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AE2A&E data recordingreference manualNovember 2020Version 2.2IMPORTANT NOTEIMPORTANT NOTEThroughout this manual, where reference is made to A&E, this includes all emergency care in or provided by:an A&E Department,an Emergency Department,a Minor Injuries Unit,the trolleyed area of an Assessment Unit (which may be further described as Medical, Surgical, Combined, or Paediatric),the trolleyed area of an Acute Medical UnitPlanned attendance (see Attendance Category for definition of ‘planned’)virtual A&E clinic.Patients admitted to staffed beds in an Assessment or Acute Medical Unit should be recorded instead on the Scottish Morbidity Record SMR01 inpatient record. Where reference is made to a ‘record of attendance’ at A&E, this should be understood to mean the data, recording a single attendance at A&E by an individual patient, which is extracted from the local system and submitted to ISD. Each time a person presents to the A&E department a single attendance is recorded.ContentsContentsContentsChanges from version 2.0General recording guidance 1General recording guidance 2General recording guidance 3General recording guidance 4Alphabetical list of Mandatory items directoryAlphabetical list optional items directoryAppendices directoryArrival date and timeArrival ModeAttendance CategoryCase Reference NumberCHIDate and time Decision to Discharge/Admit or TransferDate and time of Discharge/Admission or TransferDate and time first DiagnosticsDate and time Treatment StartDate and time TriageDiagnoses – notes on recordingDiagnosis 1, Diagnosis 2, Diagnosis 3Diagnosis 1 text, diagnosis 2 text, Diagnosis 3 textDischarge DestinationDisease 1, Disease 2, Disease 3ECDS DiagnosisEthnicityLocation CodePatient FlowPatient PostcodeReason for WaitReferral SourceWait to Bed RequestWait to Bed AvailableWait to CubicleOptional ItemsActivity when InjuredAlcohol InvolvedBodily Location of InjuryCommon Preventative MeasuresDate and time Completion of TreatmentDate and time of EventDate and time First Full Clinical AssessmentDischarge TypeExternal Cause of InjuryHCP responsible for CareImpairmentIntent of InjuryInvestigation Type 1, Investigation Type 2, Investigation Type 3Nature of InjuryObjects/Substances Involved in Producing InjuryPatient Management TypePatient Year of BirthPlace of IncidentPresenting ComplaintProcedure 1, Procedure 2, Procedure 3Referred to 1, Referred to 2, Referred to 3ReligionSexual OrientationSignificant FacilityTime since InjuryTriage CategoryChanges from V2.0data of changesMetadata of changesChanges in this version (Version 2.2 Nov 2020)All Changes are to take into account the changes in service delivery as a result of Scottish Governments Redesign of Unscheduled Care Programme – Nov 2020. This redesign introduced planned attendances at A&E departments.Important Notes: remove text ‘attendance at’ and ‘attendances for’. Add text ‘or provided by’. Add bullets:Planned attendance (see Attendance Category for description of ‘planned’)Virtual A&E clinicAdd text ‘Each time a person presents to the A&E department a single attendance is recorded’General Recording Guidance 2, Arrival Date & Time: add text ‘For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).Date & Time of discharge or Transfer: add text ‘For virtual consultations and care this the date and time the virtual connection ends (this applies to emergency/urgent and planned virtual contacts).’General Recording Guidance 3, Clock start – Arrival Date and Time: add text ‘For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).’ And add text ‘Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours. For Flow Navigation Centre data, the start and end time of the call will be captured. In the A&E dataset the start time of a call will be recorded in Arrival Date and Time and the end time of the call will be recorded in Date and Time of Discharge, Admission or Transfer from A&E Department.’Clock stop – Date and Time of Discharge, Admission or Transfer from A&E Department: add text ‘e) For virtual (telephone or video) consultations and care this is the date and time the virtual connection ends.’Arrival Date and Time, Definition and Recording Notes: add text ‘For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).’ And add text ‘Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours.’Arrival Mode: add code, value and description:09Virtual (telephone or video)Consultation and care is provided in a virtual environment e.g. telephone, Near Me.Arrival Mode, Definition: remove text ‘arrived at’ and replace with ‘came into the care of’Arrival Mode, Recording Notes: add text ‘Code 09 Virtual (telephone or video) should be used where consultation and care is provided in a virtual environment (this applies to urgent/emergency care and planned virtual contacts). The redesign of urgent care and the scheduling of consultations is a new initiative so although ‘face to face’ is not stated it is the assumed mode of contact unless this code is used’Attendance Category: Update current value and definition and add additional codes and values:01New – unplannedThe first unplanned attendance in a series, or the only attendance, in a particular A&E episode.05New – plannedThe first planned attendance in a series, or the only attendance, in a particular A&E episode.Attendance Category, Definition: remove text ‘attendance at’ and replace with ‘contact with’Attendance Category, Recording Notes:codes and values '01 New' and '03 Return - unplanned' are included in the Scottish Governments 4-hour Waiting Times Standard, whilst '02 Return - planned' and ’05 New – planned’ are not. Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored /published to ensure patients who are planned are not disadvantaged and wait longer than 4 hours,The redesign of urgent care and the scheduling of consultations and care is a new initiative (November 2020) so although code ’01 New - unplanned’ did not state ‘unplanned’ until the option for code ’05 New – planned’ became available (Nov 2020), unplanned would have been the default, There has been a new code added to Arrival Mode to capture where consultation and care is provided in a virtual environment - Code 09 Virtual (telephone or video). The redesign of urgent care and the scheduling of consultations is a new initiative so although ‘face to face’ is not stated it is the assumed mode of contact unless this code is used,Date and Time Decision to Discharge/Admit or Transfer, Definition: Remove text ‘at an A&E Department’Date and Time First Diagnostics, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),’Date and Time of Treatment Start, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),’Date and Time of Triage, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),Diagnoses – notes on recording: add text ‘or virtual consultation and care’ and remove text ‘from A&E’ and ‘A&E’Diagnosis 1 Text, Diagnosis 2 Text, Diagnosis 3 Text, Definition: remove text ‘from A&E’Discharge Destination, Definition: remove text ‘from the A&E department’Disease 1, Disease 2, Disease 3, Definition: remove text ‘from A&E’ECDS Diagnosis (Emergency Care Data Set) Cont’d, Definition: remove text ‘from A&E’ General Recording Guidance 5: New section added – see section for textLocation Code: replace ‘ISD’ with ‘PHS’Patient Flow: Flow 1 description add text ‘Includes where consultation and care is provided in a virtual environment.’Patient Flow, Definition: add text ‘urgent care pathway (including’ and ‘and virtual clinics where consultation and care is given by telephone and video’Reason for A&E Wait > 4 hours: 00 no delay description add text ‘Record this for virtual consultations and care unless there has been a technology issue (see code 09) or a DNA (see code 10).’Reason for A&E Wait > 4 hours: additional codes and values:09Telephone and video reason(s)Issues with telephone and video technology which prevents clinical decision maker and citizen/patient connecting with each other.10DNA Where a citizen/patient is not waiting for the planned video call or a planned telephone call is not answered. Or where a person does not attend for their planned face to face attendance. Reason for A&E Wait > 4 hours, Recording Notes: add bullets:Code 09 should be used for virtual appointments only, and where a technical issue, either with the NHS equipment or with the patient’s equipment stops the contact from taking placeCode 10 - should be used for planned contacts whether virtual or face to face and a patient Does Not Attend/join a call for their scheduled contact,Referral Source: additional codes and values: 02KFlow Navigation CentreReferral to A&E from a Flow Navigation Centre. A Flow Navigation Centre is where a clinical decision maker provides virtual urgent consultation and care, by telephone or video, before or as an alternative to onward referral.02LVirtual ClinicWhere a clinic which operates in a virtual capacity refers a patient to A&E for face to face consultation and care.Referral Source, Recording Notes: add text ‘This will change following the redesign of urgent care and the shift to scheduling consultations and care where appropriate’Wait to Cubical, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),’Wait to Bed Request, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),’Wait to Bed Available, Recording Notes: add text ‘not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),’Significant Facility: additional code and value41Flow Navigation CentreA Flow Navigation Centre is where a clinical decision maker provides virtual urgent consultation and care, by telephone or video, before or as an alternative to onward referral.Previous Changes (Version 2.0)The changes that have been applied to the updated A&E data recording manual version 2.0 are:Addition of page linked contents Change to layout – mandatory items grouped togetherAddition of the new items:Date and time of TriageDate and time First DiagnosticsDate and time Decision to Discharge/Admit or TransferDate and time Treatment StartWait to CubicleWait to Bed RequestWait to Bed AvailableECDS Diagnosis CategoryAddition of further guidance re clock stop and startAddition of new appendices – validation rules and A&E file layoutAddition of Significant FacilityPrevious changes (2012):Discharge Destination: Code 05 – Text change to Transfer to same/other hospitalAddition of code 05G – A&E - the patient has been transferred from an MIU in the same/other hospitalAddition of code 05H – Referred to NHS24 - the patient has been referred to NHS 24 following attendance at an MIU/EDEthnicity notes page: Removal of mention of the new values notes as these are in use Patient Flow – text change to – Flow 2 (Acute assessment – includes major injuries) The validation for ethnicity within the datamart has been switched back on. Back to contentsGeneral Recording Guidance 1 1/5 Recording GuidanceAdmission, discharge, referral and transferThis section attempts to clarify the recording of what happens to the patient after leaving A&E. It deals with the recording of admission, discharge, transfer and referral.The term ‘discharge’ is used in two senses. In the first, broader sense all patients who leave A&E are discharged from A&E. This sense is used in the titles of the data items Discharge Destination and Discharge Type. However, in the second, more specific sense used in this manual, discharge means either that there is no need for immediately continuing care, the patient being ‘sent home’, or that the patient leaves A&E before investigation/treatment is complete.Details of admission, transfer and discharge should be recorded in Discharge Destination (mandatory) and Discharge Type (optional).Admission – the patient is formally admitted as an inpatient to the same hospital. The admission may be to a ward or it may be to the staffed bed area of an assessment or emergency admission unit.Transfer – the patient is transferred to a ward in another hospital, to A&E in another hospital, or to another emergency department in the same hospital.Discharge – if there is no need for immediately continuing care the patient is discharged. If the patient leaves A&E before investigation or treatment are complete - i.e. as a ‘self-discharge’ - this can be recorded in Discharge Type as ‘incomplete’.As well as being admitted, transferred or discharged, a patient may be referred for subsequent investigation or treatment.Referral - Discharged patients may be referred by A&E staff for a subsequent appointment for care in a hospital clinic, in another healthcare facility elsewhere or in A&E itself (a planned return attendance). The type of healthcare provider to which the patient is being referred should be recorded in the data item Referred to.Note that Referred to should NOT be used to record the ward of admission, the healthcare provider to which the patient is being transferred or the discharge destination. Back to ContentsGeneral Recording Guidance 2 2/5Arrival Date & TimeThis is the date and time the patient arrives at A&E reception or is received into the A&E department, for example from an ambulance.Patients arriving by ambulance will be deemed to arrive at the time when the ambulance arrives at the A&E facility and not the (later) time when the patient is then brought in to the reception.For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).Date & Time of discharge or TransferThe National data definition states that the date and time of discharge or transfer is when the patient leaves the A&E department after an A&E attendance has concluded and/or the department is no longer responsible for the care of the patient. This is different to the date and time of completion of treatment (see the Alphabetical list of AE2 data items below).Hence for the purposes of the standard the clock continues to run until one of the following conditions has been satisfied:The patient is discharged and the A&E staff no longer has any direct responsibility for the care of the patient:the clock stops when the patient is actually uplifted. The clock is not stopped for patients who are required to wait in the A&E department for transport and who may require continuing clinical support,if a patient dies then the discharge time is the time of death,for those patients who discharge themselves the date and time of discharge is recorded as the time when the patient departed (or when staff have become aware that the patient has departed). In such circumstances if a patient subsequently returns to the department then the clock is reset and the 4-hour time period starts again – such patients are not to be counted as planned return patients.For virtual consultations and care this the date and time the virtual connection ends (this applies to emergency/urgent and planned virtual contacts).The patient has been formally admitted as an inpatient on the hospital’s PAS/HIS system to either an ordinary ward or to a staffed bed in an assessment or emergency admission unit. Patients who are simply moved to other trolleyed areas within a hospital, for example day surgery units are not regarded as admitted and are not considered to have been discharged from A&E and the clock continues to run.Patients admitted to staffed beds in Assessment or Acute Medical Units are regarded as admitted and should be recorded instead on the Scottish Morbidity Record SMR01 Inpatient Record.The patient is to be transferred directly to another hospital or other healthcare provider. The clock stops when the patient’s transfer actually starts; waiting for ambulance staff does not cause the clock to stop.Back to ContentsGeneral Recording Guidance 3 3/5Clock start – Arrival Date and Time:This is the date and time the patient arrives at A&E reception or is received into the A&E department.a) The time the patient presents at the reception desk and details are loggedb) The time the patient arrives in the department if brought in by ambulanceFor virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts). Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours. For Flow Navigation Centre data, the start and end time of the call will be captured. In the A&E dataset the start time of a call will be recorded in Arrival Date and Time and the end time of the call will be recorded in Date and Time of Discharge, Admission or Transfer from A&E Department.’Clock stop – Date and Time of Discharge, Admission or Transfer from A&E Department:The date and time of discharge or transfer is when the patients A&E attendance has concluded and/or the department is no longer responsible for the care of the patient.For the purposes of the 4-hour Emergency Access Standard (EAS), the clock continues to run until one of the following conditions has been satisfied:1. The patient is discharged and the A&E department no longer have any direct responsibility for the care of the patient;a) The clock stops when the patient is actually uplifted for admission or transfer.b) If a patient dies, the discharge time is the time of death as declared by the clinician.c) If the patient leaves the department against medical advice, the time they leave is the discharge time or the time the staff realize the patient has left. In such circumstances if a patient subsequently returns to the department then the clock is reset and the 4 hour EAS starts again – such patients are not to be counted as planned return patients.d) The clock stops when the patient is told they can leave the department:A patient may wait in a cubicle for transport but receiving no continuing care from the A&E department e.g. care home staff may be keeping a watchful eye on the patient. The clock stops when the A&E department discharges the patient.Patients who have been discharged from the A&E department and are waiting for transport in the waiting area are not on the clock.e) For virtual (telephone or video) consultations and care this is the date and time the virtual connection ends.2. The patient has been formally admitted as an inpatient, to an assessment unit, as an emergency admission unit or to a downstream specialty ward;a) The clock stops when the patient leaves the A&E department.b) Patients who are simply moved to other areas within a hospital for capacity reasons, but are not admitted, are not considered to have been discharged from A&E.c) The clock does not stop for patients in or are moved to a trolleyed area in an Acute Assessment Unit until they are admitted, transferred or discharged.3. The patient is discharged to another hospital.a) The clock stops when the patients transfer actually starts.b) If a patient is waiting for Scottish ambulance service to move them to another location the clock stops when they leave the department. Back to ContentsGeneral Recording Guidance 4 4/5Patients who need more than 4 hour’s observation/assessment:It is expected that for some patients a period of assessment and/or observation of greater than 4 hours is needed before a decision to admit or discharge will be clinically appropriate. This group of patients may include patients who suddenly deteriorate and patients recovering following reduction of fractures/dislocations.The number of true clinical exceptions to the 4 hour EAS is very small. The operational standard has been set at 98% to allow 2% for these cases.Every effort should be made to accommodate these patients, for their safety comfort, away from the main A&E department, for example in a dedicated observation or assessment ward. If the patient is formally admitted to this ward (and the ward provides appropriate facilities) then the clock stops. Otherwise the time spent by these patients is to be counted until one of the four conditions above has been met. Note that simply moving a patient to a ward which is integral to A&E will not stop the clock unless the patient is formally admitted as an inpatient and the ward has appropriate facilities.Back to ContentsGeneral Recording Guidance 5 5/5The Redesign of Urgent Care:The Scottish Governments Redesign of Urgent Care Programme (November 2020) promotes a significant change in how patients flow through the urgent care pathway to ensure patients have access first time to the right clinical care. The Programme carries a number of significant benefits such as making use of technology for virtual (telephone and video) consultation and care, and where clinically appropriate, the introduction of planned attendances at A&E departments to smooth the demand. The A&E dataset has required a significant update to take into account these changes in service delivery. The main changes have involved the following data items (please note that there are other changes): Arrival Date and Time: For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).Clock start – Arrival Date and Time: For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts). Clock stop – Date and Time of Discharge, Admission or Transfer from A&E Department: For virtual (telephone or video) consultations and care this is the date and time the virtual connection ends (this applies to emergency/urgent and planned virtual contacts).Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours. For Flow Navigation Centre data, the start and end time of the call will be captured. In the A&E dataset the start time of a call will be recorded in Arrival Date and Time and the end time of the call will be recorded in Date and Time of Discharge, Admission or Transfer from A&E Department. Arrival Mode: The new code ‘09 Virtual (telephone or video)’ should be used where consultation and care is provided in a virtual environment. The redesign of urgent care and the scheduling of consultations is a new initiative so although ‘face to face’ is not stated it is the assumed mode of contact in the A&E dataset unless this code to indicate ‘virtual’ is recorded.Attendance Category: One of the most significant changes is the differentiation of new unplanned and new planned attendances. The redesign of urgent care and the scheduling of consultations and care is a new initiative so although code ’01 New’ did not state ‘unplanned’ until the option for code ’05 New – planned’ became available in this update, unplanned was the assumed mode of attendance.Codes and values '01 New – unplanned' (‘unplanned’ added as part of this update) and '03 Return - unplanned' are already included in the Scottish Executive Waiting Times target, whilst '02 Return - planned' and the new code of ’05 New – planned’ are not. As stated above, planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours.Patient Flow: Patient Flow 1 has been updated to include where consultation and care is provided in a virtual environment.Reason for A&E Wait > 4 hours: Boards may wish to record technical connection issues (new code 09) or DNA (new code 10). Code 09 should be used for virtual appointments only, and where a technical issue, either with the NHS equipment or with the patients’ equipment stops the contact from taking place. Code 10 - should be used for planned contacts whether virtual or face to face and a patient Does Not Attend or does not join a call for their scheduled contact.Referral Source: There have been two new codes added to allow recording where a referral to A&E has come from a Flow Navigation Centre or from a virtual clinic.A Flow Navigation Centre is where a clinical decision maker provides virtual urgent consultation and care, by telephone or video, before or as an alternative to onward referral.A virtual clinic is where a clinic which operates in a virtual capacity refers a patient to A&E for face to face consultation and care.Significant Facility: For Boards who have indicated that the activity from Flow Navigation Centers will be recorded in the A&E dataset there is a code to identify ‘Flow Navigation Centre’. Recording Scenarios: There is more discussion required where virtual A&E clinics are recorded on TrakCare as outpatient clinics to facilitate creating appointments (but not submitted as SMR00 activity). Scenario 1:Patient telephones NHS 24 111 where they are referred on to a Flow Navigation Centre (FNC). Clinical decision maker in the FNC carries out virtual (telephone or video) triage and advises patient to contact their GP. In this scenario there would be no A&E attendance submitted. FNC activity would be captured on the FNC dataset and submitted to Public Health Scotland. Many NHS Boards are using ADASTRA in the FNC in which case activity would be captured centrally, however, some may record this on the A&E dataset. If the A&E dataset is being used, then Boards must record Significant Facility code 41 Flow Navigation Centre, otherwise this activity will be included in the 4hr performance figures and attributed as A&E activity and not FNC activity. Scenario 2Patient telephones NHS 24 111 where they are referred on to a FNC. Clinical decision maker in the FNC carries out virtual (telephone or video) triage and advises patient to go to A&E department urgently. As the A&E attendance has not been scheduled using a booking system this would be a new unplanned A&E attendance. Unplanned attendances, where the attendance has not been scheduled using a booking system, are included in the 4-hour Emergency Access Standard.FNC activity would be captured on the FNC dataset and submitted to Public Health Scotland. Many NHS Boards are using ADASTRA in the FNC in which case activity would be captured centrally, however, some may record this on the A&E dataset. If the A&E dataset is being used, then Boards must record Significant Facility code 41 Flow Navigation Centre otherwise this activity will be included in the 4hr performance figures and attributed as A&E activity and not FNC activity. Scenario 3Patient telephones NHS 24 111 where they are referred on to a FNC. Clinical decision maker in the FNC carries out virtual (telephone or video) triage and advises patient that they need to be seen at A&E department and books patient a scheduled appointment. As the A&E attendance has been scheduled using a booking system this would be a new planned A&E attendance. Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours.FNC activity would be captured on the FNC dataset and submitted to Public Health Scotland. Many NHS Boards are using ADASTRA in the FNC in which case activity would be captured centrally, however, some may record this on the A&E dataset. If the A&E dataset is being used, then Boards must record Significant Facility code 41 Flow Navigation Centre otherwise this activity will be included in the 4hr performance figures and attributed as A&E activity and not FNC activity. Scenario 4Patient telephones NHS 24 111 where they are referred on to a FNC. Clinical decision maker in the FNC carries out virtual (telephone or video) triage and advises patient that they need further triage by A&E department and books patient an appointment. An A&E clinical decision maker undertakes a planned virtual (telephone or video) consultation and care (if this is the first, or only contact, in the A&E episode this should be recorded as a new planned A&E attendance and ‘virtual’ would be recorded in Arrival Mode). If subsequently the patient needs to be seen as a face to face attendance for the same incident as the virtual (telephone or video) consultation this should be recorded as return planned (where the patient has been scheduled using a booking system). If the patient attends A&E for the same incident as the virtual (telephone or video) consultation but does not attend at the planned time this should be recorded as a return unplanned. If the patient is asked to attend for a face to face consultation but is not booked in this is also a return unplanned.New – unplanned and Return - unplanned are included in the Scottish Executive Waiting Times Standard, Return - planned and the new value for New – planned are not. Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours.FNC activity would be captured on the FNC dataset and submitted to Public Health Scotland. Many NHS Boards are using ADASTRA in the FNC in which case activity would be captured centrally, however, some may record this on the A&E dataset. If the A&E dataset is being used, then Boards must record Significant Facility code 41 Flow Navigation Centre otherwise this activity will be included in the 4hr performance figures and attributed as A&E activity and not FNC activity. Alphabetical List Mandatory Data ItemsAlphabetical List Mandatory Data ItemsThis manual supersedes the equivalent content in the Health and Social Care Data Dictionary and in the ‘AE2 Codes and Values’ spreadsheet.Arrival Date and TimeArrival ModeAttendance CategoryCase Reference NumberCHI NoDate and Time Decision to Discharge/Admit or Transfer Date and Time of Discharge, Admission or TransferDate and Time of First Diagnostics Date and Time of Treatment Start Date and Time of Triage Diagnoses – notes on recordingDiagnosis1, Diagnosis2, Diagnosis3Diagnosis1 Text, Diagnosis2 Text, Diagnosis3 TextDischarge DestinationDisease1, Disease2, Disease3ECDS Diagnosis Ethnicity Location CodePatient FlowPatient PostcodeReason for WaitReferral SourceWait to Bed RequestWait to Bed AvailableWait to CubicleBack to ContentsAlphabetical List Optional Data ItemsAlphabetical List Optional Data ItemsActivity when InjuredAlcohol InvolvedBodily Location of InjuryCommon Preventive MeasuresDate and Time of Completion of TreatmentDate and Time of EventDate and Time of First Full Clinical AssessmentDischarge Type External Cause of InjuryHCP Responsible for Care ImpairmentIntent of InjuryInvestigation Type1, Investigation Type2, Investigation Type3Nature of InjuryObjects/Substances Involved in Producing InjuryPatient Management TypePatient Year of Birth Place of Incident Presenting ComplaintProcedure1, Procedure2, Procedure3Referred to1, Referred to 2, Referred to3 ReligionSexual OrientationSignificant FacilityTime Since Injury Triage CategoryBack to ContentsAppendicesAppendix 1CMO’s letter on Alcohol Involvement Appendix 2CMO’s letter on Injury Data CollectionAppendix 3 File specificationAppendix 4Discharge and referral Nov 2015In this manual the data items are presented in alphabetical order, with each item starting on a new page. There are no page numbers.This will allow easy construction of double-sided printed manuals which contain only those data items relevant locally, and also will facilitate future addition or updating of individual items without reprinting the whole manual.Back to ContentsArrival Date and TimeDefinitionThe Date & Time of arrival of a patient at an A&E department. If the patient arrives by ambulance or air ambulance (with or without an A&E Retrieval Team) this will be taken from the ambulance data, otherwise this is when the patient arrives at A&E reception. For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts).ISD Data Dictionary - Arrival Date & Time (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length 25Recording notes:this is a mandatory item,for patients arriving by ambulance or air ambulance (with or without an A&E Retrieval Team), 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 in to the reception,For virtual (telephone or video) consultations and care this is the date and time that the virtual connection was made (this applies to emergency/urgent and planned virtual contacts),all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,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) ). Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored/published to ensure planned patients are not disadvantaged and do not wait longer than 4 hours.Back to ContentsArrival Mode 1/2 Arrival Date and TimeArrival ModeYour system’s drop-down code/valueNational code/valueDescription01Ambulance (road)Excludes involvement of an air ambulance or an A&E retrieval team.02Ambulance (air)Travel for all or any part of journey by an aircraft operating as an ambulance. Includes helicopter. Excludes involvement of an A&E retrieval team.03Ambulance + A&E retrieval teamClinical 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 when used by retrieval team.04Out of hours transportIncludes OOH has arranged transport Includes PTS transport, OOH contract taxi Excludes emergency ambulance.05Private transportIncludes car, motorbike, bicycle, etc.06Public transportIncludes taxi, bus, train, etc.07WalkingOn foot.08Police/prison transportPatient is brought to A&E in a police or prison vehicle.09Virtual (telephone or video)Consultation and care is provided in a virtual environment e.g. telephone, Near Me.98OtherThe 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.99Not knownBack to ContentsArrival Mode 2/2DefinitionThe substantive means by which a patient came into the care of an A&E department.ISD Data Dictionary - Arrival Mode (A&E)FormatCharactersField Length2Recording notes:this is a mandatory item,only one arrival mode should be recorded,for journeys using more than one mode of transport, select the main mode used,NOTE that if a road ambulance, an air ambulance or a retrieval team has been involved at any stage in the patient’s journey to A&E, this should always be regarded as the main mode of arrival and recorded using the appropriate code (01, 02 or 03 respectively).Code 09 Virtual (telephone or video) should be used where consultation and care is provided in a virtual environment (this applies to urgent/emergency care and planned virtual contacts). The redesign of urgent care and the scheduling of consultations is a new initiative so although ‘face to face’ is not stated it is the assumed mode of contact unless this code is used. your notes:Back to ContentsAttendance Category 1/2Your system’s drop-down code/valueNational code/valueDescription01New – unplannedThe first unplanned attendance in a series, or the only attendance, in a particular A&E episode.02Return – plannedA subsequent planned attendance at the same department, and for the same incident as the first attendance – see Notes.03Return – unplannedA subsequent unplanned attendance at the same department, and for the same incident as the first attendance – see Notes.04RecallThis code should be used for patients who have been discharged from A&E and are not expected to come back with the same complaint, but after a clinical review of results, x-rays etc the A&E department contact the patient and ask them to come back.05New – plannedThe first planned attendance in a series, or the only attendance, in a particular A&E episode. Back to ContentsAttendance Category 2/2Definition: A record of whether a patient is making a first or follow-up contact with a particular A&E department.ISD Data Dictionary - Attendance Category (A&E)Format: CharactersField Length: 2Recording notes:this is a mandatory item,a new attendance is the first or only attendance for the same incident, which may be an injury or occurrence of a condition,a return attendance is a visit to the same department for the same incident as the first visit within the episode,recurring conditions: n.b. if a patient has a recurring condition, such as epilepsy, or a tendency for joints to dislocate, there would be a new first attendance each time that the patient presents with a new recurrence of the condition,an unplanned return attendance – where a patient is not expected to, but returns in connection with the original complaint(s) note: this also includes patients who are given a specific date to return as a planned attendance but for clinical reasons attend earlier e.g. patient is give an appointment to return for dressing change, but actually returns 2 days earlier than the appointment because the dressing needs changing sooner,a recall (04) must be distinguished from a planned (02) or unplanned (03) return attendance,a subsequent attendance may not always be a return attendance. It could qualify as an attendance at a consultant outpatient clinic and if so, it needs to be recorded appropriately,codes and values '01 New' and '03 Return - unplanned' are included in the Scottish Governments 4-hour Waiting Times Standard, whilst '02 Return - planned' and ’05 New – planned’ are not. Planned attendances, whether virtual (telephone or video) or face to face, where the attendance has been scheduled using a booking system, are excluded from the 4-hour Emergency Access Standard. These times will be monitored /published to ensure patients who are planned are not disadvantaged and wait longer than 4 hours,The redesign of urgent care and the scheduling of consultations and care is a new initiative (November 2020) so although code ’01 New - unplanned’ did not state ‘unplanned’ until the option for code ’05 New – planned’ became available (Nov 2020), unplanned would have been the default, There has been a new code added to Arrival Mode to capture where consultation and care is provided in a virtual environment - Code 09 Virtual (telephone or video). The redesign of urgent care and the scheduling of consultations is a new initiative so although ‘face to face’ is not stated it is the assumed mode of contact unless this code is used,reference: 'Fair to All, Personal To Each: The next steps for Scotland' (Scottish Executive Edinburgh December 2004) Publications/2004/12/20400/48699).Back to ContentsCase Reference NumberDefinitionA Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS.ISD Data Dictionary - Health Record IdentifierFormatCharactersField Length14Recording notes:this is a mandatory item,the CHI number should always be used to identify a patient if available. However, health record identifiers, such as hospital numbers in patient administration systems (PAS), may be used locally until universal implementation of CHI has been achieved,can also be used to identify a patient within the originating system, but not in place of CHI where it exists.your notes:Back to ContentsCHI Number 1/2DefinitionThe Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index.ISD Data Dictionary - CHI NumberFormatCharactersField Length10Recording notes:this is a mandatory item,the Community Health Index (CHI) is a computer based population index whose main function at present is to support primary care services. CHI contains details of all Scottish residents registered with a General Practitioner and was originally envisaged and implemented as a population-based index to help assess the success of immunisation and screening programmes. It is therefore closely integrated with systems for child health, cervical cytology and breast screening call and recall. It is intended that this number, the Scottish equivalent of the new NHS number in England and Wales, should become the Unique Patient Identifier throughout the NHS in Scotland. From Designed to Care - Scottish Office,the CHI number is a unique numeric identifier, allocated to each patient on first registration with the system. The CHI number is a 10-character code consisting of the 6-digit date of birth (DDMMYY), two digits, a 9th digit which is always even for females and odd for males and an arithmetical check digit. (ISD, Information Services, NHS National Services Scotland),the CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records,although there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications,non-Scottish patients and other temporary residents can have a CHI number allocated if required but it is envisaged that future development may allow the identifying number used in other UK countries to be used in Scotland,Back to ContentsCHI Number 2/2where no CHI can be found or created, a dummy CHI - 9999999999 - may be recorded,NSS provides a seeding service to apply the CHI number to any electronic record. This is a mass batch process which can handle several thousand entries at one time. see chiupi.scot.nhs.uk for further information. This site holds much more detailed information about the CHI number plus a means to determine the latest known status ( dead, untraced, left the country) for every registered resident in Scotland.your notes:Back to ContentsDate and Time Decision to Discharge/Admit or TransferDefinitionThe Date & Time the decision was made to discharge/admit or transfer the patient. ISD Data Dictionary – Date and Time Decision to Discharge/Admit or Transfer (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is a mandatory item,all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,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) ).your notes:Back to ContentsDate and Time of Discharge/Admission or TransferDefinitionThis is the date and time that a patient leaves the A&E department after an A&E attendance has concluded and/or the department is no longer responsible for the care of the patient.ISD Data Dictionary - Date and Time of Discharge, Admission or Transfer (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD) - e.g. 20070722092000 (22nd July 2007 at 9.20am) Time in 24hr format with seconds.Field Length14Recording notes:this is a mandatory item,discharge is when the patient leaves the A&E department or when they are officially informed they may leave, whichever is the sooner,admission is when the patient leaves the A&E department to go directly to an inpatient ward. Where assessment areas contain allocated beds and have the normal facilities of a ward (washing and toileting facilities etc) they should be regarded as admission to a ward,transfer is when the patient leaves the A&E department to be taken to another hospital (usually by ambulance) or to another emergency department within the same hospital – e.g. transfer of a patient from the Minor Injuries Unit to the A&E Department,for those patients who died the date and time of discharge is recorded as the time when the patient was declared dead by a clinician,for those patients who discharged themselves the date and time of discharge is recorded as the time when the patient departed (or when staff have become aware that the patient departed). In such circumstances, if a patient subsequently returns to the department, then the clock is reset and the 4-hour time period starts again – such patients are not to be counted as planned return patients,For virtual consultations and care this the date and time the virtual connection ends (this applies to emergency/urgent and planned virtual contacts)this data item is 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),all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,Systems should record whether the time is Coordinated Universal Time or British Summer Time in the time zone designator. This will allow time elapsed to be calculated correctly, for example for A&E waiting times. Back to ContentsDate and Time First DiagnosticsDefinitionThe Date & Time the first diagnostic test was requested in an A&E department. This can be an ECG, ultrasound scan or blood test, or other test for the purposes of diagnosis.ISD Data Dictionary – Date and Time First Diagnostics (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,this is the start date and time which will be used in measuring the waiting time between arriving at a unit and subsequent request for the first diagnostic test to be requested. your notes:Back to ContentsDate and Time of Treatment StartDefinitionThe Date & Time that treatment started within an A&E department. This can include the patient receiving analgesia/dressings during the journey by ambulance to the department, or when the patient attends the ED and is seen in triage.ISD Data Dictionary – Date and Time of Treatment Start (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,this is the start date and time which will be used in measuring the waiting time between arriving at a unit and subsequent treatment started. your notes:Back to ContentsDate and Time of TriageDefinitionThe Date & Time that the patient was first triaged within an A&E department. ISD Data Dictionary – Date and Time of Triage (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,this is the start date and time which will be used in measuring the waiting time between arriving at a unit and the date and time that the patient was first triaged. Your notes Back to ContentsDiagnoses – notes on recordingAt least one diagnosis must be recorded in every record of attendance or virtual consultation and care.The diagnosis(es) recorded should be the working diagnosis(es) at the time of discharge, which will not necessarily be the same as any definitive diagnosis(es) made after further assessment and investigation. If no working diagnosis is made, the main symptom(s), abnormal finding(s), or problem(s) should be recorded.the working diagnosis(es) or symptom(s) (see 2 above) may be recorded using any of three separate data items, alone or in combination. These areDiagnosisdiagnosis recorded at high level using a limited number of 2-character codesDiagnosis Textdiagnosis recorded as free textDiseasediagnosis recorded as ICD10 codes.ECDS Diagnosisdiagnosis recorded as descriptionEach of these individual data items may be used to submit up to three diagnoses in any single record of attendance (hence Diagnosis1, Diagnosis2 and Diagnosis3 etc.).Any single record of attendance may contain diagnostic information recorded using more than one of these data items, so that the record of an individual attendance may have diagnostic information recorded in, for example, Diagnosis1 Text and Disease1.Therefore IT systems should allow for the recording of multiple diagnoses and allow for the recording of free text if necessary.Many local departments have their own diagnostic lists of the conditions commonly presenting locally. For data submission to ISD these lists should be mapped against one (or more) of the four data items discussed here. For example, local lists could be used to derive the 2 character codes of ‘Diagnosis’, the ICD10 codes of ‘Disease’ or there could be a direct downloading of the local list text into ‘Diagnosis Text’. The ECDS diagnosis also presents the possibility of the use of SNOMED codes to determine diagnosis.If local diagnosis lists are being mapped to ICD10 for recording in the data item Disease, it is recommended that assistance is sought from the local coding department or from Terminology Services Coding Helpdesk ( phs.terminologyhelp@phs.scot). This will help to ensure accurate use of ICD10. Use of ICD10 will facilitate electronic communication of diagnostic information and will also support departments' ability to carry out their own audits and to undertake comparisons at regional and national level.Your notes:Back to ContentsDiagnosis1, Diagnosis 2, Diagnosis 3 1/2Your system’s drop-down code/valueNational code/valueDescription00Nothing abnormal detected01Trauma/injury/poisoningIncludes all trauma/injury/poisoning/foreign bodies.02Alcohol and/or substance use problems03Cardiovascular04DentalExcludes dental injury - see 01 trauma/injury/ poisoning.05DermatologyExcludes skin injury - see 01 trauma/injury/poisoning.06Endocrine/metabolic07ENTExcludes foreign bodies - see 01 trauma/injury/ poisoning.08Gastrointestinal09Gynaecological10Haematology11InfectionExcludes infections specific to particular anatomical site or physiological system, e.g. skin, respiratory system.12MusculoskeletalExcludes musculoskeletal injury – see 01 trauma/injury/poisoning.13Neurology14ObstetricsBack to ContentsDiagnosis 1, Diagnosis 2, Diagnosis 3 2/2Your system’s drop-down code/valueNational code/valueDescription15OphthalmologyExcludes foreign bodies or eye injury - see 01 trauma/ injury/poisoning.16Psychiatry17Respiratory18Genito-urinary19Social circumstances99Diagnosis not knownDefinitionThe working diagnosis(es) on discharge, or where no working diagnosis is made, the main symptom(s), abnormal finding(s), or problem(s).ISD Data Dictionary - Diagnosis {A&E}Format2 CharactersRecording notes:see ‘Diagnoses – notes on recording’ above for essential information about recording diagnoses,these high level 2 character values are based upon the International Classification of Diseases (ICD10) chapter headings,any single record of attendance may record up to three values for Diagnosis (hence Diagnosis1, Diagnosis2 and Diagnosis3).your notes:Back to ContentsDiagnosis 1 Text, Diagnosis 2 Text, Diagnosis 3 TextDefinitionThe text of the working diagnosis(es) on discharge or, where no working diagnosis is made, the text of the main symptom(s), abnormal finding(s), or problem(s).FormatFree textRecording notes:see ‘Diagnoses – notes on recording ’ above for essential information about recording diagnoses,any single record of attendance may record up to three values for Diagnosis Text (hence Diagnosis1 Text, Diagnosis2 Text and Diagnosis3 Text).your notes:Back to ContentsDischarge Destination 1/3Your system’s drop-down code/valueNational code/valueDescription00Death01Private residence01AUsual place of residence01BNot usual place of residenceE.g. staying with relatives or friends.02Residential institution02AUsual place of residence02BNot usual place of residence03Temporary residence03AHoliday accommodation03BStudent accommodation03CLegal establishment/prison03DNo fixed abode03ZOther temporary residence04Admission to same NHS healthcare provider/hospital04AA&E wardIncludes A&E observation ward, A&E short stay ward, etc.04BAssessment unit04CMedical wardIncludes medical admissions unit, coronary care unit.04DSurgical wardIncludes surgical admissions unit, orthopaedic ward.04ZOther wardBack to ContentsDischarge Destination 2/3Your system’s drop-down code/valueNational code/valueDescription05Transfer to same/other hospital05APsychiatric hospital05BOther specialist centreE.g. eye hospital, paediatric hospital.05CCommunity hospital05Dtransferred to Out of Hours (triaged in A&E)05Etransferred to Out of Hours (not triaged in A&E)05Fadvised to attend GP/Primary Care05GA&EThe patient has been transferred from an MIU in the same/other hospital.05HReferred to NHS24The patient has been referred to NHS 24 following at- tendance at an MIU/ED.05ZOther NHS hospital06Private healthcare provider98OtherIncludes transfer between different emergency departments within the same hospital e.g MIU to A&E.99Not knownBack to ContentsDischarge Destination 3/3DefinitionThe immediate destination of the patient on discharge.ISD Data Dictionary - Discharge Destination (A&E)FormatCharactersField Length3Recording notes:this is a mandatory item,transfer from one emergency department to another within the same hospital e.g MIU to A&E should be recorded as ’98 Other’,see General Recording Guidance - Admission, discharge, referral, and transfer.your notes: HYPERLINK \l "_Contents" Back to ContentsDisease 1, Disease 2, Disease 3DefinitionThe ICD10 code(s) of the working diagnosis(es) on discharge, or where no working diagnosis is made, the ICD10 code(s) of the main symptom(s), abnormal finding(s), or problem(s).Codes & ValuesNational ICD-10 reference file Recording notes:see ‘Diagnoses – notes on recording’ above for essential information about recording diagnoses,any single record of attendance may record up to three values for Disease (hence Disease1, Disease2 and Disease3).your notes:Back to ContentsECDS Diagnosis (Emergency Care Data Set) 1/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value01Wound : lac / incised / bite : head21Sprain / ligament injury : lumbar spine02Wound : lac / incised / bite : face22Sprain / ligament injury : shoulder joint03Wound : lac / incised / bite : neck23Sprain / ligament injury : elbow joint04Wound : lac / incised / bite : shoulder24Sprain / ligament injury : wrist joint05Wound : lac / incised / bite : upper arm25Sprain / ligament injury : hand06Wound : lac / incised / bite : forearm26Sprain / ligament injury : thumb07Wound : lac / incised / bite : hand27Sprain / ligament injury : finger08Wound : lac / incised / bite : thumb28Sprain / ligament injury : hip joint09Wound : lac / incised / bite : finger29Sprain / ligament injury : knee joint10Wound : lac / incised / bite : thigh30Sprain / ligament injury : ankle joint11Wound : lac / incised / bite : knee31Sprain / ligament injury : foot12Wound : lac / incised / bite : lower leg32Sprain / ligament injury : toe13Wound : lac / incised / bite : foot33Bruise / contusion / abrasion : head14Wound : lac / incised / bite : toe34Bruise / contusion / abrasion : face15Wound : lac / incised / bite : back35Bruise / contusion / abrasion : neck16Wound : lac / incised / bite : thorax36Bruise / contusion / abrasion : thorax17Wound : lac / incised / bite : abdomen37Bruise / contusion / abrasion : back18Wound : lac / incised / bite : perineum38Bruise / contusion / abrasion : abdomen19Sprain / ligament injury : cervical spine39Bruise / contusion / abrasion : perineum20 Sprain / ligament injury : thoracic spine40Bruise / contusion / abrasion : pelvic regionBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 2/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value41Bruise / contusion / abrasion : shoulder61Muscle injury : forearm42Bruise / contusion / abrasion : upper arm62Muscle injury : hand43Bruise / contusion / abrasion : elbow 63Muscle injury : thigh44Bruise / contusion / abrasion : forearm64Muscle injury : lower leg45Bruise / contusion / abrasion : wrist65Muscle injury : foot46Bruise / contusion / abrasion : hand66Tendon injury : shoulder joint47Bruise / contusion / abrasion : thumb67Tendon injury : elbow joint48Bruise / contusion / abrasion : finger68Tendon injury : wrist joint49Bruise / contusion / abrasion : hip69Tendon injury : hand50Bruise / contusion / abrasion : thigh70Tendon injury : thumb51Bruise / contusion / abrasion : knee 71Tendon injury : finger52Bruise / contusion / abrasion : lower leg72Tendon injury : patellar tendon53Bruise / contusion / abrasion : ankle73Tendon injury : achilles tendon54Bruise / contusion / abrasion : foot74Tendon injury : ankle55Bruise / contusion / abrasion : toe75Tendon injury : foot56Muscle injury : neck76Tendon injury : toe57Muscle injury : upper back77Crush injury : head58Muscle injury : lower back 78Crush injury : face59Muscle injury : shoulder79Traumatic asphyxiation60Muscle injury : upper arm80Crush injury : neckBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 3/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value81Crush injury : thorax105Degloving injury : perineum82Crush injury : back106Degloving injury : buttock83Crush injury : abdomen107Degloving injury : shoulder84Crush injury : pelvis108Degloving injury : upper arm85Crush injury : hand109Degloving injury : forearm86Crush injury : thumb110Degloving injury : hand87Crush injury : finger111Degloving injury : thumb88Crush injury : shoulder112Degloving injury : finger89Crush injury : upper arm113Degloving injury : thigh90Crush injury : forearm114Degloving injury : lower leg91Crush injury : thigh115Degloving injury : ankle92Crush injury : lower leg116Degloving injury : foot93Crush injury : ankle117Degloving injury : toe94Crush injury : foot118Burn : head95Crush injury : toe119Burn : eye100Degloving injury : head120Burn : airway101Degloving injury : neck121Burn : face102Degloving injury : thorax123Burn : neck103Degloving injury : back124Burn : trunk104Degloving injury : abdomen125Burn : perineumBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 4/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value126Burn : buttock146Closed fracture : pubic rami127Burn : shoulder147Closed fracture : sacrum128Burn : upper arm148Closed fracture : coccyx129Burn : elbow149Closed fracture : pelvis130Burn : forearm150Closed fracture : clavicle131Burn : hand151Closed fracture : scapula132Burn : thumb152Closed fracture : humerus133Burn : finger153Closed fracture : elbow joint134Burn : thigh154Closed fracture : radius135Burn : knee155Closed fracture : ulna136Burn : lower leg156Closed fracture : radius AND ulna137Burn : foot157Closed fracture : Monteggia (frac ulna : disloc rad)138Burn : toe158Closed fracture : Galeazzi (frac rad : disloc ulna)139Closed fracture : skull159Closed fracture : scaphoid140Closed fracture : facial bones / mandible160Closed fracture : carpal bones141Closed fracture : sternum161Closed fracture : hand142Closed fracture : rib162Closed fracture : thumb metacarpal143Closed fracture : cervical spine163Closed fracture : thumb phalanx144Closed fracture : thoracic spine164Closed fracture : finger145Closed fracture : lumbar spine165Closed fracture : hip (NoF)Back to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 5/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value166Closed fracture : femur (not NoF)186Open fracture : clavicle167Closed fracture : knee187Open fracture : scapula168Closed fracture : patella188Open fracture : humerus169Closed fracture : tibia (not ankle)189Open fracture : elbow joint170Closed fracture : fibula (not ankle)190Open fracture : radius171Closed fracture : tibia AND fibula (not ankle)191Open fracture : ulna172Closed fracture : ankle192Open fracture : radius AND ulna173Closed fracture : heel193Open fracture : Monteggia (frac ulna : disloc rad)174Closed fracture : foot194Open fracture : Galeazzi (frac rad : disloc ulna)175Closed fracture : toe195Open fracture : carpal bones176Open fracture : skull196Open fracture : hand177Open fracture : facial bones / mandible197Open fracture : thumb metacarpal178Open fracture : sternum198Open fracture : thumb phalanx179Open fracture : rib (s)199Open fracture : finger180Open fracture : cervical spine200Open fracture : hip (NoF)181Open fracture : thoracic spine201Open fracture : femur182Open fracture : lumbar spine202Open fracture : knee183Open fracture : sacrum203Open fracture : patella184Open fracture : coccyx204Open fracture : tibia (not ankle)185Open fracture : pelvis205Open fracture : fibula (not ankle)Back to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 6/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value206Open fracture : tibia AND fibula (not ankle)226Dislocation : toe207Open fracture : ankle227Minor traumatic brain injury (GCS more than 12) : no LOC208Open fracture : calcaneum228Minor traumatic brain injury (GCS more than 12) : LOC less than 30s209Open fracture : foot229Minor traumatic brain injury (GCS more than 12) : LOC less than 30s210Open fracture : toe230Post concussion syndrome (more than 1 day post incident)211Dislocation : cervical spine231Subdural hematoma212Dislocation : thoracic spine232Extradural haematoma213Dislocation : lumbar spine233Traumatic subarachnoid haemorrhage214Dislocation : shoulder joint234Traumatic intracerebral haemorrhage215Dislocation : elbow joint235Diffuse axonal injury216Dislocation : wrist236Contusion of brain217Dislocation : hand237Moderate traumatic brain injury (GCS less than 13)218Dislocation : thumb238Severe traumatic brain injury (GCS less than 9)219Dislocation : finger239Fracture of tooth (simple)220Dislocation : hip (prosthetic joint)240Fracture of tooth (complex)221Dislocation : hip (natural joint)241Loose tooth / teeth222Dislocation : knee joint242Tooth/ teeth removed from socket223Dislocation : patella243Airway injury224Dislocation : ankle joint244Vascular injury225Dislocation : foot245Traumatic pneumothoraxBack to ContactsECDS Diagnosis (Emergency Care Data Set) Cont’d 7/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value246Tension pneumothorax266Amputation / partial amputation : shoulder247Flail chest267Amputation / partial amputation : upper arm248Open chest wound268Amputation / partial amputation : forearm249Haemopneumothorax269Amputation / partial amputation : hand250Massive haemothorax270Amputation / partial amputation : thumb251Lung contusion271Amputation / partial amputation : finger252Injury of heart272Amputation / partial amputation : genital253Injury of thoracic aorta273Amputation / partial amputation : hip254Injury of bowel274Amputation / partial amputation : femur255Injury of spleen275 Amputation / partial amputation : tibia/ fibula256Injury of liver276Amputation / partial amputation : foot257Injury of stomach277Amputation / partial amputation : toe258Injury of pancreas278Foreign body : in / under skin259Injury of abdominal aorta279Foreign body : ear canal260Injury of kidney280Foreign body : nose261Injury of bladder281Foreign body : respiratory tract262Abdominal trauma in pregnancy282Foreign body : alimentary tract263Amputation / partial amputation : ear283Foreign body : vulva / vagina264Amputation / partial amputation : nose284Foreign body : penis265Amputation / partial amputation : tongue285Foreign body : rectumBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 8/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value286Ring too tight on digit / extremity307Pulmonary hypertension287Complication of soft tissue injury : vascular308Malignant hypertension288Complication of soft tissue injury : neurological309Heart valve disorder289Spinal cord injury310Pericarditis290Complication of soft tissue injury : tendon311Pericardial effusion291Rhabdomyolysis312Myocarditis292Complication of soft tissue injury : compartment syndrome313Endocarditis293Acute coronary syndrome (ACS)314Cardiomyopathy294Myocardial infarction (STEMI)315Atrial fibrillation / flutter295Myocardial infarction (NSTEMI)316Supraventricular tachycardia296Angina (unstable)317Multifocal atrial tachycardia297Angina (stable)318Ventricular tachycardia298Congestive cardiac failure319Ventricular extrasystole300Left ventricular failure320Heart block : first degree301Acute pulmonary oedema321Heart block : second degree : Mobitz type I302Cardiogenic shock322Heart block : second degree : Mobitz type II303Postural hypotension323Heart block : third degree (complete)304Vasovagal syncope324Right bundle branch block305Micturition syncope325Left bundle branch block306Hypertension326Bifasicular blockBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 9/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value327Trifasicular block347Ingestion of corrosive acid / alkali328Conduction disorder / heart block348Oesophageal perforation329Sinus node dysfunction349Oesophageal varices with bleeding330Bradycardia350Hepatitis331Pre-excitation (WPW / LGL)351Chronic liver disease332Brugada syndrome352Ascites333Long QT syndrome353Hepatic failure or coma334Arrhythmia : other354Crohns disease335Mechanical complication of cardiac electronic device355Ulcerative colitis336Discharge of implantable cardiac defibrillator356Irritable bowel syndrome337Cardiac arrest357Migraine338Gastro-oesophageal reflux358Tension headache339Gastritis359Ventriculoperitoneal shunt : complication340Gastroduodenal ulcer360Stroke341Constipation361Transient ischaemic attack342Complication of gastrostomy (PEG tube)362Subarachnoid haemorrhage343Upper gastrointestinal hemorrhage363Intracerebral haemorrhage344Lower gastrointestinal hemorrhage364Status epilepticus345Oesophageal spasm365Epilepsy : generalised346Oesophageal stricture366Epilepsy : absenceBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 10/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value367Epilepsy : focal387Respiratory failure368Pseudoseizure388Respiratory arrest369Bell palsy389Cystic fibrosis370Trigeminal neuralgia390Haemoptysis371Cranial nerve palsy391Anaemia372Carpal tunnel syndrome392Anaemia : iron deficiency373Meralgia parasthetica393Idiopathic thrombocytopenic purpura374Guillain-Barre syndrome394Neutropenic sepsis375Dystonic reaction395Neutropenia376Parkinson's disease396Haemophilia377Multiple sclerosis397Bleeding / bruising tendency / coagulation defect378Intracranial space occupying lesion398Thrombocytopenia379Other nervous system disorder (see free text)399Sickle cell anaemia380Asthma400Sickle cell crisis381Chronic obstructive pulmonary disease401Thalassaemia382Pulmonary embolism402Haemangioma / lymphangioma383Spontaneous pneumothorax403Malignant tumour384Aspiration pneumonia404Myeloid leukaemia385Pleural effusion405Multiple myeloma386Empyema406Lymphoid leukaemiaBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 11/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value407Lymphoma427Urticaria408Hodgkin's disease428Rash : drug induced409Haematological condition not listed above429Psoriasis410Type 1 diabetes mellitus430Pityriasis rosea411Diabetic ketoacidosis431Erythema multiforme412Type 2 diabetes mellitus432Erythema nodosum413Hyperosmolar hyperglycaemic state (HHS)433Sunburn414Hypoglycaemia without coma434Heat rash415Hyperthyroidism / thyrotoxicosis435Sebaceous cyst416Hypothyroidism / myxoedema436Ingrowing nail of finger or toe417Adrenocortical insufficiency (Addisonian crisis)437Bedsore / pressure sore418Syndrome of inappropriate anti-diuretic hormone (SIADH)438Pyogenic granuloma419Hyperkalaemia439Pyelonephritis420Hypokalaemia440Hydronephrosis421Hypercalcaemia441Acute renal failure422Other endocrine disorder (see free text)442Chronic renal failure423Fluid electrolyte or acid-base disorder (see free text)443Nephrotic syndrome424Dermatitis : atopic / eczema444Glomerulonephritis425Dermatitis : contact445Other renal system disorder (see free text)426Dermatitis : seborrhoeic446Hayfever HYPERLINK \l "_Contents" Back to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 12/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value447Anaphylaxis467Paronychia448ACEI related angioedema468Fungal foot infection449Angioneurotic oedema (C1 esterase inhibitor deficiency)469Tinea versicolour450Angioneurotic oedema470Scarlet fever (Invasive Grp A Strep) [ND]451Scombroid toxin [ND]471Ringworm / dermatophytosis / tinea452Drug reaction472Chickenpox / varicella453Other allergic reaction (see free text)473Herpes zoster infection (shingles)454Upper respiratory tract infection474Eczema herpeticum455Lower respiratory tract infection475Hand foot and mouth disease456Bronchopneumonia476Molluscum contagiosum457Lobar pneumonia477Scabies458Legionella pneumonia [ND]478Lice infestation459Influenza479Urinary tract infection460Pertussis / whooping cough [ND]480Infectious gastroenteritis461Acute epiglottitis481Infectious gastroenteritis with bloody diahorrea [ND]462Bacterial tracheitis482Oral herpes simplex463Tuberculosis [ND]483Candidiasis464Cellulitis484Worms465Boil / abscess485Chlamydia466Impetigo486Genital herpesBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 13/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value487Genital warts507Haemolytic uraemic syndrome (HUS) [ND]488Gonorrhoea508Pathogenic E.coli infection (O157 O104 etc.) [ND]489Trichomoniasis509Diphtheria [ND]490Giardia lamblia infestation510Haemophilus influenzae type b (Hib) [ND]491Sepsis511Leptospirosis [ND]492Septic shock512Tetanus [ND]193Meningococcal sepsis [ND]513Brucellosis [ND]494Bacterial meningitis [ND]514Tularaemia [ND]495Viral meningitis515Typhus [ND]496Encephalitis [ND]516Typhoid [ND]497Infectious mononucleosis517Paratyphoid [ND]498Measles [ND]518Dysentery [ND]499Mumps / parotitis [ND]519Cholera [ND]500Rubella / german measles [ND]520SARS [ND]501Malaria [ND]521Hepatitis A [ND]502Necrotising fasciitis [ND]522Hepatitis B [ND]503Human immunodeficiency virus infection523Acute infectious hepatitis [ND]504Fungal infection / fungaemia / mycosis524Relapsing fever [ND]505Pyrexia of unknown origin525West Nile fever [ND]506Food poisoning [ND]526Viral haemorrhagic fever (VHF) [ND]Back to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 14/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value527Yellow fever [ND]547Anal fissure528Leprosy [ND]548Perforated / ruptured bowel529Rabies [ND]549Peritonitis530Smallpox [ND]550Acute pancreatitis531Anthrax [ND]551Chronic pancreatitis532Botulism [ND]552Ischaemic bowel533Plague [ND]553Stoma problem534Acute poliomyelitis [ND]554Rectal prolapse535Paralytic poliomyelitis [ND]555Inguinal hernia536Appendicitis556Umbilical hernia537Mesenteric lymphadenitis557Incisional hernia538Biliary colic558Volvulus539Cholecystitis559Renal / ureteric colic due to stone540Ascending cholangitis560Urinary retention541Gallstones with cholecystitis561Haematuria542Bowel obstruction562Testicular torsion543Diverticulitis563Torsion of hydatid of Morgagni544Abscess : perianal or anal564Epididymitis / orchitis / epidymo-orchitis545Haemorrhoids565Hydrocele546Anorectal bleeding566Indwelling urinary catheter : problem related toBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 15/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value567Prostatitis587Chronic otitis media568Prostatic enlargement588Mastoiditis569Foreskin problem anatomical : phimosis / paraphimosis589Benign paroxysmal vertigo570Foreskin problem infection : balanitis / balanoposthitis590Vestibular neuronitis571Deep vein thrombosis591Labyrinthitis572Thrombophlebitis of leg592Meniere's disease573Varicose veins593Epistaxis574Peripheral vascular disease594Tonsillitis575Aortic dissection595Quinsy / peritonsillar abscess576Thoracic aneurysm without rupture596Sinusitis577Thoracic aneurysm with leak597Attention to tracheostomy578Abdominal aneurysm without rupture598Conjunctivitis579Abdominal aneurysm with rupture599Eyelid abscess / cellulitis / stye580Arterial embolism / thrombosis600Corneal abrasion581Superior vena cava obstruction601Foreign body : external eye582Otitis media / middle ear infection602Corneal ulcer : non-traumatic583Otitis externa603Pterygium584Ear wax (impacted)604Keratitis585Acute otitis media with drum rupture605Keratitis due to ultraviolet light586Traumatic rupture of ear drum606Corneal burnBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 16/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value607Anterior uveitis627Penetrating eye injury608Hyphaema628Orbital fracture609Scleritis / episcleritis629Dental abcess610Dry eye syndrome630Dental Caries611Subconjunctival haemorrhage631Gingivitis / gingivostomatitis612Retinal vascular occlusion632Salivary gland stone613Retinal vasculitis633Salivary gland abscess614Intra-ocular haemorrhage634Temporomandibular joint disorder615Chronic glaucoma635Dislocation of temporomandibular joint616Acute glaucoma636Surgical procedure complication617Retinal detachment +/- tear637Attention to or removal of surgical dressings618Vitreous detachment638Attention to or removal of surgical sutures619Age-related macular degeneration639Change of plaster / plaster check620Retinal oedema640Sciatica621Optic neuritis641Cauda equina syndrome622Papilloedema642Tendonitis623Cataract643Tenosynovitis624Periorbital cellulitis644Tendon rupture : non-traumatic625Orbital cellulitis645Rotator cuff syndrome626Intraocular infection646Frozen shoulderBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 17/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value647Septic arthritis667Jaundice in newborn648Osteomyelitis668Hypoglycaemia in newborn649Bursitis669Crying : persistent / irritable infant650Complex regional pain syndrome670Congenital heart disease651Osteoporosis671Sudden unexplained death in infancy652Costochondritis672Congenital dislocation of hip653Osteoarthritis673Pyloric stenosis654Rheumatoid arthritis674Intussusception655Gout675Intestinal malrotation656Pseudo gout676Undescended testis657Haemarthrosis (spontaneous)677Irritable hip658Bronchiolitis678Pulled elbow659Croup679Perthes disease660Non-specific viral rash680Slipped upper femoral epiphysis661Nappy rash681Osgood-Schlatter disease / traction apophysitis662Henoch-Schonlein purpura682Threatened abortion (miscarriage)663Seizure : febrile683Missed abortion (miscarriage)664Seizure : newborn684Complete abortion (miscarriage)665Apnoeic episode / breath-holding attacks685Incomplete abortion (miscarriage)666Feeding problems in newborn686Incomplete abortion (miscarriage) with infectionBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 18/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value687Retained products of conception707Premature rupture of membranes688Hyperemesis gravidarum708Ante-partum haemorrhage689Ectopic pregnancy709Active labour690Menorrhagia710Baby born in emergency care facility691Dysmenorrhoea711Post-partum haemorrhage692Postmenopausal bleeding712Post-partum infection693Postcoital and contact bleeding713Breast problem : pregnancy-related694Vaginal infection714Dementia695Pelvic inflammatory disease715Delirium (acute confusion)696Endometriosis716Personality disorder697Ovarian disorder717Eating disorder698Uterine fibroid718Anxiety disorder699Abscess of labia or vulva719Depressive disorder700Complication of intrauterine contraceptive device720Bipolar affective disorder701Endometritis (NOT endometriosis)721Schizophrenia702Genital prolapse722Psychotic disorder703Female genital mutilation723Somatisation disorder704Pre-eclampsia724Somatoform pain disorder705Eclampsia725Dissociative (conversion) disorder706Early / threatened / premature / pre-term labour726Factitious disorderBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 19/20Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value727Paracetamol overdose747Needlestick injury / exposure to body fluids728NSAID overdose748Post exposure prophylaxis729Antidepressant overdose749Hypothermia730Benzodiazepine overdose750Cold injury731Opiate overdose751Heat stroke / sun stroke732Ingestion of methanol / ethylene glycol752Sub-aqua diving / barotrauma injury733Methaemoglobinaemia753Drowning / non-fatal immersion734Toxic effect of venom / sting754Social problem735Toxic effect of plant755Homelessness736Side effect of medication756Malnutrition737Inhalation of toxic gas / vapour757Safeguarding concern738Inhalation of smoke758No abnormality detected739Poisoning (NOT plant / venom / gas / vapour)759Left before clinical assessment740Alcohol (ethanol) intoxication760Referred to GP / urgent care741Alcohol dependence syndrome761Direct admit to a specialty742Alcohol withdrawal syndrome762Prescription request743Alcohol withdrawal seizure763Request of medical certificate744Recreational drug use764Attendance for specimen collection745Dependence on sedatives or hypnotics765Died in emergency care facility746Dependence on opioids766Dead on arrivalBack to ContentsECDS Diagnosis (Emergency Care Data Set) Cont’d 20/20DefinitionThe ICD10 code(s)/SNOMED code(s) of the working diagnosis(es) on discharge, or where no working diagnosis is made, the ICD10 code(s)/SNOMED code(s) of the main symptom(s), abnormal finding(s), or problem(s).Codes & ValuesISD Data Dictionary – ECDS DiagnosisNational ICD-10 reference file Recording notes:see ‘Diagnoses – notes on recording’ above for essential information about recording diagnoses,your notes:Back to ContentsEthnicity 1/4A – WhiteYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value1AScottish1BOther British1CIrish1KGypsy/Traveller1LPolish1ZAny other white ethnic groupB – Mixed or multiple ethnic groupsYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value2AAny mixed or multiple ethnic groupsBack to ContentsEthnicity 2/4C – Asian, Asian Scottish or Asian BritishC – Asian, Asian Scottish or Asian BritishYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value3FPakistani, Pakistani Scottish or Pakistani British3GIndian, Indian Scottish or Indian British3HBangladeshi, Bangladeshi Scottish or Bangladeshi British3JChinese, Chinese Scottish or Chinese British3ZOther Asian, Asian Scottish or Asian BritishD – African, Caribbean or BlackD – AfricanYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value4DAfrican, African Scottish or African British4YOther AfricanBack to ContentsEthnicity 3/4E – Carribbean or BlackE – Carribbean or BlackYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value5CCarribbean, Carribbean Scottish or Carribbean British5DBlack, Black Scottish or Black British5YOther Carribbean or BlackF – Other ethnic groupF – Other ethnic groupYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value6AArab, Arab Scottish or Arab British6ZOther ethnic groupG – Refused/Not provided by patientG – Refused/Not provided by patientYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value98Refused/Not provided by patientH – Not knownH – Not knownYour system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ value99Not KnownBack to ContentsEthnicity 4/4DefinitionThis list is representative of 2011 Scottish Census Ethnicity Categories. These should be used by NHS Scotland organisations for local and SMR return purposes. Local systems may record more detailed codes as required but these must map to 2011 Scottish Census categories for purposes of national returns.ISD Data Dictionary - Ethnicity codeFormatCharactersField Length2Recording notes:the codes in the table under the heading ‘OLD VALUES’ may continue to be used for records of attendance dated up to and including 31 March 2012,the letters (A, B, C, etc.) that appear in the group headings in each table refer to positions in the provisional and final 2011 census lists and are not valid codes. Please only use the codes in the code list (1A, 1B etc.).your notes:Back to ContentsLocation CodeDefinitionThis is the reference number of any building or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client's home.ISD Data Dictionary - Location codeFormatCharactersField Length5Recording notes:this is a mandatory item,the system in use will normally add Location Code automatically to any record created on it,Each location has a location code, which is maintained jointly by PHS and General Register Office (Scotland), - data files,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 PHS is informed using form LOC-NEW which can be downloaded from so that a new code may be issued as appropriate,Information about location should be electronically stored, managed and transferred using the relevant location code. IT systems should allow the recording and display of locations on the user interface as the relevant location name and associated address, etc.your notes:Back to ContentsPatient Flow 1/2Your system’s drop-down code/valueNational code/valueDescription1Flow 1 (Minor injury & illness)Including care provided in A&E Departments, in Minor Injury Units and through schemes such as Paramedic See and Treat. Includes where consultation and care is provided in a virtual environment.2Flow 2 (Acute assessment - includes major injuries)This includes the ‘majors patients’ in A&E and patients referred to Acute Assessment/Medical and Receiving Units. The key to understanding the definition of this flow is the patients’ predominant need for ongoing assessment to determine the next step in their care pathways. Generally stays in Acute Medical/Assessment Units are limited to no more than72 hours reflecting patient needs as appropriate. However, the 4-hour waiting time target applies to trolleyed areas in these units, to ensure that patients are treated equitably irrespective of the point of access and in the most appropriate clinical environment. Flow 2 includes patients who have died in A&E.3Flow 3 (Medical admissions)Patients who require a period of acute hospital care under the management of a Medical or Elderly Care team. Work in this flow will be linked to the chronic disease management agenda.4Flow 4 (Surgical admissions)Patients who require a period of acute hospital care, under the management of a Surgical Team. Work in this flow will be linked to redesign of the elective surgical flow and links to theatres’ redesign.5Flow 5 (Out of hospital care)This flow will support the development of alternatives to hospital attendance and admission, reducing waits and delays for patients who need urgent hospital assessment and treatment, and facilitating timely discharge for those who are ready for discharge from hospital.Involvement of partners in community care will be essential to delivery of significant change.Back to ContentsPatient Flow 2/2Alcohol InvolvedDefinitionData item created by the Unscheduled Care Collaborative to analyse the flow of patients through the urgent care pathway (including Emergency Departments, Acute Medical Units/ Assessment Units and virtual clinics where consultation and care is given by telephone and video.ISD Data Dictionary - Patient FlowFormatDigitsField Length1Recording notes:this is a mandatory item,Flow 2 Acute Medical/Assessment Units - the 4-hour waiting time target applies to trolleyed areas in these units, to ensure that patients are treated equitably irrespective of the point of access and in the most appropriate clinical environment.your notes:Back to ContentsPatient PostcodeDefinitionThe code allocated by the Post Office to identify a group of postal delivery points.ISD Data Dictionary - PostcodeFormatCharactersField Length8Recording notes:this is a mandatory item,main source of standard: Government Data Standards Catalogue,postcode is included in Address (BS7666) (GDSC) but there also is also a separate postcode standard which will be populated from Address (BS7666) Postcode,the UK Postal Address might be recorded only, in which case a separate standard to record postcode is required,where patients address is not known and all reasonable means of attempting to trace the address have been exhausted the following entry should be recorded in the postcode field: NK01 0AA. For patients with no fixed abode the following should be recorded in the postcode field: NF1 1AB.your notes:Back to ContentsReason for A&E Wait > 4 hours 1/3Your system’s drop-down code/valueNational code/valueDescription00No delayPatients whose stay in A&E is less than or equal to 4 hours. Record this for virtual consultations and care unless there has been a technology issue (see code 09) or a DNA (see code 10). 01Wait for a bed02Wait for transportWait for transport commissioned by A&E.03Wait for a specialist03AWait for orthopaedics03BWait for medical specialty03CWait for mental health/ psychiatrist04Wait for initial A&E treatments04AWait for initial A&E treatment to commenceThere was a delay in the treatment starting i.e. the patient has had a clinical assessment or a diagnostic test and it is known that they need a specific treatment e.g. IV antibiotics, but due to some reason or other this treatment is delayed, resulting in the patient breaching the 4 hour standard.04BWait for initial A&E treatment to be completed05Wait for diagnostics test(s)05AWait for diagnostics test(s) to be performedThere was a wait for a diagnostic test to be carried out e.g. wait for an x-ray, ultrasound etc and this test needed to be carried out before a treatment plan could be carried out, resulting in the patient breaching the 4 hour standard.05BWait for diagnostics test(s) awaiting resultsRefers to results which will determine the next step in the patient journey.Back to ContentsReason for A&E Wait > 4 hours 2/3Your system’s drop-down code/valueNational code/valueDescription06Wait for first assessment07Clinical reason(s)In the judgement of the senior emergency department doctor and/or nurse involved, the patient’s condition mandates a stay in the emergency department of greater than 4 hours, i.e. where the patient is too ill to be moved.08Major incidentThe A&E department has a formal role as part of a major incident.09Telephone and video reason(s)Issues with telephone and video technology which prevents clinical decision maker and citizen/patient connecting with each other.10DNA Where a citizen/patient is not waiting for the planned video call or a planned telephone call is not answered. Or where a person does not attend for their planned face to face attendance. 98Other reason99Not knownBack to ContentsReason for A&E Wait > 4 hours 3/3DefinitionThe reason(s) for keeping the patient in the A&E department if the patient spends longer than 4 hours between arriving at the A&E department and admission, discharge or transfer.ISD Data Dictionary - Reason for A&E Wait > 4 hours (A& E)Format: CharactersField Length:3Recording notes:this is a mandatory item,this data item is required for the Scottish Executive National Waiting Times target. Reference: ‘Fair (Scottish Executive Edinburgh December 2004),this item should be used to record reasons for breaching which arise BEFORE the 4-hour period is over,if there are multiple reasons contributing to breaching, select the main reason which arose before the 4-hour period is over. This is not necessarily the reason occurring last in the 4-hour period,if the delay in patients leaving the department is due to resource constraints then it cannot be considered a clinical reason. Lack of an appropriate bed for a patient is not a clinical reason. For example, if a patient needs a critical care bed and resuscitation is complete but no bed is available and they remain in the department for over four hours, this should not be counted as a clinical reason,codes and values '07 - Clinical reason' or '98 - Other reason' should only be recorded if values 01 – 06,09 and 10 are not appropriate.Code 09 should be used for virtual appointments only, and where a technical issue, either with the NHS equipment or with the patient’s equipment stops the contact from taking placeCode 10 - should be used for planned contacts whether virtual or face to face and a patient Does Not Attend/join a call for their scheduled contact,your notes:Back to ContentsReferral Source 1/4Your system’s drop-down code/valueNational code/valueDescription01Self Referral To be used when the individual arrives at A&E/MIU without prior contact with ambulance/NHS24/GP services to NOT be used if the patient called the ambulance. 01ABy patientPatient came in to A&E on their ownexcludes ambulance called by patient - see 02c.01BBy associated personPatient brought in to A&E by spouse/parent/child/neighbour/bystanderexcludes ambulance called by spouse/parent/child/neighbour/bystander- see 02c.02Healthcare professional/ service/organisation02AGPUsual or temporary GP practice - usually referrals within working hours, but may be out-with hours where usual GP practice performs out of hours care.02BOOH servicesReferral out-with normal working hours from a primary care OOH service– excludes where usual GP practice performs out of hours care -. see 02A.02C999 emergency servicesThis value should be used when the patient arrives in A&E by ambulance, regardless of who called the ambulance UNLESS the patient was clinically assessed by an HCP, who then makes the decision to call an ambulance.02DNHS2402EMinor injuries unitAt same or different hospital.02FSame hospitalExcludes Minor injuries unit see 02E.02GOther hospitalExcludes Minor injuries unit see 02E.02HOther HCPAnother person acting in their healthcare professional capacity but outwith a hospital, minor injuries unit or GP practice e.g. dentist, private healthcare professional, pharmacist.Back to ContentReferral Source 2/4Your system’s drop-down code/valueNational code/valueDescription02JGP referral for admissionOnly to be used for patients whose GP has assessed them in the community and has then directly arranged an inpatient bed for them, but due to the policy within the hospital all patients must go through the Emergency Department before being admitted to a bed, thereby creating an A&E attendance. N.B. the bed can be in any facility or ward- this code is not just for patients being admitted to Acute Medical/ Assessment Units. See Notes.02KFlow Navigation CentreReferral to A&E from a Flow Navigation Centre. A Flow Navigation Centre is where a clinical decision maker provides virtual urgent consultation and care, by telephone or video, before or as an alternative to onward referral.02LVirtual ClinicWhere a clinic which operates in a virtual capacity refers a patient to A&E for face to face consultation and care.03Local Authority03AEducationE.g. patient brought in to A&E by teacher or school nurse, or arrives with a letter from school nurse.03BSocial ServicesE.g. patient brought in to A&E by social worker or arrives with a letter from social worker.03CPolicePatient brought in to A&E by police, or sent by police nurse or police surgeon.03DOther local authority depart- mentPatient brought in to A&E by other local authority worker e.g. care worker.03ECare or nursing homePatient brought in to A&E by someone from local authority care home.04Private professional/agency/organisation04APrivate care or nursing homePatient brought in to A&E by staff from private care home.Back to ContentsReferral Source 3/4Your system’s drop-down code/valueNational code/valueDescription05Other agency05APrison/penal establishmentPrison medical service sends patient.05BJudicialCourt sends patient to A&E.05CVoluntary organisationE.g. Red Cross brings in patient.05DArmed forcesArmy/airforce/navy personnel bring or send patient to A&E.98OtherThe true value to be recorded is not covered by any of the specific given categories.99Not knownBack to ContentReferral Source 4/4DefinitionA&E referral source is either the individual, healthcare professional or service e.g. police that makes the decision that the person is to attend A&E.ISD Data Dictionary - Referral Source (A&E)FormatCharactersField Length3Recording notes:this is a mandatory item,attendances at GP Out of Hours services are not A&E attendances,where a GP is employed to attend to patients within an A&E department, the attendance is classified as an A&E attendance,an A&E referral may be a verbal or written referral,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.However, in certain circumstances, a referral may be received before a patient presents, e.g. advance notification (usually by telephone) of the imminent arrival of a patient. This will change following the redesign of urgent care and the shift to scheduling consultations and care where appropriate.NOTE all patients who arrive by ambulance should be recorded as 02C 999 Emergency services UNLESS the patient has first been assessed by a health care professional who then makes the decision that the patient should attend A&E, in which case referral source would be recorded using a code from 02 other than 02C,02J GP referral for admission: Hospitals allowing direct admissions, whereby patients can be referred straight to the ward by the GP without passing through the Emergency Department, should not use this code.your notes:Back to ContentsWait to CubicleDefinitionThe time in minutes from arrival to cubicle for assessment/treatment.ISD Data Dictionary – Wait to Cubicle (A&E)FormatNumbersField Length3Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,your notes:Back to ContentsWait to Bed RequestDefinitionThe time in minutes from the decision to admit to a bed being requested. ISD Data Dictionary – Wait to Bed Request (A&E)FormatNumbersField Length3Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,your notes: Back to ContentsWait to Bed AvailableDefinitionThe time in minutes from a bed being requested to a bed becoming available. ISD Data Dictionary – Wait to Bed Available (A&E)FormatNumbersField Length3Recording notes:this is a mandatory item, not applicable where consultation and care is provided in a virtual environment (this applies to emergency/urgent and planned virtual contacts),values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times,your notes:Back to ContentsDue to time constraints involved in the implementation of the redesign of urgent care optional data items will be reviewed with regard to the recording of planned and virtual attendances as part of the formal review in 2021. The exception is the data item Significant Facility which has been updated now (Nov 2020) to add an additional code for Flow Navigation Centre.Optional Data Items in Alphabetical orderBack to ContentsActivity when injured 1/3Your system’s drop-down code/valueNational code/valueDescription01WorkIncludes:01APaidInjury occurred whilst the injured person was working for income. Excludes travelling and those involved in sport or exercise as part of their work.01BUnpaidIncludes unpaid domestic duties such as: caring for children and relatives, cleaning, gardening, household maintenance or other duties for which income is not gained (e.g. unpaid work in a family business).02EducationInjury occurred whilst engaged in formal educational activity as a student, including school sports. Excludes travel toand from school or other place attended for education.Excludes those providing education as part of their work.03Organized sportsInjury occurred whilst participating in supervised sport or exercise. Includes those involved in sport or exercise as part of their work. Excludes physical education at school.04Leisure play, exercise or physical activityRefers to play, hobbies, and other activities undertaken mainly for pleasure, relaxation, or leisure. May be passive (watching TV) or active (dancing at a party), undertaken alone (reading) or with other people. Excludes those involved in supervised sport or exercise during their leisure time, and travelling.Back to ContentsActivity when injured 2/3Case Reference NumberYour system’s drop-down code/valueNational code/valueDescription05TravellingIncludes:05AWork relatedInjury occurred whilst the injured person was travelling by any means in the course of their work.05BCommutingInjury occurred whilst the injured person was travelling by any means travelling to and from work or school/ educational facility.05ZOther travel98Other specified activityIncludes:98AVital activityInjury occurred whilst the injured person was resting, sleeping, eating and other personal activity.98BBeing taken care ofInjury occurred whilst the injured person was being nursed or cared for by someone else.98CReligious/spiritual activities98DGeneral home activities not elsewhere classified99Not knownBack to contentsActivity when injured 3/3CHI NumberMain Source of StandardICECI Guidelines type of activity the injured person was engaged in when the injury occurred. (ICECI)ISD Data Dictionary - Activity when InjuredFormatCharacters Field Length 3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2).your notes:Back to ContentsAlcohol Involved DefinitionA subjective judgement about whether or not the person’s alcohol consumption constituted a factor in this attendance at the Emergency Department.ISD Data Dictionary - Alcohol InvolvedCodes and values01 = Yes02 = NoFormat Characters Field Length 2Recording notes:this is an optional item,in his letter “Alcohol Related Attendances at Accident and Emergency Departments” (11/03/2011) to A&E Clinical Leads, A&E Managers, IT/Information contacts and SAS Contacts, the Chief Medical Officer stated “I would be grateful if, where you have not already done so, you could ensure that this data item is now incorporated into your A&E IT systems, and recording commenced” (see Appendix 1),does the Healthcare Professional think that this person’s alcohol consumption was a factor in this attendance at the Emergency Department? Thisinformation will be subjective as the only way of knowing for definite is to breathalyse or take blood from everyone attending,this data item:can now be sent to ISD Scotland as part of the monthly data submission to the A&E datamart (this may or may not be collected locally);will help to identify the demand placed on EDs as a result of alcohol consumption;will not identify persons who are injured as a result of someone else’s alcohol consumption;this information may be recorded at any point during the patients’ attendance but is generally captured at triage your notes:Back to ContentsBodily Location of Injury 1/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value00None03Face01Intracranial/brain03AOrbit01AFocal03BMaxilla01BDiffuse03CZygoma01CExtradural03DCheek01DSubdural03EUpper lip01ZOther intracranial03FLower lip02Head03GTemporomandibular joint02AScalp03HMandible02BFrontal03ZOther face02CParietal04Eye02DOccipital04AUpper eyelid02ETemporal04BLower eyelid02FCranial nerves04CPeriorbital area02ZOther head04DCorneaBack to ContentsBodily Location of Injury 2/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value04ESclera07Oral cavity04FConjunctiva07AOral mucosa04GLens07BTongue04HIntraorbital tissue07CTeeth04ZOther eye07DTonsil05Nose07EEpiglottis05ASkin07FUvula05BNasal bones07GGingiva05CNasal septum07HPalate05DNasal cavity07JVallecula05ZOther nose07ZOther oral cavity06Ear08Neck06APinna08ASkin and superficial area06BLobe08BLarynx and trachea06CEar canal/external auditory canal08COesophagus (cervical)06DEar drum/tympanic membrane08DBlood vessels06EMiddle ear08EVertebra/spine (cervical)06FInner ear08FCervical cord06ZOther ear08GBrachial plexus08ZOther neckBack to ContentsBodily Location of Injury 3/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value09Thorax10Abdomen09ASkin and superficial fascia10ASkin09BFront wall of chest10BAbdominal wall09CBack wall of chest10CStomach09DBreast10DSmall bowel09ERibs10ELarge bowel09FSternum10FSpleen09GVertebrae/spine (thoracic)10GLiver09HSpinal cord (thoracic)10HGallbladder09JMajor blood vessels10JKidney09KHeart and pericardium10KUreter09LOesophagus (thoracic)10LBladder09MTrachea (thoracic)10MAbdominal aorta09NBronchus10NMajor blood vessels09PLungs10ZOther abdomen09QDiaphragm09ZOther thoraxBack to ContentsBodily Location of Injury 4/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value11Back13Anorectal11ASkin13ARectum11BButtocks13BAnus11CLumbar spine14Pelvis11DLumbar spinal cord14ASacrum11ENerves of lumbar plexus14BCoccyx11ZOther back14CSacro-iliac joint12Genitalia/ Reproductive organs14DPubic ramus12AForeskin14EIlium12BPenis14FAcetabulum12CTestes14GPubic symphysis12DScrotum14HCauda equina12EVulva14ZOther pelvis12FVagina12GUterus & adnexa12ZOther genitalia Back to ContentsBodily Location of Injury 5/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value15Shoulder16Axilla15ASkin16ASkin15BClavicle16BAxillary blood vessels15CScapula16CNerves15DHead of humerus16ZOther axilla15ENeck of humerus17Upper arm15FTuberosity of humerus17ASkin15GShoulder joint17BShaft of humerus15HAcromioclavicular joint17CDistal end of humerus15JSternoclavicular joint17DRadial nerve15KSub-acromial bursa17EBlood vessels15LRotator cuff17FBiceps15MDeltoid17GTriceps15NOther muscle17HOther muscle15ZOther shoulder17ZOther upper arm18Elbow18ASkin18BSupracondylar18CLateral epicondyle18DMedial epicondyle Back to ContentsBodily Location of Injury 6/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value18EHead of radius20Wrist18FNeck of radius20ASkin18GOlecranon20BRadius18HElbow joint20CUlna18JBiceps tendon20DRadius and ulna18KNerves20ETubercle of scaphoid18LBlood vessels20FScaphoid18ZOther elbow20GOther carpal bones19Forearm20HCarpal ligaments19ASkin20JWrist joint19BRadius20KNerves19CUlna20LArtery19DRadius and ulna20MTendons19ENerves20ZOther wrist19FBlood vessels19GMuscles/tendons19ZOther forearmBack to ContentsBodily Location of Injury 7/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value21Hand22Thumb21ASkin of dorsum22ADistal phalanx21BSkin of palm22BInterphalangeal joint21CMetacarpal22CProximal phalanx21DMetacarpophalangeal joint22DMetacarpophalangeal joint21EOther carpal bones22EMetacarpal21FCarpometacarpal joint22FCarpometacarpal joint21GNerves22GTrapezium21HArtery22HMuscles21JMuscles22JArtery21ZOther hand22KNerves23Finger23AIndex finger23BMiddle finger23CRing finger23DLittle finger23EDigital arteries23FDigital nervesBack to ContentsBodily Location of Injury 8/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value24Hip26FLigaments24ASkin26GCartilage24BNeck of femur26HMedial meniscus24CTrochanter26JLateral meniscus24DHip joint26KNerves25Thigh26LBlood vessels25ASkin26MQuadriceps tendon25BShaft of femur26ZOther knee25CDistal end of femur27Lower leg25DMuscles27ASkin25EBlood vessels27BTibia25FNerves27CFibula25ZOther thigh27DTibia and fibula26Knee27EAchilles tendon26ASkin26BPatella26CFemoral condyle26DProximal end of tibia26EKnee jointBack to ContentsBodily Location of Injury 9/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/valueNational code/value27FMuscles29Foot27GBlood vessels29ASkin27HNerves29B1st metatarsal27ZOther lower leg29C2nd metatarsal28Ankle29D3rd metatarsal28ASkin29E4th metatarsal28BLigaments29F5th metatarsal shaft/neck/ head28CLateral malleolus29G5th metatarsal base28DMedial malleolus29HCalcaneus28ETalus29JOther bones28FAnkle joint29KJoints28ZOther bones29LBlood vessels29MTendons/muscles29NNervesBack to ContentsBodily Location of Injury 10/11 Your system’s drop-down code/valueNational code/valueYour system’s drop-down code/value30Toes30ABig toe30B2nd toe30C3rd toe30D4th toe30E5th toe31Multiple body regionsBack to ContentsBodily Location of Injury 11/11 Main Source of StandardAdapted from ICD-10 chapters.DefinitionThe bodily location of the injury chiefly responsible for occasioning the attendance of the person at the health care facility.ISD Data Dictionary - Bodily Location of InjuryFormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),it is recommended that the 2 character codes and values should be used as the absolute minimum, but ideally the relevant sub-values should also be implemented (3 character codes). Further subdivisions at a third level may be recorded locally if greater detail is required.your notes:Back to ContentsCommon Preventive Measures 1/8 Your system’s drop-down code/valueNational code/valueDescription00None01Prevention of Transport injuries01ASeat belts01BChild safety seats01CAir bags01DHeadrests01EHelmetsFor cyclists and motor cyclists.01FProtective/High Visibility Clothing01GGoggles for motorcycle and moped riders01HPedestrian crossing01JCycle lanes01KWarning devicesE.g. reflective triangles, cones or flashing amber lights.01ZOtherBack to ContentsCommon Preventive Measures 2/8 Your system’s drop-down code/valueNational code/valueDescription02Prevention of injuries due to Falls02AAnti-slip productsIncludes stickers on the floor or bath, bath safety mats.02BStair safety gates02CGrab bars02DSafety catches on windows02EHarness02FImpact-absorbing surfaces02GSafety glass on windows02HOccupational fall prevention activitiesIncludes such as full body harness, safety boards, warning signs, building codes and regulations, etc.02ZOther03Prevention of poisoning03AChild-resistant containers03BChild safety catches/locksOn drawers, cupboards, etc.03CCarbon monoxide alarms03ZOtherBack to ContentsCommon Preventive Measures 3/8 Your system’s drop-down code/valueNational code/valueDescription04Prevention of thermal injuries04AFunctioning smoke alarms/detectorsElectric or battery operated.04BFire alarms04CSprinkler systems04DFire fighting equipmentFire extinguisher, fire blanket.04EFire guards04FShort cords on appliancesOn electric appliances etc; e.g. kettles, irons etc.04GCooker and hob guards04HWater temperature regulationMixer taps, thermostatic mixing valves.04ZOther05Prevention of injuries due to contact with inanimate objects05ACorner guards on furniture05BPadding on other structures05ZOtherBack to ContentsCommon Preventive Measures 4/8 Your system’s drop-down code/valueNational code/valueDescription06Prevention of injuries due to crushing force06ADoor slam protectors06BMachine guards06ZOther07Prevention of injury caused by piercing, penetrating force07ASafe storageE.g. guns and ammunition locked in separate locations.07BOccupational protective apparelE.g. meat aprons and mesh gloves, bullet proof vest.07CSafety glass07ZOther08Mechanical threat to breathing08AToy safety adviceIncludes age recommendations, warning symbols and safety marks on toys, e.g. European Standard BS EN 71, Lion Mark, CE mark.08ZOther09Drowning/near drowning09ALifejackets and personal buoyancy aids09BAdequate supervision09CPresence of Life guardBack to ContentsCommon Preventive Measures 5/8 Your system’s drop-down code/valueNational code/valueDescription09DNational water safety signs09EFenced home swimming pools09FBarriers for residential hot tubs, spas and Jacuzzis09ZOther10Sports injury10AAdequate supervision10BBraces, guards, orthoses10CRigid taping of joint10DPadding10ESplints10FWet suits10GJock straps, protective cups10HGloves10JMouth guard10KEye goggles, protective glassesBack to ContentsCommon Preventive Measures 6/8 Your system’s drop-down code/valueNational code/valueDescription10LHelmet10MFace mask10NAppropriate foot wear10PProtective padding on competition surface10QPadded goal posts, corner markers10RPhysical conditioning and stretching10ZOther11Playground safety11AImpact-absorbing surfaces11BFenced play areas11CSeparated play areas for different ages11ZOther12Occupational safety12ACodes, guidelines and regulations12BEye protectionIncludes safety spectacles, goggles, face shields, visors etc.Back to ContentsCommon Preventive Measures 7/8 Your system’s drop-down code/valueNational code/valueDescription12CHard hats, helmets12DEarmuffs, headphonesProtection against noise.12EFilters and facemasksProtection against dust, vapours, and oxygen deficient environments.12FSpecialist protective clothingDisposable overalls, boiler suits, chain mail aprons etc.12GGloves, gauntlets, mitts etcProtection against cuts, temperature extremes, electric shock etc.12HSafety bootsProtection against slipping, cuts and punctures, falling objects, metal and chemical splash etc.12ZOther98Other99Not knownBack to ContentsCommon Preventive Measures 8/8 DefinitionThe presence of measures or devices in place, installed, worn, or otherwise situated to prevent injury to persons.ISD Data Dictionary - Common Preventive MeasuresFormatCharactersField Length3Recording notes:this is an optional item,specific protective devices, clothing and equipment have a role in minimising harm in a number of hazardous situations. Identification of cases in which such items were, and were not, in use is potentially of use as a basis for conducting studies of their protective effect, and for assessments of the potential population benefits of increasing the prevalence of use.your notes:Back to ContentsDate and Time Completion of Treatment Source of StandardDerived from NHS Connecting for Health (England).DefinitionThe date and time, recorded using a 24 hour clock that a patient's treatment in A&E is completed and they are ready for discharge, admission or transfer.ISD Data Dictionary - Date and Time of Completion of Treatment (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is an optional item,this date and time is not necessarily the same as date & time of discharge, admission or transfer. For those patients admitted into hospital, or transferred from A&E, the date and time of completion of treatment is recorded as the time when the decision to admit or transfer was made,for those patients who died or had an incomplete discharge, the date and time of completion of treatment (attendance concludes) is recorded as the time when the patient was declared dead by a clinician or when the incomplete discharge was recorded,all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times.your notes:Back to ContentsDate and Time of Event Main Source of StandardNDS-IS level 2 date and time when a particular event, incident or injury occurred.ISD Data Dictionary - Date and Time of EventFormatCharacters CCYY-MM-DDThh: mm: ssTZDField Length25Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),in the case of injury, the actual date of injury will usually be known, although time of injury will often be an estimate, in which case it can be rounded to the nearest hour, half hour, etc. Where an injury had gradual onset, then this is the date and time when it was first noticed,all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times.your notes:Back to ContentsDate and Time of First Full Clinical Assessment DefinitionThe date and time when a clinical assessment that results in positive progress of the patient through the A&E department is made by either a doctor or emergency nurse practitioner. This may be when the decision to treat is made.ISD Data Dictionary - Date and Time of First Full Clinical Assessment (A&E)FormatCharacters (CCYY-MM-DDThh:mm:ssTZD)Field Length25Recording notes:this is an optional item,n.b. this is the date and time the assessment STARTS, not when it ends,at this stage, active, positive intervention may occur (e.g. issuing pain relief) to advance the progress of the patient through the A&E department. This does not include initial triage assessment,all times must be expressed in the 24 hour clock format, e.g. one minute past midnight is 00:01:00,values of any element less than 10 should be entered with a zero in the first position,all times for UK transactions/events will be assumed to be GMT,systems should record whether the time is Coordinated Universal Time or British Summer Time in the "Time zone designator". This will allow time elapsed to be calculated correctly, for example for A&E waiting times.your notes:Back to ContentsDischarge Type 1/2 Your system’s drop-down code/valueNational code/valueDescription01Discharged01AWith no follow upDid not require any follow up treatment (other than GP letter). Includes patients treated and discharged by nurse.01BWith follow up by Primary Care teamFollow up treatment to be provided by patient's own GP/other member of the Primary Care Team. Includes specialist GPs/nurses, own dentist, etc.01CWith referralReferral made to another professional, service or organisation. Includes referral to an out-patient clinic.02AdmittedTo same health care provider/hospital.03TransferredTo other health care provider/hospital or to another emergency department within same hospital (e.g. Minor Injuries Unit to A&E department).04Incomplete04APatient left before assessment completed04BPatient left before being treated04CPatient refused treatment04DPatient left after treatment started04EPatient removed by policeE.g. into police custody.05Died05ADied in department05BDead on arrival05CDied at sceneOnly applies where A&E retrieval team has gone to provide care to patient at scene.98Other99Not knownBack to ContentsDischarge Type 2/2 DefinitionThe outcome of an attendance or series of attendances at an A&E department in connection with a specific complaint.ISD Data Dictionary - Discharge Type (A&E)FormatCharactersField Length3Recording notes:this is an optional item,see General Recording Guidance - Admission, discharge, referral, and transfer,transfer from one emergency department to another within the same hospital e.g. MIU to A&E should be recorded as ‘03 Transfer’,it is recommended that the 2 character codes and values should be used as the minimum. For those departments wishing to record Discharge Type in greater detail, then the relevant sub-values can also be implemented (full 3 character codes). Local sub-values for,'02 - Admitted', '03 - Transferred' and '98 -Other' can be developed as appropriate.your notes:Back to ContentsExternal Cause of Injury 1/6 Your system’s drop-down code/valueNational code/valueDescription00None01TransportAll injuries that involve a device designed primarily for, and being used at the time primarily for, conveying persons or goods from one place to another. Include falls in or from transport device when not involved in a derailment, collision, or crash.01APedestrian01BCycle01CMotor cycle01DCar01EBus01FInvolvement of other land transportIncludes truck, train, underground, tram, etc.01GWatercraftIncludes passenger and merchant ship, fishing boats, yachts, sail boats, kayak, canoe, etc.01HAircraftIncludes powered aircraft such as aeroplane, helicopter, etc, and unpowered aircraft such as balloon, glider, hang glider, etc.01ZInvolvement of other modes of transportHovercraft, construction vehicles, snowmobiles, Quad bikes etc.Back to ContentsExternal Cause of Injury 2/6 Your system’s drop-down code/valueNational code/valueDescription02Falls02AFall on same level or from below 1 metre02BFall from height of 1 metre or more02CFall into hole or other opening in surface02DDiving or jumping into water03Poisons & drugs03AFood03BAlcohol03CMedication03DIllegal drugsIncludes opiates, cocaine, ecstasy etc.03ESolvents03FHousehold products03GPlants and berries03HVenom03ZOther substancesBack to ContentsExternal Cause of Injury 3/6 Your system’s drop-down code/valueNational code/valueDescription04Thermal04AHot liquid or steam04BHot object04CFlame04DRadioactivity04EElectricity04FChemicals04GSmoke inhalation04HExposure to excessive heat04JExposure to extreme cold04ZOther thermal causesContact with or inhalation of dry ice, liquid air, nitrogen, or hydrogen.05Contact with object or animal05AMoving objectBlunt weapon e.g. cudgel, sports equipment, e.g. hockey stick.05BStatic objectIncludes walking into a wall.05CStruck by thrown or falling objectIncludes falling rock, stone or tree, cave-in, collapse of building (other than by fire), struck by thrown ball while standing still. Excludes being shot by firearm, collapse of burning building, etc.05DContact with animalIncludes being struck or kicked by animal. Excludesbeing bitten, scratched or clawed by animal.Back to ContentsExternal Cause of Injury 4/6 Your system’s drop-down code/valueNational code/valueDescription06Contact with person06AStruck or kicked by a personIncludes hit, struck, kicked, shaken, head butted or twisted by another person - whether intentional or not. Force applied by oneself.06BSexual assaultIncludes rape, attempted rape, sodomy, and attempted sodomy.06ZOther personal contact07Crushing force07APinching, crushing between objectsCaught or jammed between stationary and moving objects.07BCrushed beneath an object07CCrushing between personsCrushed by or in a crowd.07ZOther crushing08Piercing/penetrating force08AScratching, cutting, tearing, severingIncludes cut by knife, broken glass, severing of a body part with an axe, etc. Excludes human bite or animal bite.08BPuncturing, stabbingIncludes penetrating/piercing wounds caused by knife, sword, sharp glass, etc.08CShootingIncludes shooting by bullet, pellet, lead shot, arrow, etc.08DBites, stingsIncludes being bitten by oneself, another person or being bitten or stung by venomous or non-venomous animal or insect.08ZOther piercing or penetrating forceBack to ContentsExternal Cause of Injury 5/6 Your system’s drop-down code/valueNational code/valueDescription09Mechanical threat to breathing09AHanging09BStrangling09CExternal compression of airway or chest09DChokingIncludes effect of cave-in.09ESuffocation09ZOther mechanical threat to breathing10Drowning/near drowning10AFollowing fall into water10BWhile in a body of water11Foreign body12Complication of medical/surgical care98Other external cause98APhysical overexertion98BExposure to (effect of) weather, natural disaster, or other force of nature98CExposure to sound and vibration98DAir pressureIncludes effects of deep water diving, mountain sickness, exposure to high altitudes, etc.98ENeglect, abandonmentIncludes starvation, dehydration, destitution' etc.99Not knownBack to ContentsExternal Cause of Injury 6/6 Main Source of StandardAdapted from ICD-10, ICECI event, circumstance or condition associated with the occurrence of injury, poisoning or violence. (NDS-IS)ISD Data Dictionary - External Cause of InjuryFormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),record only one External Cause of Injury. If more than one external cause is involved, select either the cause associated with the most severe injury or the cause considered most important,it is recommended that the 2 character codes and values should be used as the absolute minimum, but ideally the relevant sub-values should also be implemented (3 character codes).your notes:Back to ContentsHCP Responsible for Care DefinitionThe health professional responsible for care (HCP) is the person who carries clinical responsibility for a patient's healthcare during an episode. This is usually a consultant but may be another healthcare professional, for example a midwife or GP.ISD Data Dictionary - Healthcare Profession CodeCodes & ValuesThe 8 digit personal identification number (PIN) allocated to other healthcare professionals (e.g. midwives) is used as the HCP code. In the case of a midwife the PIN consists of an 8 character alpha/numeric code, although this format may differ for other HCPs (e.g. Podiatrists).The 7 digit General Medical Council (GMC) Number allocated to each doctor is used as the consultant code. The GMC number can consist of 7 numeric, L + 6 numeric.Recording notes:this is an optional item,a healthcare professional (HCP) is a person who is contracted to provide a healthcare service to a patient. A healthcare professional is associated with either a specialty or a discipline and belongs to one of the following groups: medical and dental staff (associated with one or more specialties) nurses, midwives and health visitors professions allied to medicine (PAMs), e.g. clinical psychologists, dieticians, physiotherapy. Accident & Emergency ambulance staff/paramedics other professionals who have direct patient contact, e.g. pharmacists, medical photographers.your notes:Back to ContentsImpairment Your system’s drop-down code/valueNational code/valueDescription00None01Specific learning difficulties02Hearing impairment03Language and communication disorder04Physical or motor impairment05Visual impairment06Cognitive impairment07Combined sight and hearing loss98Other impairment99Not knownDefinitionAn indicator of whether the client/patient has any impairment, which may affect the ability of professionals to communicate with the client/patient, or may impact on the assessment process or the delivery of services.ISD Data Dictionary - ImpairmentFormatCharactersField Length2Recording notes:this is an optional item.your notes:Back to ContentsIntent of Injury 1/2 Your system’s drop-down code/valueNational code/valueDescription01UnintentionalIncludes accidental injury event. Injuries to children under age five years who harm themselves should be regarded as unintentional, except in the case of a child who bangs his or her head in anger or frustration. Includes injuries resulting from animal attacks, unless the animal was used as a weapon by a person intent on inflicting injury.02Deliberate self-harm02ASelf-mutilation02BChild intentional self-harmIncludes injuries to children under age five years who harm themselves by banging his or her head in anger or frustration.02CAttempted suicideIncludes suicide, parasuicide (incomplete suicide attempt).02ZOther self-harm03Assault03ASexual03BUse of bodily forceExcludes sexual assault.03CBy use of objects/substancesObjects/substances involved in producing injury.03DIndirect involvementIncludes injuries sustained by a bystander to a violent event, or by a non-combatant in a conflict.03ZOther98Other intent98ALegal/politicalIncludes legal intervention, operations of war, terrorism or civil conflict.98BComplications of medical or surgical careOnly if relevant to nature of injury.98ZOtherIncludes euthanasia.99Not knownIncludes unspecified intent and injury resulting from unknown event.Back to ContentsIntent of Injury 2/2 Main Source of StandardAdapted from ICECI role of human intent in the occurrence of the injury as assessed by the treating practitioner. (NDS-IS)ISD Data Dictionary - IntentFormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),personal, social, and legal sensitivities often apply to intentional conceptual reasons, therefore determination of the intent of injury cases is often difficult. In general, intent is primarily determined by the event and not by the resulting injury,select one code that best describes the intent of the injury event,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).your notes:Back to ContentsInvestigation Type 1, Investigation Type 2, Investigation Type 3 1/2 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value00None05Biochemistry01Radiology05ABlood alcohol01AX-ray05BBlood gases01BComputerised Tomography (CT)05CBlood glucose01CUltrasound05DPregnancy test/HCG01DMagnetic Resonance Imaging (MRI)05EToxicology/drug levels01ZOther radiology05ZOther biochemistry02Cardiac investigations06Microbiology02AECG06ABacteriology02BEchocardiogram06BVirology02ZOther cardiac investigation06ZOther microbiology03Haematology07Histology03AFull blood count08Near patient testing03BClotting studies08AUrinalysis03CESR08BPeak flow03ZOther haematology08CSlit lamp examination04Cross match08ZOther near patient test98Other investigation99Not knownBack to ContentsInvestigation Type 1, Investigation Type 2, Investigation Type 3 2/2 Main Source of StandardDerived from NHS Connecting for Health (England).DefinitionA broad coding of types of investigation which may be requested to assist with diagnosis during attendance at an A&E department.ISD Data Dictionary - Investigation Type (A&E)FormatCharactersField Length3Recording notesthis is an optional item,any single record of attendance may record up to three values for Investigation Type (hence Investigation Type 1, Investigation Type 2 and Investigation Type 3),therefore IT systems should allow for the multiple recording of this data item,appropriate sub-codes and sub-values can be further developed if required locally provided they map to the codes and values in the table above,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).your notes:Back to ContentsNature of Injury 1/4 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value00None02DFracture dislocation01Wound03Soft tissue injury01AAbrasion03ACrush injury01BContusion includes bruise, haematoma03BLigament avulsion01CBlisters03CLigament tear01DLaceration03DLigament rupture01EIncision03ELigament strain01FNeedlestick03FMuscle avulsion01GBite animal03GMuscle tear01HBite human03HMuscle rupture01JBite/sting insect03JMuscle strain01KFlap laceration03KTendon dislocation01LDegloving wound03LTendon rupture01MPenetrating wound03MTendon subluxation01NSkin avulsion03NTendon strain01ZOther03PTendon division02Bone and joint injury03QNeuropraxia02AClosed fracture03RNerve compression02BOpen fracture03SComplete transection of nerve02CDislocation of joint03TPartial division of nerveBack to ContentsNature of Injury 2/4 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value03UNerve contusion06FArterial transection03VNerve entrapment06GVenous haemorrhage03ZOther Soft tissue injury06HVenous contusion04Head injury06JVenous avulsion04AConcussion06KVenous rupture04BExtradural haemorrhage06LVenous transection04CSubdural haemorrhage06ZOther vascular04DTraumatic cerebral oedema07Visceral injury04ZOther head injury07ATraumatic haemothorax05Dental injury07BTraumatic pneumothorax05AAvulsion07CPulmonary contusion05BFracture07DTraumatic haemopneumothorax05ZOther dental injury07ETraumatic haemopericardium06Vascular injury07FCardiac contusion06AArterial haemorrhage07GPneumomediastinum06BArterial contusion07HRupture *06CArterial avulsion07JPerforation *06DArterial perforation07KAvulsion *06EArterial rupture* Refer ‘Bodily Location of Injury’ for specific visceral organsBack to ContentsNature of Injury 3/4 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value08Burn12Hypothermia08A1st degree/duperficial13Frostbite08B2nd degree/partial thickness13ASuperficial08C3rd degree/full thickness13BWith tissue necrosis09Scald13ZOther frostbite10Corrosion14Poisoning excludes corrosions10A1st degree15Electric shock10B2nd degree16Multiple injuries10C3rd degree98Other nature of injury11Injury related to heat exposure11AInjury related to heat exposure11BHeat rash11CHeat cramps11DHeat/sunstroke11ZOther injuries related to heat exposureBack to ContentsNature of Injury 4/4 Main Source of StandardICD-10DefinitionThe nature of the injury chiefly responsible for occasioning the attendance of the person at the health care facility. (NDS-IS) pubs/manuals/ndsis/ndsisman.htmlISD Data Dictionary - Nature of InjuryFormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),it is recommended that where Nature of Injury is recorded, IT systems should require the recording of Bodily Location of Injury, where appropriate,it is recommended that the 2 character codes and values should be used as the absolute minimum, but ideally the relevant sub-values should also be implemented (3 character codes).your notes:Back to ContentsObjects/Substances Involved in Producing Injury 1/11 Your system’s drop-down code/valueNational code/valueDescription00None01Land transport01APedal cycleIncludes bicycle, mountain bikes, cycle rickshaws.Excludes child's toy tricycle, ride on toys.01BMotorised two/three wheelersIncludes motorcycles, mopeds.01CLight transport vehiclesIncludes cars, minibuses, small vans etc.01DHeavy vehiclesIncludes bus, coach, trucks, trailers etc.01ERail transportIncludes trains, trams, funiculars, street cars, monorail etc.01FParts/components of vehicleIncludes vehicle doors, airbags, steering wheel, seat belts, windscreen/windshield, engine, tyres etc.01GAnimal being riddenIncludes horses, camels, elephants, donkeys etc.Excludes other contact with animals.01HAnimal drawn cartsExcludes animal drawn farm machinery.01JSpecial purpose vehiclesIncludes ambulances, fire engines police cars etc.01ZOtherIncludes motor homes, cable cars, ski chair lifts etc.02Watercraft02APowered watercraftIncludes merchant ships, passenger ships, motorized trawlers, motorboats, ferries, jet skis, submarines, houseboats, hovercrafts etc.02BUnpoweredIncludes sailboat, rowboat, canoe, kayak, surfboard, windsurfer, paddle ski etc.02CPart/component of watercraftIncludes boarding plank, propeller, machinery, oars etc.02ZOther watercraftAny watercraft not included elsewhere.Back to contentsObjects/Substances Involved in Producing Injury 2/11 Your system’s drop-down code/valueNational code/valueDescription03Aircraft03APowered aircraftIncludes passenger and cargo aeroplanes, helicopters, fixed wing aircraft, spacecrafts etc.03BUnpowered aircraftGliders, hang gliders, parachutes, balloons etc.03CPart/component of aircraftBoarding steps, propellers, machinery, overhead lockers etc.03ZOther aircraftAny other type of aircraft or air transport not included elsewhere.04Mobile machinery04AAgriculturalIncludes tractors, harvesters, fertilizer spreaders, ride on lawnmowers, animal drawn machinery etcExcludes fixed machines e.g. threshers, fodder cutter etc.04BIndustry/constructionIncludes forklifts, mobile crane, bull dozer, excavator, digger, mechanical shovel, road roller etc.04ZOther05Tool, machine, work related machinery05AFixed machineryIncludes cutting, slicing, crushing machinery, conveyors, lathes, threshers, garbage compactors etc.05BPowered hand toolIncludes power drills, chainsaws, welding equipment, powered garden equipment, powered push lawnmower, nail gun, sander, polisher etc.05CUnpowered hand toolIncludes push lawnmower, hammer, mallet, axe, hatchet, chisel, handsaw, spade, shovel, pitchfork, nail, screw, tack etc. Excludes cutting tool when used as weapon.05DPressure based equipmentIncludes gas cylinders, pressurized hose pipe etc.05ZOther equipmentLadder, scaffolding, welding mask, helmet, gloves etc.Back to ContentsObjects/Substances Involved in Producing Injury 3/11 Your system’s drop-down code/valueNational code/valueDescription06Household furniture/furnishing, appliances and utensils06AFurniture/furnishingsIncludes bed, bedding, chair, cot, table, cupboard, curtains, decoration, decorating items etc.06BKitchen/cooking appliancesIncludes cookers, stoves, electric kettles, barbeques, toasters, blenders, deep fat fryers, microwave ovens, dishwashers, refrigerators, freezers etc.06CCleaning or laundry applianceIncludes washing machine/drier, clothes iron, clothes line, clotheshorse, broom, mop, duster, vacuum cleaner, etc.06DLighting appliancesIncludes electric lamps, lampshades, candle, candlestick, battery operated torch etc.06EHeating or cooling appliancesIncludes radiators, heaters, fans, boilers hot water systems etc.06FEntertainment/office appliancesIncludes television, radio, sound systems, personal computers and accessories.06GUtensil or containerIncludes cutlery, crockery, pressure cooker, cooking vessels, kitchen knife, glassware, food containers, rubbish bins, cleaning utensils like pail, bucket etc. Excludes knives used as weapons.06ZOtherIncludes sewing equipment, needles, threads etc.07Infant or child products07ABaby/child equipmentIncludes articles used for bedding, working with, confining or transporting a baby or child, e.g. pram, baby walker, potty, cot, play pen, barriers, baby carrier, dummy, etc.07BToysIncludes tricycles, toy guns, knives, board games accessories, marbles, balls, balloon, play house, dolls, bow and arrow designed as a toy etc.07CPlayground equipmentIncludes tree house, monkey bar, slide, swing, see saw, amusement rides etc.07ZOther infant or child products.Includes merchant ships, passenger ships, motorized trawlers, motorboats, ferries, jet skis, submarines, houseboats, hovercrafts etc.Back to ContentsObjects/Substances Involved in Producing Injury 4/11 Your system’s drop-down code/valueNational code/valueDescription08Weapon08AKnifeIncludes hunting, flick and sheath knife, kitchen knife, Stanley knife, cutting tool used as weapon.08BBroken glassIncludes broken bottles, window glass etc.08COther sharp objectsIncludes arrow, dagger, spear, machete, and bayonet.08DAir gun08EShot gun08FHandgun08GRifle08HOther firearm related objectsIncludes rubber bullets, pellets etc.08ZOther weaponsClub, cudgel, rod, sprays, electrical prod, stun gun etc.09Hot objects/substances09AHot water09BHot air and gases09CMolten metal09DFire/flameIncludes burning oil, fire in fireplace, campfires, open fires for cooking etc.09ESmoke09ZOtherBack to ContentsObjects/Substances Involved in Producing Injury 5/11 Your system’s drop-down code/valueNational code/valueDescription10Sports equipment10AFootball10BSquash ball10CTennis ball10DGolf ball10ECricket ball10FHockey ball10GBaseball10HBats10JRacquets10KRoller skates10LSkateboards10MSki equipment10NTrampoline10PFitness equipment10ZOtherIncludes nets, goal posts, diving board.Back to ContentsObjects/Substances Involved in Producing Injury 6/11 Your system’s drop-down code/valueNational code/valueDescription11Animal, plant or person11ADog11BCat11CHorse11DOther mammals11EBird11FInsect11GJelly fish11HShark11JOther marine animal11KSnake11LVenomous frog11MOther venomous reptile or amphibian11NPlants11PBerry11QFungi11RPerson - self11SPerson - other11ZOther animal or plantBack to ContentsObjects/Substances Involved in Producing Injury 7/11 Your system’s drop-down code/valueNational code/valueDescription12Building, building component, fitting etc12ABath12BShower12CToilet12DDoor12EWindow12FFloorIncludes carpet, wood, brick floor etc.12GWall12HFireplace12JStairs12KLift12LEscalator12MGate/fence12NElectric fittings12PRoof12ZOther building component, fixtureIncludes balcony.Back to contentsObjects/Substances Involved in Producing Injury 8/11 Your system’s drop-down code/valueNational code/valueDescription13Surface13ACliff13BSlope/ramp13COpen drain13DLake13ERiver13FSea13GSwamp/marsh13HSnow13JIce13KGrass13LGravel13MMan made surfaceIncludes artificial grass, asphalt, tarmac etc.13ZOther types of surface14Food or drink related14ASolid food14BDrinks14CVomit/regurgitated food14ZOtherBack to ContentsObjects/Substances Involved in Producing Injury 9/11 Your system’s drop-down code/valueNational code/valueDescription15Medicines and drugs15APrescribed medicines15BOver the counter medicines15CStreet/recreational drug15DAlcohol15EHerbal and complementary medicines15ZOther16Non pharmaceutical chemicals16AGlue or adhesive16BFuel/solvent16CPaint, varnish16DPesticides16EHerbicides16FCarbon monoxide16GMercury16HLead16JDyes16KCleaning agents16ZOtherBack to ContentsObjects/Substances Involved in Producing Injury 10/11 Your system’s drop-down code/valueNational code/valueDescription17Law enforcement equipmentExcludes firearms, cudgels etc.17AHandcuffs17BWater cannon17ZOther18Explosive material18AFireworks18BDynamite18CHomemade bombs18ZOther98OtherMaterial such as clothing and other personal equipment.99Not knownBack to ContentsObjects/Substances Involved in Producing Injury 11/11 Main Source of StandardICECI is the specific object or substance that contributed to causing the injury or was wholly responsible causing the injury. This may include objects/substances producing the actual physical harm, those involved at the start of the injury event and those otherwise involved in the injury event.ISD Data Dictionary - Objects/Substances Involved in Producing InjuryFormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),where there are multiple injuries, code the object/substance producing the most severe injury.your notes:Back to ContentsPatient Management Type Your system’s drop-down code/valueNational code/valueDescription01ResuscitationPatients underwent resuscitation, regardless of outcome.02MajorPatients required a longer period of assessment and observation in addition to diagnostics and treatment.03MinorPatients treated and discharged relatively quickly and who may have had straightforward diagnostic assessment eg. Single plain X-ray.99Not knownDefinitionA retrospective classification of the patient according to the clinical management received during their A&E attendance.ISD Data Dictionary - Patient Management Type (A&E)FormatCharactersField Length2Recording notes:this is an optional item.your notes:Back to ContentsPatient Year of Birth DefinitionThe year which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate.Main Source of StandardMain Source of Standard: Government Data Standards Catalogue Government Data Standards Catalogue.Recording notes:this is an optional item,a notional birth date may be recorded where an informant has reported an approximate age for a person whose actual date of birth is unknown.your notes:Back to ContentsPlace of Occurrence of Incident 1/3 Your system’s drop-down code/valueNational code/valueDescription01Place of residenceIncludes:01AHomePerson's home, home of third party, farmhouse, home premises, house, non-institutional place of residence, apartment, boarding house, private caravan park (residential).01BResidential institutionHome for the elderly, nursing home, prison, children's home, hospice, military institution, etc.02Transport areaIncludes:02APublic highway, street or roadPublic-owned highway, street or road, pavements or cycle path.02BOther transport areaPrivate road, ferry terminal, parking area, public transport area/facility such as bus terminal, railway station, underground station, airport, pedestrian mall, railway line etc.03Business areaExcludes Recreation & sports areas.Includes:03AIndustrial or construction areaIndustrial buildings, other structures, excavations and adjacent grounds. Demolition sites, mines quarries, factory/plant, oil and gas extraction facility, power station etc.03BFarm or other place of primary productionFarm or other place of primary productionExcludes injuries occurring in the residential area of a farm, where the farm is the injured person’s home.03CCommercial area - non recreationalShop, store, commercial garage, office building, café, hotel, restaurant, casino, bar, dance/night club, swimming pool of hotel, etc.Back to ContentsPlace of Occurrence of Incident 2/3 Your system’s drop-down code/valueNational code/valueDescription04School, educational areaAny educational establishment, - nursery, school, college, university. Includes actual educational building and associated grounds, e.g. school playground.05Sports & recreational areaIncludes:05ASports and athletic areaAny place specifically intended for formal sporting purposes, e.g. leisure centre. Excludes places where informal sporting recreation may take place.05BRecreational area, cultural area or public buildingPrimarily 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 reli- gious place.05CCountryside/open nature areaArea not classified elsewhere e.g. beach, cave, forest. Includes injuries occurring in water or the sea, where not part of a formal transport areae.g. marsh/swamp, river, loch.06Medical service area/ healthcare areaAny formal healthcare establishment, including hospital, health centre, mobile screening van, etc98Other specifiedThe true value to be recorded is not covered by any of the specific given categories.99Not knownBack to contentsPlace of Occurrence of Incident 3/3 DefinitionWhere the person was when the incident started. This refers to the high level type of area, building or place where the injury event commenced.ISD Data Dictionary - Place of Occurrence of Incident {A&E}FormatCharactersField Length3Recording notes:this is an optional item,see CMO’s letter on ‘Injury Data Collection Project At Accident And Emergency Departments’ (Appendix 2),record where the person was when the injury-causing incident STARTED,generally “a place” includes any attached grounds, outbuildings, etc belonging to it e.g.:home includes the dwelling, garden, garage, shed, driveway, paths, swimming pool in house or garden,factory/plant includes buildings, roadways, parking areas, industrial yards.record this item at a high level - choose a category referring to the whole entity (i.e. a structure or space owned or operated as a whole) within which an injury occurred, rather than a category referring to only a part of such an entity. For example if an injury occurs in a:hotel swimming poolcode as03C commercial area - non recreational,school swimming poolcode as04 school/educational area,sports centre swimming poolcode as05A sports and athletic area.if patient has different injuries occurring in different places, select the place associated with the most severe injury,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).your notes:Back to ContentsPresenting Complaint DefinitionThe main complaint that the patient presents with at the Emergency Department.ISD Data Dictionary - Presenting ComplaintFormatFree textRecording notes:this is an optional item.your notes:Back to CommentsProcedure1, Procedure2, Procedure3 1/3 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value00None04Procedure on bones & joints01Wound care04AReduction of dislocation01AToilet only04BManipulation of fracture01BDebridement04CJoint aspiration/injection01CRemoval of foreign material04ZOther procedure on bones & joints01DDressing05Airway management01EWound closure05ANasopharyngeal airway01ZOther wound care05BLaryngeal mask02Burn care05CIntubation02AToilet only05DSurgical airway02BDebridement05ZOther airway management02CRemoval of slough06Ventilation02DDressing06AManual02ZOther burn care06BMechanical03Limb immobilisation07Circulatory support03APlaster immobilisation07AExternal cardiac massage03BSplint immobilisation07BCardio-version including defibrillation03ZOther limb immobilisation07CTemporary pacingBack to ContentsProcedure1, Procedure2, Procedure3 2/3 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value07DFluid resuscitation11Other specific procedures07EBlood transfusion11ARemoval of foreign body from orifice07ZOther circulatory support11BGastric lavage08Vascular access11CUrinary catheterisation08ACentral venous access (including femoral)11DIncision & drainage08BArterial line98Other08CIntra-osseous access99Not known08ZOther vascular access09Pleural cavity procedures09AAspiration09BInsertion of chest drain09ZOther pleural cavity procedures10DecontaminationBack to ContentsProcedure1, Procedure2, Procedure3 3/3 DefinitionA broad coding of types of procedure which may be performed upon a patient during attendance at an A&E department.ISD Data Dictionary - Procedure (A&E)FormatCharactersField Length3Recording notes:this is an optional item,this data item may be used to submit up to three procedures in any single record of attendance (hence Procedure1, Procedure2 and Procedure3),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).your notes:Back to ContentsReferred to1, Referred to2, Referred to3 1/3 Your system’s drop-down code/valueNational code/valueOther agency01Clinic01AA&E clinic01BFracture clinic01ZOther clinic02Healthcare professional/ service or organisation02AGP02BPractice nurse02CCommunity nurseExcludes Community psychiatric nurse.02DSpecialist nurse02EPhysiotherapist02FOther AHP02GDentist02HMental health serviceIncludes Community psychiatric nurse.02JCommunity pharmacy02ZOtherBack to ContentsReferred to1, Referred to2, Referred to3 2/3 Your system’s drop-down code/valueNational code/valueDescription03Local authority03AEducation03BSocial work03ZOtherIncludes Police.04Private agency/ organisation05Other agencyIncludes voluntary agency.06Drug/alcohol serviceMay be provided by health service, local authority, private or voluntary agency.98Other99Not knownBack to ContentsReferred to1, Referred to2, Referred to3 3/3 DefinitionThe professionals, services or organisations a patient may be referred on to for the purpose of further investigation and/or ongoing care following an attendance at an A&E department.ISD Data Dictionary - Referrals (A&E)FormatCharactersField Length3Recording notes:this is an optional item,see General Recording Guidance - Admission, discharge, referral, and transfer,patients may be referred on to more than one professional, service or organisation, so more than one may be recorded. If they are discharged from A&E it does not necessarily mean that their health problem/issue no longer exists. The problem may be best dealt with by referral to another professional for subsequent investigation or treatment,NOTE that Referred to should not be used to record the ward of admission, the healthcare provider to which the patient is being transferred or the discharge destination,this data item may be used to submit up to three values in any single record of attendance (hence Referred to1, Referred to2, Referred to3),therefore IT systems should allow for the recording of multiple values,appropriate sub-codes and sub-values can be further developed if required locally (e.g. Rapid access chest pain clinic as a sub value of 01Z Other clinic) provided they map to the codes and values in the table above,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).your notes:Back to ContentsReligion 1/2 Your system’s drop-down code/ valueNational code/valueYour system’s drop-down code/ valueNational code/value00Atheist, agnostic or no religious affiliation04Buddhist00R003Agnostic05Hindu00R012Atheist06Muslim00R121None07Jewish01Christian – Church of Scotland08Sikh02Christian – Roman Catholic97Not disclosed03Other Christian98Any other religion03R014Baptist98RXXXSee religion subsidiary codes03R043Church of England99Not known03R083Free Church of Scotland03R109Methodist03R131Pentecostal03R137Protestant03R148Salvation Army03R153Scottish Episcopal Church03R170United Free Church of Scotland03R171United Reformed Church03RXXXFor other christian religions see religion subsidiary codesBack to ContentsReligion 2/2 DefinitionA statement made by the service user about their current religious affiliation/faith community.ISD Data Dictionary - ReligionFormatCharactersField LengthUp to 6 (2 + 4)Recording notes:this is an optional item,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,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:record a person's religion using only the 2 digit codes listed under Codes and values.where required, the subsidiary 4 character codes for the common sub-values within values "00" or "03" can be used, making 6 characters (see Religion Subsidiary Codes).where the full range of possible religions is required, a detailed code list for "98 Any other religion" and "03 Other Christian" is available as follows Religion Subsidiary Codes: to ContentsSexual Orientation Your system’s drop-down code/valueNational code/valueDescription01Heterosexual02Gay man03Lesbian04Bisexual05Not certain97Not disclosed98Other99Not knownDefinitionAn [individual's] orientation towards persons of the same sex (this covers gay men and lesbians); the opposite sex (this covers heterosexual men and women); or both sexes (this covers bisexual men and women). This should be self assigned. From Employment Equality Sexual Orientation Regulation (2003).ISD Data Dictionary - Sexual OrientationFormatCharactersField Length2Recording notes:this is an optional item which has been included in the dataset although it is appreciated that it is unlikely to be populated.your notes:Back to ContentsSignificant Facility Your system’s drop-down code/valueNational code/valueDescription32Accident and Emergency Department39Ambulatory Emergency Care Unit40Acute Assessment Unit (AAU)41Flow Navigation CentreA Flow Navigation Centre is where a clinical decision maker provides virtual urgent consultation and care, by telephone or video, before or as an alternative to onward referral.DefinitionA Significant Facility is a type of clinical facility which is identified for clinical and/or costing purposes.ISD Data Dictionary – Significant FacilityFormatCharactersField Length2Recording notes:this is an optional item which has been included in the dataset although it is appreciated that it is unlikely to be populated.your notes:Back to ContentsTime Since Injury Your system’s drop-down code/valueNational code/valueDescription01Up to 6 hours026 to 12 hours0312 to 24 hours0424 to 48 hours05Over 48 hoursDefinitionThe time elapsed since the injury happened.ISD Data Dictionary - Time Since InjuryFormatCharactersField Length2Recording notes:this is an optional item,if Date and Time of the Event ( i.e. the event causing the injury) is not recorded, please record Time Since Injury.your notes:Back to ContentsTriage Category 1/2 Your system’s drop-down code/valueNational code/valueDescription00Not triaged01Immediate resuscitationPatients in need of immediate treatment for preservation of life.02Very urgentSeriously ill or injured patients whose lives are not in immediate danger.03UrgentPatients with serious problems, but apparently stable condition.04StandardStandard A&E cases without immediate danger or distress.05Non-urgentPatients whose conditions are not true accidents or emergencies.Main Source of StandardNumber1ColourRedNumberImmediate2OrangeVery urgent3YellowUrgent4GreenStandard5BlueNon-urgentDerived from Manchester Triage Scale. Manchester Triage Scale:Reference: Triage and case-mix accident and emergency medicine. Marrow, J. European Journal of Emergency Medicine 1998; 5: 53-58.Back to ContentsTriage Category 2/2 DefinitionThe category assigned to a patient as a result of an initial assessment by medical or nursing staff in an A&E department.ISD Data Dictionary - Triage CategoryFormatCharactersField Length2Recording notes:this is an optional item.your notes:Back to ContentsAppendix 1 – Alcohol Related Attendances Text of CMO letter on ALCOHOL RELATED ATTENDANCESto A&E Clinical Leads, A&E Managers, IT /Information contacts, SAS Contactsdated 11 March 2011Dear ColleagueALCOHOL RELATED ATTENDANCES AT ACCIDENT AND EMERGENCY DEPARTMENTSI am writing to ask your support in the recording of alcohol related attendances at Accident and Emergency Departments (A&E) across Scotland.As you may be aware the Scottish Parliament’s Public Audit Committee (PAC) highlighted the lack of comparable data on the impact of alcohol relatedattendances at Scottish A&E Departments during their consideration of the “Overview of the NHS in Scotland's performance 2008/09”, last year.During the PAC evidence taking the Director General Health and Chief Executive of the NHS in Scotland, Kevin Woods and I, stated that Information Services Division Scotland (ISD) would develop a dataset to enable the collection of this information on a consistent basis. ISD and the Scottish Branch of the College of Emergency Medicine have now clarified the definition of the existing data item (Alcohol Involved) to facilitate the capture of this information on a consistent basis (see Annex 1 for the data item and definition).I would be grateful if, where you have not already done so, you could ensure that this data item is now incorporated into your A&E IT systems, and recording commenced. The information collected should be included as part of your future routine monthly A&E data submissions to ISD (by the 10th of each month).I would be grateful if you would advise if this will present any difficulties.If you would like to discuss further please do not hesitate to contact Alison Douglas (a.douglas@scotland..uk), 0131 244 3513). For advice on the definition and monthly A&E data submission process to ISD please contact NSS.isdunscheduledcare@.Yours sincerelyHarry BurnsBack to ContentsAppendix 2 – Injury Collection 1/2 Text of CMO letter on injury data collectionFor action: Directors of Public Health, Medical Directorsdated 15 April 2011 For information: NHS Chief Executives, NHS Chairs, A&E Clinical Leads, A&E ManagersDear ColleagueISD INJURY DATA COLLECTION PROJECT AT ACCIDENT AND EMERGENCY DEPARTMENTSI am writing to ask for your co-operation in collecting and inputting data on attendances involving intentional and unintentional injury at Accident and Emergency Departments (A&E) across Scotland.Injuries are one of the most significant causes of presentations to the NHS and represent a significant overall cost. It is estimated that unintentional injury results in some 500,000 hospital A&E visits and a million GP visits annually at an estimated cost of ?200 million to the NHS each year. In 2009, there were 1,347 deaths and almost 62,000 emergency hospital admissions (16% of the total) as a result of unintentional injury in Scotland.BackgroundThe HEAT target set in order to reduce the rates of attendance at A&E has been aligned with the Healthcare Quality Strategy for NHSScotland. There is now an undertaking to focus on primary prevention of health problems, shifting the balance of care to prevention and early intervention and work around injury prevention will have a significant role to play in achieving this aimThere is a significant lack of existing data to allow us to make policy decisions either locally or nationally that can contribute to reducing unintentional injury. The Scottish Government has therefore funded ISD to take forward a project to ensure a more comprehensive collection of injury data in Scotland which will contribute to informing policy interventions by the Scottish Government and other agencies and stakeholders to tackle, reduce and prevent intentional and unintentional injury.What are we asking you to do?Up until 2002, data were collected at Monklands General Hospital for home injuries and extrapolated to a Scotland level. The first Accident and Emergency data mart was established in 2006 primarily to collect waiting times information but all Boards were advised that they would need to meet the National Standards and that this should include injury information. All Boards should therefore be collecting at least some information from A&E Departments and it should therefore be comparatively simple to use this existing data, expanding it where necessary, to input to the ISD project.Appendix 2 – Injury Collection 2/2 The project recommends that the following data should be submittedintent of injury e.g. unintentional, self harm, assault,place of incident e.g. home, public highway, school,date and time of event i.e. when the injury happened,cause of the injury e.g. transport, fall, contact with person,nature of injury e.g. wound, fracture,bodily location of injury e.g. hand, face,activity when injured e.g. work, education, leisure,objects/substances involved e.g. firework, gun.We are asking you to communicate this information need to your A&E Department Leads and ask them to work with ISD and the Scottish Government to collect this data.Initially, the project will run until the end of March 2012 and I would urge Boards to start inputting data from their A&E Departments as soon as possible if they are not already doing so, in order that we can establish baseline levels from which to focus future activity.ConclusionWhile there are obvious advantages of having a national dataset on injury for Scotland to inform policy direction it will also undoubtedly have a useful purpose locally in order to help with local planning and monitoring, identifying trends and informing potential preventative measures.The costs to society from injuries are similar to the societal costs from smoking and I am keen that we begin to focus similar energies that have been put into smoking cessation and tobacco control into what we do around injury prevention in future.I have already raised the need for better injury data collection with NHS Board Chief Executives and intend to engage further with A&E Consultants on how we can make the best use of the expanded injury data mart once it becomes available.I would be grateful if you would advise me if this will present any difficulties by 13 May 2011. Yours sincerelyHarry BurnsBack to ContentsAppendix 3 – A&E File Layout Data Content Format - Aggregate Level Data Format to be used for the monthly and weekly aggregate data files.Column Name FormatNull?DescriptionLocation CodeVarchar(5)NoHospital locationNumber of AttendancesVarchar(6)NoNumber of A&E attendancesNumber Meeting TargetVarchar(6)NoNumber of A&E attendances seen within 4 hoursEpisode Level Data – Original formatFormat of the original episode level file.Column NameFormatNull?Description Location CodeVarchar(5)NoHospital locationCHI NoVarchar(10)YesPatient’s CHI numberCase Record NumberVarchar(14)NoPatient’s CRNPatient Year of Birth Varchar(4)YesPatient’s year of birthArrival Mode Varchar(2)NoMode of arrival at A&EReferral SourceVarchar(3)YesSource of referral to A&EPlace of IncidentVarchar(3)YesPlace incident occurredTriage CategoryVarchar(2)YesUrgency of need for triage Patient Management TypeVarchar(2)YesSeriousness of management requiredDiagnosis1 Varchar(2)YesDiagnosis made in A&EDisease1Varchar(6)YesICD10 disease codeDiagnosis1 TextVarchar(100)YesDescription of diagnosisDiagnosis2Varchar(2)YesDiagnosis made in A&EDisease2Varchar(6)YesICD10 disease codeDiagnosis2 TextVarchar(100)YesDescription of diagnosisDiagnosis3 Varchar(2)YesDiagnosis made in A&EDisease3Varchar(6)YesICD10 disease codeDiagnosis3 TextVarchar(100)YesDescription of diagnosisDate & Time of First Full Clinical AssessmentDateTime(14)YesDate/time of first clinical assessmentDate & Time of Completion of TreatmentDateTime(14)YesDate/time of completion of treatment Investigation Type1Varchar(3)YesType of investigation carried outInvestigation Type2Varchar(3)YesType of investigation carried outInvestigation Type3Varchar(3)YesType of investigation carried outProcedure1Varchar(3)YesType of A&E procedure Procedure2Varchar(3)YesType of A&E procedure Procedure3Varchar(3)YesType of A&E procedure Discharge TypeVarchar(3)YesType of discharge Discharge DestinationVarchar(3)YesDestination following discharge from A&EReferred To 1 Varchar(3)YesWhere the patient is referred to from A&EReferred To 2Varchar(3)YesWhere the patient is referred to from A&EReferred To 3 Varchar(3)YesWhere the patient is referred to from A&EArrival Date and TimeDateTime(14)NoDate/time of arrival at A&EAttendance CategoryVarchar(2)NoNew or return attendance Date & Time of Discharge, Admission or TransferDateTime(14) No Date/time left A&EReason for WaitVarchar(3)YesReason patient waited longer than 4 hours to be seenPatient FlowVarchar(1)YesPatient flowPatient Postcode Varchar(8)YesPatient postcode Activity when InjuredVarchar(3)YesActivity of patient when injuredAlleged Perpetrator of ViolenceVarchar(3)YesAlleged perpetrator of violenceBodily Location of InjuryVarchar(3)YesLocation on the body of the injuryCommon Preventive MeasuresVarchar(3)Yes Measures that had been taken to avoid the injuryDate and Time of EventDateTime(14)YesDate/time of event that caused the patient to need to attend A&ETime Since InjuryVarchar(3)YesTime band of the time between the injury occurring and attending A&EExternal Cause of InjuryVarchar(3)YesCause of injuryIntent of InjuryVarchar(3)YesIntent of the injuryNature of InjuryVarchar(3)YesNature of injuryObjects/Substances Involved in Producing InjuryVarchar(3)YesObjects/substances used to cause the injuryAlcohol InvolvedVarchar(2)YesIndicates if alcohol was involvedHCP Responsible for Care Varchar(8)YesHealth care professional responsible for the patient’s carePresenting ComplaintVarchar(100)YesComplaint the patient attends A&E withImpairmentVarchar(2)YesImpairmentEthnicity Varchar(6)YesPatient’s ethnic groupReligion Varchar(6)YesPatient’s religionSexual OrientationVarchar(2)YesPatient’s sexual orientation Significant FacilityVarchar(2)YesSignificant Facility type in A&EBack to ContentsEpisode Level Data – Updated FormatFormat of the updated episode level file.Column NameFormatNull?Description Location CodeVarchar(5)NoHospital locationCHI NoVarchar(10)YesPatient’s CHI numberCase Record NumberVarchar(14)NoPatient’s CRNPatient Year of Birth Varchar(4)YesPatient’s year of birthArrival Mode Varchar(2)NoMode of arrival at A&EReferral SourceVarchar(3)YesSource of referral to A&EPlace of IncidentVarchar(3)YesPlace incident occurredTriage CategoryVarchar(2)YesUrgency of need for triage Patient Management TypeVarchar(2)YesSeriousness of management requiredDiagnosis1 Varchar(2)YesDiagnosis made in A&EDisease1Varchar(6)YesICD10 disease codeDiagnosis1 TextVarchar(100)YesDescription of diagnosisDiagnosis2Varchar(2)YesDiagnosis made in A&EDisease2Varchar(6)YesICD10 disease codeDiagnosis2 TextVarchar(100)YesDescription of diagnosisDiagnosis3 Varchar(2)YesDiagnosis made in A&EDisease3Varchar(6)YesICD10 disease codeDiagnosis3 TextVarchar(100)YesDescription of diagnosisDate & Time of First Full Clinical AssessmentDateTime(14)YesDate/time of first clinical assessmentDate & Time of Completion of TreatmentDateTime(14)YesDate/time of completion of treatment Investigation Type1Varchar(3)YesType of investigation carried outInvestigation Type2Varchar(3)YesType of investigation carried outInvestigation Type3Varchar(3)YesType of investigation carried outProcedure1Varchar(3)YesType of A&E procedure Procedure2Varchar(3)YesType of A&E procedure Procedure3Varchar(3)YesType of A&E procedure Discharge TypeVarchar(3)YesType of discharge Discharge DestinationVarchar(3)YesDestination following discharge from A&EReferred To 1 Varchar(3)YesWhere the patient is referred to from A&EReferred To 2Varchar(3)YesWhere the patient is referred to from A&EReferred To 3 Varchar(3)YesWhere the patient is referred to from A&EArrival Date and TimeDateTime(14)NoDate/time of arrival at A&EAttendance CategoryVarchar(2)NoNew or return attendance Date & Time of Discharge, Admission or TransferDateTime(14) No Date/time left A&EReason for WaitVarchar(3)YesReason patient waited longer than 4 hours to be seenPatient FlowVarchar(1)YesPatient flowPatient Postcode Varchar(8)YesPatient postcode Activity when InjuredVarchar(3)YesActivity of patient when injuredAlleged Perpetrator of ViolenceVarchar(3)YesAlleged perpetrator of violenceBodily Location of InjuryVarchar(3)YesLocation on the body of the injuryCommon Preventive MeasuresVarchar(3)Yes Measures that had been taken to avoid the injuryDate and Time of EventDateTime(14)YesDate/time of event that caused the patient to need to attend A&ETime Since InjuryVarchar(3)YesTime band of the time between the injury occurring and attending A&EExternal Cause of InjuryVarchar(3)YesCause of injuryIntent of InjuryVarchar(3)YesIntent of the injuryNature of InjuryVarchar(3)YesNature of injuryObjects/Substances Involved in Producing InjuryVarchar(3)YesObjects/substances used to cause the injuryAlcohol InvolvedVarchar(2)YesIndicates if alcohol was involvedHCP Responsible for Care Varchar(8)YesHealth care professional responsible for the patient’s carePresenting ComplaintVarchar(100)YesComplaint the patient attends A&E withImpairmentVarchar(2)YesImpairmentEthnicity Varchar(6)YesPatient’s ethnic groupReligion Varchar(6)YesPatient’s religionSexual OrientationVarchar(2)YesPatient’s sexual orientation Significant FacilityVarchar(2)YesSignificant Facility type in A&EDate & Time of TriageDateTime(14)YesDate/time of triageDate & Time of First DiagnosticsDateTime(14)YesDate/time of first diagnosticsDate & Time of Decision to Discharge, Admit or TransferDateTime(14)YesDate/time the decision was made to treat, admit or dischargeDate & Time of Treatment StartDateTime(14)YesDate/time treatment startedWait to CubicleNumberYesTime in minutes from arrival to cubicle for assessmentWait to Bed RequestNumberYesTime in minutes from decision to admit to a bed being requestedWait to Bed AvailableNumberYesTime in time from a bed being requested to a bed becoming availableECDS Diagnosis CategoryVarchar (100)YesDiagnosis category for Emergency Care DatasetBack to ContentsAppendix 4 – Discharge and referral letter November 2015 Public Health & IntelligenceGyle Square1 South Gyle CrescentEdinburgh EH12 9EBTelephone 0131 275 6000NHS Board Unscheduled Care Leadscc Information LeadsDate12 November 2015Your RefOur RefEnquiries toDirect Line 0131 275 2092Direct Fax Emailnss.isdaewaiting@Dear Colleague,Recording specific A&E data itemsThere continues to be variation in the application of recording rules between NHS Boards and I am writing to you to reinforce the current recording guidance around ‘Referral Source’ and ‘Date and Time of Discharge’ data items for the A&E dataset. Referral SourceRevised guidance was issued in 2011 for the recording of the data item ‘Referral Source’. Some Boards continue to record ‘self referral’ incorrectly for patients who arrive by ambulance. Patients who are brought to A&E by the ambulance service should not be recorded as a ‘Self referral’ For example, if a patient or bystander calls an ambulance, the ambulance crew will assess the patient and make the clinical decision whether the patient needs to be taken to A&E. In this situation, the ‘Referral Source’ should be recorded as ‘02C 999 emergency services’. If a GP sees a patient and then calls an ambulance to take a patient to hospital, it would be the GP that is recorded as the ‘Referral Source’. Back to ContentsDate and time of dischargeThe ‘Date and Time of discharge’ is used to calculate the length of time that patients spend in the A&E department and measure compliance with the 4-hour emergency care standard. Several NHS Boards have recently requested guidance on the recording of patients waiting for transport. Patients who have been discharged from any further care in A&E, may sit in the departments reception area waiting on transport (either private or Scottish Ambulance Service). These patients are no longer ‘on the clock’ and the time of discharge is the time the A&E care ended. However, if it is not safe for the patient to be discharged from A&E care whilst waiting on transport (private or Scottish Ambulance Service) then they remain ‘on the clock’ until they leave the department. The full A&E data manual and recording guidance is available here. Please do not hesitate to contact the team here at ISD should you require assistance with the definitions or mapping of local to national codes either via telephone on 0131 275 2092 or email NSS.isdaewaiting@ or NSS.isdunscheduledcare@. Yours sincerely,Fiona MacKenzieService ManagerISD Back to Contents ................
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