Role.
                                                        Recording Guidance: Only
                                                        one role should be
                                                        recorded in any particular
                                                        situation, whichever is
                                                        most relevant.



                          02 GP for correspondence
                          This is a GP who is being
                          corresponded with
                          concerning the
                          patient/client

                          03 Registered This is now
                          historic since most
                          patients are now
                          registered with a GP
                          practice and not a specific
                          GP
                          04 Previous registered GP
                          For historical purposes
                          where a patient/client has
                          moved practice

                          98 Other Includes when
                          patient/client is receiving
                          care as a temporary
                          resident
                          99 Not known
http://www.datadictionarya 00 Patient requested no  Further Information:
dmin.scot.nhs.uk/isddd/11 specific spiritual care   All staff routinely provide a
240.html                                            baseline level of spiritual
                                                    care to patients/ clients as
                                                    appropriate, however, a
                                                    patient/ client may
                                                    express their preference
                                                    for additional spiritual care
                                                    they wish to receive. This
                                                    may vary according to
                                                    circumstances and should
                                                    be provided according to
                                                    local policy.
                                                    Spiritual Care in NHS
                                                    Scotland HDL(2002)76
                                                    (November 2002):
                                                    "Chief Executives of NHS
                                                    Boards are required to
                                                    develop and implement a
                                                    spiritual care policy for
                                                    their Board area that
                                                    complies with this
                                                    guidance."
                                                    See local unified board
                                                    spiritual care policy:
                                                    http://www.chaplains.co.uk
                                                    /sp_policies.htm
                                                    Recording Guidance:
                                                    Multiple options may
                                                    apply, e.g. a patient
                                                    wishes both chaplaincy
                                                    team involvement and
                          01 Chaplaincy team input their own external pastoral
                          requested
                          02 Externally provided
                          spiritual/ religious care
                          requested
                          03 Patient undecided
http://www.datadictionarya 00 None                       Further Information: The
dmin.scot.nhs.uk/isddd/23                                inclusion of this data item
213.html                                                 does not imply that a
                                                         formal risk assessment
                                                         has been carried out. The
                                                         item is intended to act as
                                                         a flag to alert colleagues
                                                         to any possible risks
                                                         which may be present
                                                         when attending a patient/
                                                         client's home. It is
                                                         assumed that this data
                                                         item will be completed by
                                                         an associated
                                                         professional following an
                                                         initial visit to a patient/
                                                         client's home.
                                                         Where possible this risk
                                                         summary should be
                                                         populated from
                                                         information identified
                                                         during a risk assessment.
                                                         Generic assessment of
                                                         risk may help staff decide
                                                         on the precautions to take
                                                         in specific circimstances;
                                                         for example, by identifying
                                                         particular types of visit
                                                         which should not be
                                                         carried out by a lone
                                                         member of staff.
                                                         It is essential to set up
                         01 Issues with location of      systems to ensure
                         residence/building
                         01A Difficult to find
                         location Staff may be put
                         at risk when travelling in
                         certain situations
                         01B Isolated
                         01C Threat to personal
                         safety
                         01D Parking issues
                         01Z Other (specify)
                         02 Issues with access to
                         residence/ building
                         02A Risks associated with
                         the building e.g. Multi
                         storey, non-functioning lift,
                         poor lighting

                         02B Occupant(s) not able
                         to provide access
                         changed If alternative
                         arrangements in place,
                         please state, e.g. keypad,
                         key holder
02C Risk associated with
people other than
patient/client(s) This could
include risk from family
members or public etc

02Z Other (specify)
03 Issues with building
structure
03A Risks associated with
roof or windows changed

03B Risks associated with
bathroom and/or toilet
provision changed
03Z Other (specify)
04 Issues with
pets/animals/infestation
04A Risk of attack
04B Pest control e.g.
rodent or insect infestation

04Z Other (specify) e.g.
fur allergy
05 Risks related to using
power supply within
residence/ building
05A Unsafe Gas/ Electric
appliances
05B Exposed electric
wiring
05Z Other (specify)
06 Slip/trip risks within
residence/ building
06A Floor surface risk e.g.
Slippery/uneven surface

06B Obstruction
06C Poor lighting
06Z Other (specify)
07 Client/Patient manual
handling risk
07A
Adaptations/equipment
declined
07B Restricted space
07C Unapproved aids/
adaptations
07Z Other (specify)
08 Fire risks within
residence/ building
08A Resident smokes e.g.
Patient/client or other
person within the house/
building
                             08B Oxygen cylinder/
                             concentrator
                             08C No smoke detectors
                             08D Open fire
                             08Z Other (specify)
                             98 Other risk/safety
                             hazard
                             99 Not known
http://www.datadictionarya                            Further Information: This
dmin.scot.nhs.uk/isddd/11                             data format, which is
945.html                                              taken from the
                                                      Government Data
                                                      Standards Catalogue,
                                                      should be used for
                                                      storage, management and
                                                      transmission of dates by
                                                      IT systems, but the way in
                                                      which a date is recorded &
                                                      displayed on a user
                                                      interface may be decided
                                                      according to local user
                                                      preference.

http://www.datadictionarya                            Recording guidance: The
dmin.scot.nhs.uk/isddd/11                             structured name approach
145.html                                              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).
http://www.datadictionarya   Further Information: Main      Attributes
dmin.scot.nhs.uk/isddd/11    Source of Standard:
188.html                     British Hypertension            Posture
                             society                        · Sitting
                             Unless specified, SBP is       · Lying
                             generally understood to        · Standing
                             be measured at rest with       Laterality
                             the patient sitting. IT        · Left
                             systems could use 'sitting'    · Right
                             as the default posture         · Bilateral
                             where appropriate.             Limb
                             In certain clinical            · Upper
                             conditions, it may be          · Lower
                             necessary to record
                             laterality and/ or limb e.g.
                             in coarctation of the aorta.


http://www.datadictionarya   Attributes
dmin.scot.nhs.uk/isddd/22
711.html                     Body temperature
                             measure
                               Basal body temperature
                               Core body temperature
                                Axillary temperature
                                Groin temperature
                                Oral temperature
                                Rectal temperature
                                Tympanic temperature
                                Peripheral body
                             temperature
                                Digital temperature
                                Elbow joint temperature
                                Temperature of skin
                             Thermometer
                               Liquid crystal strip
                              Single-use chemical
                              Infrared ear
                              Thermistor
                              Thermocouple
http://www.datadictionarya   Further Information: Main Sub Data Items
dmin.scot.nhs.uk/isddd/11    source of standard:
286.html                     Government Data             Address Type
                             Standards Catalogue
                             1) The flat reference (e.g. SEE TABLE
                             2F3 - 2nd 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
http://www.datadictionarya                          Further Information: Main Sub Data Items
dmin.scot.nhs.uk/isddd/11                           source of standard:
288.html                                            Government Data            Telephone Number Type
                                                    Standards Catalogue
                                                    Care needs to be           SEE TABLE
                                                    exercised to avoid the
                                                    inappropriate sharing of
                                                    telephone number e.g.
                                                    where a number is ex-
                                                    directory.
                                                    The complete telephone
                                                    number should always be
                                                    transferred for
                                                    international operation
                                                    and clarity as to which
                                                    country (in this case UK)
                                                    the number belongs e.g.
                                                    +447710287657.
                                                    Note no leading zero after
                                                    country code."
                                                    (From Government Data
                                                    Standards Catalogue)
                                                    Recording Guidance:
                                                    Telephone number could
                                                    be a repeating field in
                                                    order to store as many
                                                    numbers as are required
                                                    or may be useful.
                                                    A telephone number type
                                                    should be recorded for
                                                    each recorded UK
                                                    Telephone Number.
                                                    Related an option to
http://www.datadictionarya 01 - NHS 24 e.g. a Nurse There is Data Items:
dmin.scot.nhs.uk/isddd/19 Advisor giving advice on Location Code,
107.html                   self-care                Accommodation Type
                                                    Further Informationl: The
                                                    Unscheduled Care
                                                    Service Location is
                                                    designed to allow the user
                                                    to determine which
                                                    service was used and the
                                                    location in which care was
                                                    delivered.
                                                    The data item
                                                    Accommodation type has
                                                    sub-codes and sub-values
                                                    to differentiate between
                                                    Nursing Homes and
                                                    Residential Care Homes
                                                    and as such must be used
                                                    as a related data item.
                                                    Recording Guidance:
                                                    Systems should allow for
                                                    multiple entries.
02 - Local Primary Care
Emergency Centre
03 - Minor Injuries Unit
04 - A&E Department
05 - Community Hospital
06 - Public Location
06A Public Location
Transport area
06B Public Location
Business area (excluding
recreational & sports
areas)
06C Public Location
School, educational area
06D Public Location
Sports & recreational area

07 - Residential Location
Includes any residential
location. Exact type of
residential location (i.e.
care home, residential
home) can be determined
from the related data item
of Accommodation Type.

08 - Emergency Dental
Centre
09 - Community
Pharmacy/ Pharmacy
http://www.datadictionarya                            Further Information:
dmin.scot.nhs.uk/isddd/11                             Person Full Name and
246.html                                              Person Requested Name
                                                      are specific examples of
                                                      unstructured names.
                                                      Recording Guidance:
                                                      Structured name
                                                      recording should always
                                                      be the preferred option.
                                                      Name should only be
                                                      recorded in an
                                                      unstructured fashion when
                                                      it is the only means of
                                                      recording the name.
                                                      The unstructured name
                                                      approach records the
                                                      name in a single
                                                      unstructured
                                                      concatenation of some or
                                                      all of the elements that
                                                      make up a person's full
                                                      name. It may be
                                                      appropriate as an
                                                      alternative to structured
                                                      name recording where:
                                                      · Care provider IT systems
                                                      cannot handle structured
                                                      name recording
                                                      · The person recording the
                                                      data does not know which
                                                      of the name words is the
                                                      family name and which
http://www.datadictionarya 01 Urgent For clinical     are forenames
                                                      Further Information:
dmin.scot.nhs.uk/isddd/22 reasons, a patient          Examples of referring
850.html                   requires to be seen at the agents making such a
                           earliest possible          judgment are an NHS 24
                           opportunity.               Nurse Advisor or an Out-
                                                      of-Hours GP making a
                                                      professional judgment.
                                                      Recording Guidance: Only
                                                      one option may be
                                                      selected.

                             02 Within an hour
                             03 Within 2 hours
                             04 Within 4 hours
                             05 Within 12 hours
                             06 Within 24 hours
                             07 Within 36 hours
                             96 Not applicable
                             99 Not known
http://www.datadictionarya   Further Information: If        Sub Data Items
dmin.scot.nhs.uk/isddd/11    weight cannot be
184.html                     measured, record recently      Verification level
                             documented or self-            0 Unverified
                             reported weight (if reliable   1 Verified
                             and realistic) as
                             '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.
Sub-Headings              Specialty      Clinical Domain   Sub-Section Heading




 Socio Environmental                                       Social and Personal
                       Communications   Unscheduled Care
       Details                                               Circumstances
Socio Environmental                                       Social and Personal
                      Communications   Unscheduled Care
      Details                                               Circumstances
 Patient Admin and
                         Communications   Unscheduled Care
  Demographics




   Care Episode                                              Care Journey and
                         Communications   Unscheduled Care
Administration Details                                          Encounter
Background Health
                    Communications   Unscheduled Care   Family Circumstances
   Information
   Care Episode
                         Communications   Unscheduled Care
Administration Details
   Care Episode                                              Care Journey and
                         Communications   Unscheduled Care
Administration Details                                          Encounter
                                                           Carer(s), Care
                                                          Professional(s),
Associated Person
                    Communications   Unscheduled Care   Team(s), Service(s),
     Details
                                                         Organisation(s) or
                                                             Sector(s)
                                                           Carer(s), Care
                                                          Professional(s),
Associated Person
                    Communications   Unscheduled Care   Team(s), Service(s),
     Details
                                                         Organisation(s) or
                                                             Sector(s)
                                                           Carer(s), Care
                                                          Professional(s),
Associated Person
                    Communications   Unscheduled Care   Team(s), Service(s),
     Details
                                                         Organisation(s) or
                                                             Sector(s)
                                                           Carer(s), Care
                                                          Professional(s),
Associated Person
                    Communications   Unscheduled Care   Team(s), Service(s),
     Details
                                                         Organisation(s) or
                                                             Sector(s)
Sector(s)
                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)
                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)




                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)
                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)
                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)
                                                                 Carer(s), Care
                                                                Professional(s),
Associated Professional
                          Communications   Unscheduled Care   Team(s), Service(s),
        Details
                                                               Organisation(s) or
                                                                   Sector(s)
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
Patient Admin and
                    Communications   Unscheduled Care   Person Identification
 Demographics
Socio Environmental
                      Communications   Unscheduled Care
      Details
Socio Environmental
                      Communications   Unscheduled Care
      Details




Background Health
                      Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
Ethnic and Cultural
                      Communications   Unscheduled Care   Lifestyle
     Diversity




Background Health
                      Communications   Unscheduled Care   Lifestyle
   Information
Background Health
                    Communications   Unscheduled Care   Lifestyle
   Information
   Care Episode                                              Care Journey and
                         Communications   Unscheduled Care
Administration Details                                          Encounter
Background Health
                    Communications   Unscheduled Care   Lifestyle
   Information
Background Health
                    Communications   Unscheduled Care   Lifestyle
   Information
Background Health
                    Communications   Unscheduled Care   Lifestyle
   Information
   Care Episode
                         Communications   Unscheduled Care
Administration Details
   Care Episode
                         Communications   Unscheduled Care
Administration Details
   Care Episode
                         Communications   Unscheduled Care
Administration Details
   Care Episode
                         Communications   Unscheduled Care
Administration Details




   Referral Details      Communications   Unscheduled Care




   Referral Details      Communications   Unscheduled Care
Patient Needs and                                         Social and Personal
                    Communications   Unscheduled Care
     Wishes                                                 Circumstances




Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
   Care Episode
                         Communications   Unscheduled Care
Administration Details




Socio Environmental                                          Social and Personal
                         Communications   Unscheduled Care
      Details                                                  Circumstances
                          Communications   Unscheduled Care
        Details                                               Circumstances




  Associated Person
                          Communications   Unscheduled Care
       Details




Associated Professional
                          Communications   Unscheduled Care
        Details
Ethnic and Cultural
                      Communications   Unscheduled Care   Diversity
     Diversity
 General Medical
                       Communications   Unscheduled Care
Practitioner Details
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information




Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
 General Medical
                       Communications   Unscheduled Care
Practitioner Details




Background Health
                       Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information




                                                            Care Planning,
Patient Needs and
                    Communications   Unscheduled Care      Management and
     Wishes
                                                             Outcome(s)
Patient Needs and
                    Communications   Unscheduled Care   Problem(s) and Issue(s)
     Wishes
                                                              Assessment(s),
   Care Episode
                         Communications   Unscheduled Care   Examination(s) and
Administration Details
                                                              Investigation(s)
   General Medical
                          Communications   Unscheduled Care
  Practitioner Details




  Associated Person
                          Communications   Unscheduled Care
        Details
Associated Professional
                          Communications   Unscheduled Care
        Details




  Ethnic and Cultural
                          Communications   Unscheduled Care
       Diversity
   Care Episode
                         Communications   Unscheduled Care
Administration Details




Socio Environmental
                         Communications   Unscheduled Care   Finding(s) and Result(s)
      Details
Socio Environmental
                      Communications   Unscheduled Care   Finding(s) and Result(s)
      Details
Patient Admin and
                    Communications   Unscheduled Care
 Demographics




  Care Episode                                          Care Journey and
                    Communications   Unscheduled Care
   Care Episode                                                 Care Journey and
                         Communications   Unscheduled Care
Administration Details                                             Encounter




 Background Health
                         Communications   Unscheduled Care   Finding(s) and Result(s)
    Information
Patient Needs and                                       Care Journey and
                    Communications   Unscheduled Care
     Wishes                                                Encounter




Risks and Alerts    Communications   Unscheduled Care
Risks and Alerts   Communications   Unscheduled Care
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Patient Admin and
                    Communications   Unscheduled Care   Diversity
 Demographics
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Socio Environmental
                      Communications   Unscheduled Care
      Details
Socio Environmental
                      Communications   Unscheduled Care
      Details
Patient Admin and                                       Social and Personal
                    Communications   Unscheduled Care
 Demographics                                             Circumstances
Patient Admin and                                       Social and Personal
                    Communications   Unscheduled Care
 Demographics                                             Circumstances
Patient Admin and                                       Social and Personal
                    Communications   Unscheduled Care
 Demographics                                             Circumstances
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
 General Medical
                       Communications   Unscheduled Care
Practitioner Details
Ethnic and Cultural
                      Communications   Unscheduled Care
     Diversity
Ethnic and Cultural
                      Communications   Unscheduled Care
     Diversity
Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Associated Person
                    Communications   Unscheduled Care
     Details
                    Communications   Unscheduled Care   Finding(s) and Result(s)




Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information




Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information




 Referral Details   Communications   Unscheduled Care   Finding(s) and Result(s)




                    Communications   Unscheduled Care
                                                       Care Journey and
Referral Details   Communications   Unscheduled Care
                                                          Encounter
                                                       Care Journey and
Referral Details   Communications   Unscheduled Care
                                                          Encounter
                                                              Carer(s), Care
                                                             Professional(s),
 General Medical
                       Communications   Unscheduled Care   Team(s), Service(s),
Practitioner Details
                                                            Organisation(s) or
                                                                Sector(s)
Ethnic and Cultural
                      Communications   Unscheduled Care
     Diversity
                                                              Carer(s), Care
                                                             Professional(s),
 General Medical
                       Communications   Unscheduled Care   Team(s), Service(s),
Practitioner Details
                                                            Organisation(s) or
                                                                Sector(s)
                                                              Carer(s), Care
                                                             Professional(s),
 General Medical
                       Communications   Unscheduled Care   Team(s), Service(s),
Practitioner Details
                                                            Organisation(s) or
                                                                Sector(s)
Ethnic and Cultural
                      Communications   Unscheduled Care   Diversity
     Diversity
Risks and Alerts   Communications   Unscheduled Care
Risks and Alerts   Communications   Unscheduled Care
Associated Person
                    Communications   Unscheduled Care
     Details




Patient Admin and
                    Communications   Unscheduled Care
 Demographics
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information




Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
 General Medical
                       Communications   Unscheduled Care
Practitioner Details
  General Medical
                         Communications   Unscheduled Care
 Practitioner Details




   Care Episode
                         Communications   Unscheduled Care
Administration Details
   Care Episode
                         Communications   Unscheduled Care
Administration Details
Associated Person
                    Communications   Unscheduled Care   Person Identification
     Details




                                                         Care Journey and
 Referral Details   Communications   Unscheduled Care
                                                            Encounter
Background Health
                    Communications   Unscheduled Care   Finding(s) and Result(s)
   Information
  Section Heading




Socio-Environmental
Socio-Environmental
Person Demographic(s)




Clinical / Care Process
Socio-Environmental
Date(s) and Time(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)
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Clinical / Care Process
Person Demographic(s)
Risk(s) and Alert(s)
 Risk(s) and Alert(s)




Clinical / Care Process
Socio-Environmental




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




Date(s) and Time(s)




Date(s) and Time(s)
Socio-Environmental




Clinical / Care Process
Date(s) and Time(s)




Socio-Environmental
Socio-Environmental




 Date(s) and Time(s)




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




Person Demographic(s)

Person Demographic(s)




Personal Preference(s)
Person Demographic(s)




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




Clinical / Care Process
Clinical / Care Process




 Risk(s) and Alert(s)
Risk(s) and Alert(s)
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Risk(s) and Alert(s)
Risk(s) and Alert(s)
Socio-Environmental
Socio-Environmental
Socio-Environmental
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Personal Preference(s)
Personal Preference(s)
Personal Preference(s)
Clinical / Care Process




Clinical / Care Process
Clinical / Care Process




Clinical / Care Process




Clinical / Care Process




  Document(s) and
  Correspondence
Clinical / Care Process
Clinical / Care Process
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Person Demographic(s)
Risk(s) and Alert(s)
Risk(s) and Alert(s)
 Date(s) and Time(s)




Person Demographic(s)
Clinical / Care Process




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




Clinical / Care Process
Clinical / Care Process
v1.1   Hyperlinks amended
       Formal name unmerged and shaded to enhance searching
v1.2   Codes and Values put into separate cells and removed comment boxes
       New Data Dictionary Headings added

				
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