NHS Information Authority

Data Standards Programme

The National Cancer Data Set Project, run by the NHS Information Authority, has produced a set of data items relating to the diagnosis and management of cancer.

The purpose of the National Cancer Minimum Data Set is to advise organisations within the National Health Service on a transferable set of data. These data will meet the needs of clinical audit, assist in the generation of National Performance Indicators and will allow outcome assessment.

Data Standards to support parts of the National Cancer Data Set have been released earlier in the following DSCNs:
10/2002 Data Standards: Radiotherapy Treatments
23/2002 Data Standards: Chemotherapy HRGs
30/2002 Data Standards: change to Monitoring of the Cancer Waiting Times

More information about the project and the Data Set can be found at:

DSCN 53/2002 defines NHS Data standards to support Version 1.3_ISB core data set, and this DSCN defines NHS data standards to support Version 1.3_ISB additional site specific data items for seven types of cancer: Breast, Colorectal, Lung, Head & Neck, Urological, Upper Gastro-Intestinal and Gynaecological.

A+E PATIENT DIAGNOSIS

A type of CLINICAL CLASSIFICATION FOR PERSON. A type of CLINICAL DIAGNOSIS FOR PERSON.

An ACCIDENT AND EMERGENCY DIAGNOSIS recorded for an ACCIDENT AND EMERGENCY ATTENDANCE.

This class is also known by these names:

Context	Alias
plural	A+E PATIENT DIAGNOSES

BREAST CANCER CARE SPELL

BREAST CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care, for a PATIENT who has been diagnosed as suffering from breast cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	BREAST CANCER CARE SPELLS

Attributes of this Class are:

		BREAST CANCER NURSE SEEN
	O	LMP DATE
		if not postmenopausal
		MENSTRUAL STATUS

Each BREAST CANCER CARE SPELL

may be the result of one and only one REFERRAL FOR BREAST ASSESSMENT

CANCER CARE SPELL

Attributes of this Class are:

		CANCER STATUS
	O	DIAGNOSTIC ROUTE
		QUALITY OF LIFE
	O	SPECIALIST PALLIATIVE CARE DATE
	O	SYMPTOMS FIRST NOTED DATE

CANCER CARE SPELL

Each CANCER CARE SPELL

	must be a spell for one and only one PATIENT
	must be initiated as a result of one and only one REFERRAL REQUEST
	may be the context for one or more ANTI-CANCER DRUG PROGRAMME
	may be subject to one or more CANCER CLINICAL STATUS ASSESSMENT
	may be associated for endocrine therapy with one or more CLINICAL INTERVENTION
	may be associated with one or more PATIENT CLINICAL TRIAL STATUS
	may be associated with one or more PATIENT PROCEDURE

CLINICAL CLASSIFICATION

Each CLINICAL CLASSIFICATION

	may be the classifier for one or more CLINICAL CLASSIFICATION FOR PERSON
	may be the classifier of one or more CLINICAL DIAGNOSIS FOR PERSON
	may be the classifier of one or more CLINICAL SIGN OR SYMPTOM OF PERSON
	may be the classifier for one or more INTERVENTION CLASSIFICATION ASSOCIATION
	may be classification of a cancer site for one or more PERSON RELATIONSHIP

CLINICAL CLASSIFICATION FOR PERSON

CLINICAL CLASSIFICATION FOR PERSON

CLINICAL DIAGNOSIS FOR PERSON

CLINICAL CLASSIFICATION FOR PERSON

A type of PERSON OBSERVATION.

Diagnostic observations recorded about a PERSON. These observations include PATIENT DIAGNOSIS and A+E PATIENT DIAGNOSIS.

This class is also known by these names:

Context	Alias
plural	CLINICAL CLASSIFICATIONS FOR PERSON
plural	CLINICAL DIAGNOSES FOR PERSON

CLINICAL CLASSIFICATION FOR PERSON

Each CLINICAL CLASSIFICATION FOR PERSON Each CLINICAL DIAGNOSIS FOR PERSON

K	must be classified by one and only one CLINICAL CLASSIFICATION
	must be related to one or more CLINICAL DIAGNOSIS FOR PERSON
	must be a complication arising from one and only one CLINICAL DIAGNOSIS FOR PERSON
	may be related to one and only one CLINICAL CLASSIFICATION
	may be a complication arising from one and only one PATIENT PROCEDURE

CLINICAL INTERVENTION

Each CLINICAL INTERVENTION

K	must be associated with one and only one PATIENT
	may be endochrine therapy for one and only one CANCER CARE SPELL
	may be related to one or more CLINICAL INVESTIGATION RESULT ITEM
	may be associated with one or more HEALTH CARE PROFESSIONAL INVOLVEMENT
	may be classified by one or more INTERVENTION CLASSIFICATION ASSOCIATION
	may be related to one and only one SERVICE PROVIDED

CLINICAL SIGN OR SYMPTOM OF PERSON

CLINICAL SIGN OR SYMPTOM OF PERSON

A type of PERSON OBSERVATION.

Signs or symptoms of a PERSON's condition or disease. This could be either an objective indication of the existence of a disease or condition as perceptible to the examiner (sign) or the subjective evidence of a disease or condition as reported by the PERSON (symptom). This includes signs and symptoms such as weight loss, jaundice, abdominal pain, headaches, dysphagia, vomiting and anaemia.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	CLINICAL SIGNS OR SYMPTOMS OF PERSON

Attributes of this Class are:

CLINICAL SIGN OR SYMPTOM

Each CLINICAL SIGN OR SYMPTOM OF PERSON

may be classified by one and only one CLINICAL CLASSIFICATION

COLORECTAL CANCER CARE SPELL

COLORECTAL CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care for a PATIENT who has been diagnosed as suffering from colorectal cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	COLORECTAL_CANCER_CARE_SPELLS

Attributes of this Class are:

COLORECTAL OR STOMA NURSE SEEN DATE

This class has no relationships.

DRUG DOSAGE AND ADMINISTRATION

Information which provides a full specification of a DRUG TREATMENT. This may include forms of presentation, route of administration, unit dose, dosage regime, maximum daily dose, trigger for administration and precautions.

References:
The Version 1.0 Trial NHS Standard EDIFACT Messages for GP-Hospital Communications - 17.5.95 National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	DRUG DOSAGES AND ADMINISTRATIONS

DRUG DOSAGE AND ADMINISTRATION

Attributes of this Class are:

K		DRUG DOSAGE AND ADMIN IDENTIFIER
		DRUG DOSAGE AND ADMIN SPECIFICATION
		DRUG ROUTE OF ADMINISTRATION
		for the delivery of chemotherapy/immunotherapy treatment only
	O	LAST DOSAGE DATE
	O	LAST DOSAGE TIME

ENDOCRINE THERAPY

ENDOCRINE THERAPY

A type of CLINICAL INTERVENTION.

A record of the type of endocrine therapy given to the PATIENT as part of a CANCER CARE SPELL.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	ENDOCRINE_THERAPIES

Attributes of this Class are:

ENDOCRINE THERAPY TYPE

This class has no relationships.

GYNAECOLOGICAL CANCER CARE SPELL

GYNAECOLOGICAL CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care for a PATIENT who has been diagnosed as suffering from gynaecological cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	GYNAECOLOGICAL CANCER CARE SPELLS

This class has no attributes.

This class has no relationships.

HEAD AND NECK CANCER CARE SPELL

HEAD AND NECK CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care for a PATIENT who has been diagnosed as suffering from head or neck cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	HEAD_AND_NECK_CANCER_CARE_SPELLS

Attributes of this Class are:

	O	NUTRITIONAL SUPPORT PROVIDED TYPE
		if nutritional support given
		PREVIOUS TREATMENT ELSEWHERE

This class has no relationships.

HEALTH CARE PROFESSIONAL

Attributes of this Class are:

	O	GRADE OF RESPONSIBLE HCP
	O	GYNAECOLOGICAL ONCOLOGY ACCREDITATION
	O	SPECIALIST HIV SKILLS AVAILABLE
	O	SPECIALIST REGISTRAR FLAG
		for paediatric surgery only

LUNG CANCER CARE SPELL

LUNG CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care, for a PATIENT who has been diagnosed as suffering from lung cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	LUNG_CANCER_CARE_SPELLS

Attributes of this Class are:

COPD PRESENT

Each LUNG CANCER CARE SPELL

may be associated with one or more LUNG CAPACITY

LUNG CAPACITY

LUNG CAPACITY

A type of PERSON OBSERVATION.

The lung capacity of a PERSON.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	LUNG_CAPACITIES

Attributes of this Class are:

		FEV1 ABSOLUTE AMOUNT
		FEV1 PERCENTAGE

Each LUNG CAPACITY

may be associated with one and only one LUNG CANCER CARE SPELL

PATHOLOGY LABORATORY INVESTIGATION

A type of CLINICAL INTERVENTION.

A type of CLINICAL INTERVENTION.

A single (laboratory) service resulting from a REQUEST FOR DIAGNOSTIC TEST, to be carried out in respect of a specified subject of investigation that leads to the production of one or more results.

References:
The version 1.1 NHS Standard EDIFACT Messages for Pathology Requests and Reports, 2001

This class is also known by these names:

Context	Alias
plural	PATHOLOGY LABORATORY INVESTIGATIONS

PATHOLOGY LABORATORY INVESTIGATION

Attributes of this Class are:

	O	MARKER LYMPH NODE RESULT
	O	PATHOLOGY INVESTIGATION PRIORITY
	O	PATHOLOGY RESULT DUE DATE
	O	PATHOLOGY RESULT DUE TIME

PATIENT

Attributes of this Class are:

		ALCOHOL STATUS
	O	CARER SUPPORT INDICATOR
		CHRONICALLY SICK OR DISABLED
		mandatory only during a HOSPITAL PROVIDER SPELL
	O	SECURE ACCOMMODATION TYPE
		only for patients requiring secure accommodation
	O	YEAR OF FIRST KNOWN PSYCHIATRIC CARE
		patients who have received specialist psychiatric care

PATIENT

Each PATIENT

	may be absent for one or more ABSENCE WITHOUT LEAVE
	may be related to one or more ACCIDENT AND EMERGENCY EPISODE
	may be the subject of one or more CANCER CARE SPELL
	may be associated with one or more CLINICAL INTERVENTION
	may be related to one or more COMMUNITY EPISODE
	may be the subject of one or more CONSULTANT EPISODE (ACUTE HOME-BASED)
	may be related to one or more CONSULTANT OUT-PATIENT EPISODE
	may be related to one or more DECISION TO ADMIT
	may be related to one or more DENTAL EPISODE
	may be related to one DISABLEMENT APPLIANCE
	may be related to one or more DISABLEMENT APPLIANCE REPAIR
	may be in receipt of one or more DISPENSED ITEM
	may be related to one or more DOMICILIARY CONSULTATION
	may be related to one or more ELECTIVE ADMISSION LIST ENTRY
	may be related to one or more EMERGENCY DENTAL ATTENDANCE
	may be related to one or more FACE TO FACE CONTACT DENTAL
	may be the subject of one or more FACE TO FACE CONTACT OPTICAL
	may be related to one or more GENITO-URINARY EPISODE
	may be related to one or more HOME DIALYSIS EPISODE
	may be related to one or more HOME LEAVE
	may be the subject of one or more HONOS SCORE FOR PERSON
	may be related to one or more HOSPITAL PROVIDER SPELL
	may be granted leave for one or more LEAVE OF ABSENCE
	may be related to one or more LEGAL STATUS
	may be related to one or more LITHOTRIPSY COURSE ATTENDANCE
	may be related to one or more MATERNITY DOMICILIARY VISIT
	may be subject to one or more MENTAL HEALTH CARE SPELL
	may be related to one or more MIDWIFE EPISODE
	may be related to one or more NURSING EPISODE
	may be related to one or more NURSING HOME STAY (MIDWIFE CARE)
	may be related to one or more NURSING HOME STAY (NURSING CARE)
	may be in receipt of health care services under one or more OUT OF AREA TREATMENT
	may be related to one or more OUT-PATIENT APPOINTMENT
	may be related to one or more PATIENT JOURNEY
	may be issued with one or more POWERED WHEELCHAIR
	may be related to one or more PREGNANCY EPISODE
	may be in receipt of one or more PRESCRIPTION
	may be related to one or more PROFESSIONAL STAFF GROUP EPISODE
	may be related to one or more RADIOTHERAPY TREATMENT COURSE
	may be related to one or more REFERRAL FOR BIOPSY
	may be related to one or more REFERRAL FOR BREAST ASSESSMENT
	may be related to one or more REFERRAL FOR BREAST TREATMENT
	may be related to one or more REFERRAL FOR SCREENING TEST
	may be related to one or more REFERRAL REQUEST
	may be related to one or more REGULAR ATTENDER EPISODE
	may be related to one or more REQUEST FOR DIAGNOSTIC TEST
	may be related to one or more RESIDENTIAL CARE OR GROUP HOME STAY
	may be the subject of one or more ROAD TRAFFIC ACCIDENT TREATMENT
	may be identified as needing one or more SECURE ACCOMMODATION REQUIREMENT
	may be related to one or more SERVICE REPORT HEADER
	may be related to one or more THEATRE CASE
	may be associated with one or more TOBACCO USAGE
	may be associated with one or more TOBACCO USAGE
	may be related to one or more WARD ATTENDANCE
	may be issued with one or more WHEELCHAIR SERVICES VOUCHER

PATIENT DIAGNOSIS

A type of CLINICAL CLASSIFICATION FOR PERSON. A type of CLINICAL DIAGNOSIS FOR PERSON.

This class is also known by these names:

Context	Alias
plural	PATIENT DIAGNOSES

PATIENT PROCEDURE

Attributes of this Class are:

	O	COLONOSCOPY INCOMPLETE REASON
		if procedure is colonoscopy
		OPERATIVE PATIENT PROCEDURE INDICATOR
	O	PATIENT INFORMED BIOPSY RESULT DATE
		colposcopy only
	O	PATIENT PROCEDURE RESULT
		if procedure is colonoscopy or other for cancer detection
	O	SURGICAL URGENCY
		for operative procedures only

PATIENT PROCEDURE

Each PATIENT PROCEDURE

	must be performed on a patient within one and only one CONSULTANT EPISODE (ACUTE HOME-BASED)
	or must be related to one and only one CONSULTANT EPISODE (HOSPITAL PROVIDER)
	or must be performed on a patient within one and only one DAY CARE ATTENDANCE
	or must be related to one and only one LABOUR AND DELIVERY
	or must be related to one and only one OUT-PATIENT ATTENDANCE CONSULTANT
	or must be related to one and only one WARD ATTENDANCE
	must be related to one or more PATIENT PROCEDURE CLASSIFICATION
	may be performed as treatment during one and only one CANCER CARE SPELL
	may be recorded by one and only one CARE PROGRAMME APPROACH REVIEW
	may be the cause of complications recorded as one or more CLINICAL DIAGNOSIS FOR PERSON
	may be the responsibility as anaesthetist of one and only one CONSULTANT
	may be the responsibility as surgeon of one and only one HEALTH CARE PROFESSIONAL
	may be performed in response to one and only one REFERRAL FOR BREAST TREATMENT
	may be the reason for one or more REQUEST FOR PATHOLOGY INVESTIGATION
	may be during one and only one THEATRE CASE

PERSON OBSERVATION

Observations made regarding a PERSON. These observations do not include information about a treatment or intervention. The observation may be a CLINICAL CLASSIFICATION FOR PERSON. The observation may be a CLINICAL DIAGNOSIS FOR PERSON. The observer may be a related PERSON or a HEALTH CARE PROFESSIONAL. PERSON OBSERVATIONS may be recorded during, or as a result of, a course of treatment.

PERSON OBSERVATIONS include CARDIAC ARREST, ACUTE MYOCARDIAL INFARCTION HISTORY ITEM and CO-MORBIDITY INDEX FOR ADULTS.

References:
The version 1.1 NHS Standard EDIFACT Messages for Pathology Requests and Reports, 2001
The Version 1.0 Trial NHS Standard EDIFACT Messages for GP-Hospital Communications - 17.5.95

This class is also known by these names:

Context	Alias
plural	PERSON OBSERVATIONS

PERSON RELATIONSHIP

Each PERSON RELATIONSHIP

K	must be to one and only one PERSON
K	must be from one and only one PERSON
K	must be to one and only one PERSON
	may be related to a cancer site classified by one and only one CLINICAL CLASSIFICATION

REFERRAL FOR BREAST ASSESSMENT

Attributes of this Class are:

K		REFERRAL NUMBER
	O	BREAST ASSESSMENT DATE
		recorded when patient attends for assessment
	O	BREAST ASSESSMENT FINAL OUTCOME
		recorded when assessment completed
		BREAST ASSESSMENT FIRST APPOINTMENT DATE
		CLINICAL EXAMINATION FINDINGS

REFERRAL FOR BREAST ASSESSMENT

Each REFERRAL FOR BREAST ASSESSMENT

K	must be related to one and only one PATIENT
	must be related to one and only one SCREENING TEST
	may be resultant in one or more BREAST CANCER CARE SPELL
	may be related to one or more REFERRAL FOR BIOPSY
	may be related to one or more REFERRAL FOR BREAST TREATMENT

TOBACCO USAGE

TOBACCO USAGE

The history of a PATIENT's tobacco usage.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	TOBACCO_USAGES

Attributes of this Class are:

K		START DATE
K		TOBACCO USAGE TYPE
	O	CIGARETTES PER DAY
		if current or ex-smoker
	O	DATE STOPPED SMOKING
		if ex-smoker
	O	NUMBER OF YEARS SMOKED
		if current or ex-smoker
		SMOKING STATUS
	O	TOBACCO CHEWING HISTORY

Each TOBACCO USAGE

must be the usage of one and only one PATIENT

UPPER GI CANCER CARE SPELL

UPPER GI CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care for a PATIENT who has been diagnosed as suffering from upper gastro-intestinal cancer, which includes stomach and gastro-oesophageal cancers.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	UPPER_GI_CANCER_CARE_SPELLS

Attributes of this Class are:

		POSSUM SCORE (AFTER SURGERY)
		POSSUM SCORE (AT DIAGNOSIS)

This class has no relationships.

UROLOGICAL CANCER CARE SPELL

UROLOGICAL CANCER CARE SPELL

A type of CANCER CARE SPELL.

A continuous period of care, including assessment for care for a PATIENT who has been diagnosed as suffering from urological cancer.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This class is also known by these names:

Context	Alias
plural	UROLOGICAL_CANCER_CARE_SPELLS

Attributes of this Class are:

	O	S CATEGORY FINAL PRETREATMENT
		for testis cancer only
	O	SERUM TUMOUR MARKER PSA
		for prostate cancer only

This class has no relationships.

ALCOHOL STATUS

ALCOHOL STATUS

The alcohol status of the PATIENT at the time the ALCOHOL USAGE is recorded.

National codes:

1	Current heavy
2	Heavy in the past
3	Current light
4	Never

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	ALCOHOL_STATUSES

BREAST CANCER NURSE SEEN

BREAST CANCER NURSE SEEN

An indicator of whether the PATIENT has seen a specialist breast care nurse during a BREAST CANCER CARE SPELL.

National codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	BREAST_CANCER_NURSES_SEEN

CIGARETTES PER DAY

CIGARETTES PER DAY

The number of cigarettes smoked by the patient where they are a current or ex-smoker.

This attribute is also known by these names:

Context	Alias
plural	CIGARETTES_PER_DAY

CLINICAL EXAMINATION FINDINGS

CLINICAL EXAMINATION FINDINGS

The findings from the clinical examination performed on the PATIENT at the start of a BREAST CANCER CARE SPELL.

National codes:

P1	Normal
P2	Benign
P3	Uncertain
P4	Suspicious
P5	Malignant

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CLINICAL_EXAMINATIONS_FINDINGS

CLINICAL SIGN OR SYMPTOM

CLINICAL SIGN OR SYMPTOM

An objective indication of the existence of a disease or condition as perceptible to the examiner (sign) or the subjective evidence of a disease or condition as reported by the PERSON (symptom). This includes signs and symptoms such as weight loss, jaundice, abdominal pain, headaches, dysphagia, vomiting and anaemia.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	CLINICAL_SIGNS_OR_SYMPTOMS

COLONOSCOPY INCOMPLETE REASON

COLONOSCOPY INCOMPLETE REASON

The reason that a colonoscopy was incomplete.

National codes:

1	Obstructing tumour
2	Poor bowel presentation
3	Patient intolerance/technical reasons
4	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	COLONOSCOPY_INCOMPLETE_REASONS

COLORECTAL OR STOMA NURSE SEEN DATE

COLORECTAL OR STOMA NURSE SEEN DATE

The date when the PATIENT first saw the colorectal nurse or stoma therapist during a COLORECTAL CANCER CARE SPELL.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	COLORECTAL_OR_STOMA_NURSE_SEEN_DATES

COPD PRESENT

COPD PRESENT

An indication of evidence of Chronic Obstructive Pulmonary Disease in a PATIENT with a LUNG CANCER CARE SPELL.

National codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	COPD_PRESENT

DATE STOPPED SMOKING

DATE STOPPED SMOKING

The date on which the PATIENT stopped smoking where they are an ex-smoker. If the exact date is not known the year should be recorded.

This attribute is also known by these names:

Context	Alias
plural	DATES_STOPPED_SMOKING

DIAGNOSTIC ROUTE

DIAGNOSTIC ROUTE

An indication of a PATIENT'S route to diagnosis of cancer for a CANCER CARE SPELL.

National codes:

1	Cancers detected by national screening programme
2	Interval cancers occurring in patients screened by a national screening programme
3	Other route

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DIAGNOSTIC_ROUTES

DRUG ROUTE OF ADMINISTRATION

DRUG ROUTE OF ADMINISTRATION

The method of delivery of the chemotherapy/immunotherapy treatment.

National codes:

01	Intra-vesicular
97	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	DRUG_ROUTES_OF_ADMINISTRATION

ENDOCRINE THERAPY TYPE

ENDOCRINE THERAPY TYPE

The type of ENDOCRINE THERAPY given to the PATIENT during a CANCER CARE SPELL.

National codes:

R	Radiotherapy ablation (e.g. radiation induced menopause)
S	Surgical ablation (e.g. oophrectomy, orchidectomy)
M	Medical ablation (e.g. LHRH analogues)
A	Adjuvant endocrine therapy (e.g. Tamoxifen + surgery)
D	Definitive endocrine therapy (e.g. Tamoxifen alone)
O	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	ENDOCRINE_THERAPY_TYPES

FEV1 ABSOLUTE AMOUNT

FEV1 ABSOLUTE AMOUNT

The forced expiratory volume of the lungs in 1 second measured in litres.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	FEV1_ABSOLUTE_AMOUNTS

FEV1 PERCENTAGE

FEV1 PERCENTAGE

The forced expiratory volume of the lungs in 1 second as a percentage of the predicted value.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	FEV1_PERCENTAGES

GRADE OF RESPONSIBLE HCP

GRADE OF RESPONSIBLE HCP

The grade of the operating surgeon.

National codes:

1	Associate Specialist
2	Consultant
3	Staff grade/clinical assistant
4	Specialist Registrar (SPR)
5	Senior House Officer (SHO)
6	House Officer (HO)
7	Other

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	GRADES_OF_RESPONSIBLE_HCP

GYNAECOLOGICAL ONCOLOGY ACCREDITATION

GYNAECOLOGICAL ONCOLOGY ACCREDITATION

An indicator of accreditation in Gynaecological Oncology for the HEALTH CARE PROFESSIONAL.

National codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	GYNAECOLOGICAL_ONCOLOGY_ACCREDITATIONS

LMP DATE

LMP DATE

The date of the PATIENT's last menstrual period (LMP) at the start of the BREAST CANCER CARE SPELL.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	LMP_DATES

MARKER LYMPH NODE RESULT

MARKER LYMPH NODE RESULT

An indicator of the presence or absence of metastases in a marker lymph node that is of therapeutic and prognostic importance relating to a CANCER CARE SPELL.

For breast cancer, the marker lymph node will be the sentinal node.

For colorectal cancer, the marker lymph node will be the apical node.

National codes:

N	Marker lymph node 1 negative
Y	Marker lymph node 1 positive present

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	MARKER_LYMPH_NODE_RESULTS

MENSTRUAL STATUS

MENSTRUAL STATUS

The PATIENT's menstrual status at the start of the BREAST CANCER CARE SPELL.

National codes:

1	Premenopausal
2	Perimenopausal
3	Postmenopausal

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	MENSTRUAL_STATUSES

NUMBER OF YEARS SMOKED

NUMBER OF YEARS SMOKED

The number of years that a patient was smoking where they are a current or ex-smoker. This is used with the CIGARETTES PER DAY to calculate the estimated pack years of smoking.

This attribute is also known by these names:

Context	Alias
plural	NUMBERS_OF_YEARS_SMOKED

NUTRITIONAL SUPPORT PROVIDED TYPE

NUTRITIONAL SUPPORT PROVIDED TYPE

The type of nutritional support that has been given during a HEAD AND NECK CANCER CARE SPELL.

National codes:

E	Enteral (by the functioning gut)
P	Parenteral (via intravenous feeding)

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	NUTRITIONAL_SUPPORT_PROVIDED_TYPES

OPERATIVE PATIENT PROCEDURE INDICATOR

OPERATIVE PATIENT PROCEDURE INDICATOR

An indication of whether or not the PATIENT PROCEDURE is an operative procedure.

National codes:

N	No
Y	Yes

This attribute is also known by these names:

Context	Alias
plural	OPERATIVE_PATIENT_PROCEDURE_INDICATORS

PATIENT PROCEDURE RESULT

PATIENT PROCEDURE RESULT

The result of a procedure such as a colonoscopy.

National codes:

1	Normal
2	Abnormal
3	Inadequate
4	Not done

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	PATIENT_PROCEDURE_RESULTS

POSSUM SCORE (AFTER SURGERY)

POSSUM SCORE (AFTER SURGERY)

The Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity after surgery for an UPPER GI CANCER CARE SPELL. Further information can be found in the Upper GI Appendix on http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	POSSUM_SCORES_(AFTER_SURGERY)

POSSUM SCORE (AT DIAGNOSIS)

POSSUM SCORE (AT DIAGNOSIS)

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity at the point of diagnosis for an UPPER GI CANCER CARE SPELL. Further information can be found in the Upper GI Appendix on http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	POSSUM_SCORES_(AT_DIAGNOSIS)

PREVIOUS TREATMENT ELSEWHERE

PREVIOUS TREATMENT ELSEWHERE

An indicator of whether the PATIENT has had previous treatment for head and neck cancer elsewhere, as another HEAD AND NECK CANCER CARE SPELL.

National codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	PREVIOUS_TREATMENTS_ELSEWHERE

QUALITY OF LIFE

QUALITY OF LIFE

A quality of life measurement at the time of diagnosis for a CANCER CARE SPELL for Head & Neck cancers only. The measurement tool is the UW-QOL (University of Washington Quality of Life) head and neck questionnaire. Further information can be found in the Head & Neck Appendix on http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	QUALITY OF LIFE

RELATIONSHIP TO PERSON

RELATIONSHIP TO PERSON

The relationship of the second PERSON to the first PERSON. Note that this is a limited list.

National codes:

A	Aunt
B	Brother
C	Child unspecified
D	Daughter
F	Father
G	Grandparent
H	Husband
K	Cousin
M	Mother
N	Nephew/neice
P	Parent unspecified
S	Sister
U	Uncle
W	Wife
X	Grandchild unspecified
Z	Son

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	RELATIONSHIPS_TO_PERSON

RELATION WITH CANCER

RELATION WITH CANCER

An indicator of whether the second PERSON in the PERSON RELATIONSHIP has had cancer.

National codes:

Y	Yes
N	No

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	RELATIONS_WITH_CANCER

S CATEGORY FINAL PRETREATMENT

S CATEGORY FINAL PRETREATMENT

The final pre-treatment measure of the stage based on the serum tumour marker for testis cancer only. This is coded according to the UICC (Union Internationale Contre le Cancer) coding (5th Edition, 1997) guidelines. Further information can be found in the Urology Appendix on: http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	S_CATEGORIES_FINAL_PRETREATMENT

SERUM TUMOUR MARKER PSA

SERUM TUMOUR MARKER PSA

The serum tumour marker elevation of Prostate Specific Antigen for prostate cancer recorded at the time of diagnosis for a UROLOGICAL CANCER CARE SPELL.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	SERUM TUMOUR MARKERS PSA

SMOKING STATUS

SMOKING STATUS

The smoking status of the PATIENT at the time their TOBACCO USAGE is recorded.

National codes:

1	Current smoker
2	Ex-smoker
3	Non-smoker - history unknown
4	Never smoked
9	Unknown

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	SMOKING STATUSES

SURGICAL URGENCY

SURGICAL URGENCY

The surgical urgency relating to an operative procedure. A classification based on the National Confidential Enquiry into Perioperative Deaths (NCEPOD) classification of operation urgency. Used for local surgical and anaesthesia audits.

National codes:

01	Elective - operation pre-planned at a time to suit both patient and surgeon
02	Scheduled - an early operation usually within 3 weeks. Often applicable to cancer surgery
03	Urgent - operation as soon as possible and usually within 24hrs
04	Immediate - requires immediate surgery without time for preparation or resuscitation

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	SURGICAL URGENCIES

SYMPTOMS FIRST NOTED DATE

SYMPTOMS FIRST NOTED DATE

The month and year that the PATIENT first noted any symptoms related to the site of cancer recorded as part of a CANCER CARE SPELL.

This attribute is also known by these names:

Context	Alias
plural	SYMPTOMS FIRST NOTED DATES

TOBACCO CHEWING HISTORY

TOBACCO CHEWING HISTORY

The PATIENT's history of tobacco chewing as part of their TOBACCO USAGE.

National codes:

1	Current
2	Ex
3	Smoker

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	TOBACCO CHEWING HISTORIES

TOBACCO USAGE TYPE

TOBACCO USAGE TYPE

The type of a PATIENT's TOBACCO USAGE.

National codes:

G	Cigarettes
P	Pipe
W	Chewing

References:
National Cancer Data Set Version 1.3_ISB October 2002

This attribute is also known by these names:

Context	Alias
plural	TOBACCO USAGE TYPES

ALCOHOL STATUS

ALCOHOL STATUS

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	ALCOHOL STATUSES

BREAST CANCER NURSE SEEN

BREAST CANCER NURSE SEEN

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	BREAST CANCER NURSES SEEN

CLINICAL EXAMINATION FINDINGS (BREAST CANCER)

CLINICAL EXAMINATION FINDINGS (BREAST CANCER)

Format/length:	an2
HES item:
National Codes:
Default Codes:

CLINICAL EXAMINATION FINDINGS (BREAST CANCER) is the same as attribute CLINICAL EXAMINATION FINDINGS.

This data element is also known by these names:

Context	Alias
plural	CLINICAL EXAMINATION FINDINGS (BREAST CANCER)

CLINICAL SIGN OR SYMPTOM (ICD)

CLINICAL SIGN OR SYMPTOM (ICD)

Format/length:	an6
HES item:
National Codes:
Default Codes:

CLINICAL SIGN OR SYMPTOM classified using ICD coding.

See DIAGNOSTIC CODING for details of coding.

This data element is also known by these names:

Context	Alias
plural	CLINICAL SIGNS OR SYMPTOMS (ICD)

CODE OF RESPONSIBLE HCP (OPCS)

CODE OF RESPONSIBLE HCP (OPCS)

Format/length:	an8
HES item:	See Table below
National Codes:
Default Codes:	C9999998 - Consultant, GMC code not known
	D9999998 - Dentist, DPB code not known
	G9999998 - General Medical Practitioner, GMP code not known
	H9999998 - Other health care professional
	M9999998 - Midwife
	N9999998 - Nurse
	P9999998 - Non-consultant doctor, GMC code not known

CODE OF RESPONSIBLE HCP (OPCS) is the GMC, DPB or other professional registration code for the HEALTH CARE PROFESSIONAL undertaking the OPCS-4 classified operative PATIENT PROCEDURE. This will usually, but not exclusively, be the lead health care professional or a junior member of the same team.

Where the actual professional registration code is unknown or the professional is not a doctor or a dentist, the appropriate default code should be used.

This data element is also known by these names:

Context	Alias
plural	CODES OF RESPONSIBLE HCPS (OPCS)

COLONOSCOPY INCOMPLETE REASON

COLONOSCOPY INCOMPLETE REASON

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	COLONOSCOPY INCOMPLETE REASONS

COLORECTAL NURSE OR STOMA THERAPIST SEEN

COLORECTAL NURSE OR STOMA THERAPIST SEEN

Format/length:	an1
HES item:
National Codes:
Default Codes:

This is derived from the presence of COLORECTAL OR STOMA NURSE SEEN DATE.

National codes:

Y	Yes
N	No

This data element is also known by these names:

Context	Alias
plural	COLORECTAL NURSES OR STOMA THERAPISTS SEEN

COLORECTAL OR STOMA NURSE SEEN DATE

COLORECTAL OR STOMA NURSE SEEN DATE

Format/length:	ccyymmdd
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	COLORECTAL OR STOMA NURSE SEEN DATES

CO-MORBIDITY (ICD)

CO-MORBIDITY (ICD)

Format/length:	an6
HES item:
National Codes:
Default Codes:	99 Not known

This is PATIENT DIAGNOSIS with a PATIENT DIAGNOSIS CODING SIGNIFICANCE of not 'Primary'.

This is primarily to record whether the patient has Pancreatitis CANCER CARE SPELL.

See DIAGNOSTIC CODING for details on coding.

This data element is also known by these names:

Context	Alias
plural	CO-MORBIDITIES (ICD)

CONTACT DATE (DIETITIAN INITIAL)

CONTACT DATE (DIETITIAN INITIAL)

Format/length:	ccyymmdd
HES item:
National Codes:
Default Codes:

This is the CONTACT DATE of the INITIAL CONTACT with a PROFESSIONAL STAFF GROUP TYPE c. 'Dietetics'.

This data element is also known by these names:

Context	Alias
plural	CONTACT DATES (DIETITIAN INITIAL)

COPD PRESENT

COPD PRESENT

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	COPD PRESENT

DIAGNOSTIC CODING

Format/length:	annnaa for ICD-10 (see ICD 10th Revision), an7 for Clinical Terms (The Read Codes)
HES item:	DIAGNSIS
National Codes:
Default Codes:

Notes:

This is a DIAGNOSIS.

See Clinical Coding for International Classification of Diseases (ICD-10) and Read Coded Clinical Terms.

See Clinical Coding.

The recording system will require you to classify diagnoses where possible using ICD-10 or other classification codes approved centrally for mapping to ICD-10 codes. Clinical Terms (The Read Codes) can be used in addition to ICD-10 codes for Patient Diagnosis. However Clinical Terms (The Read Codes) are not accepted for the purposes of central HES data, where ICD-10 is mandatory.

ICD-10 diagnostic codes are at least four characters in length. The first character is always alphabetic. Where an undivided three character code is used, the fourth character must be filled with 'X'.

Fifth characters should be used in accordance with the guidance in Introduction. Where they are not used the character must be filled with a '-'. The sixth character of the code is used to designate an asterisk or dagger indicator in ICD-10; it may be an 'A' or 'D'.

This data element is also known by these names:

Context	Alias
plural	DIAGNOSTIC CODINGS

DIAGNOSTIC ROUTE

DIAGNOSTIC ROUTE

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	DIAGNOSTIC ROUTES

DRUG ROUTE OF ADMINISTRATION

DRUG ROUTE OF ADMINISTRATION

Format/length:	n2
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	DRUG ROUTES OF ADMINISTRATION

ENDOCRINE THERAPY TYPE

ENDOCRINE THERAPY TYPE

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	ENDOCRINE THERAPY TYPES

ESTIMATED PACK YEARS

ESTIMATED PACK YEARS

Format/length:	n3
HES item:
National Codes:
Default Codes:

ESTIMATED PACK YEARS is the estimated number of pack years of smoking. This is the average number of cigarettes smoked per day divided by 20 (a pack) multiplied by the number of years smoked. This is calculated from the CIGARETTES PER DAY and NUMBER OF YEARS SMOKED.

For example: 20 cigarettes smoked per day for 20 years equals 20 pack years and 10 cigarettes per day for 20 years equals 10 pack years.

References:
National Cancer Data Set Version 1.3_ISB October 2002

This data element is also known by these names:

Context	Alias
plural	ESTIMATED PACK YEARS

FAMILY OR SURNAME OF RELATION WITH CANCER

FAMILY OR SURNAME OF RELATION WITH CANCER

Format/length:
HES item:
National Codes:
Default Codes:

This is the PERSON NAME WORD TYPE b. 'Family or Surname' of the PERSON who is a RELATION WITH CANCER to the PERSON with a CANCER CARE SPELL.

This data element is also known by these names:

Context	Alias
plural	FAMILY OR SURNAMES OF RELATION WITH CANCER

FEV1 ABSOLUTE AMOUNT

FEV1 ABSOLUTE AMOUNT

Format/length:	n.nn
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	FEV1 ABSOLUTE AMOUNTS

FEV1 PERCENTAGE

FEV1 PERCENTAGE

Format/length:	nn.nn
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	FEV1 PERCENTAGES

GRADE OF RESPONSIBLE HCP

GRADE OF RESPONSIBLE HCP

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	GRADES OF RESPONSIBLE HCP

GYNAECOLOGICAL ONCOLOGY ACCREDITATION

GYNAECOLOGICAL ONCOLOGY ACCREDITATION

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	GYNAECOLOGICAL ONCOLOGY ACCREDITATIONS

LMP DATE

LMP DATE

Format/length:	ccyymmdd
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	LMP DATES

MARKER LYMPH NODE RESULT

MARKER LYMPH NODE RESULT

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	8 - Not applicable
	9 - Not known

This data element is also known by these names:

Context	Alias
plural	MARKER LYMPH NODE RESULTS

MENSTRUAL STATUS

MENSTRUAL STATUS

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	MENSTRUAL STATUSES

NUTRITIONAL PROCEDURE (OPCS)

NUTRITIONAL PROCEDURE (OPCS)

Format/length:	an4
HES item:
National Codes:
Default Codes:

This is the code for the PATIENT PROCEDURE that has been performed on the PATIENT to enable nutritional support as part of the HEAD AND NECK CANCER CARE SPELL.

See PROCEDURE CODING for details on coding.

This data element is also known by these names:

Context	Alias
plural	NUTRITIONAL PROCEDURES (OPCS)

NUTRITIONAL PROCEDURE COMPLICATION (ICD)

NUTRITIONAL PROCEDURE COMPLICATION (ICD)

Format/length:	an6
HES item:
National Codes:
Default Codes:

This is the CLINICAL DIAGNOSIS FOR PERSON to describe a complication arising from a NUTRITIONAL PROCEDURE (OPCS).

See DIAGNOSTIC CODING for details on coding.

This data element is also known by these names:

Context	Alias
plural	NUTRITIONAL PROCEDURES COMPLICATION (ICD)

NUTRITIONAL SUPPORT PROVIDED (CANCER)

NUTRITIONAL SUPPORT PROVIDED (CANCER)

Format/length:	an1
HES item:
National Codes:
Default Codes:

This is derived from the presence of NUTRITIONAL SUPPORT PROVIDED TYPE.

National codes:

N	No
Y	Yes

References:
National Cancer Data Set Version 1.3_ISB October 2002

This data element is also known by these names:

Context	Alias
plural	NUTRITIONAL SUPPORT PROVIDED (CANCER)

NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER)

NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER)

Format/length:	an1
HES item:
National Codes:
Default Codes:	9 - Not known

NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER) is the same as attribute NUTRITIONAL SUPPORT PROVIDED TYPE.

This data element is also known by these names:

Context	Alias
plural	NUTRITIONAL SUPPORT PROVIDED TYPES (CANCER)

PATIENT HISTORY (CANCER DIAGNOSIS)

PATIENT HISTORY (CANCER DIAGNOSIS)

Format/length:	an6
HES item:
National Codes:
Default Codes:

PATIENT HISTORY (CANCER DIAGNOSIS) is the primary cancer of a previous or subsequent CANCER CARE SPELL. It is the PATIENT DIAGNOSIS that defines the CANCER CARE SPELLS

It is similar to data item note PRIMARY DIAGNOSIS (ICD).

This data element is also known by these names:

Context	Alias
plural	PATIENT HISTORIES (CANCER DIAGNOSIS)

PATIENT PROCEDURE RESULT (COLONOSCOPY)

PATIENT PROCEDURE RESULT (COLONOSCOPY)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Not known

PATIENT PROCEDURE RESULT (COLONOSCOPY) is the same as attribute PATIENT PROCEDURE RESULT.

This data element is also known by these names:

Context	Alias
plural	PATIENT PROCEDURE RESULTS (COLONOSCOPY)

PERSON OBSERVATION HISTORY (ASTHMA OR COPD)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

Any form of obstructive airways disease.

The derived values are:

0	- No
1	- Yes

CCAD item name:
Asthma or COPD

This data element is also known by these names:

Context	Alias
plural	PERSONS OBSERVATION HISTORY (ASTHMA OR COPD)
plural	PERSON OBSERVATION HISTORIES (ASTHMA OR COPD)

PERSON OBSERVATION HISTORY (CEREBROVASCULAR DISEASE)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

A history of symptoms of cerebrovascular ischaemia. To include transient cerebral ischaemic episodes and events with deficit lasting >24 hrs.

The derived values are:

0	- No
1	- Yes

CCAD item name:
Cerebrovascular disease

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (CEREBROVASCULAR DISEASE)
plural	PERSON OBSERVATION HISTORIES (CEREBROVASCULAR DISEASE)

PERSON OBSERVATION HISTORY (DIABETES TYPE)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION and DRUG TREATMENT history. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION and DRUG TREATMENT history.

Identifies the type of management, if any, for diabetes.

The derived values are:

0	- Not Diabetic
1	- Diabetes (dietary control)
2	- Diabetes (oral medicine)
3	- Diabetes (insulin)
4	- Newly diagnosed diabetes

CCAD item name:
Diabetes

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (DIABETES TYPE)
plural	PERSON OBSERVATION HISTORIES (DIABETES TYPE)

PERSON OBSERVATION HISTORY (HEART FAILURE)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

A previously validated diagnosis of heart failure on any therapeutic regime.

The derived values ares:

0	- No
1	- Yes

CCAD item name:
Heart failure

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (HEART FAILURE)
plural	PERSON OBSERVATION HISTORIES (HEART FAILURE)

PERSON OBSERVATION HISTORY (PERIPHERAL VASCULAR DISEASE)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

Indicates if the patient has a history of peripheral vascular disease.

The presence of peripheral vascular disease, either presently symptomatic or previously treated by intervention or surgery. Include known renovascular disease and aortic aneurysm.

The derived values ares:

0	- No
1	- Yes

CCAD item name:
Peripheral vascular disease

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (PERIPHERAL VASCULAR DISEASE)
plural	PERSON OBSERVATION HISTORIES (PERIPHERAL VASCULAR DISEASE)

PERSON OBSERVATION HISTORY (PREVIOUS AMI)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

Any previously validated episode of acute myocardial infarction.

The derived values ares:

0	- No
1	- Yes

CCAD item name:
Previous AMI

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (PREVIOUS AMI)
plural	PERSON OBSERVATION HISTORIES (PREVIOUS AMI)

PERSON OBSERVATION HISTORY (PREVIOUS ANGINA)

Format/length:	n1
HES item:
National Codes:
Default Codes:	9 - Unknown

Notes:
Derive from DIAGNOSIS in the CLINICAL CLASSIFICATION FOR PERSON sub type of PERSON OBSERVATION. Derive from DIAGNOSIS in the CLINICAL DIAGNOSIS FOR PERSON sub type of PERSON OBSERVATION.

Symptoms thought to be indicative of ischaemic cardiac pain either at rest or on exertion existing at least two weeks prior to this admission.

The derived values ares:

0	- No
1	- Yes

CCAD item name:
Previous Angina

This data element is also known by these names:

Context	Alias
plural	PERSON OBSERVATION HISTORY (PREVIOUS ANGINA)
plural	PERSON OBSERVATION HISTORIES (PREVIOUS ANGINA)

POSSUM SCORE (AFTER SURGERY)

POSSUM SCORE (AFTER SURGERY)

Format/length:	n3
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	POSSUM SCORES (AFTER SURGERY)

POSSUM SCORE (AT DIAGNOSIS)

POSSUM SCORE (AT DIAGNOSIS)

Format/length:	n3
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	POSSUM SCORES (AT DIAGNOSIS)

PREVIOUS TREATMENT ELSEWHERE

PREVIOUS TREATMENT ELSEWHERE

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	PREVIOUS TREATMENTS ELSEWHERE

PRIMARY DIAGNOSIS OF RELATION (ICD)

PRIMARY DIAGNOSIS OF RELATION (ICD)

Format/length:	an6
HES item:
National Codes:
Default Codes:

This is the PRIMARY DIAGNOSIS (ICD) related to the CANCER CARE SPELL of the second PERSON in the PERSON RELATIONSHIP who is a RELATION WITH CANCER.

This data element is also known by these names:

Context	Alias
plural	PRIMARY DIAGNOSIS OF RELATION (ICD)

PROCEDURE CODING

Format/length:	annn for OPCS-4, an7 for Clinical Terms (The Read Codes)
HES item:	OPERATN
National Codes:
Default Codes:	X998 - Out-patient procedure carried out but no appropriate OPCS-4 code available
	X999 - No out-patient procedure carried out

Notes:

This is a CLINICAL CLASSIFICATION CODE.

See Clinical Coding for Classification of Surgical Operations and Procedures (OPCS - 4) and Read Coded Clinical Terms.

See the 'Classification of Surgical Operations and Procedures (OPCS-4)' and 'Read Coded Clinical Terms' sections within the Clinical Coding page.

Record any operative procedures carried out, such as an endoscopy or electro-convulsive therapy (ECT), as part of the current consultant episode.

Clinical Terms (The Read Codes) (an7) may be used as an optional addition to OPCS-4.

The recording of procedures using OPCS-4 is now optional for the Out-Patient/Ward Attenders CDS. If required, a default procedure code may be used in the first procedure field and subsequent procedure fields space-filled.

The default codes are classified as entries in the Classification of Surgical Operations and Procedures Fourth Revision Consolidated Version (OPCS-4).

This data element is also known by these names:

Context	Alias
plural	PROCEDURE CODINGS

QUALITY OF LIFE (AT DIAGNOSIS)

QUALITY OF LIFE (AT DIAGNOSIS)

Format/length:	n4
HES item:
National Codes:
Default Codes:

QUALITY OF LIFE (AT DIAGNOSIS) is the same as attribute QUALITY OF LIFE.

This data element is also known by these names:

Context	Alias
plural	QUALITY OF LIFE (AT DIAGNOSIS)

RELATIONSHIP TO PERSON

RELATIONSHIP TO PERSON

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	RELATIONSHIPS TO PERSON

S CATEGORY FINAL PRETREATMENT

S CATEGORY FINAL PRETREATMENT

Format/length:	an2
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	S CATEGORIES FINAL PRETREATMENT

SERUM TUMOUR MARKER PSA

SERUM TUMOUR MARKER PSA

Format/length:	nnnn.n
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	SERUM TUMOUR MARKERS PSA

SMOKING STATUS

SMOKING STATUS

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	SMOKING STATUSES

SURGICAL URGENCY

SURGICAL URGENCY

Format/length:	n2
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	99 - Urgency not known

The SURGICAL URGENCY for each of the recorded operative PATIENT PROCEDURE (OPCS). An operative PATIENT PROCEDURE is identified by the OPERATIVE PATIENT PROCEDURE INDICATOR Y 'yes'.

This data element is also known by these names:

Context	Alias
plural	SURGICAL URGENCIES

SYMPTOMS FIRST NOTED DATE

SYMPTOMS FIRST NOTED DATE

Format/length:	ccyymm
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	SYMPTOMS FIRST NOTED DATES

THEATRE CASE START TIME

THEATRE CASE START TIME

Format/length:	hh:mm
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	THEATRE CASES START TIMES

TOBACCO CHEWING HISTORY

TOBACCO CHEWING HISTORY

Format/length:	n1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:	9 - Not known

This data element is also known by these names:

Context	Alias
plural	TOBACCO CHEWING HISTORIES

TOBACCO USAGE TYPE

TOBACCO USAGE TYPE

Format/length:	an1
HES item:
National Codes:	Press Definition button for the National Codes
Default Codes:

This data element is also known by these names:

Context	Alias
plural	TOBACCO USAGE TYPE

YEAR CANCER DIAGNOSED

YEAR CANCER DIAGNOSED

Format/length:	ccyy
HES item:
National Codes:
Default Codes:

YEAR CANCER DIAGNOSED is derived from DIAGNOSIS DATE (CANCER) for the primary cancer of a previous or subsequent CANCER CARE SPELL.

This data element is also known by these names:

Context	Alias
plural	YEAR CANCER DIAGNOSED