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Maternity Phase 1

Antenatal Data Standards

September 2007

National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 74A Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7066 Email to: [email protected] Website: www.clinicaldatasets.scot.nhs.uk

mailto:[email protected]

http://www.clinicaldatasets.scot.nhs.uk/

Maternity Phase 1- Antenatal Data Standards

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Contents Overview & Background.......................................................................................................5

Overview...........................................................................................................................5 Maternity Data Standards.................................................................................................6 Background to NCDDP.....................................................................................................6 Generic Data Standards ...................................................................................................7 Clinical Terminology .........................................................................................................7 Date Recording.................................................................................................................7

Published Data Standards....................................................................................................9 Generic and Previously Consulted ...................................................................................9

Data Standards Currently under Development ..................................................................10 Data Standards for Consultation ........................................................................................11 1. Carer(s), Care Professional(s), Team(s), Service(s), Organisation(s) or Sector(s)........11

1.1 Associated Person Role {Maternity} .........................................................................11 1.2 Associated Professional Group {Maternity} ..............................................................12 1.3 Associated Professional Role {Maternity}.................................................................13 1.4 Independent Midwife Indicator..................................................................................14 1.5 Referred To {Maternity} ............................................................................................14 1.6 Referral to Physiotherapy Reason {Maternity} .........................................................16

2. Social and Personal Circumstances...............................................................................17 2.1 Health and Safety Assessment – Maternity..............................................................17 2.2 Health and Safety in the Workplace (Assessment Advice) ......................................17

3. Previous Pregnancies ....................................................................................................18 3.1 Parity ........................................................................................................................18 3.2 Gravidity ...................................................................................................................19 3.3 Pregnancy Problems ................................................................................................19 3.4 Onset of Labour........................................................................................................21 3.5 Delivery Mode...........................................................................................................21 3.6 Presentation .............................................................................................................22 3.7 Vaginal Delivery Instrument Type.............................................................................23 3.8 Delivery Mode Reason (Instrumental Vaginal Delivery) ...........................................24 3.9 Failed Vaginal Instrumental Delivery Indicator .........................................................24 3.10 Failed Vaginal Instrumental Delivery – Instrument Type ........................................25 3.11 Delivery Mode Reason (Abdominal Delivery).........................................................26 3.12 Urgency of Caesarean Section...............................................................................26 3.13 Pregnancy Outcome...............................................................................................27 3.14 Livebirth Outcome Indicator....................................................................................28 3.15 Neonatal Death (Stage of)......................................................................................29 3.16 Termination of Pregnancy Method .........................................................................29 3.17 Termination of Pregnancy Reason.........................................................................30 3.18 Post-Delivery Problems (Previous Pregnancies)....................................................31 3.19 Neonatal Concern(s) Indicator (Previous Pregnancies) .........................................32 3.20 Neonatal Unit Admission (Previous Pregnancies)..................................................32 3.21 Feeding Status .......................................................................................................33

4. Family Circumstances ....................................................................................................34 4.1 Family History (Conditions) {Maternity} ....................................................................34 4.2 Genetic Clinic Attendance by Family........................................................................35 4.3 Blood Relationship of Parents ..................................................................................36

5. Personal Health Information...........................................................................................37


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5.1 Personal History (Conditions) {Maternity}.................................................................37 5.2 Colposcopy Referral Indicator ..................................................................................39 5.3 Female Genital Mutilation Type................................................................................39 5.4 Folic Acid Status.......................................................................................................40 5.5 Folic Acid Dosage.....................................................................................................40 5.6 Diet Type ..................................................................................................................40 5.7 Dental Registration...................................................................................................41 5.8 Dental Attendance Indicator .....................................................................................41 5.9 Passive Smoke Exposure Status .............................................................................42 5.10 Passive Smoke Exposure Location ........................................................................42 5.11 Blood Group Type - ABO........................................................................................42 5.12 Rh Antigen Status...................................................................................................43 5.13 Anti-D Indicator.......................................................................................................43

6. Current Pregnancy Details .............................................................................................44 6.1 Pregnancy Test Result .............................................................................................44 6.2 Pregnancy Test Method ...........................................................................................45 6.3 Last Menstrual Period Date ......................................................................................46 6.4 Contraception Failure ...............................................................................................46 6.5 Estimated Delivery Date ...........................................................................................47 6.6 Estimated Delivery Date (Agreed) ............................................................................47 6.7 Vaginal Bleeding Indicator since Last Menstrual Period (Self-Reported)................48 6.8 Vaginal Bleeding Flow since Last Menstrual Period (Self-Reported) .......................48 6.9 Vaginal Bleeding Frequency since Last Menstrual Period (Self-Reported).............49 6.10 Menstrual Cycle Pattern (Self-Reported)................................................................49 6.11 Menstrual Cycle Duration (Self-Reported)..............................................................50 6.12 Menstrual Cycle Duration Range (Self-Reported) ..................................................50 6.13 Menstrual Cycle Shortest Duration (Self-Reported) ...............................................51 6.14 Menstrual Cycle Longest Duration (Self-Reported)................................................51 6.15 Gestation ................................................................................................................52 6.16 Pregnancy Specific Risk Level ...............................................................................53 6.17 Level of Care (Antenatal)........................................................................................53 6.18 Level of Care (Reason for Change)........................................................................54 6.19 Urinary Tract Infection (UTI) Indicator ....................................................................54 6.20 Birth Place Type .....................................................................................................55 6.21 Birth Place (Reason for Change)............................................................................56

7. Examinations..................................................................................................................57 7.1 Examination Performed (Gravid Uterus) ..................................................................57 7.2 Uterine Fundus Palpable ..........................................................................................57 7.3 Uterine Fundal Height...............................................................................................58 7.4 Lie (Fetus) ................................................................................................................58 7.5 Engagement Status (Fetus)......................................................................................58 7.6 Degree of Engagement (Fetus) ................................................................................59 7.7 Fetal Heart Activity Checked (Indicator) ...................................................................59 7.8 Fetal Heart Activity Checked (Method).....................................................................60 7.9 Fetal Heart Activity Detected (Indicator)...................................................................60 7.10 Fetal Heart Rate .....................................................................................................60 7.11 Fetal Movements Felt .............................................................................................61 7.12 Fetal Movement Concern(s) ...................................................................................61 7.13 Fetal Movement Concern(s) Reason......................................................................61

8. Education/Advice............................................................................................................62 8.1 Education Advice Indicator .......................................................................................62 8.2 Education Advice Topic(s) {Maternity}......................................................................62 8.3 Parent Education Class Attendance.........................................................................63

Appendix 1 - Working Group Membership .........................................................................64


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Membership of the Maternity Antenatal Data Standards Working Group.......................64 Appendix 2 - Consultation Distribution List.........................................................................65


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Overview & Background Overview The Maternity Data Standards were developed to support the work of the Maternal and Child Health Information Strategy Group (MCHISG) in procuring and implementing an IT system across Scotland. These data standards ensure a national approach to the collection of clinical and non-clinical data items relating to maternity. The data standards for maternity care will ensure a national approach in the collection of clinically relevant data items recorded in a wide variety of settings. This will ensure inter-compatibility of national clinical information systems and the Scottish Woman-Held Maternity Record (SWHMR) and support the implementation of an electronic integrated maternity health record and data sharing with other agencies. A Maternity Clinical Working Group was established in September 2006 to progress this work, supported by the National Clinical Dataset Development Programme (NCDDP) Support Team in Information Services (ISD). Following a review of the NHSScotland National eHealth Strategy and the eHealth Programme Board’s decision to accelerate the acquisition of an information system to support Maternity services, it was decided that a phased approach to developing the Maternity Data Standards would be required. Phase 1 (Antenatal) is addressed in this Consultation Document. Work on Phase 2 (Birth and Labour) will commence in mid - late 2007 and it is forecast that Phase 3 (Postnatal) will commence in 2008. The Maternity Data Standards will:

• Support the care of patients through more accessible and timely collection of information

• Prevent duplication of records • Encourage high standards of record keeping • Contribute to multidisciplinary maternity care • Promote woman–centred, holistic maternity care • Support the development of an electronic health record

There is a potential impact on existing IT systems, as some re-design may be required to comply with the agreed data standards. It is important to emphasise that these are data standards rather than a dataset. This means that the individual data items included in this document are not required to be recorded together in a single clinical information system. For example it may not be necessary to record every item for every person subject to their maternal assessment. However, where it is considered appropriate to record a particular data item as part of a person’s maternal assessment, the information should be recorded in accordance with the nationally agreed standard. Some data items may only be appropriate for use by clinicians within certain specialist settings and therefore would not be used by a clinician outwith such a setting. The data standards contain data items from Generic Data Standards and other Clinical Datasets, which have previously been developed through the NCDDP and are freely available in the Clinical Datasets section of the web-based Health & Social Care Data Dictionary.

http://www.datadictionary.scot.nhs.uk/



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We are now seeking feedback from the wider clinical community in order to ensure that these data standards are fit for purpose. We invite all interested organisations and individuals to take part in this consultation by completing the attached Consultation Response Form and then returning it to [email protected]. Comments on all or any part of the document are welcome. Some background information on the NCDDP and the Data Standards development can be found below. If you have any further queries, please go to our website: http://www.clinicaldatasets.scot.nhs.uk/ or contact [email protected]. Maternity Data Standards The membership of the Maternity Data Standards Clinical Working Group is shown in Appendix 1. This group agreed the inclusion of individual data items concerning maternity using the following criteria: • Is the data item one, which would reasonably be expected to be collected for women,

unborn/newborn baby(ies) accessing maternity health services/care? • Will it prevent unnecessary duplication of data recording? • Is the data item one, which would be used by the maternity health service to ensure

appropriate care? • Is the data likely to be shared among health care professionals (as justified by clinical

need and patient consent) Once consultation is complete the Maternity Data Standards will be submitted to the NCDD Programme Board for formal approval as a national standard. Once approved the Maternity Standards will be freely and widely available through publication in the Health & Social Care Data Dictionary. As far as possible they are UK compatible. It is expected that the Maternity Data Standards will be implemented within existing and emerging national clinical information systems and commercially procured national products, as well as being available to commercial developers to ensure the ability of their systems to support national information requirements. Following approval, the Maternity Data Standards will be reviewed every two years to ensure that they remain fit for purpose. Background to NCDDP The National Clinical Dataset Development Programme (NCDDP) supports clinicians to develop sets of interoperable national datasets to facilitate the implementation of the integrated care records across NHS Scotland. These standards will:

• Support direct patient care, by reflecting current best practice guidance • Facilitate effective communication between health care professionals • Improve data quality and support secondary data requirements where possible

including data to support clinical governance • Be freely and widely available through publication in the web-based Health & Social

Care Data Dictionary






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• Incorporate agreed national clinical definitions and implement national terminology • Be UK compatible where possible

The Chief Medical Officer established the programme in 2003 to support clinicians developing national clinical data standards, initially to support the national priority areas. These standards are an essential element of the Electronic Health Record, a central aim of the National e-Health Strategy. More information can be found on our website: http://www.clinicaldatasets.scot.nhs.uk/. Generic Data Standards Data standards which are relevant to all patients and are used across specialties, disciplines and settings have already been developed by other clinical working groups and approved as national data standards for NHS Scotland. Those data items identified by the Maternity Working Group as appropriate for inclusion in their dataset are listed in this document for information. The full details of these existing standards are published on the web-based Health and Social Care Data Dictionary. Clinical Terminology

The strategic standard for clinical terminology in NHS Scotland is SNOMED-Clinical Terms. This means that over the next few years, clinical information systems will progress to record clinical data using this international standard. The NCDDP Support Team will commence in the near future, development of recommended SNOMED-CT specifications as part of the data standards and datasets it supports. Date Recording It is good record-keeping practice always to identify the date of recording of any clinical information. It is expected that all clinical information systems should include “date stamping” as standard functionality; therefore the Maternity Data Standards do not deal with this issue. In many clinical situations, the date of an event, investigation, etc is required for clinical purposes and should be visible to the health care professional. This date may not be the same as the date on which the data are entered onto the system. In these instances the system must allow the health care professional to enter whichever date is appropriate. These issues must be addressed during system specification and development. The date format for storage and management within a system should conform to the Government Data Standards Catalogue format: CCYY-MM-DD. However, this does not preclude entry or display of data on the user interface using the traditional DD-MM-CCYY format. An example of a date & time in correct format is: 1997-07-16T19:20:30+01:00 (CCYY-MM-DDThh: mmTZD). It is recommended that a time should always be recorded with the appropriate date and not on its own, however it may not be necessary to display the date along with the time. This is of particular importance where any calculations or analyses are likely to be performed. Automated times recorded by IT systems should include all elements of the time, i.e. hour, minutes and seconds, and are expected to be actual. Where times are entered manually, it is likely that only the hours and minutes will be required, although in some circumstances only hours may be required.




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Time, or any element of the time (hours, minutes or seconds) may be actual or estimated. In some circumstances only an actual time may be acceptable, whilst in others an estimated time may be allowed. In the latter situation, it may be necessary to identify whether the time recorded is actual or estimated. Times identified as actual may be used in calculations and analyses. Times marked as estimated should be treated with caution and the implications of undertaking any calculations or analyses should be considered in the particular context within which the time is recorded or to be made subsequent use of. Where an estimated time is allowed, the appropriate degree of verification detail required should be decided, again dependent on the context in which it is recorded and how the time is to be used. Government Data Standards Catalogue 1. All times must be expressed in the 24 hour clock format, e.g. one minute past midnight is

00:01:00. 2. Values of any element less than 10 should be entered with a zero in the first position. 3. All times for UK transactions/ events will be assumed to be GMT. 4. 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


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Published Data Standards Generic and Previously Consulted The following table contains data standards that have already been consulted on previously and are published on the data dictionary. They serve to give an example of the data standards that can be used when implementing data standards within a system. Additional data standards are available on the Health and Social Care Data Dictionary. Patient Administration and Demographics Referral Details CHI Number Referral Source Structured Name Date of Referral Person Full Name (Unstructured) Date Referral Received Person Birth Date Urgency of Referral Address (BS7666) Referral Response Postcode Reason for Referral Person Marital Status Associated Professional Details Person Sex at Birth Associated Professional Postal Address Associated Professional Identifier

Health Record Identifier Associated Professional Group UK Telephone Number Associated Professional Role Internet Email Address Base of Service Ethnic, Cultural and Diversity Associated Professional Address Ethnic Group (self assigned) Associated Professional Employing Organisation Name Occupation Associated Professional Employing Organisation Type Religion Basic Health Measurements Preferred Language Height Country of Birth Weight Spiritual Care Preferences Body Mass Index Socio-Environmental Details Systolic Blood Pressure Accommodation Type Diastolic Blood Pressure Dwelling Type Lifestyle Risk Factors Household Composition Smoking Status Lives With Smoking Method Accommodation Permanence Status Cigarettes Smoked (Number) Dependency upon Patient/Client Tobacco Quantity Smoked Risks and Alerts Smoking Start Age Interpretation Assistance Indicator Year Stopped Smoking Preferred Communication Method Total Number of Years Smoked General Practitioner Details Estimated Pack Years Registered GP Practice Code Tobacco and Nicotine Consumption (Other than smoking) GP General Medical Council Number Tobacco Chewing Status Specified General Medical Practitioner Snuff Status Specified General Medical Practitioner Role Nicotine Containing Substance (Other) General Practice Registration Status of Patient Consumption Status Associated Person Details Alcohol Drinking Status Associated Person Alcohol Units Consumed (Average Number) Associated Person Relationship to Client/Patient Alcohol Units Consumed (Maximum Daily) Medications and Devices Record Alcohol Consumed Days Per Week (Number) Medication or Device Name Substance Misuse Status Medication or Device Code Medications and Immunisations Medication or Device Status Specific Medication Record Duration Reason Specific Medication Not Prescribed Medication Dosage Complementary and Alternative Medicine or Route of Administration Therapy Background Health Information Medication Advice Ancestry-Related Health Risk Care Episode Administration Details Impairment Location Code


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Date of Contact Time of Next Appointment Date of Next Appointment

More Closely Related Items Pregnancy Episode Number Glycated Haemoglobin Emergency Contraception Cervical Smear Test Status Type of Contraception History of Specific Investigation (Cervical Smear Rubella Immunity Status Test) Frequency of Recurrence of Urinary Tract Infection (UTI)

Human Immunodeficiency Virus (HIV) Test Status

Bladder Dysfunction Signs and Symptoms History of Specific Investigation (Human Menstrual Problems (Self-Reported) Immunodeficiency Virus (HIV) Antibody Test Menstrual Blood Loss (Self-Reported) Personal History of Hepatitis B Immunisation Menstruation Duration (Self-Reported) Specific Immunisation Stage (Hepatitis B) Menstruation Duration Range (Self-Reported) Hepatitis B Test Status Menstruation Duration Shortest Duration (Self-Reported)

History of Specific Investigation (Hepatitis B Test) Record of Specific Immunisation (Hepatitis B)

Menstruation Duration Longest Duration (Self-Reported)

Chlamydia Test Status History of Specific Investigation (Chlamydia Test)

Menstrual Cycle Bleeding Days (Total)

Data Standards Currently under Development There will be an opportunity to consult on the following data standards when they are circulated for consultation by the appropriate specialty:

Allergies Relevant Medical History Relevant Surgical History Generic Consent Data Standards (currently out for consultation until 17th August 2007) Disability Needs and Personal Requirements (currently out for consultation until 17th August 2007)


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Data Standards for Consultation 1. Carer(s), Care Professional(s), Team(s), Service(s), Organisation(s) or Sector(s) Data Item Number Associated Person Role {Maternity} 1.1 Associated Professional Group {Maternity} 1.2 Associated Professional Role {Maternity} 1.3 Independent Midwife Indicator 1.4 Referred To {Maternity} 1.5 Referral to Physiotherapy Reason {Maternity} 1.6

1.1 Associated Person Role {Maternity}

Reason for Maternity Specific: Addition of Birthing Partner

We are asking for your feedback on the addition of ‘Birthing Partner’ in the context of Maternity Care and not the remainder of the standard as it has already been consulted on

previously and approved by the Programme Board. Common Name: Person Role Definition: A description of the particular involvement(s) with/function(s) fulfilled by an associated person towards the client/patient. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

Code Sub-Value Explanatory Notes

00 No Role The person does not carry out any particular role for the client/patient. A Main Carer † 01 Carer B Secondary

Carer †

A Main Key Holder

† 02 Key Holder

B Additional Key Holder

†

A Advocate † 03 Appointed Representative B Proxy †

04 Emergency Contact

A person who may be contacted in the event of an accident, emergency or crisis befalling the client/patient.

05 Person with Parental Responsibility

†

06 Relevant Person

†

07 Next of Kin †


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08 Birthing Partner 98 Other Specific

Role Any other role not covered by the above categories.

99 Not Known †For ‘Explanatory Notes’ please refer to the Health & Social Care Data Dictionary. Further Information: Other specific role can refer to an associated person involved in a professional (but not a care professional) capacity such as the person’s lawyer, business partner, etc. For household members who do not carry out any particular role in relation to the client/patient, record “00 No Role”. Recording Guidance: Multiple relevant roles may be recorded for each associated person. 1.2 Associated Professional Group {Maternity}

Reason for Maternity Specific: Addition of Maternity Specific Healthcare Professionals Common Name: Associated Care Professional Group Definition: The recognised professional group to which the care professional belongs and in which they are employed. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

Code Sub-Value

A Obstetrician B Obstetric Anaesthetist C Anaesthetist D Neonatologist E Paediatrician F Gynaecologist G Infertility Specialist H General Practitioner J Endocrinologist (diabetes) K Haematologist L Cardiologist M Psychiatrist N Radiologist

01

Medical Doctor

Z Other (specify) 02 Dentist

A Community Psychiatric Nurse B Diabetic Nurse Specialist C Practice Nurse D Continence Advisor E Learning Disability Nurse F Neonatal Nurse G Smoking Cessation Nurse Specialist H District Nurse

03 Registered Nurse

Z Other (specify)


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04 Registered Midwife 05 Biomedical Scientist 06 Chiropodist/ Podiatrist 07 Clinical Scientist 08 Dietician 09 Occupational Therapist 10 Operating Department

Practitioner

11 Orthoptist 12 Orthotist 13 Paramedic 14 Pharmacist 15 Pharmacy Technician 16 Physiotherapist 17 Prosthetist

A Clinical 18 Psychologist B Educational

19 Public Health Practitioner A Diagnostic 20 Radiographer B Therapeutic A Family Health Nurse 21 Specialty Community Public

Health Nurse B Health Visitor 22 Speech & Language Therapist

A Maternity Care Assistant 23 Other Healthcare Professionals who have direct patient contact B Nursery Nurse

24 Arts Therapist 25 Complementary and Alternative

Medicine Therapist

A Social Worker B Family Support Worker

26 Social Care Professional

C Substance Misuse Worker 27 Teacher 98 Other (specify) 99 Not Known

Further Information: The specialist capacity in which a professional is employed is not necessarily the same as the specialist registration status of that person with their professional body. Other aspects such as the grade of the professional should be taken into account. For example, a doctor in a training grade or Staff and Associated Specialist (SAS) grade may legitimately be employed to work in a specialist area without being registered on the GMC Specialist Register for that specialty. However, a consultant employed in that specialist area would probably be expected to have appropriate specialist registration. It is the responsibility of the employing body to ensure that the professional is suitably qualified for the post to which they are appointed. Recording Guidance: Each clinical working group may augment this data model by defining their own sub-specialty code list suitable for local use. 1.3 Associated Professional Role {Maternity} Common Name: Associated Care Professional Role Definition: Professionals are those individuals who are involved with the client/patient in a professional capacity (e.g. Consultant, Social Worker, Occupational Therapist etc). The particular role(s) carried out by each professional is (are) indicated by this data item.


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Format: Characters Field Length: 2 Codes and Values: Code Value 01 Lead Clinician 02 Named Midwife 98 Other (specify) 99 Not Known

Further Information: This item indicates the role(s) carried out by the people who are involved with the person in a professional capacity, recorded as free text. It is important to note the distinction between a professional’s designation within an agency (i.e. job role – e.g. Social Worker, District Nurse) and their role with regard to a particular client (e.g. Key Worker, Lead Assessor, Named nurse, Lead clinician, Operating surgeon, Case manager, Care Team Manager, Locum GP). Recording Guidance: The most appropriate role should be recorded in relation to the contact with the patient/client. 1.4 Independent Midwife Indicator Definition: An indication of whether or not the midwife is self-employed and working as an independent midwife. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

1.5 Referred To {Maternity} Definition: The professionals, organisations or services a patient may be referred to for the purpose of further investigation and/or ongoing care. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

Code Sub-Value

A Obstetrician 01

Medical Doctor B Obstetric Anaesthetist


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C Neonatologist D General Practitioner E Endocrinologist (diabetes) F Haematologist G Cardiologist H Psychiatrist J Radiologist Z Other (specify)

02 Dentist A Community Psychiatric Nurse B Diabetic Nurse Specialist C Practice Nurse D Continence Advisor E Learning Disability Nurse F Neonatal Nurse G Smoking Cessation Nurse Specialist H District Nurse

03 Registered Nurse

Z Other (specify) 04 Registered Midwife 05 Biomedical Scientist 06 Chiropodist/ Podiatrist 07 Clinical Scientist 08 Dietician 09 Occupational Therapist 10 Operating Department

Practitioner

11 Orthoptist 12 Orthotist 13 Paramedic 14 Pharmacist 15 Pharmacy Technician 16 Physiotherapist 17 Prosthetist

A Clinical 18 Psychologist B Educational

19 Public Health Practitioner A Diagnostic 20 Radiographer B Therapeutic A Family Health Nurse 21 Specialty Community Public

Health Nurse B Health Visitor 22 Speech & Language Therapist

A Maternity Care Assistant 23 Other Healthcare Professionals who have direct patient contact B Nursery Nurse

24 Arts Therapist 25 Complementary and Alternative

Medicine Therapist

A Social Worker B Family Support Worker

26 Social Care Professional

C Substance Misuse Worker 27 Teacher 98 Other (specify) 99 Not Known

Recording Guidance: Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the service referred to. Systems should allow for the recording of multiple options.


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1.6 Referral to Physiotherapy Reason {Maternity} Common Name: Reason for Physiotherapy Referral Definition: A record of the reason why the woman has been referred to the physiotherapy service. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

code Sub-Value Explanatory Notes

A Symphysis Pubis Dysfunction

01 Pelvic Girdle Pain or Dysfunction

B Sacroiliac Pain A Cervical Pain B Thoracic Pain C Lumbar Back Pain

02 Musculo-skeletal Pain

D Nerve Entrapment Syndromes

E.g. carpal tunnel, thoracic outlet

03 Urinary Incontinence Includes detrusor instability, genuine stress incontinence etc.

04 Faecal Incontinence 05 Pelvic Organ Prolapse 06 Significant Perineal Trauma E.g. bruising, oedema 07 3rd and 4th Degree Tears 08 Diastasis Rectus 09 General Decreased Mobility 10 Respiratory Conditions 97 Not Disclosed 98 Other (specify) 99 Not Known

Recording Guidance: Systems should allow for the recording of multiple options. Where ‘98 – Other’ is recorded, systems may be configured to include a text box to allow specification of the reason for referral.


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2. Social and Personal Circumstances Data Item Number Health and Safety Assessment – Maternity 2.1 Health and Safety in the Workplace (Assessment Advice) 2.2

2.1 Health and Safety Assessment – Maternity Definition: An indication of whether or not the woman has had a health and safety assessment performed at her workplace since becoming pregnant. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 96 Not Applicable 99 Not Known

2.2 Health and Safety in the Workplace (Assessment Advice) Definition: An indication of whether or not the clinician has advised that a workplace health and safety assessment should be carried out. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes


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3. Previous Pregnancies The following section contains data standards that could be relevant in both the Antenatal and Birth and Labour parts of a woman’s record. It is envisaged that in this section the attribute ‘Previous Pregnancy’ relates to the Antenatal section of care, whereas ‘Current Pregnancy’ will relate to the next phase of development – Birth and Labour. Data Item Number Parity 3.1 Gravidity 3.2 Pregnancy Problems 3.3 Onset of Labour 3.4 Delivery Mode 3.5 Presentation 3.6 Vaginal Delivery Instrument Type 3.7 Delivery Mode Reason (Instrumental Vaginal Delivery) 3.8 Failed Vaginal Instrumental Delivery Indicator 3.9 Failed Vaginal Instrumental Delivery – Instrument Type 3.10 Delivery Mode Reason (Abdominal Delivery) 3.11 Urgency of Caesarean Section 3.12 Pregnancy Outcome 3.13 Livebirth Outcome Indicator 3.14 Neonatal Death (Stage of) 3.15 Termination of Pregnancy Method 3.16 Termination of Pregnancy Reason 3.17 Post-Delivery Problems (Previous Pregnancies) 3.18 Neonatal Concern(s) Indicator (Previous Pregnancies) 3.19 Neonatal Unit Admission (Previous Pregnancies) 3.20 Feeding Status 3.21

3.1 Parity

The following data standard has been produced by modifying the existing item that is displayed in the Health and Social Care Data Dictionary. Its adoption will mean that change

control is required to the existing item. Please refer to the attached document ‘Maternity-Proposed Changes Document’ for a comparison of the existing and proposed data standard.

Before this item can be published in the Health and Social Care Data Dictionary, it will be put

through the Change Control process to authorise the proposed changes. Definition: The total number of pregnancies a woman has had prior to any current pregnancy. Format: Characters Field Length: nn+nn (total 5) Codes and Values: N/A Further Information: Clinically, these pregnancies are usually expressed as firstly the number that have resulted in the birth of an infant capable of survival or stillborn and secondly the number of pregnancies that have ended in miscarriage or termination.


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Parity refers to the number of pregnancies not the number of babies. A woman who has only had one pregnancy, but it resulted in twins is para 01+00. Recording Guidance: Can be derived from the Data Standard ‘Pregnancy Outcome’. 3.2 Gravidity Definition: The total number of times in her lifetime a woman has been pregnant, including her current pregnancy. Format: Numeric Field Length: 2 Codes and Values: N/A Further Information: Gravidity refers to the number of pregnancies not the number of babies, regardless of outcome. A twin or multiple pregnancy would count as 1. 3.3 Pregnancy Problems Definition: A record of any type(s) of problem(s) experienced during pregnancy, which is (are) of relevance to the antenatal care of the woman and/or care of the baby. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

CodeSub-Value Explanatory

Notes A Gestational Diabetes

Mellitus 01 Diabetes

B Impaired Glucose Tolerance A With Proteinuria B Without Proteinuria C Eclampsia D HELLP Syndrome

02 Hypertensive Diseases of Pregnancy

Z Other 03 Toxoplasmosis 04 Obstetric Cholestasis 05 Acute Fatty Liver 06 Oligohydramnios 07 Polyhydramnios 08 Hyperemesis

Gravidarum

09 Cervical Incompetence

A Chicken Pox B Cytomegalovirus (CMV) C Hand, Foot and Mouth

Disease

10 Viral Infections

D Genital Herpes


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E Measles F Parvovirus B19 G Rubella H Herpes Zoster J Hepatitis K HIV Z Other A Group B Streptococcus

(GBS)

B Listeriosis C Urinary Tract Infection (UTI) D Bacterial Vaginosis E Syphilis F Chlamydia

11 Bacterial Infections

Z Other A Thalassaemia B Sickle Cell Disease C Hereditary Spherocytosis D Thrombo-embolic Disease E Pregnancy-associated

Thrombocytopaenia

F Allo-immune Thrombocytopaenia

G Idiopathic Thrombocytopaenia

H Disseminated Intravascular Coagulopathy (DIC)

12 Blood Disorders

Z Other A Placental Abruption B Placenta Accreta C Placenta Increta D Placenta Percreta E Major Placenta Praevia Formerly Grades 3

and 4 F Minor Placenta Praevia Formerly Grades 1

and 2 G Vasa Praevia

13 Placental Conditions

Z Other 14 Mental Health

Problems

15 Concern(s) for Fetal Well-being

96 Not Applicable 97 Not Disclosed 98 Other (specify) 99 Not Known

Attributes: Previous pregnancy Current pregnancy Related Data Item: Gestation Recording Guidance: To record the gestation of the previous pregnancy at which the problem occurred, the data standard Gestation would be used. Systems should allow for the recording of more than one pregnancy-related problem.


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When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one pregnancy. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other pregnancy problems. 3.4 Onset of Labour Definition: A record of the way in which labour began. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Spontaneous 02 Induction 96 Not Applicable Where a woman did not experience labour. 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Further Information: Labour, which is started by clinical intervention, i.e. induction, is not the same as augmentation, which is clinical intervention to augment labour that has already commenced. Where labour has been augmented, the process by which labour began before augmentation should be recorded in this data standard. Not all pregnant women labour, e.g. elective caesarean section. Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby. 3.5 Delivery Mode




through the Change Control process to authorise the proposed changes. Definition: A record of the substantive method by which the baby is/was delivered. Format: Characters Field Length: 3


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Codes and Values: Code Value Sub-

Code Sub-Value

A Spontaneous 01

Vaginal B Instrumental A Lower Uterine Segment Caesarean Section 02 Abdominal B Classical Caesarean Section

Attributes: Previous Pregnancy Current Pregnancy Recording Guidance: Only one mode of delivery can be recorded for each baby. Where more than one delivery mode is attempted, the method by which the delivery is actually achieved should be recorded. For example, where a vaginal delivery is not successful and delivery is achieved by a type of abdominal caesarean section, the mode of delivery should be recorded as ‘Abdominal’ with the relevant Sub-Value (if known). When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery. 3.6 Presentation Definition: A description of the presentation of the fetus or baby.

Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

Code Sub-Value

Explanatory Notes

01 Normal Cephalic Occipito-anterior presentation/position, i.e. with head-first, facing downwards.

A Face 02 Abnormal Cephalic B Brow A Frank B Extended

03 Breech

C Footling 04 Shoulder/Arm 05 Compound 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Sub-Data Items: Date of Examination (see data standard for “Date”)

Method of Antenatal Examination


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Code Value 01 Vaginal Examination 02 Palpation 03 Ultrasound Scan

Time Applicability Code Value 01 At Antenatal Examination 02 At Onset of Labour 03 At Delivery

Related Data Item: Lie (Fetus) Recording Guidance: Only one presentation can be recorded for each baby but this may be recorded at antenatal examination, at the onset of labour and/or at delivery. Systems should allow for the recording of information on more than one fetus’s/baby’s presentation, to account for recording previous pregnancies and multiple births within the same pregnancy (e.g. twins). 3.7 Vaginal Delivery Instrument Type Definition: A record of the instrument by which delivery of the baby was actually achieved. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Rotational Forceps 02 Non-Rotational Forceps 03 Ventouse 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Failed Vaginal Instrumental Delivery – Instrument Type Recording Guidance: Only one type of instrument can be recorded for each baby. Where more than one instrument is used, the instrument by which the delivery is actually achieved should be recorded. For example, where forceps have been unsuccessfully employed and delivery is achieved by using ventouse, the type of instrument should be recorded as ‘Ventouse’. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery.


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3.8 Delivery Mode Reason (Instrumental Vaginal Delivery) Common Name: Reason for Instrumental Vaginal Delivery Definition: The reason why an instrumental vaginal delivery mode was employed. Format: Characters (In the future all diagnoses, health problems and issues should be recorded using SNOMED-Clinical Terms) Field Length: 2 Codes and Values: Code Value 01 Maternal Medical/Obstetric Problems 02 Fetal Anomaly 03 Failure to Progress 04 Fetal Distress 05 Maternal Distress/Exhaustion 06 Malposition 07 Malpresentation 98 Other (specify) 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Recording Guidance: Systems should allow for the recording of multiple options. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery. 3.9 Failed Vaginal Instrumental Delivery Indicator Definition: An indication of whether or not during labour there was a failed attempt to deliver the baby using an instrument. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy


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Related Data Item: Failed Vaginal Instrumental Delivery – Instrument Type

Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery. 3.10 Failed Vaginal Instrumental Delivery – Instrument Type Definition: A record of the type of instrument that was employed during labour, that resulted in a failed instrumental attempt to deliver the baby. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Rotational Forceps 02 Non-Rotational Forceps 03 Ventouse 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Failed Vaginal Instrumental Delivery Indicator Recording Guidance: Systems should allow for the recording of multiple options. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery.


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3.11 Delivery Mode Reason (Abdominal Delivery) Common Name: Reason for Abdominal Delivery Definition: The reason why an abdominal delivery mode was employed. Format: Characters (In the future all diagnoses, health problems and issues should be recorded using SNOMED-Clinical Terms) Field Length: 2 Codes and Values: Code Value 01 Maternal Medical/Obstetric Problems 02 One Previous Caesarean Section 03 Two or More Previous Caesarean Sections 04 Fetal Anomaly 05 Current Multiple Pregnancy 06 Maternal Choice 07 Failure to Progress (1st stage of labour) 08 Failure to Progress (2nd stage of labour) 09 Maternal Distress/Exhaustion 10 Fetal Distress 11 Subacute Concerns About Fetal Wellbeing 12 Malposition 13 Malpresentation 14 Failed Instrumental Delivery 98 Other (specify) 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Urgency of Caesarean Section Recording Guidance: Systems should allow for the recording of multiple options. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one baby’s delivery. 3.12 Urgency of Caesarean Section Common name: Classification of Caesarean Section Main Source of Standard: NICE Guidelines: Clinical Guideline 13 Caesarean Section April 2004: (http://www.nice.org.uk/guidance/CG13/niceguidance/pdf/English) Definition: A record of the classification of urgency by which the caesarean section was performed. Format: Characters

http://www.nice.org.uk/guidance/CG13/niceguidance/pdf/English


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Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 CS1 Immediate threat to the life of the woman or fetus 02 CS2 Maternal or fetal compromise which is not immediately

life-threatening 03 CS3 No maternal or fetal compromise but needs early

delivery 04 CS4 Delivery timed to suit woman or staff

Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Delivery Mode Reason (Abdominal Delivery) Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one caesarean section. 3.13 Pregnancy Outcome Common Name: Outcome of Pregnancy Definition: A description of the outcome of the pregnancy. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-


01 Live Birth

A Antepartum Before labour. 02 Stillbirth B Intrapartum During labour and delivery or childbirth.

A Early Miscarriage

Up to 11 weeks and 6 days gestation.

B Mid-term Miscarriage

Between 12 weeks to 23 weeks and 6 days gestation.

C Ectopic Pregnancy

A gestation elsewhere than in the uterus.

03 Pre-Viable Fetal Loss

D Molar Pregnancy

A hydatidiform mole (or molar hydatidiforma) is a disease of trophoblastic proliferation. It can mimic pregnancy, causes high human chorionic gonadotropin (HCG) levels and therefore gives false positive readings of pregnancy tests.

04 Induced Abortion

The removal or expulsion of an embryo or fetus from the uterus, resulting in or caused by its death. Artificially induced by chemical, surgical


28

or other means. 98 Other

(specify)

99 Not Known Attributes: Previous Pregnancy Current Pregnancy Further Information: The World Health Organisation definition of a live birth can be found at: (http://www.wpro.who.int/NR/rdonlyres/EFD3A0FD-E836-4C13-BA04-5614011BDE25/0/35definitions.pdf) The General Register Office definition of a stillbirth can be found at: (http://www.gro.gov.uk/gro/content/stillbirths/registeringastillbirth/definition.asp) Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby/fetus. 3.14 Livebirth Outcome Indicator Common Name: Baby Survived First Year of Life Definition: An indication of whether or not the liveborn baby survived their first year of life. Format: Characters Field Length: 2 Codes and Values: Code Value 00 Did Not Survive 01 Survived 99 Not Known

Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Neonatal Death (Stage of) Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby.

http://www.wpro.who.int/NR/rdonlyres/EFD3A0FD-E836-4C13-BA04-5614011BDE25/0/35definitions.pdf

http://www.wpro.who.int/NR/rdonlyres/EFD3A0FD-E836-4C13-BA04-5614011BDE25/0/35definitions.pdf

http://www.gro.gov.uk/gro/content/stillbirths/registeringastillbirth/definition.asp


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3.15 Neonatal Death (Stage of) Definition: A record of the stage at which the liveborn baby died if they died within the first year of their life. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Early Neonatal Death Dying within first 6 days (less than 168 completed hours of life). 02 Late Neonatal Death Dying on or after the 7th completed day but before the 28th day. 03 Post Neonatal Death Dying on or after the 28th completed day, but before the end of the

first year of life. Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Livebirth Outcome Indicator Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby. 3.16 Termination of Pregnancy Method Common Name: Abortion Method, Method of Abortion Definition: A record of the method used to perform the abortion. Format: Characters Field Length: 3 Codes and Values: Code Value 01 Surgical 02 Medical

99 Not Known Attributes: Previous Pregnancy Current Pregnancy With Feticide Without Feticide Related Data Item: Gestation


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Further Information: Further Information on the Abortion Act (1967) can be viewed at: (http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthGeneralInformation/SexualHealthGeneralArticle/fs/en?CONTENT_ID=4063863&chk=j%2B0Hly) Recording Guidance: To record the gestation at which the abortion was performed, the data standard Gestation would be used. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one pregnancy. 3.17 Termination of Pregnancy Reason Common Name: Abortion Reason, Reason for Abortion, Grounds for Abortion Main Source of Standard: Certificates A & B of Abortion Act 1967. Definition: A description of the grounds for aborting the pregnancy. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Risk to Woman’s Life The continuance of the pregnancy would involve risk to

the life of the pregnant woman greater than if the pregnancy were terminated (corresponds to category A of Certificate A).

02 Prevent Grave Injury to Physical/ Mental Health of Woman

The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman (corresponds to category B of Certificate A).

03 Risk of Injury to Physical/Mental Health of Woman

The pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. (corresponds to category C of Certificate A).

04 Prevent Injury to Physical/ Mental Health of Existing Children

The pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child (ren) of the family of the pregnant woman (corresponds to category D of Certificate A).

05 Child Would Suffer Physical/ Mental Abnormalities

There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped (corresponds to category E of Certificate A).

06 To Save Woman’s Life Performed as an emergency to save the life of the pregnant woman (corresponds to category F of Certificate B).

07 To Prevent Injury to Physical/ Mental Health of Woman

Performed as an emergency to prevent grave permanent injury to the physical or mental health of the pregnant woman (corresponds to category G of Certificate B).

99 Not Known

http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthGeneralInformation/SexualHealthGeneralArticle/fs/en?CONTENT_ID=4063863&chk=j%2B0Hly




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Attributes: Previous Pregnancy Current Pregnancy Related Data Item: Gestation Further Information: Further Information on the Abortion Act (1967) can be viewed at: (http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthGeneralInformation/SexualHealthGeneralArticle/fs/en?CONTENT_ID=4063863&chk=j%2B0Hly) Recording Guidance: To record the gestation at which the abortion was performed, the data standard ‘Gestation’ would be used. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one pregnancy. 3.18 Post-Delivery Problems (Previous Pregnancies) Definition: A description of any type(s) of problem(s) experienced following birth in any previous pregnancy(ies), which is (are) of relevance to the current care of the woman. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

CodeSub-Value

00 None A Pain B Discharge C Infection D Bleeding

01

Vaginal Problems

E Prolapse A Pain B Breakdown of Wound C Labial Adhesions

02 Perineal Trauma and Repair Concerns

D Dyspareunia A Deep Vein Thrombosis 03 Thromboembolic

Disease B Pulmonary Embolism 04 After Pains

A Retention B Incontinence

05 Urinary Problems

C Fistula 06 Haemorrhoids

A Faecal Incontinence B Constipation

07 Bowel Concerns

C Fistula A Cracked Nipples B Mastitis C Candidiasis D Inverted Nipples

08 Breast Problems

E Engorged Breasts 09 Postpartum A Primary





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Haemorrhage B Secondary A Urinary Tract Infection B Respiratory C Wound Infection D Endometritis

10 Infection

E Pyrexia of Unknown Origin 11 Epidural Complication 12 Musculo-Skeletal

A Post-Natal Depression 13 Mental Health Problems B Puerperal Psychosis

97 Not Disclosed 98 Other (specify) E.g. post-abortion complications 99 Not Known

Related Data Item: Delivery Mode Recording Guidance: Systems should allow for the recording of more than one previous post-delivery problem. When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one pregnancy. 3.19 Neonatal Concern(s) Indicator (Previous Pregnancies) Common Name: Concern for Babies During Neonatal Period in Previous Birth(s) Definition: An indication of whether or not there were factors of concern regarding the baby during its neonatal period in the woman’s previous birth(s). Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby. 3.20 Neonatal Unit Admission (Previous Pregnancies) Definition: An indication of whether or not the baby was admitted to a Neonatal Unit during its neonatal period in the woman’s previous birth. Format: Characters Field Length: 2


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Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby. 3.21 Feeding Status Definition: A record of the type of nutrition given to the baby. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Breast Milk Only Includes feeding with expressed breast milk. 02 Standard Formula Milk Only 03 Mixed (Breast and Formula

Milk)

98 Other (specify) The clinical condition of the baby may result in feeding with specialised formula, parenteral nutrition etc.

99 Not Known Attributes: Previous Pregnancy Current Pregnancy Sub-Data Item: Time Applicability Code Value 01 At 24 hours 02 At Transfer to Community Midwife 03 At Discharge from Community

Midwife 04 At 19 Days 05 At 6 Weeks

Recording Guidance: When using this standard to record information on previous pregnancies, systems should allow for the recording of information on more than one previous baby. Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other post-delivery problems.


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4. Family Circumstances Data Item Number Family History (Conditions) {Maternity} 4.1 Genetic Clinic Attendance by Family 4.2 Blood Relationship of Parents 4.3

4.1 Family History (Conditions) {Maternity} Definition: A record of any condition(s) known to be present in at least one of the first, second or third degree relatives of the pregnant woman and/or of the biological father of her baby which are of relevance to a particular involvement of the patient with care services. Format: Characters (In the future all diagnoses, health problems and issues should be recorded using SNOMED-Clinical Terms) Field Length: Minimum 18 Codes and Values: Code Value 00 No Diagnosis 01 Allergies 02 Asthma 03 Diabetes 04 Genetic Disorders 05 Pre-eclampsia 06 Thromboembolic Disease 07 Tuberculosis (TB) 08 Developmental Dysplasia of the Hip (DDH) 09 Congenital Abnormalities 10 Learning Disabilities 11 Mental Health Disorders 12 Permanent Hearing Loss 98 Other (specify) 99 Not Known

Attributes: Laterality Right Left Bilateral Midline Severity Mild Moderate Severe Chronicity Acute Chronic Recurrent


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Sub-Data Items: Date of Diagnosis (See data standard for “Date”). Applicable Parent Code Value 01 Biological Mother 02 Biological Father

Related Data Items: Degree of Relative (Existing and published in the Health and Social Care Data Dictionary) Family History Age at First Onset † Family History Age at Death‡

Further Information: This item should be recorded with the Degree of Relative. Often only family history in first-degree relatives is documented as of interest to clinicians. This data item records the presence of any conditions and diagnoses known to be diagnosed in at least one first, second or third degree relative. Drop-down lists of terms for common family history conditions can be developed within the context of specific clinical data standards/datasets. Where an IT system is currently unable to implement the appropriate clinical terminology(ies) within its functionality, it may be possible to record family history using free text. This is not recommended as a long-term option. Recording Guidance: This data item may be applied using a list of SNOMED-CT (SCT) codes for the conditions of interest in the clinical area in question. Systems should allow for recording of multiple conditions. It may be appropriate to record associated date(s) of diagnosis. It is recommended that IT systems incorporate a clinical terminology browser to facilitate recording of personal history. The browser should allow selection and display of clinical terms on the user interface whilst storing, managing and transferring such data by the corresponding clinical code. Family History should be recorded on admission or date of contact as appropriate to the episode of care. 4.2 Genetic Clinic Attendance by Family Definition: An indication of whether or not anyone in the pregnant woman’s family and/or the baby’s biological father’s family have attended, or are attending a genetics clinic in relation to genetic issues. Format: Characters

† Family History Age at First Onset This data standard is under development and is likely to replace the existing item that is displayed in the Health and Social Care Data Dictionary: Family History Age at First Onset (First Degree Relative). The proposed change is that it will also take into account second and third degree relatives. ‡ Family History Age at Death This data standard is under development and is likely to replace the existing item that is displayed in the Health and Social Care Data Dictionary: Family History Age at Death (First Degree Relative). The proposed change is that it will also take into account second and third degree relatives.


36

Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not Disclosed 99 Not Known

Sub-Data Item: Applicable Parent Code Value 01 Biological Mother 02 Biological Father

Related Data Items: Family History of Conditions {Maternity} Personal History of Conditions {Maternity} 4.3 Blood Relationship of Parents Definition: An indication of whether or not the pregnant woman and the baby’s biological father are blood relatives. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not Disclosed 99 Not Known

Related Data Item: Associated Person Relationship to Client/Patient


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5. Personal Health Information Data Item Number Personal History (Conditions) {Maternity} 5.1 Colposcopy Referral Indicator 5.2 Female Genital Mutilation Type 5.3 Folic Acid Status 5.4 Folic Acid Dosage 5.5 Diet Type 5.6 Dental Registration 5.7 Dental Attendance Indicator 5.8 Passive Smoke Exposure Status 5.9 Passive Smoke Exposure Location 5.10 Blood Group Type - ABO 5.11 Rh Antigen Status 5.12 Anti-D Indicator 5.13

5.1 Personal History (Conditions) {Maternity} Common Names: Past History, Co-morbidities Definition: A record of any condition(s) the patient has previously had diagnosed, including any chronic diseases/long-term conditions, of relevance to a particular involvement with care services. Format: Characters (In the future all diagnoses, health problems and issues should be recorded using SNOMED-Clinical Terms) Field Length: 2 Codes and Values: Code Value 01 Operations 02 Asthma 03 Allergies 04 Lung Disorders 05 Hypertension 06 Cardiac Disorders 07 Diabetes 08 Thyroid Disorders 09 Endocrine Disorders 10 Epilepsy 11 Neurological Disorders 12 Sexually Transmitted Infections (STI) 13 Thromboembolic Disorders 14 Renal Disorders 15 Urinary Disorders 16 Hepatic Disorders 17 Gastro-intestinal Disorders 18 Fertility Disorders 19 Reproductive Disorders 20 Vaginal Infections 21 Female Genital Mutilation 22 Mental Health Disorders 23 Genetic Disorders 24 Cancers


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25 Bone Disorders 26 Joint Disorders 27 Disabilities 96 Not Applicable 99 Not Known

Attributes: Laterality Right Left Bilateral Midline Severity Mild Moderate Severe

Chronicity Acute Chronic Recurrent Sub-Data Item: Date of Diagnosis (See data standard for “Date”) Further Information: This data item records the presence of pre-existing conditions and diagnoses which have been made in the past. Recording Guidance: This data item may be applied using a list of SNOMED-CT (SCT) codes for the conditions of interest in the clinical area in question. Systems should allow for recording of multiple conditions. It may be appropriate to record associated date(s) of diagnosis. It is recommended that IT systems incorporate a clinical terminology browser to facilitate recording of personal history. The browser should allow selection and display of clinical terms on the user interface whilst storing, managing and transferring such data by the corresponding clinical code. This information may be taken from the patient, carer, or recorded in the patient’s case record or on the referral document pertaining to an illness, injury or associated health care problem experienced by the patient. Do not include suspected conditions. Remember that patients do not always disclose all their medical problems. Personal History should be recorded on admission or date of contact as appropriate to the episode of care. Complications and recurrences during an episode of care should be recorded with the date of diagnosis. Personal History will also be recorded on discharge (SCI Immediate Discharge letter).


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5.2 Colposcopy Referral Indicator Definition: An indication of whether or not the woman has ever been referred for colposcopy examination. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not Disclosed 99 Not Known

Sub-Data Item: Date of Colposcopy Referral (See data standard for “Date”). 5.3 Female Genital Mutilation Type Common Name: Type of Female Genital Mutilation Definition: A record of the type of genital mutilation that the female has undergone. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Type I Excision of the prepuce, with or without excision of part or all of the

clitoris. 02 Type II Excision of the clitoris with partial or total excision of the labia minora. 03 Type III Excision of part or all of the external genitalia and stitching/narrowing

of the vaginal opening (infibulation). 04 Type IV Pricking, piercing or incising of the clitoris and/or labia; stretching of the

clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue.

05 Scraping Scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts).

06 Introduction of Corrosive Substances

Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above.

07 Type Not Known 96 Not Applicable e.g. No genital mutilation. 97 Not Disclosed 99 Not Known


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Further Information: The World Health Organization have identified that there are six different types of female genital mutilation known to be practised. For Further Information, please refer to the Female Genital Mutilation fact sheet from the World Health Organization. http://www.who.int/mediacentre/factsheets/fs241/en/ 5.4 Folic Acid Status For the recording of information on Folic Acid use, the following Medication and Devices data standards, which were published previously in the Health and Social Care Data Dictionary, are available for use: Medication or Device Name Medication or Device Status 5.5 Folic Acid Dosage For the recording of information on Folic Acid Dosage, the following Medication and Devices data standard, which was published previously in the Health and Social Care Data Dictionary, is available for use: Medication Dosage 5.6 Diet Type




through the Change Control process to authorise the proposed changes. Definition: A description of the main type of diet usually eaten by the patient/client. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

CodeSub-Value

01 Non-Specific A Gluten Free Diet B Wheat Free Diet C Diabetic Diet D Treating Weight Loss E Treating Weight Gain F Treating Metabolic Disorder

02 Healthcare Prescribed

Z Other (specify) 03 Non-Healthcare A Weight Loss Diet

http://www.who.int/mediacentre/factsheets/fs241/en/


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B Weight Gain Diet C Vegetarian Diet D Vegan Diet E Halal Diet F Kosher Diet

Prescribed

Z Other (specify) 98 Other (specify) 99 Not Known

Recording Guidance: IT systems should allow for recording of multiple options. Users may wish to augment code 98 – “Other (specify)” and Sub-Code Z – “Other (specify)” with a free text field for recording other descriptions of main diet. 5.7 Dental Registration Definition: An indication of whether or not the patient/client is registered with a dentist. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

5.8 Dental Attendance Indicator Definition: An indication of whether or not the patient/client has attended the dentist in the last two years. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not Disclosed 99 Not Known

Further Information: NICE guidelines recommend that under-18s should attend the dentist between 3 - 12 months. For adults the frequency of dental check-ups should be between 3 - 24 months. Further information can be obtained from http://www.nice.org.uk/page.aspx?o=228924.

http://www.nice.org.uk/page.aspx?o=228924


42

5.9 Passive Smoke Exposure Status Definition: An indication of whether or not, in the patient’s opinion, they are exposed to passive smoke on a regular basis. Format: Characters Field Length: 2 Codes and Values: Code Value 00 Not Exposed 01 Exposed 99 Not Known

Further Information: Passive smoke is smoke that is breathed in from other people's tobacco smoke. This smoke is also referred to as environmental tobacco smoke (ETS) or second hand smoke (SHS). Further information can be obtained from http://www.ashscotland.org.uk/. 5.10 Passive Smoke Exposure Location Definition: A record of the type of location in which the patient is exposed to passive smoke. Format: Characters Field Length: 2 Codes and Values: Code Value 01 At Home 02 At Work 03 In Other People’s Homes 04 In Other Public Places 97 Not Disclosed 98 Other

Further Information: Passive smoke is smoke that is breathed in from other people's tobacco smoke. This smoke is also referred to as environmental tobacco smoke (ETS) or second hand smoke (SHS). This definition has been obtained from http://www.ashscotland.org.uk/ 5.11 Blood Group Type - ABO Definition: A record of the person’s ABO blood group type. Format: Characters Field Length: 2

http://www.ashscotland.org.uk/

http://www.ashscotland.org.uk/


43

Codes and Values:

Sub-Data Item: Verification Code Value 00 Unverified 01 Verified 99 Not Known

5.12 Rh Antigen Status Definition: A record of whether the person’s RhD antigen status is negative or positive. Format: Characters Field length: 2 Codes and Values: Code Value Explanatory Notes 01 RhD Negative Does not contain D antigen 02 RhD Positive Contains D antigen 98 Other (Specify) 99 Not Known

Sub-Data Item: Verification Code Value 00 Unverified 01 Verified 99 Not Known

5.13 Anti-D Indicator Definition: An indication of whether or not the woman has received Anti-D Immunoglobulin for Rh Prophylaxis. Format: Characters Field Length: 2 Codes and Values:

Code Value 01 A 02 B 03 AB 04 O 99 Not Known


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Code Value 00 Not Received 01 Received 99 Not Known

Related Data Items: Gestation Medication Dosage Recording Guidance: To record the gestation at which Anti-D was given, the data standard ‘Gestation’ would be used.

6. Current Pregnancy Details Data Item Definition Investigation/Test Name (HCG) 1

A record of the specific investigation/test performed.

1The data item in the table above is part of the Laboratory Investigations data standards, which have been submitted to the NCDDP Programme Board Data Item Number Pregnancy Test Result 6.1 Pregnancy Test Method 6.2 Investigation/Test Name (HCG) 1 6.3 Last Menstrual Period Date 6.4 Contraception Failure 6.5 Estimated Delivery Date 6.6 Estimated Delivery Date (Agreed) 6.7 Vaginal Bleeding Indicator since Last Menstrual Period (Self-Reported) 6.8 Vaginal Bleeding Flow since Last Menstrual Period (Self-Reported) 6.9 Menstrual Cycle Pattern (Self-Reported) 6.10 Menstrual Cycle Duration (Self-Reported) 6.11 Menstrual Cycle Duration Range (Self-Reported) 6.12 Menstrual Cycle Shortest Duration (Self-Reported) 6.13 Menstrual Cycle Longest Duration (Self-Reported) 6.14 Gestation 6.15 Pregnancy Specific Risk Level 6.16 Level of Care (Antenatal) 6.17 Level of Care (Reason for Change) 6.18 Urinary Tract Infection (UTI) Indicator 6.19 Birth Place Type 6.20 Birth Place (Reason for Change) 6.21

6.1 Pregnancy Test Result




through the Change Control process to authorise the proposed changes. Definition: A record of the result of the pregnancy test.


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Format: Characters Field Length: 2 Codes and Values: Code Value 00 Negative (Not Pregnant) 01 Positive (Pregnant) 02 Inconclusive 99 Not Known

Sub-Data Item: Date of Pregnancy Test (see data standard for “Date”) Related Data Item: Pregnancy Test Method, Last Menstrual Period 6.2 Pregnancy Test Method Common Name: Method of Pregnancy Test Definition: A record of the method of pregnancy test used. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-

Code Sub-Value

A Self-test, e.g. Home Pregnancy Test 01 Urine Beta Human Chorionic Gonadotropin (B-HCG) B Carried out by Healthcare Professional

02 Serum Human Chorionic Gonadotropin (HCG)

99 Not Known Related Data Items: Pregnancy Test Result Biochemistry Investigations/Tests Recording Guidance: Systems should allow for more than one pregnancy test method to be recorded.


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6.3 Last Menstrual Period Date




through the Change Control process to authorise the proposed changes. Common Name: Date of Last Menstrual Period Definition: The date of the first day of the woman’s last menstrual period. Format: Characters (CCYY-MM-DD) Field Length: 10 Codes and Values: N/A Sub-Data Item: Last Menstrual Period Date Certainty Code Value 01 Sure 02 Fairly Sure 03 Not Sure

Recording Guidance: Where the date of the woman’s last menstrual period is unknown, systems should allow for users to enter 9999-99-99. 6.4 Contraception Failure Definition: An indication of whether or not there was failure of any form of contraception used by the individual. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not disclosed 99 Not Known

Related Data Item: Contraception Type (Existing and published in the Health and Social Care Data Dictionary) Further Information: Contraception failure is where any method of contraception was not used correctly (e.g. condom not used throughout entire sexual intercourse, missing pills in a


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pack of contraceptive pills etc.) or where a contraceptive method did not function in its required way (e.g. condom splitting, drug interaction, i.e. antibiotics etc.). 6.5 Estimated Delivery Date




through the Change Control process to authorise the proposed changes. Common Name: Due Date, Estimated Date of Delivery, EDD Definition: The anticipated due date for the delivery of the baby. Format: Characters (CCYY-MM-DD) Field Length: 10 Codes and Values: N/A Sub-Data Item: Mode of Estimation Code Value Explanatory Notes 01 Ultrasound Scan The anticipated due date for delivery derived from

measurement of the fetus by ultrasound. 02 Last Menstrual Period The anticipated due date for delivery assuming exactly

38 weeks from conception to delivery date, derived from the first day of the last menstrual period and cycle length (where known).

03 Assisted Conception The anticipated due date for delivery according to the method of assisted conception, i.e. In-Vitro Fertilisation (IVF)/Intra-Cytoplasmic Sperm Injection (ICSI)– Estimated Delivery Date would be calculated from the date the embryos were implanted; i.e. Intrauterine Insemination – Estimated Delivery Date would be calculated from the date of insemination.

98 Other (specify) Recording Guidance: Systems should allow for more than one date and mode of estimation to be recorded. 6.6 Estimated Delivery Date (Agreed) Common Name: Agreed EDD Definition: The date the woman and health professional have agreed as being the estimated date of delivery.


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Format: Characters (CCYY-MM-DD) Field Length: 10 Codes and Values: N/A 6.7 Vaginal Bleeding Indicator since Last Menstrual Period (Self-Reported) Definition: An indication of whether or not the woman has experienced any vaginal bleeding since her last menstrual period, as reported by the woman. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 97 Not Disclosed 99 Not Known

Further Information: Vaginal bleeding is any intermenstrual bleeding that is not a continuance of a previous menstrual period nor the start of a new one. 6.8 Vaginal Bleeding Flow since Last Menstrual Period (Self-Reported) Definition: A description of the flow of the intermenstrual bleeding since the woman’s last menstrual period, as reported by the woman. Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Lighter than Usual e.g. bleeding lighter than that of woman’s usual

menstrual period. 02 Similar to Usual e.g. bleeding similar to woman’s usual menstrual

period. 03 Heavier than Usual e.g. bleeding heavier than woman’s usual menstrual

period. 98 Other e.g. where the woman does not have a usual

menstrual period flow. 97 Not Disclosed 99 Not Known


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6.9 Vaginal Bleeding Frequency since Last Menstrual Period (Self-Reported) Definition: An indication of the number of vaginal bleeds the woman experienced since her last menstrual period, as reported by the woman. Format: Numeric Field Length: 2 Codes and Values: N/A Sub-Data Item: Date(s) of Intermenstrual Bleeding (see data standard for "Date") Further Information: Vaginal bleeding is any intermenstrual bleeding that is not a continuance of a previous menstrual period nor the start of a new one. 6.10 Menstrual Cycle Pattern (Self-Reported) Common Name: Pattern of Menstrual Cycle Definition: A record of the usual pattern of the woman’s menstrual cycle, as reported by the woman. Format: Characters Field Length: 3 Codes and Values: Code Value Sub-


01 Regular Pattern can be identified from one cycle to the next.

02 Irregular No useful pattern can be identified. A Primary Absence of menstrual periods in a

woman who has never had a menstrual period before.

03 Amenorrhoea

B Secondary Absence of menstrual periods in a woman who previously used to have menstrual periods.

97 Not Disclosed 99 Not Known

Related Data Item: Contraception Type (Existing and published in the Health and Social Care Data Dictionary) Attributes: Current Previous (includes pre-pregnancy)


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Further Information: The first day of the woman’s menstrual period should be counted as day 1 of the cycle and counted up for each subsequent day until another menstrual period occurs at which the cycle count is reset to day 1. The usual pattern should ordinarily cover the past 12 months. 6.11 Menstrual Cycle Duration (Self-Reported) Common Name: Length of Menstrual Cycle Definition: A record of the usual duration of the woman’s menstrual cycle, measured as a number of days, as reported by the woman. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related Data Item: Contraception Type (Existing and published in the Health and Social Care Data Dictionary) Further Information: The first day of the woman’s menstrual period should be counted as day 1 of the cycle and counted up for each subsequent day until another menstrual period occurs at which the cycle count is reset to day 1. The usual pattern should ordinarily cover the past 12 months. Recording Guidance: In circumstances where the woman reports that she is amenorrheic then ‘00’ should be entered into the numeric field. If the woman reports her menstrual cycle duration as a range, the shortest and longest values should be recorded using the related data standards, ‘Menstrual Cycle Shortest Duration’ and ‘Menstrual Cycle Longest Duration’. 6.12 Menstrual Cycle Duration Range (Self-Reported) Definition: The shortest to longest duration of the menstrual cycle, expressed as a range and measured in days. Related Data Items: Menstrual Cycle Shortest Duration Menstrual Cycle Longest Duration Recording Guidance: Within a system this could be displayed as a range for example:

Menstrual Cycle Duration Range Menstrual Cycle Shortest Duration Menstrual Cycle Longest Duration

28

to 35


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6.13 Menstrual Cycle Shortest Duration (Self-Reported) Common Name: Shortest Duration of Menstrual Cycle Definition: A record of the shortest duration of the woman’s menstrual cycle, as reported by the woman, measured as a number of days. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related Data Items: Menstrual Cycle Duration Range Menstrual Cycle Longest Duration Contraception Type (Existing and published in the Health and Social Care Data Dictionary). Further Information: The first day of the woman’s menstrual period should be counted as day 1 of the cycle and counted up for each subsequent day until another menstrual period occurs at which the cycle count is reset to day 1. The usual pattern should ordinarily cover the past 12 months. Recording Guidance: If the woman reports her menstrual cycle duration as a range, the shortest and longest values can be recorded using the data standards, ‘Menstrual Cycle Shortest Duration’ and ‘Menstrual Cycle Longest Duration’. 6.14 Menstrual Cycle Longest Duration (Self-Reported) Common Name: Longest Duration of Menstrual Cycle Definition: A record of the longest duration of the woman’s menstrual cycle, as reported by the woman, measured as a number of days. Format: Numeric (nnn) Field Length: 3 Codes and Values: N/A Related Data Items: Menstrual Cycle Duration Range Menstrual Cycle Shortest Duration Contraception Type (Existing and published in the Health and Social Care Data Dictionary). Further Information: The first day of the woman’s menstrual period should be counted as day 1 of the cycle and counted up for each subsequent day until another menstrual period occurs at which the cycle count is reset to day 1. The usual pattern should ordinarily cover the past 12 months.


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Recording Guidance: If the woman reports her menstrual cycle duration as a range, the shortest and longest values can be recorded using the data standards, ‘Menstrual Cycle Shortest Duration’ and ‘Menstrual Cycle Longest Duration’. 6.15 Gestation




through the Change Control process to authorise the proposed changes. Common Name: Number of Weeks Pregnant Definition: The best estimate of the length of gestation, recorded in weeks and days. Format: Characters (nn+n) Field Length: 4 Codes and Values: N/A Sub-Data Item: Time Applicability Code Value 01 At Booking 02 At Clinic Appointment 03 At Scan 04 At Time of Delivery 05 Unscheduled Consultations/

Admissions 06 At Abortion/Miscarriage 98 Other (specify)

Further Information: Gestational age will normally be based on the agreed estimated date of delivery and nominally calculated from the date of the first day of the last menstrual period. In some circumstances the paediatrician may estimate gestational age after examination of the baby. Recording Guidance: For example a gestational age of 28 weeks and 3 days should be recorded as 28+3. The value 99 should be used when the gestational age is unknown.


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6.16 Pregnancy Specific Risk Level Main Source of Standard: Framework for Maternity Services in Scotland http://www.scotland.gov.uk/library3/health/ffms-00.asp Definition: A description of the level of pregnancy specific risk to the woman. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Normal/Low Risk 02 High Risk 03 Complex/Very High Risk 99 Not Known

Recording Guidance: The assigned level of pregnancy specific risk may change during the course of a woman’s pregnancy. 6.17 Level of Care (Antenatal) Definition: A record of the level of care assigned to the woman during her pregnancy. Main Source of Standard: Framework for Maternity Services in Scotland (http://www.scotland.gov.uk/library3/health/ffms-00.asp). Format: Characters Field Length: 2 Codes and Values: Code Value Explanatory Notes 01 Level I Community/home based care, midwife managed (Normal Pregnancy) 02 Level IIa Community/clinic based care from midwife, GP or obstetrician (Low or

high risk pregnancy). 03 Level IIb Maternity Unit based care from consultant obstetrician linking with GP and

midwife (High risk pregnancy). 04 Level III Tertiary maternity unit based care from specialist consultant in maternal

fetal medicine (Complex or very high risk pregnancy). 99 Not Known

Sub-Data Item: Date of Assignation of Level of Care (Antenatal) (see data standard for “Date”) Further Information: See Framework for Maternity Services in Scotland, Table 13: Incremental Approach to Antenatal care, page 37. http://www.scotland.gov.uk/library3/health/ffms-00.asp Recording Guidance: The assigned level of care may change during the course of a woman’s pregnancy.

http://www.scotland.gov.uk/library3/health/ffms-00.asp




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6.18 Level of Care (Reason for Change) Definition: A description of the reason for a change in the level of care of the pregnant woman. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Reassessment of Risk 02 Maternal Preference 03 Location Issues 98 Other (specify) 99 Not Known

Attributes: Action Status Planned Actual Sub-Data Item: Date of Assignation of Level of Antenatal Care (see data standard for “Date”) Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other reasons for changes to level of care. 6.19 Urinary Tract Infection (UTI) Indicator Definition: An indication of whether or not the individual currently has a urinary tract infection. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Sub-Data Item: Urinary Tract Infection (Location) Upper Urinary Tract Lower Urinary Tract Related Data Items: Medication or Device Status* Medication or Device Name* Frequency of Recurrence Urinary Tract Infection*


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*Existing and published in the Health and Social Care Data Dictionary Recording Guidance: If the individual is being treated for the Urinary Tract Infection (UTI), the information pertaining to this can be recorded by using the data standards 'Medication or Device Status' and 'Medication or Device Name'. 6.20 Birth Place Type




through the Change Control process to authorise the proposed changes. Definition: A record of the type of place the woman plans to give birth in or where the baby was born. Main Source of Standard: Framework for Maternity Services in Scotland (http://www.scotland.gov.uk/library3/health/ffms-00.asp). Format: Characters Field Length: 3 Codes and Values: Code Value Sub-


01 Home Where a caravan or boat is the person’s usual place of residence, then this would be considered their home.

02 Community Maternity Unit RCOG level of care – Ib, c & d

03 Consultant-led Maternity Unit

RCOG level of care – II

04 Consultant-led Specialist Maternity Unit

RCOG level of care - III

A Ambulance Birth occurred in an ambulance whilst mother in transit to a planned place of delivery.

05 Vehicle

B Other Vehicle Birth occurred in a car, taxi or other place of transit whilst mother en route to a planned place of delivery. Includes helicopter.

98 Other 99 Not Known

Attributes: Action Status Planned



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Actual Sub-Data Item: Date of Assignation of Planned Birth Place Type (see data standard for “Date”) Further Information: Community Maternity Unit, Consultant-led Maternity Unit and Consultant-led Specialist Maternity Unit can be mapped to levels of care I, II and III of the ‘Royal College of Obstetricians and Gynaecologists (RCOG) Three Level Tiered Model’ respectively. The RCOG’s approach to incremental care is outlined in the Expert Group on Acute Maternity Services (EGAMS) – Reference Report (Levels of Intrapartum Care by Location and Childbirth). SEHD, December 2002 (http://www.show.scot.nhs.uk/sehd/publications/egas/egas.pdf) Recording Guidance: If recording information on ‘planned’ Birth Place Type, code 05 should not be made available. 6.21 Birth Place (Reason for Change) Definition: A description of the reason for a change in the place of birth. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Reassessment of Risk 02 Maternal Preference 03 Location Issues 98 Other (specify) 99 Not Known

Attributes: Action Status Planned Actual Sub-Data Item: Date of Assignation of Place of Birth (see data standard for “Date”) Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other reasons for changes to birth place type.


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7. Examinations Data Item Number Examination Performed (Gravid Uterus) 7.1 Uterine Fundus Palpable 7.2 Uterine Fundal Height 7.3 Lie (Fetus) 7.4 Engagement Status (Fetus) 7.5 Degree of Engagement (Fetus) 7.6 Fetal Heart Activity Check (Indicator) 7.7 Fetal Heart Activity Check (Method) 7.8 Fetal Heart Activity Detected (Indicator) 7.9 Fetal Heart Rate 7.10 Fetal Movements Felt 7.11 Fetal Movements Concern(s) 7.12 Fetal Movements Concern(s) Reason 7.13

7.1 Examination Performed (Gravid Uterus) Definition: An indication of whether or not an examination of the gravid uterus was performed. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Further Information: The gravid uterus is examined by means of abdominal palpation. 7.2 Uterine Fundus Palpable Definition: An indication of whether or not the uterine fundus is palpable. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes

Sub-Data Item: Date (see data standard for “Date”)


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7.3 Uterine Fundal Height Common Name: Height of Uterus Definition: A record of the measurement from the superior surface of the pubic bone to the fundus of the uterus, measured in centimetres. Format: Numeric Field Length: 2 Codes and Values: N/A 7.4 Lie (Fetus) Definition: A description of the position of the baby’s spine in relation to its mother’s spine. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Longitudinal 02 Transverse 03 Oblique 99 Not Known

Sub-Data Items: Date of Examination (see data standard for “Date”)

Method of Examination Code Value 01 Ultrasound Scan 02 Palpation

Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.5 Engagement Status (Fetus) Definition: An indication of whether or not the presenting part of the fetus is engaged. Format: Characters Field Length: 2


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Codes and Values: Code Value 00 Not Engaged 01 Engaged 99 Not Known

Sub-Data Item: Date of Examination (see data standard for “Date”) Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.6 Degree of Engagement (Fetus) Common Name: Fifths Palpable Definition: A record of the degree of engagement of the fetal head. Format: Characters Field Length: 2 Codes and Values: Code Value 01 0/5 02 1/5 03 2/5 04 3/5 05 4/5 06 5/5 99 Not Known

Sub-Data Item: Date of Examination (see data standard for “Date”) Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.7 Fetal Heart Activity Checked (Indicator) Definition: An indication of whether or not fetal heart activity was checked. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Sub-Data Item: Date of Examination (see data standard for “Date”)


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7.8 Fetal Heart Activity Checked (Method) Definition: A record of which methods were used to check the heart activity of the fetus. Format: Characters Field Length: 2 Codes and Values: Code Value 01 Ultrasound 02 Pinnards 03 Doppler 04 Cardiotocography (CTG) 98 Other 99 Not Known

Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for more than one method being used to record the heart activity of the fetus. Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.9 Fetal Heart Activity Detected (Indicator) Definition: An indication of whether or not fetal heart activity was detected. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.10 Fetal Heart Rate Definition: A record of the fetal heart rate, recorded in beats per minute (bpm). Format: Numeric Field Length: 3 Codes and Values: N/A


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Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.11 Fetal Movements Felt Definition: An indication of whether or not fetal movements have been felt by the woman. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Sub-Data Item: Date of Examination (see data standard for “Date”) Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.12 Fetal Movement Concern(s) Definition: An indication of whether or not the healthcare professional is concerned about fetal movements felt by the woman. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes

Recording Guidance: Systems should allow for the recording of multiple values for this standard to account for multiple births within the same pregnancy (e.g. twins). 7.13 Fetal Movement Concern(s) Reason Common Name: Reason for Fetal Movement Concerns Definition: A description of the reason(s) why the healthcare professional is concerned about fetal movements felt by the woman. Format: Characters Field Length: 2


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Codes and Values: Code Value 01 Fetal Movement(s) Never Felt 02 Loss of Fetal Movement(s) 03 Reduction in Number of Movements 04 Increase in Number of Movements 98 Other (specify)

Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other fetal movement concern reasons.

8. Education/Advice Data Item Number Education Advice Indicator 8.1 Education/Advice Topic(s) {Maternity} 8.2 Parent Education Class Attendance 8.3

8.1 Education Advice Indicator Definition: An indication of whether or not the standard leaflets or documentation have been given to the individual. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known

Related Data Items: Education Advice (Non-specialist) Method(s) (Existing and published in the Health and Social Care Data Dictionary) Education/Advice Topic(s) {Maternity}

8.2 Education Advice Topic(s) {Maternity} Definition: A record of the topic(s) covered by the education/advice or materials supplied. Format: Characters Field Length: 2


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Codes and Values: Code Value Explanatory Notes 01 Lifestyle Considerations e.g. working during pregnancy, diet, exercise. 02 Medication e.g. prescribed medication, nutritional supplements. 03 Dental 04 Travel e.g. air/car travel. 05 Physical Issues e.g. back pain, bladder health. 06 Birth and Labour Issues e.g. pain management, labour positions, breathing/relaxation

techniques. 07 Post-natal Considerations e.g. breastfeeding, weaning, contraception. 08 Screening 98 Other (specify) 99 Not Known

Attributes: Type Individual Group

Action Status Planned Actual Sub-Data Item: Date Education/Advice or Materials Given (see data standard for “Date”) Recording Guidance: Users may wish to augment code 98 – “Other (specify)” with a free text field for recording other education/advice Systems should allow for the recording of more than one topic. 8.3 Parent Education Class Attendance Definition: An indication of whether or not the woman attended parent education classes. Format: Characters Field Length: 2 Codes and Values: Code Value 00 No 01 Yes 99 Not Known


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Appendix 1 - Working Group Membership Membership of the Maternity Antenatal Data Standards Working Group Name Position Organisation

Joan Baker Midwife NHS Lothian

Jim Chalmers Consultant in Public Health Medicine ISD, National Services Scotland

Fiona Dagge-Bell (Chair)

Professional Practice Development Officer (Women, Children & Learning Disability Nursing)

NHS Quality Improvement Scotland

Philip Dutton Clinical Research Fellow Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH)

Janice Falconer Senior Physiotherapist NHS Forth Valley

Evelyn Forrest Deputy Service Manager/Midwife Royal College of Midwives NHS Lanarkshire

Marie Gallagher Katy Rangeley Zareena Rafiq

Data and Terminology Developers NCDDP

ISD, National Services Scotland

Helen Gray District Nurse/Midwife NHS Forth Valley

Anne Leigh-Brown Programme Principal (Women and Children’s Health Information Programme)

ISD, National Services Scotland

Danka Macleod Maternity/Neonatal Systems Project Manager

NHS Tayside

Mags McGuire Professional Advisor Women and Children

Scottish Executive Health Department

Gopi Menon Consultant Neonatologist NHS Lothian

Rhian Morgan Information Manager - NCDDP ISD, National Services Scotland

Mathilde Peace Lay Member Lothian Maternity Services Liaison Committee

Gillian Penney Programme Director/Consultant Universities of Edinburgh and Aberdeen

Mary Ross-Davie Practice Development Midwife NHS Quality Improvement Scotland

Jackie Stevenson Community Midwife NHS Lanarkshire

Susan Stewart Women’s Service Manager Royal College of Midwives NHS Lanarkshire

Alison Wallis Clinical Advisor (Nursing) ISD, National Services Scotland


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Appendix 2 - Consultation Distribution List Chief Executives Chief Medical Officer Chief Nursing Officer Directors of Nursing Directors of Public Health Medical Directors National Advisory Committees Managed Clinical Networks (MCNs) Scottish Intercollegiate Guidelines Network Maternity Specific Stakeholders Association of Chartered Physiotherapists in Women's Health British Association of Community and Child Health Community & District Nursing Association Community Practitioners and Health Visitors Association Independent Midwives Association Maternity Services Liaison Committees Ministerial Action Groups National Childbirth Trust National Sexual Health Advisory Committee NMAHP eHealth Midwife Ambassadors NMAHP eHealth Programme Board Nursing & Midwifery Council Practice Nurse Association Public Health Information Network for Scotland Royal College of Midwives Royal College of Nursing (Information in Nursing Forum) Royal College of Nursing (Midwifery Group) Royal College of Obstetricians and Gynaecologists Royal College of Paediatrics & Child Health Scotland Stillbirth and Neonatal Deaths Society NCDDP Stakeholders Clinical eHealth Leads Community Nursing Network Electronic Clinical Communications Implementation Health & Social Care Information Centre, Datasets Development Programme (England) Improving Mental Health Information Programme Information Services Division, National Services Scotland Information Standards Group NHS Health Scotland NHS Quality Improvement Scotland NHS24 Open Scotland Information Age Framework Royal College of General Practitioners (Scotland) Royal College of Nursing (Scotland) Royal College of Physicians Royal College of Physicians and Surgeons Glasgow Royal College of Physicians, London Royal College of Surgeons Royal College of Psychiatrists Scottish Clinical Information Management Practice (SCIMP)


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Scottish Executive Delivery Unit Scottish Executive Data Standards Branch Scottish Executive Health Department UK Data Standards Forum Voluntary Health Scotland NCDDP Reference & Working Groups NCDDP Board NCDDP Support Team Current NCDDP Working Groups

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