| Change Request |
| Reference: | Change Request 295 |
| Version No: | 1.1 |
| Subject: | DSCN 59/2002 - Accident & Emergency Diagnosis code format |
| Type of Change: | Change to NHS Data Standards |
| Effective Date: | 1 January 2003 |
| Reason for Change: | Amendment of data standards relating to Accident and Emergency Anatomical Side. |
ACCIDENT AND EMERGENCY DIAGNOSIS was previously described in the NHS Data Dictionary Version.2 as a six character code, comprising:
| Diagnosis Condition | n2 |
| Sub-Analysis | n1 |
| ACCIDENT AND EMERGENCY ANATOMICAL AREA | n2 |
| ACCIDENT AND EMERGENCY ANATOMICAL SIDE | n2 |
The specific code for ACCIDENT AND EMERGENCY ANATOMICAL SIDE had the format n2, due to a transcribing error when the transition was made from the PDF version of the NHS Data Dictionary and Data Manual, to the web-based HTML version of the NHS Data Dictionary & Manual. This required a correction back to a 1 character code, in addition to changing the format from 'n' to 'an', which is a more accurate description of the permitted values. This DSCN introduces that change into the NHS Data Dictionary Version.2.
Summary of changes:| Supporting Information | |
| CLINICAL CODING | Change to supporting information |
| Name: | Michelle Cambridge |
| Date: | 27 January 2003 |
| Sponsor: | Data Standards Team |
| Accident and Emergency Clinical Coding Structure |
A broad classification of types of diagnoses which may be made as a result of ACCIDENT AND EMERGENCY ATTENDANCES. The full description is made up of codes from three tables - ACCIDENT AND EMERGENCY DIAGNOSIS, ACCIDENT AND EMERGENCY ANATOMICAL AREAS and ACCIDENT AND EMERGENCY ANATOMICAL SIDE. Anatomical Area (a classification of parts of the human body) and Anatomical Side (an indication of the side of the human body) together give the Anatomical Site of clinical problems presented at Accident And Emergency Attendances.
Certain items are sub-analysed to specify the diagnosis, investigation or treatment more precisely. These are marked with an asterisk. The diagnosis sub-analysis list follows the main diagnosis list, and the treatment sub-analysis list follows the main treatment list.
| Diagnosis Condition | n2 |
| Sub-Analysis | n1 |
| ACCIDENT AND EMERGENCY ANATOMICAL AREA | n2 |
| an1 |
Accident and Emergency Diagnosis - Diagnosis Condition
| Diagnosis Condition | Code |
|---|---|
| Laceration | 01 |
| Contusion/abrasion* | 02 |
| Soft tissue inflammation | 03 |
| Head injury* | 04 |
| Dislocation/fracture/joint injury/amputation* | 05 |
| Sprain/ligament injury | 06 |
| Muscle/tendon injury | 07 |
| Nerve injury | 08 |
| Vascular injury | 09 |
| Burns and scalds* | 10 |
| Electric shock | 11 |
| Foreign body | 12 |
| Bites/stings | 13 |
| Poisoning* (including overdose) | 14 |
| Near drowning | 15 |
| Visceral injury | 16 |
| Infectious disease* | 17 |
| Local infection | 18 |
| Septicaemia | 19 |
| Cardiac conditions* | 20 |
| Cerebro-vascular conditions | 21 |
| Other vascular conditions | 22 |
| Haematological conditions | 23 |
| Central Nervous System conditions* (excluding strokes) | 24 |
| Respiratory conditions* | 25 |
| Gastrointestinal conditions* | 26 |
| Urological conditions (including cystitis) | 27 |
| Obstetric conditions | 28 |
| Gynaecological conditions | 29 |
| Diabetes and other endocrinological conditions* | 30 |
| Dermatological conditions | 31 |
| Allergy (including anaphylaxis) | 32 |
| Facio-maxillary conditions | 33 |
| ENT conditions | 34 |
| Psychiatric conditions | 35 |
| Ophthalmological conditions | 36 |
| Social problem (includes chronic alcoholism and homelessness) | 37 |
| Diagnosis not classifiable | 38 |
| Nothing abnormal detected | 39 |
Item sub-analysed
Accident and Emergency Diagnosis - Sub-analysis
| Sub-analysis | Code | |
|---|---|---|
| Contusion/abrasion | - contusion - abrasion | 1 2 |
| Head Injury | - concussion - other head injury | 1 2 |
| Dislocation/fracture/joint injury/amputation | - dislocation - open fracture - closed fracture - joint injury - amputation | 1 2 3 4 5 |
| Burns and scalds | - electric - thermal - chemical - radiation | 1 2 3 4 |
| Poisoning | - prescriptive drugs - proprietary drugs - controlled drugs - other, including alcohol | 1 2 3 4 |
| Infectious disease | - notifiable disease - non-notifiable disease | 1 2 |
| Cardiac conditions | - myocardial ischaemia & infarction - other non-ischaemia | 1 2 |
| Respiratory conditions | - bronchial asthma - other non-asthma | 1 2 |
| Central Nervous System conditions | - epilepsy - other non-epilepsy | 1 2 |
| Gastrointestinal conditions | - haemorrhage - acute abdominal pain - other | 1 2 3 |
| Diabetes and other endocrinological conditions | - diabetic - other non-diabetic | 1 2 |
Anatomical Site
Accident And Emergency Anatomical Area - Area
| Anatomical Area | Code |
|---|---|
| Head and Neck | |
| Brain | 01 |
| Head | 02 |
| Face | 03 |
| Eye | 04 |
| Ear | 05 |
| Nose | 06 |
| Mouth, Jaw, Teeth | 07 |
| Throat | 08 |
| Neck | 09 |
| Upper Limb | |
| Shoulder | 10 |
| Axilla | 11 |
| Upper Arm | 12 |
| Elbow | 13 |
| Forearm | 14 |
| Wrist | 15 |
| Hand | 16 |
| Digit | 17 |
| Trunk | |
| Cervical spine | 18 |
| Thoracic | 19 |
| Lumbosacral spine | 20 |
| Pelvis | 21 |
| Chest | 22 |
| Breast | 23 |
| Abdomen | 24 |
| Back/buttocks | 25 |
| Ano/rectal | 26 |
| Genitalia | 27 |
| Lower Limb | |
| Hip | 28 |
| Groin | 29 |
| Thigh | 30 |
| Knee | 31 |
| Lower leg | 32 |
| Ankle | 33 |
| Foot | 34 |
| Toe | 35 |
| Multiple Site | 36 |
| Accident and Emergency Anatomical Side | |
| Left | L |
| Right | R |
| Bilateral | B |
| Not applicable | 8 |
Please address enquiries about this DSCN to:-
Data Standards Team
NHS Information Authority
Aqueous II
Aston Cross
Rocky Lane
Birmingham
B6 5RQ
Tel: 0121 333 0333