Maternity Inpatient and Day Case - Scottish Morbidity Record (SMR02)

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[{"id": "", "description": "Development Data", "name": "Development Data", "dataElementsCount": 12, "dataElements": [{"id": "", "description": "Definition\n\nPriority (as below)\n\nA contract identifier is a code which identifies each health care contract. It is a three part code:\n\nProvider code\nPurchaser code\nContract number which uniquely identifies the contract between the contracting parties\n\n\nProvider Code (5 characters) - Priority Mandatory\n\nThis is a UK national code which uniquely identifies a Health Board/Health Care Provider which is an organisation acting as a direct provider of health care services. It is a legal entity, or a subset thereof, which may contract for the provision of health care, and it may operate in one or more locations within and outside hospitals.\n\nPoints to Note\n\nWhen completing the provider code on ISD returns, the code of the Health Board/Health Care Provider which actually provides clinical services must be recorded.\nExample\nIf a consultant from Health Board/Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care on outreach basis (i.e. continues to be employed by Health Board/Health Care Provider A), recorded provider should be Health Board/Health Care Provider A.\n\nIf a consultant from Health Board/ Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care and Health Board/Health Care Provider B pays for this work either directly to the consultant or to Health Board/Health Care Provider A, the consultant is thought of as temporarily employed by Health Board/Health Care Provider B and the recorded provider should be Health Board/Health Care Provider B.\n\nCross Checks\n\nMust be valid provider code.\n\nPurchaser Code (5 characters) - Priority Optional\n\nThis is a UK national code which uniquely identifies a health care organisation that commissions health care services on behalf of its residents or patients, e.g. a Health Board which is responsible for commissioning comprehensive healthcare services for its residents.\n\nPoints to Note\n\nThis field may be blank.\nCross Checks\n\nIf Purchaser Code is present, then it must be a valid code and will be validated against the organisation reference file.\n\nContract Number (6 characters) - Priority Local\n\nThis is an alphanumeric code which uniquely identifies the contract between the contracting parties.\n\nPoints to Note\n\nThis field may be blank.\nContract Identifier\nContract Identifier (which consists of 16 characters) should be entered thus:\n\nProvider (first 5 digits), Purchaser (next five digits), Contract Number (final six digits).", "name": "Contract Identifier", "type": "PrimitiveType"}, {"id": "", "description": "This section is reserved to be used for the collection of data items which are being piloted and evaluated, for specific epidemiological/ clinical research projects, and for short term surveys.\n\nThis may be used for local purposes, and for agreed national projects.", "name": "Development Data Section", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Optional (up to four allowed, two on forms)\n\nSome interest was shown during the consultative process in the USA developments of disease staging, originally developed to classify oncology patients and now extended to all diseases typically seen in hospital inpatient and outpatient care. It allows the noting of increased severity based on the spread of the disease and the presence of complications. The Disease Category codes (3 characters) and Disease Stage codes (3 characters) area relate currently to ICD9-CM and DRG codes. They can be related to \"resource\" measures and \"outcome\" measures.\n\nThey are indicative of the possible use of the SMR Dataset for experimental and developmental purposes, and space has been allowed for these, or other, codes such as Read codes. Up to 4 codes have been included, each of up to 6 characters.", "name": "Severity Measures", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Local\n\nThese fields together uniquely identify the invoice and the line within that invoice into which the charge for this patient has been aggregated.", "name": "Invoice Number and Invoice Line", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Optional (up to four allowed, two on forms)\n\nInterest was shown during the consultative process in the use of dependency measures particularly in the areas of Geriatric Long Stay (SMR Record Type 50) and Mental Health (SMR Record Type 04). Optional provision has therefore been made in the SMR Dataset for the future, or extended, use of such dependency measures as used with the Scottish Health Resource Utilisation Groups (SHRUGS), which involve the collection of data on patient characteristics at defined intervals during the period of care.\n\nFor example, with Geriatric Long Stay (SHRUGS), patient characteristics are collected from care staff who know the patient well, defined in terms of need for special care, clinically complex conditions or treatments, behavioural difficulties, and personal dependency. An algorithm is used to determine a resource use group for each patient on the basis of these characteristics.\n\nWith Mental Health (using the Dependency and Needs Information System, DANIS), similar data is collected, including major sustained training needs, complex nursing care needed, clinically complex treatments or conditions, and behavioural difficulties.\n\nProvision has been made in the SMR Dataset for the developmental use of these measures. Up to four measures have been included, each with up to six characters, to allow for a variety of codes that may be used.", "name": "Dependency Measures", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Optional\n\nPatient care events occur at different points in time; some are discrete, and some may need to be associated with others, for example, for budgeting or contracting for 'care packages' across inpatient and outpatient episodes, and for the evaluation and monitoring of the efficiency of care.\n\nIt is proposed that a separate code be included for the overall clinical problem associated with an episode, a group of episodes, or a 'care package'. For example, a diabetes condition may result in episodes associated with vascular and ophthalmological disease.\n\nUp to six characters have been included, so as to allow for Read or ICD10 codes. The ways in which this data item may be used for 'care packages' will depend upon the definition and characteristics of such packages as agreed by Providers and Purchasers for different Specialties.", "name": "Clinical Problem Identifier for Spell/Care Package", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Optional (up to four allowed, two on forms)\n\nThe consultative process indicated that Optional provision should be allowed for the future recording of lifestyle factors of interest to particular Specialties.\n\nThese are those factors inherent in a patient's way of living that may have a significant effect on their propensity to ill health or the likely success of treatment. These may include the degree of smoking, alcohol, or drug abuse, diet, exercise, and other factors indicated in the ICD10 Z chapter, or relevant Read codes.\n\nUp to four such factors have been included, with up to six characters per factor, to allow for the use of ICD10 or Read codes.", "name": "Lifestyle Factors", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Local\n\nThis field allows further mapping of the contracted service within a contract for invoice verification, where the database in use uses this construct. It should be left blank where there is only one contracted service under the contract.", "name": "Contract Service Number", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Local\n\nA patient is chronically sick or disabled if he/she is blind, deaf or dumb, or is substantially and permanently handicapped by illness, injury, or congenital deformity.\n\nThis is recorded at the time of admission and it is used under the Chronically Sick and Disabled Persons Act 1970 to record the number of such people who are accommodated inappropriately, e.g. admitted to or resident in wards intended for elderly people.\n\nThis data item may be of value for specific clinical or contracting purposes within certain Specialties.", "name": "Chronic Sick/Disabled", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Optional (up to four allowed, two on forms)\n\nDuring the consultative process it was noted that there was a strong interest from Purchasers and Providers in developing the use of outcome measures related to the individual patient episode. It was also noted that these had not yet been sufficiently developed, and could include the following:\n\n\"general\" outcome measures, such as mortality within specific periods after discharge, readmission rates (to the same or other hospitals), discharges to home or other institution, and reoperation rates, etc. (These are best able to be analysed at present using the ISD SMR Record Linked database, and will be significantly extended by the SMR Dataset.)\n\"medium term\" outcome measures, related to specific Specialties, that could only be followed up after a specified period after discharge, through follow-up appointments or by communication with the GP.\n\"on discharge\" outcome measures, which relate the assessment on admission of the patient with the result of the treatment or operation during the period of care that the patient was under the responsibility of a particular Consultant, Department, or Hospital. This would include infection rates.\nThe Clinical Outcomes Working Group of CRAG (Clinical Resource and Audit Group) are proposing national guidelines and a continuing development programme for specific clinical outcome measures.\n\nOptional provision has been made in the SMR Dataset for up to four measures to be recorded for each episode, each of up to six characters, to allow for a variety of codes, including Read codes.", "name": "Outcome Measures", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Local\n\nThis is the charge applicable to this patient episode.\n\nThe last five fields indicated above (Contract Service Number to Contract Charge) are optional. The way in which they are used will be dependent upon local arrangements between Providers and Commissioners as part of their contract management reporting arrangements.", "name": "Contract Charge", "type": "PrimitiveType"}, {"id": "", "description": "Definition\n\nPriority Local\n\nDiagnostic Related Groups (DRG) or Health Resource Groups (HRG) may not necessarily be part of the information available following local processing of the SMR data. If the DRG/HRG is required in the contract assignments process, then arrangements have to be made locally for grouping software to be run against the ICD10 and OPCS4 coding to produce the DRG/HRG.", "name": "Iso-resource Group", "type": "PrimitiveType"}]}, {"id": "", "description": "Episode Management Data", "name": "Episode Management Data", "dataElementsCount": 23, "dataElements": [{"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nMandatory\n\nDefinition\nDischarge date is the date on which a patient is discharged from an episode of care.\n\nRecording Rules\nThe full date should be entered thus:\n12 June 2004 =\n\n1\t2\t0\t6\t0\t4\nPoints to Note\n\nSMR01 and 04 If a patient dies whilst on pass, the Discharge Date is the date of death, the Discharge Type is code 43, Death whilst on pass and the Discharge Transfer To is code 01 Patient died whilst on pass.\nWhen a patient does not return from on pass on the expected date, the Discharge Date should be the date the patient was expected to return.\nSMR04 If a patient is transferred to another hospital, general or psychiatric and there is intention to return, treat as if on pass.\nPriority is C for SMR02, SMR04.\nFor patients, whose organs are to de donated, Discharge Date will be the date the patient is certified/confirmed dead and NOT the date when the organs are harvested. The date and time of death should be recorded as the time of completion of the first set of these formal brain stem tests that confirms irreversible brain dysfunction, or date and time of cardiac death.\nCross Checks\n\nDischarge Date is checked to be in sequence with the other dates recorded.\nDuration of Stay is calculated by subtracting Date of Admission from Discharge Date and is used in cross checks involving:\nManagement of Patient\nSignificant Facility\nDiagnosis\nSMR02 and 04 - Discharge Date must not equal Date of Birth.\nSMR01 - If Discharge Date equals Date of Birth this record will always be queried.\nSMR01 - If Discharge Date equals Date of Birth then Significant Facility must equal 11 (Other), 12 (Postnatal Cot), 15 (Neonatal Unit) or 16 (Childrens Unit).\nSMR Validation - Discharge Date\n\n\nRelated items:\n\nEpisode of Care\nTags:\nepisode  care  patient  discharged  SMR01  SMR02  SMR04", "name": "Discharge Date", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n10\n\nPriority\nLocal\n\nDefinition\nA spell/care package is the healthcare provided usually in connection with a single condition. It may comprise several SMR episodes and cover one or more types of care, e.g. inpatient care, outpatient care, day patient care.\n\nRecording Rules\n\nDuring the consultative process on the SMR Dataset it was requested that provision should be made for a data item that would allow a number, or group, of SMR Episodes to be related together.\nThe need for this could be either for clinical reasons (where a patient has an overall clinical problem common to a number of different episodes, e.g. a diabetes complication associated with both vascular and ophthalmological diseases); or for health management reasons (where a patients episodes - inpatient, day case, outpatient, community - may be grouped into a \"care package\", e.g. Multi-disciplinary Team working).\nAn Optional 10 digit data item is therefore included for such future use\nPoints to Note\n\nThis data item may be defined locally by the provider.\nCross Checks\nNone.\n\nSMR Validation - Spell/Care Package Identifier\n\nTags:\nhealthcare  condition  SMR  episode  inpatient  outpatient  day  patient  clinical  reasons  SMR00  SMR01  SMR02  SMR04", "name": "Spell/Care Package Identifier", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n5\n\nPriority\nOptional\n\nDefinition\nAdmission/transfer from - location gives the location code, where appropriate, of the location from where a patient is admitted.\n\nEach location in Scotland, at which events pertinent to the NHSScotland take place, is allocated a Location Code. Locations include hospitals, health centres, clinics, NHS board offices, private nursing homes, homes for the elderly, children\u2019s homes and schools. The code is a five character code and is maintained by ISD.\n\nRecording Rules\nWhere applicable, enter the Location code as follows:\n\nExample:\nNinewells Hospital =\n\nT\t1\t0\t1\tH\nPoints to Note\nNone.\n\nCross Checks\n\nAdmission/Transfer From - Location must be a valid Location code.\nThe Location must be open at the Admission Date.\nSMR Validation - Admission Transfer From Location\n\n\nRelated items:\n\nLocation\nLocation Code\nTags:\npatient  code  admitted  hospitals  health  centres  clinics  nursing  homes  schools  SMR01  SMR02  SMR04", "name": "Admission/Transfer From - Location", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory\n\nDefinition\nHealthcare data for individual patients is collected as a series of Scottish Morbidity Records (SMR). The record type denotes the general type of healthcare received during an episode and/or the nature or status of the patient.\n\nRecording Rules\n\nThis data item will allow the separate datasets to be identifiable within a comprehensive general SMR dataset.\nSpecialty specific data items may be related to particular SMR Record Types, e.g. Maternity Episode details (SMR02). This would allow, for example, only those data items and code assignments related to a particular SMR Record Type to be displayed on a computer screen for data input purposes. If manual input, use the appropriate form.\nPoints to Note\n\nIf you complete SMR paper forms, this data item will be hard-coded on the form.\nCross Checks\n\nRecord type will be cross-checked against:\n* Specialty\n* Significant Facility\n* Diagnosis\n* Location\nCodes and Values: SMR Record Type\n\nHospital Activity SMRs\n00 - Outpatient Attendance (exc. A&E Attenders, Ward Attenders and Bedside Consultations)\n01 - General/Acute Inpatient & Day Case\n02 - Maternity Inpatient & Day Case\n04 - Mental Health Inpatient & Day Case\n\nOther SMRs\n06 - Cancer Registration\n25 - Scottish Drugs Misuse Database\n\nSMR Validation - SMR Record Type\n\nTags:\nhealthcare  data  individual  patient  episode  specialty  significant  facility  diagnosis  location  SMR00  SMR01  SMR02  SMR04", "name": "SMR Record Type", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n5\n\nPriority\nOptional\n\nDefinition\nDischarge/transfer to - location gives the location code, where appropriate, of a patient's destination following discharge from an episode of care.\n\nEach location in Scotland, at which events pertinent to the NHSScotland take place, is allocated a Location Code. Locations include hospitals, health centres, clinics, NHS board offices, private nursing homes, homes for the elderly, childrens homes and schools. The code is a five character code and is maintained by ISD.\n\nRecording Rules\nWhere applicable, enter the Location code as in the following example:\nNinewells Hospital =\n\nT\t1\t0\t1\tH\nCross Checks\n\nDischarge/Transfer To - Location must be a valid Location code.\nThe Location must be open at the Discharge Date.\nSMR Validation - Discharge-Transfer-To-Location\n\n\nRelated items:\n\nDischarge\nEpisode of Care\nLocation\nLocation Code\nTags:\ncode  patient  destination  episode  care  SMR01  SMR02  SMR04", "name": "Discharge/Transfer To - Location", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n1\n\nPriority\nMandatory\n\nDefinition\nManagement of Patient indicates the patient type and the pattern of bed use of a patient for SMR Record Types 01, 02, and 04.\n\nPoints to Note\n\nRules for the generation of each of the SMR record types are to be found at the beginning of each Specialty Specific Section.\nManagement of Patient codes: 2,4,6 are all types of Day Case.\nManagement of Patient codes: 1,3,5,7, A and B are all types of Inpatient.\nWhere a patient comes in as a day case and stays overnight (3, 5, 7) and then transfers, the subsequent episodes should be coded 1 (Inpatient).\nCode A covers those patients who are admitted to or transferred to the Day Bed Unit as an emergency for a day case procedure. They are admitted as inpatients and discharged the same day as admission. Code A does not cover patients who are inpatients within a hospital and as part of their treatment plan are transferred to the Day Bed Unit or other clinical area for a procedure and then transferred back to their original ward on the same day. The correct code in these circumstances would be either 2, 4 or 6 depending upon the type of facility the patient was admitted to for the day case procedure. These are sometimes referred to as Embedded Day Cases.\nWhere a patient is admitted as Management of Patient code A (Inpatient admitted to and discharged from a DBU on the same day) and stays overnight the Management of Patient code should be amended to code 3, the subsequent episodes should be coded to 1 (Inpatient).\nCross Checks\n\nManagement of Patient is cross-checked with Record Type.\nExample: Codes 1-7, A and B are valid on SMR01\nManagement of Patient is cross-checked with Length of Stay.\nExample: Codes 2, 4, 6 and A must have a length of stay = 0 days\nManagement of Patient is cross-checked with Admission Reason.\nExample: If Admission Reason 21, Management of Patient must be Codes 1-7 or A\nManagement of Patient is crosschecked with Record Type.\nExample: MoP must be blank if Record Type = 00\nCodes and Values: Management of Patient (Code order)\n\n0 - Home Birth SMR02\n1 - Inpatients (except for categories 3,5,7 and A below)\n2 - Day Case in Day Bed Unit (except where retained overnight or longer)\n3 - Inpatient originally admitted as a Day Case in Day Bed Unit, then moved to Inpatient Ward for intended overnight retention or longer\n4 - Day Case in Inpatient Ward (except where retained overnight or longer)\n5 - Inpatient originally admitted as Day Case in Inpatient Ward and retained overnight or longer\n6 - Day Case - Other than in Day Bed Unit or Inpatient Ward (except where retained overnight or longer)\n7 - Inpatient originally admitted as Day Case Other, then moved to Inpatient Ward for intended overnight retention or longer\nA - Inpatient admitted to and discharged from a Day Bed Unit on the same day\nB - Hospital at Home\n\nSMR Validation - Management of Patient\n\n\nRelated items:\n\nAdmission Reason\nAdmission Type\nDay Bed Unit\nDay Case\nInpatient\nTags:\nadmission  record  reason  type  pattern  bed  use  day  case  hospital  at  home  inpatient  ward  overnight  retained  SMR01  SMR02  SMR04", "name": "Management of Patient", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory\n\nDefinition\nAdmission/transfer from indicates the source of admission, or type of location from which a patient has been admitted.\n\nPoints to Note\n\nThe no additional detail code assignments are for use only when the lack of detailed information about the admission prevents the use of one of the more detailed codes provided.\nPatients on pass from a Mental Health or Long Stay specialty are TRANSFERRED to an acute specialty ONLY if the acute episode is the reason for the patient being on pass. Patients who are ALREADY on pass who undergo an acute episode during their period of pass are ADMITTED to the acute episode. Please refer to Specialty Grouping for Transfer Codes.\nIf a patient is involved in an accident and returns to their usual place of residence before they are admitted to hospital, the admit/transfer code should be one of the Private Residence Codes (10-19) or Residence (Institution) codes (20-29).\nPatients who are admitted from a day hospital or an outpatient clinic, whether held in the hospital to which they are admitted or in another hospital should be coded to the location of the start of the journey to hospital.\nCode 68 should be used when a patient is admitted after an RTA, or from a public place without returning to their usual place of residence.\nCodes 41 and 51 apply only to patients who were admitted to an Accident and Emergency Ward before being transferred. Patients admitted following an attendance at an Accident and Emergency Department should be recorded using one of the residence codes or code 68 Other type of location depending upon where the patient was prior to their Accident and Emergency attendance.\nCross Checks\n\nAdmit/Transfer from is cross-checked with Record Type.\nAdmit/Transfer from is cross-checked with age.\nCodes and Values: Admission/Transfer From\n\nInstitution\n20 Place of Residence - Institution, no additional detail added\n24 NHS Partnership hospital\n25 Care home\n26 Intermediate Care\n28 Place of Residence - Institution - other type\n29 Place of Residence - Institution - type not known\n\nOther\n60 Admission from other types of location etc - no additional detail added\n61 Private Hospital\n62 Hospice\n68 Other type of location\n69 Type of location - not known\n70 Home Birth (SMR02 only)\n\nPrivate Residence\n10 - Private Residence - No additional detail given\n11 - Private Residence - Living alone\n12 - Private Residence - Living with relatives or friends\n14 - Private Residence - (supported)\n18 - Private Residence - Other type (e.g.Foster Care)\n19 - Private Residence - Type not known\n\nTemporary\n30 - Temporary place of residence, no additional detail needed\n31 - Holiday Accomodation\n32 - Student Accomodation\n33 - Legal establishment, including prison\n34 - No fixed abode\n38 - Other type of temporary residence (includes hospital residences, hotel facilities)\n39 - Temporary place of residence - type not known\n\nTransfer from another NHS provider\n50 - Transfer from another Health Board/Health Care Provider - no additional detail addedTransfer from another NHS provider\n50 - Transfer from another Health Board/Health Care Provider - no additional detail added\n51 - Accident and Emergency Ward\n52 - Surgical specialty\n53 - Medical specialty\n54 - Obstetrics/Postnatal Cots\n55 - Paediatrics\n56 - Neonatal Paediatrics\n57 - GP Obstetrics/Postnatal cots\n58 - Other Specialty not seperately identified\n59 - Transfer from another Health Board/ Health Care Provider - specialty not known\n5A - GP Non Obstetrics\n5B - Geriatrics (except for patient on pass)\n5C - Geriatrics (patient on pass)\n5D - Psychiatry (except for patient on pass)\n5E - Psychiatry (patient on pass)\n5F - Orthopaedics\n5G - Learning Disability\n5H - Hospital at Home\n\nTransfer within the same provider\n40 - Transfer within the same Health Board/Health Care Provider - no additional detail added\n41 - Accident and Emergency Ward\n42 - Surgical specialty\n43 - Medical specialty\n44 - Obstetrics/Postnatal Cots\n45 - Paediatrics\n46 - Neonatal Paediatrics\n47 - GP Obstetrics/Postnatal cots\n48 - Other Specialty not separately identified\n49 - Transfer within the same Health Board/ Health Care Provider - specialty not known\n4A - GP Non Obstetrics\n4B - Geriatrics (except for patient on pass)\n4C - Geriatrics (patient on pass)\n4D - Psychiatry (except for patient on pass)\n4E - Psychiatry (patient on pass)\n4F - Orthopaedics\n4G - Learning Disability\n4H - Hospital at Home\n\nSMR Validation - Admission Transfer From\n\n\nRelated items:\n\nAdmission\nPatient on Pass\nSpecialty/Discipline\nTags:\nsource  type  location  patient  codes  pass  mental  health  long  stay  specialty  acute  episode  SMR01  SMR02  SMR04", "name": "Admission/Transfer From", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory\n\nDefinition\nAn inpatient admission is categorised as an emergency, urgent or routine inpatient admission except for Maternity and Neonatal admissions. The appropriate admission category depends on the clinical condition of the patient as assessed by the receiving consultant. The patient may or may not be on a waiting list.\n\nNotes\n\nRoutine Admission\nA routine admission occurs when a patient is admitted as planned.\n\nUrgent Admission\nAn urgent admission is a type of emergency admission where the admission is delayed for hospital/patient reasons and the patients condition is such that he/she is not clinically compromised or disadvantaged by the short delay.\n\nAn example of an urgent admission is a patient who attends for an outpatient appointment at which the doctor decides there is a clinical need to admit the patient within the next few days.\n\nNote 1: If the patient is not already on a waiting list, he/she is NOT placed on one for the duration of the delay. Urgent admissions from a waiting list can be identified from the patients Waiting List Type code.\n\nEmergency Admission\nAn emergency admission occurs when, for clinical reasons, a patient is admitted at the earliest possible time after seeing a doctor.\n\nNote 1: The patient may or may not be admitted through Accident & Emergency.\nNote 2: Emergency admissions from a waiting list can be identified from the patients Waiting List Type code\n\nOther Admission\nOther admission is a type of admission which is neither emergency, urgent, routine nor pertains to Maternity or Neonatal admissions, e.g. a patient who is admitted from an outpatient clinic, not for clinical need but because a bed is available.\n\nPoints to Note\n\nRoutine Admission (Code 10)\nThis code should be used for patients being admitted for respite care and for patients routinely re-admitted having exceeded their pass period.\nRoutine Admission: Patient, not on waiting list, admitted on same day (Code 12)If the patient is not already on a waiting list, s/he must be placed on one with a Waiting List Date recorded as the date the decision is made to admit the patient.\nEmergency - deliberate self inflicted injury or poisoning (Code 31)This code should be used ONLY IF THE CASE NOTES HAVE SPECIFIED injury or poisoning as self-inflicted; otherwise the appropriate code should be 33 or 35.\nThe use of codes 19 and 39 will always be queried.\nCodes 40 & 48 are not valid on SMR01.\nEmergency - Road Traffic Accident (Code 32)\nIn strict terms, \"Road Traffic Accident\" is one that involves one or more vehicles on the public highway. However, for SMR01 a looser definition is used, to include not only accidents involving vehicles (cars, buses, motor bikes, etc.) but also pedal bicycles and horses, provided the accident takes place on the public highway.\nEmergency - Home Incident (includes accidental poisoning) (Code 33)\nThis code should be used for any accident, injury or poisoning that takes place in the patients own home or the garden or grounds of that home, provided that there was no intention (determined by medical staff) on the part of the patient to injure or kill himself. This code should also be used when a patient has been the victim of an assault in the home.\nEmergency - Work Incident (includes accidental poisoning) (Code 34)\nThis code should be used for any accident, injury or poisoning that takes place in the patients work place, provided that there was no intention (determined by medical staff) on the part of the patient to injure or kill himself. This code should also be used when a patient has been the victim of an assault in the work place.\nEmergency - Other Injury (includes accidental poisoning) (Code 35)\nThis code should be used for any accident, injury, assault or poisoning that takes place other than in the patients own home or workplace (see notes 7 & 8) provided that there was no intention (determined by medical staff) on the part of the patient to injure or kill himself. This code should also be used for incidents occurring in residential homes.\n\nExample 1\nAn accidental fall from the window of the patients home or jumping from the window to escape a fire would be given Admission Type Code 33, while jumping from the same window intending to commit suicide would be given Admission Type Code 31.\n\nExample 2\nA child drinking, for example, weed killer or bleach, thinking it was lemonade, or taking pills thinking they were sweets, would be given Admission Type Code 33. A patient taking an excessive amount of normal drug in the belief that this might be more beneficial than the stated dose would also be given Admission Type Code 33. However, a patient who takes an overdose of drugs with the intention of suicide, or even as a \"cry for help\", should be given Admission Type Code 31.\n\nExample 3\nA patient is admitted from home with cuts to both wrists. There is no indication in the case notes that the injuries were deliberately self-inflicted, i.e. that the patient intended to harm himself. The case is therefore given Admission Type Code 33.\n\nExample 4\nA patient admitted following an assault which took place in the home should be given Admission Type Code 33.\n\nPatient Non-Injury (Code 36)\nThis code is to be used for emergencies which are not accidents, injuries or poisonings, whenever they occur. Examples are myocardial infarction, acute asthma, ruptured appendix, or post-operative complications.\nOther Emergency Admission (Code 38)\nAn example of the use of this code is an emergency admission for respite care and a patient awaiting routine admission whose condition deteriorates.\nCross Checks\n\nAdmission Type is cross-checked against Management of Patient codes, e.g. Day Cases cannot be emergency admissions.\nSMR01 - Admission Type is cross-checked against Admission Reason (when present).\nAdmission Type is cross-checked against Record Type.\nAdmission Type is cross-checked against Waiting List Type.\nCodes and Values: Admission Type (Code order)\n\nEmergency Admission\n30 - Emergency Admission, no additional detail added\n31 - Patient Injury - Self Inflicted (Injury or Poisoning)\n32 - Patient Injury - Road Traffic Accident (RTA)\n33 - Patient Injury - Home Incident (including Assault or Accidental Poisoning in the home)\n34 - Patient Injury - Incident at Work (including Assault or Accidental Poisoning at work)\n35 - Patient Injury - Other Injury (inc. Accidental Poisoning other than in the home) - not elsewhere classified\n36 - Patient Non-Injury (e.g. stroke, MI, Ruptured Appendix)\n38 - Other Emergency Admission (including emergency transfers)\n39 - Emergency Admission, type not known\n\nOther Admission\n40 - Other admission types, no additional detail added\n41 - Home Birth (SMR02 only)\n42 - Maternity Admission (SMR02 only)\n48 \u2013 Other\n\nRoutine Admission\n10 - Routine Admission, no additional detail added\n11 - Routine elective (i.e. from waiting list as planned, excludes planned transfers)\n12 - Patient admitted on day of decision to admit, or following day, not for medical reasons, but because suitable resources are available\n18 - Planned transfers\n19 - Routine Admission, type not known\n\nUrgent Admission\n20 - Urgent Admission, no additional detail added\n21 - Patient delay (for domestic, legal or other practical reasons)\n22 - Hospital delay (for administrative or clinical reasons e.g. arranging appropriate facilities, for test to be carried out, specialist equipment, etc.)\n\nSMR Validation - Admission Type\n\n\nRelated items:\n\nInpatient Admission\nWaiting List Admission\nManagement of Patient\nSMR Record Type\nWaiting List Type\nTags:\ninpatient  emergency  urgent  routine  other  category  clinical  condition  patient  assessed  receiving  consultant  SMR01  SMR02  SMR04", "name": "Admission Type", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory\n\nDefinition\nDischarge type indicates whether a discharge from an inpatient or day case episode is regular, irregular (e.g. self-discharge) or as a result of the patients death.\n\nRecording Rules\nPriority is C for SMR04\n\nPoints to Note\n\nThe no additional detail code assignments are for use only when the lack of any further information about the patient episode prevents the use of the more detailed codes provided.\nALL Regular Discharges are on clinical advice, or with clinical consent.\nTransfers to other consultants within the same Significant Facility in the same Specialty in the same NHS Board (code 12) must be for medical reasons.\nCode 28 is for use to record patients who leave, or disappear, from hospital and have not gone through the formal process of discharging themselves against medical advice (i.e. code 21).\nA psychiatric patient on leave (on pass) must, for legal reasons, continue to be regarded as an inpatient. For the purpose of national recording there is no limit on length of absence for patients on pass and NHS Boards should continue to be responsible for monitoring patients status. See definition for Patient on Pass.\nSMR01 and 04 - Patients on pass in a Mental Health or Long Stay specialty undergoing an acute episode are TRANSFERRED out of the acute specialty ONLY if the acute episode is the reason for the patient being on pass. Patients who are ALREADY on pass who undergo an acute episode during their period of pass are DISCHARGED from the acute episode.\nSMR04 - If a patient dies whilst on pass the Discharge Date is the date of death, the Discharge Type is code 43 Death Whilst on Pass and Discharge/Transfer To is code 01 Patient Died Whilst on Pass.\nCross Checks\n\nDischarge Type is cross-checked against Record Type.\nDischarge Type is cross-checked with Discharge/Transfer To,e.g.\nIf Discharge Type is 40, 41 or 42, then Discharge Transfer To must equal 00.\nIf Discharge Type is 12, then Discharge Transfer To must be 4_.\nIf Discharge Type is 13, then Discharge/Transfer To must be 2_, 5_ or 6_.\nFrom 1 April 2000 if Discharge Type is 43 then Discharge/Transfer To must be 01.\nThe use of codes 19 and 29 will always be queried.\nDischarge Type is cross checked against Management of Patient.\nCodes and Values: Discharge type\n\nDeath\n40 - Death, no additional detail added\n41 - Death - Post Mortem\n42 - Death - No Post Mortem\n43 - Death - whilst on pass\n\nIrregular Discharge\n20 - Irregular Discharge, no additional detail added\n21 - Patient discharged himself/herself against medical advice\n22 - Patient discharged by relative\n23 - Patient absconded from detention (SMR04 only)\n28 - Other type of irregular discharge\n29 - Irregular discharge, type not known\n\nRegular Discharge\n10 - Regular discharge, no additional detail added\n11 - Discharge from NHS inpatient/day case care\n12 - Transfer within the same Health Board/Health Care Provider\n13 - Transfer to another Health Board/Health Care Provider\n18 - Other type of regular discharge\n19 - Regular discharge, type not known\n70 - Home Birth (SMR02 only)\n\nSMR Validation - Discharge Type\n\n\nRelated items:\n\nDischarge/Transfer To\nPatient on Pass\nTags:\ninpatient  day  case  episode  regular  irregular  self-discharge  death  SMR01  SMR02  SMR04", "name": "Discharge Type", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nOptional\n\nDefinition\nReady-for-discharge date is the date on which a hospital inpatient is clinically ready to move on to a more appropriate care setting. This is determined by the consultant/GP responsible for the inpatient medical care in consultation with all agencies involved in planning the patients discharge, both NHS and non-NHS (Multi-Disciplinary Team). The Team must be satisfied that it is safe and reasonable to transfer/discharge the patient. A patient who continues to occupy a hospital bed after his/her ready-for-discharge date during the SAME inpatient episode experiences a delayed discharge.\n\nRecording Rules\nThe full date should be entered thus:\n2 August 2004 =\n\n0\t2\t0\t8\t0\t4\nNotes\n\n\u201cA more appropriate care setting\u201d covers all appropriate destinations outwith short-stay specialties and outwith the NHS (patient\u2019s home, nursing home etc).\nFrom a service provider\u2019s perspective an \u201cappropriate care setting\u201d can be defined as a place that:\n\nMeets the particular care needs of a person.\nMeets those needs cost effectively.\n\nIf a patient who is clinically ready for discharge is being transferred for non-clinical reasons to another NHS facility whilst awaiting final discharge (which will result in the start of another NHS episode) i.e. to free up short-stay beds, the original Ready for Discharge date should be recorded.\nPoints to Note\n\nThis item is a core criterion of the national standard definition of delayed discharge contained in MEL(2000)07. It can be used to measure duration of delay by looking at the time elapsed between \"Ready for Discharge Date\" and the actual date of discharge.\nICD10 codes can be used in the clinical section to indicate reason for delay in discharge, e.g. living alone - Z60.2.\nSMR02 - Mother staying in hospital because baby is in Neonatal Unit. An SMR02 should be completed to cover the entire episode. Complete Ready for Discharge Date and routine clinical coding for the delivery episode. In addition, use Z39.2 (routine postpartum follow-up) and Z76.3 (healthy person accompanying sick person) to indicate the reasons for delayed discharge. If the mother returns to hospital to be with a sick baby more than 10 days after the delivery, she is a nonpatient and no SMR02 should be completed.\nCross Checks\n\nReady for Discharge Date is checked to be in sequence with other dates.\nReady for Discharge Date must not be present for all types of day cases.\nSMR Validation - Ready for Discharge Date\n\n\nRelated items:\n\nDelayed Discharge\nDischarge\nDischarge Date\nInpatient\nInpatient Episode\nTags:\ninpatient  responsible  consultant  multi-discipline  team  MDT  episode  GP  agencies  patient  transfer  hospital  bed  duration  of  delay  SMR01  SMR02  SMR04  appropriate  care  setting", "name": "Ready for Discharge Date", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n1\n\nPriority\nMandatory (where applicable)\n\nDefinition\nWaiting list type indicates whether or not a patient who is admitted for inpatient/day case care is on a waiting list for the condition giving rise to the admission.\n\nPoints to Note\n\nCode 8 should be used for emergency and urgent admissions who are not on a waiting list for the condition prompting admission.\nCode 8 may also be used for planned transfers although it is good recording practice to record the date the decision was made to transfer the patient as this will enable any wait the patient has experienced to be identified.\nIf code 8 is used, Admission Type should not = 10, 12 or 19.\nCross Checks\n\nWaiting List Type is cross checked against Record Type. It is not applicable to SMR02 and SMR00.\nWaiting List Type is cross-checked against Waiting List Date, e.g. if Waiting List Type is 8, Waiting List Date must be blank; if Waiting List Type is 1 Waiting List Date must be present.\nIf Waiting List Type is 8, Admission Type must not = 11 (Elective Admission)\nCodes and Values: Waiting List Type (Code order)\n1 True waiting list\n2 Planned repeat waiting list\n8 Not on waiting list (see points to note)\n9 Not known (this is allowed locally as a holding code until the correct code is assigned and is not valid centrally)\n\nSMR Validation - Waiting List Type\n\n\nRelated items:\n\nAdmission\nTags:\npatient  inpatient  day  case  admission  true  repeat  condition  SMR01  SMR04", "name": "Waiting List Date", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n1\n\nPriority\nMandatory\n\nDefinition\nPatient (administrative) category refers to a patients status regarding payment for NHS services. It indicates whether (s)he is a category II patient, NHS patient, private patient (paying), amenity patient, or an overseas visitor who is or is not liable to pay for treatment.\n\nPoints to Note\n\nAn amenity patient is an inpatient who undertakes to pay for the use of an amenity bed, i.e. accommodation made available for patients who give an undertaking to pay charges determined by the Trust in single rooms or side wards which are not for the time being needed by any patient on medical grounds. NB. Code 1 Amenity is not applicable to SMR00 (outpatients).\nAn overseas visitor is a patient who is defined under section 98 of the NHS (Scotland) Act 1978 and is charged, where appropriate, in accordance with the guidance given in NHS Circular No. 1982 (Gen)29, as amended.\n\nNote\nTrusts have a statutory duty to identify overseas visitors and make charges in accordance with section 98 of the Act.\nAn overseas visitor may opt to become a private patient.\n\nOverseas visitors who pay fees for treatment should be coded 4 - Overseas visitor liable to pay for treatment. Overseas visitors who do not pay fees for treatment should be coded 5 - Overseas visitors not liable to pay - reciprocal arrangements.\nAn overseas visitor may opt to become a private patient.\nIf an overseas visitor has opted to become a private patient, code 2 should be used.\nCode 2 should be used where patients pay for all or part of their treatment.\nPatients referred by a court for NHS psychiatric assessment where the court pays should be recorded as NHS code 3 rather than Paying code 2.\nCross Checks\n\nCategory of Patient - Overseas Visitors codes 4 & 5 will be checked against postcode and if it is not one of the dummy codes for overseas patients a query will be produced.\nCategory of Patient is cross-checked with Record Type.\nFor SMR00 the Patient Category must not be 1 (Amenity). (01/04/2000)\nFor SMR04 the Patient Category must not be 1 (Amenity). (01/04/2008)\nCodes and Values: Patient category (Code order)\n1 Amenity\n2 Paying\n3 NHS\n4 Overseas visitor - liable to pay for treatment\n5 Overseas visitor - not liable to pay (reciprocal arrangements)\n8 Other (including Hospice)\n\nSMR Validation - Patient Category\n\nTags:\nadministrative  status  payment  NHS  charges  overseas  visitor  private  amenity  SMR00  SMR01  SMR02  SMR04", "name": "Patient Category", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n3\n\nPriority\nMandatory\n\nDefinitions\n\nSpecialty\nA Specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties.\n\nClick here for a complete list of Specialties\n\nDiscipline\nA Discipline is a non-medical profession related to healthcare, for which a formal training leading to a recognised professional qualification is undertaken. Examples of disciplines are physiotherapy, nursing, pharmacology.\n\nRecording Rules\nThis field should be coded to the Specialty/Discipline of the consultant/GP/HCP who is in charge of the patient episode. If the consultant is formally recognised and contracted to work in more than one specialty then the patients problem or condition should dictate the specialty.\n\nNote that this is the ONLY rule for completing this field. The designation of the beds is not used.\n\nSpecialty/Discipline comprises four characters, the first three of which are allocated by ISD for each specialty, and is mandatory for completion. For the majority of Specialty/Discipline codes, which are two characters, the 3rd character space must be left blank if the 4th character extension is used. The 4th character is an Optional extension of the code for local special interests.\n\nThe Specialty/Discipline code should be entered in the character spaces provided and left justified.\n\nPoints to Note\n\nA separate SMR record is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds\nGPs: Patients under the care of a GP in a GP hospital must be given the Specialty code E12 (GP other than Obstetrics) regardless of whether the patients are in a short stay or long stay facility.\nStaff Wards: The Specialty recorded is that of the consultant/GP in charge of the patient. Record Significant Facility as 11 (Other: including all Standard Specialty Wards, Clinical Facility 1K, Day Bed Unit 1J).\nYounger Physically Disabled: Record the Specialty of the consultant in charge of the patient, which will usually be geriatric medicine. Record Significant Facility as 18 (Ward for Younger Physically Disabled) or 1E (Long Stay Unit for Care of the Elderly).\nSee additional notes under Significant Facility.\nFor SMR02 records this should reflect the speciality of the person who was responsible for the care for the mother on original admission.\nExample 1- If the mother was originally admitted under the care of a midwife in an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU), then the midwifery specialty should be recorded in this section, irrespective of whether the mother was then transferred to an Obstetric unit during labour/delivery. When a transfer has occurred Speciality should NOT be attributed to Obstetrics.\n\nExample 2 - If the mother was originally admitted under the care of a Consultant in an Obstetric Unit then the Obstetrics specialty should be recorded here.\n\nCross Checks\n\nSpecialty is checked against Location Code.\nSpecialty is checked against Consultant.\nSpecialty is checked against the Patients Age (at Date of Admission).\nSpecialty is checked against Duration of Stay calculated between Date of Admission and Date of Discharge.\nSpecialty is checked against Record Type\nSpecialty is checked against Significant Facility.\nSMR Validation - Specialty/Discipline\n\n\nRelated items:\n\nHCP Responsible for Care\nLocation Code\nSignificant Facility\nSMR Record Type\nTags:\ndivision  medicine  dentistry  clinical  activity  royal  college  faculties  consultant  GP  HCP  patient  episode  alongside  midwifery  unit  AMU  freestanding  FMU  SMR00  SMR01  SMR02  SMR04", "name": "Specialty/Discipline", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n5\n\nPriority\nMandatory\n\nDefinition\nThis is a UK national code which uniquely identifies a Health Board/Health Care Provider which is an organisation acting as a direct provider of health care services. It is a legal entity, or a subset thereof, which may contract for the provision of health care, and it may operate in one or more locations within and outside hospitals.\n\nPoints to Note\n\nWhen completing the provider code on ISD returns, the code of the Health Board/Health Care Provider which actually provides clinical services must be recorded.\nExample\nIf a consultant from Health Board/Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care on outreach basis (i.e. continues to be employed by Health Board/Health Care Provider A), recorded provider should be Health Board/Health Care Provider A.\n\nIf a consultant from Health Board/ Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care and Health Board/Health Care Provider B pays for this work either directly to the consultant or to Health Board/Health Care Provider A, the consultant is thought of as temporarily employed by Health Board/Health Care Provider B and the recorded provider should be Health Board/Health Care Provider B.\n\nCross Checks\n\nMust be valid provider code.\nTags:\nhealth  board  services  legal  provision  location  hospital  national  identifier    SMR00  SMR01  SMR02  SMR04", "name": "Provider Code", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory (excluding SMR00 and A&E which is Optional)\n\nDefinition\nA Significant Facility is a type of clinical facility which is identified for clinical and/or costing purposes.\n\nRecording Rules\nWith the revised specification of Specialty restricting it to a division of clinical work, it is necessary to define a separate data item to indicate these Significant Facilities.\n\nA separate SMR record type is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds.\n\nNote: For outpatients, a change in significant outpatient facility attended on its own does NOT generate a new SMR outpatient episode.\n\nPoints to Note\n\nOther (including Standard Specialty Wards)\nThis code (code 11) is a general code assigned to records for inpatients and day cases who receive their healthcare in any Clinical Facility which is not designated as significant, e.g. Code 11 includes Day Bed Unit.\nNeonatal Unit\nSMR01 should not be completed in any circumstances. Babies readmitted to a Neonatal Unit after initial discharge will have a SBR completed.\nICU (Intensive Care Unit)\nIf a patient is in a bed in a Standard Ward under the care of a General Surgeon and is then transferred to ICU under an Anaesthetist, this generates two SMR01 records:\na. SMR - Specialty = C1 (General Surgery) and Significant Facility = 11 (Standard Specialty Ward)\nb. SMR - Specialty = C3 (Anaesthetics) and Significant Facility = 13 (ICU)\nCCU (Cardiac Care Unit, formerly Coronary Care Unit)\nIf a patient is admitted into CCU under a cardiologist and is then transferred to a cardiology ward under the same consultant, this generates two SMR01 records:\na. SMR - Specialty = A2 (Cardiology) and Significant Facility = 14 (CCU)\nb. SMR - Specialty = A2 (Cardiology) and Significant Facility = 11 (Standard Specialty Ward)\nA & E\nIf a patient is admitted into an A&E ward under the care of an orthopaedic surgeon and later transferred to an orthopaedics ward, this generates two SMR01 records:\na. SMR - Specialty = C8 (Trauma & Orthopaedic Surgery) and Significant Facility = 17 (A & E Ward)\nb. SMR - Specialty = C8 (Trauma & Orthopaedic Surgery) and Significant Facility = 11 (Standard Specialty Ward)\nSee also notes under Specialty/Discipline.\n\nPriority is Optional for outpatients..\n\nFor A&E datamart, please only use codes 32, 39 and 40.\nCross Checks\n\nSignificant facility is cross-checked against age.\nExample: Patient in Younger Physically Disabled unit must have age less than 65 years.\nSignificant facility is cross-checked against Record Type.\nExample: Significant Facility must be present for Record Types 01, 02 and 04.\nSignificant facility is cross-checked against Specialty.\nExample: Secure Psychiatric Inpatient Facility (1Q) is only valid for Mental Health Specialties.\nSignificant Facilities 1A, 1D, 1E and 18 are cross-checked against length of stay.\nCodes and Values:\n11 - Other (inc. the Clinical Facilities of Standard Specialty Ward 1K, Day Bed Unit 1J)\n13 - Intensive Care Unit\n14 - Cardiac Care Unit\n16 - Childrens Unit\n17 - Accident & Emergency (A&E) Ward\n18 - Ward for Younger Physically Disabled\n19 - Spinal Unit\n1A - Geriatric Orthopaedic Rehabilitation Unit (GORU)\n1B - Rehabilitation Ward (except GORU)\n1C - Burns Unit\n1D - Geriatric Assessment Unit\n1E - Long Stay Unit for Care of the Elderly\n1F - Convalescent Unit\n1G - Palliative Care Unit\n1H - High Dependency Unit\n1L - Adolescent Unit\n1M - Transplant Unit\n1N - Mother and Baby Unit\n1P - Stroke Unit\n1Q - Secure Psychiatric Inpatient Facility\n1R - Intensive Psychiatric Care Unit (IPCU)\n1S - Long Stay Unit - Mental Health\n1T - Psychiatric Rehabilitation Unit (PRU)\n31 - Outpatient Department\n32 - Accident & Emergency Department\n33 - Day Hospital\n34 - Health Centre\n35 - GP Surgery Premises\n36 - Patients home\n37 - Other Community Premises\n38 - Rapid Access Chest Pain Clinic\n39 - Ambulatory Emergency Care Unit\n40 - Acute Assessment Unit (AAU)\n\nSMR Validation - Significant-Facility\n\nTags:\nclinical  costing  inpatient  day  case  healthcare  episode  SMR00  SMR01  SMR02  SMR04", "name": "Significant Facility", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nMandatory\n\nDefinition\nAdmission Date is the date on which an inpatient or day case admission occurs.\n\nRecording Rules\nThe full date should be entered thus: 2 December 2004=\n0\t2\t1\t2\t0\t4\nPoints to Note\nNone.\n\nCross Checks\n\nDate of Admission is checked to be in sequence with the other dates recorded.\nThe Patient\u2019s Age is calculated between Date of Birth and Date of Admission, and is used in cross-checks with:\n* Specialty\n* Diagnosis\nDuration of Stay (Stay) is calculated as the time between Date of Admission and Date of Discharge, and is used in cross-checks involving\n* Management of Patient\n* Significant Facility\n* Diagnosis\nSMR01 and SMR50 - Waiting Time (Wait) is calculated as the time between Date Placed on Waiting List (when present) and Date of Admission, and is used in cross-checks involving all the Diagnoses recorded.\nSMR01 and SMR11 - If Admission Date equals Date of Birth and the Significant Facility is not 11 (Other), 12 (Postnatal Cot), 15 (Neonatal Unit) or 16 (Childrens Unit), the record will always be queried.\nSMR02,SMR04 and SMR50 - Admission Date must not equal Date of Birth.\nAdmission Date is checked against Waiting List Date and, if both dates are the same, the record is queried.\nSMR Validation - Admission-Date\n\n\nRelated items:\n\nDay Case Admission\nInpatient Admission\nTags:\ninpatient  day  case  sequence  SMR01  SMR02  SMR04", "name": "Admission Date", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nMandatory\n\nDefinition\nThe healthcare professional responsible for care (HCP) is the clinician who has overall clinical responsibility for a patients\u2019 healthcare during an episode. This is usually a medical consultant but may be another healthcare professional, for example a midwife, GP, nurse or Allied Healthcare Professional.\n\nPoints to Note\n\nA separate SMR record is submitted when a patient changes Specialty, Significant Facility or Consultant/Health Care Professional Responsible for Care on medical grounds.\nEach hospital will have a list of Consultant/Healthcare Professional Responsible for Care PIN numbers appropriate to the hospital concerned. Where GPs have responsibility for patients a list of GMC numbers of the GPs concerned must be available.\nA Senior Registrar/Registrar/Specialist/Associate Specialists code number must not be used in lieu of the Consultant Code number where the clinical responsibility of care is retained by the Consultant. This may apply where patients only consult with non-consultant grade medical staff and do not see the consultant, for example SAS clinicians. For additional information please refer to this flow chart.\nA nurse/AHPs PIN number must not be used in lieu of the Consultant where the clinical responsibility of the care is retained by the consultant. Where nurses and other AHPs run clinics concurrently or separately, but the responsibility for those clinics rests with the consultant, then the activity must not be recorded on SMR00 for the nurse/AHP. This activity must only be recorded under ISD(S)1 Card Class 7 for AHPs or Card Class 9 for nurses. For additional information please refer to this flow chart.\n\nFurther clarification on points 3&4\n\nA SMR should be attributed to the person who is clinically responsible for care (not just for an outpatient appointment).\nWhere a HCP has determined/prescribed a course of treatment for a patient but has someone else deliver care on their behalf then the SMR should be attributed to the original HCP who would remain clinically responsible for care.\nHowever, when a HCP refers the patient to another specialty for alternative/additional treatment or care then the SMR should be attributed to the new HCP who would then be clinically responsible for the alternative/additional care.\n\nFor example\nIf an Oncologist has prescribed a course of Chemotherapy for a patient but this is delivered by a specialist nurse then the SMR should be attributed to the Consultant. SMR for Oncologist\nIf an Orthopaedic Surgeon considers that the patient needs an orthotic then they would refer them to the Orthotic Team who would then determine best orthotic/treatment plan for the patient. SMR for Orthotics\n\nIt is important to continue recording this data item in this way to allow for comparison/trends across the years.\nA New data item will be introduced in due course to record the Staff Group who delivered Care, e.g. SAS, Specialist Nurse, AHP and this will pick up who is actually seeing the patient.\n\nThese two data items will then complement each other, but measure two types of activity.\n\nIt is the NHS Board responsibility to ensure any new HCP they appoint who meets the definition above is entered in to the National Reference files to ensure records pass validation. This can be done via the eForms process, and must include the date from which the appointment is to be regarded as effective, together with the specialty/discipline or specialties/disciplines in which the HCP may work. When a HCP retires, dies or moves elsewhere, the effective end date should also be amended on the system. Details of how the add HCPs to the reference files can be found here.\nSMR00s must not be completed:-\n- Where a Midwifery clinic is overseen by an obstetrician\n- Where a nurse is carrying out routine nursing work such as bloods, dressings etc\nFor SMR02 records this should reflect the person who was responsible for the care of the mother on original admission to the unit.\nExample 1 - If the mother was originally admitted under the care of a midwife in an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU), then the midwife should be recorded in this section, irrespective if the mother was then transferred during her care episode.\nExample 2 - If the mother was originally admitted to an Obstetric Unit then the Consultant initially responsible for her care should be recorded here, irrespective of whether care was primarily provided by midwifery staff.\nRecording Rules\n\nIt is the Hospitals responsibility to register individuals on the National Reference Files that meet the definition of Consultant/HCP Responsible for Care as above.\n\nThe 7 digit General Medical Council (GMC) Number allocated to each doctor is used as the consultant code. The General Dental Council Number consists of D + 6 numberic.\n\nThe 8 digit personal identification number (PIN) allocated to other healthcare professionals (e.g. midwives) is used as the HCP code. In the case of a midwife the PIN consists of an 8 character alpha/numeric code, although this format may differ for other HCPs (e.g. Podiatrists).\n\nRecording GMC/GDC/PIN\nThe code number of the HCP who had clinical responsibility for the patient during the episode should be right justified in the character spaces provided.\n\nCross Checks\n\nConsultant GMC/HCP number must be present on the appropriate reference file. It is important that additions and changes are notified to ISD as soon as possible. Request Forms for updating of the Consultant/HCP reference files can be found here .\nThe GMC/HCP number must be on the reference file at clinic date (record type SMR00) or Admission Date (record type SMR01, 02 and 04).\nIf the record type is SMR02 and an 8 digit HCP code is used, Specialty/Discipline must be T2 or T21 (midwife).\nSMR Validation - HCP Responsible for Care\n\nRelated terms: Healthcare professional\n\nTags:\nprofessional  healthcare  episode  consultant  nurse  AHP  midwife  GP  GMC  SMR00  SMR01  SMR02  SMR04", "name": "Consultant/HCP Responsible for Care", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nThis is the identification number taken from the GPs referral letter.\n\nPoints to Note\nThis is a 6 digit number.\n\nCross Checks\nNone.\n\nSMR Validation - GP-Referral-Letter-Number\n\nTags:\ngeneral  practitioner  identification  SMR00  SMR01  SMR02  SMR04", "name": "GP Referral Letter Number", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory for SMR02 only\n\nDefinition\nAdmission reason indicates the primary reason why a patient is admitted for inpatient or day case care.\n\nRecording Rules\nPriority is Mandatory for SMR02\n\nPoints to Note\n\nThe no additional detail code assignments are for use only when the lack of detailed information about the admission prevents the use of one of the more detailed codes provided.\nSMR02\nCode 22 should be used when a patient is admitted in false labour and discharged still pregnant, or admitted for a threatened abortion.\nCode 25 should be used for patients delivered at home as planned but who require admission to a maternity hospital after the delivery.\nCode 28 should be used for incomplete abortions following a complete abortion episode and missed abortions.\nCare must be taken to ensure that the Admission Reason code entered is compatible with the Condition on Discharge code.\nCross Checks\n\nReason for Admission is cross-checked against Record Type.\nSMR02 - Admission Reason is cross-checked against:\nType of Abortion\nManagement of Abortion\nCondition on Discharge\nManagement of Patient\nMode of Delivery\nLocation\nCodes and Values: Admission Reason\n\nCode\tMaternity Admission Reason (Codes for SMR02 only)\n20\t20 Home Birth (Not Admitted) To be used only for a completed Home Birth\n21\tAbortion (includes ectopic pregnancy)\n22\tPregnant but not in labour (includes threatened abortion)\n23\tIn labour\n24\tBorn before Arrival\nMaternity Admission where the baby was born before arrival at the hospital\n25\tAdmitted after delivery at home\nAdmission following a home birth\n26\tAdmitted after delivery in any hospital\nTransfer of mother where the birth occurred in another hospital\n28\tOther type of maternity admission (including doubtfully pregnant and incomplete abortion following complete abortion episode)\nSMR Validation - Admission Reason\n\nTags:\nprimary  patient  admitted  inpatient  day  case  SMR  codes  values  care  SMR01  SMR02  SMR04", "name": "Admission Reason", "type": "PrimitiveType"}, {"id": "", "description": "Definition\nThis table shows which Admission/Transfer From (4_ & 5_) and Discharge/Transfer To (4_ & 5_) code to use for each specialty that a patient may be transferred to or from in the same or a different Provider.\n\n41/51 Accident & Emergency\nC2 - Accident & Emergency\n\n42/52 Surgical specialty\nC1 - General Surgery\nC11 - General Surgery (excludes Vascular)\nC12 - Vascular Surgery\nC13 - Oral & Maxillofacial Surgery\nC31 - Pain Management\nC3 - Anaesthetics\nC4 - Cardiothoracic Surgery\nC41 - Cardiac Surgery\nC42 - Thoracic Surgery\nC5 - Ear, Nose & Throat (ENT)\nC51 - Audiological Medicine\nC6 - Neurosurgery\nC7 - Ophthalmology\nC9 - Plastic Surgery\nC91 - Cleft Lip and Palate Surgery\nCB - Urology\nD3 - Oral Surgery\nF2 - Gynaecology\nR11 - Surgical Podiatry\n\n43/53 Medical specialty\nA1 - General Medicine\nA11 - Acute Medicine\nA2 - Cardiology\nA3 - Clinical Genetics\nA6 - Infectious Diseases [Communicable Diseases]\nA7 - Dermatology\nA8 - Endocrinology & Diabetes\nA81 - Endocrine\nA82 - Diabetes\nA9 - Gastroenterology\nAA - Genito-Urinary Medicine\nAC - Homeopathy\nAD - Medical Oncology\nAG - Renal Medicine\nAH - Neurology\nAK - Occupational Medicine (SMR Data Manual, Version 1.4, July 2003)\nAM - Palliative Medicine\nAP - Rehabilitation Medicine\nAQ - Respiratory Medicine\nAR - Rheumatology\nAV - Clinical Neurophysiology\nAW - Allergy\nD4 - Oral Medicine\nH2 - Clinical Oncology\nJ3 - Chemical Pathology\nJ4 - Haematology\nJ5 - Immunology\n\n44/54 Obstetrics/Postnatal cots\nF3 - Obstetrics\nF31 - Obstetrics Antenatal\nF32 - Obstetrics Postnatal\nT2 - Midwifery\nT21 - Community Midwifery\n\n45/55 Paediatrics\nAF - Paediatrics\nCA - Paediatric Surgery\n\n46/56 Neonatal Paediatrics\nAF - Paediatrics\nE12 - GP Other than Obstetrics\n\n47/57 GP Obstetrics/Postnatal cots\nE11 - GP Obstetrics\n\n48/58 Other Specialty not separately identified\nD1 - Community Dental Practice\nD5 - Orthodontics\nD6 - Restorative Dentistry\nD8 - Paediatric Dentistry\nH1 - Clinical Radiology [Diagnostic Radiology]\n\n4A/5A GP Non Obstetrics\nE12 - GP Other than Obstetrics\n\n4B/4C/5B/5C Geriatrics\nAB - Geriatric Medicine\nE12 - GP Other than Obstetrics\n\n4D/4E/5D/5E Psychiatry\nG1 - General Psychiatry (Mental Illness)\nG2 - Child & Adolescent Psychiatry\nG21 - Child Psychiatry\nG22 - Adolescent Psychiatry\nG3 - Forensic Psychiatry\nG4 - Psychiatry of Old Age\nG6 - Psychotherapy\nG61 - Behavioural Psychotherapy\nG62 - Child & Adolescent Psychotherapy\nG63 - Adult Psychotherapy\n\n4F/5F Orthopaedics\nC8 - Trauma & Orthopaedic Surgery [Orthopaedics]\n\n4G/5G Learning Disability\nG5 - Learning Disability", "name": "Specialty Groupings for Admission/Discharge/Transfer", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nConditional for SMR01 and 04\nNot applicable for SMR00 and 02\n\nDefinition\nWaiting list date is the date that a decision is made, by the healthcare professional responsible for a patients care, to put the patient on a waiting list.\n\nRecording Rules\n\nThe full date must be entered. It should reflect the date the decision was made to put the patient on the Waiting List or the patient was Booked or put in the Diary.\nPoints to Note\n\nThe date is never altered or removed until the patient is treated or the treatment is no longer required. You need to record this date, i.e. the date associated with the treatment, on all subsequent elective admission list entries for this treatment, regardless of any change to provider.\nThe field should be left blank for Not on Waiting List (Waiting List Type 8).\nRejected Waiting List Patient - Upon subsequent re-admission of patients who have previously been admitted but had to be sent home because they were considered unfit for the procedure, the original Date Placed on the Waiting List should be entered.\nWhen patients who on a previous occasion either could not attend (CNA) or did not attend (DNA) are admitted, the original Date Placed on the Waiting List should be entered.\nAs a last resort when the date is not available, enter as the Waiting List Date either the date on the appropriate copy outpatient letter from the hospital to the GP or the date from the appropriate annotation in the clinical record when the decision was made to put the patient on the Waiting List.\nCross Checks\n\nWaiting Time (calculated as the time between Date Placed on Waiting List and Date of Admission) is used in a cross-check involving all the diagnoses recorded.\nDate Placed on Waiting List is checked to be in sequence with the other dates recorded on the record.\nWaiting List Date is cross-checked with Waiting List Type. Date Placed on Waiting List must be completed for all records where Waiting List Type is coded 0 and 1.\nWaiting List Date is checked against Date of Admission and if both are the same, the record is queried, unless Admission Type = 12.\nSMR Validation - Waiting-List-Date\n\nTags:\ndecision  patient  smr01  smr04  elective  admission  list  placed  healthcare  professional  responsible  care", "name": "Waiting List Type", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nMandatory\n\nDefinition\nDischarge/Transfer to gives the type of location to which a patient is discharged or transferred following an episode of care.\n\nRecording Rules\nPriority is C for SMR04.\n\nPoints to Note\n\nThe no additional detail code assignments are for use only when the lack of detailed information about the discharge prevents the use of one of the more detailed codes provided.\nPatients on pass in a Mental Health or Long Stay specialty undergoing an acute episode are TRANSFERRED out of the acute specialty ONLY if the acute episode is the reason for the patient being on pass. Patients who are ALREADY on pass who undergo an acute episode during their period of pass are DISCHARGED from the acute episode.\nSMR01 and 04 - If a patient dies whilst on pass the Discharge Date is the date of death, the Discharge Type is code 43 and the Discharge/ Transfer To code is 01 Patient died whilst on pass.\nPlease refer to Specialty Groupings for Transfers (Codes 4_ & 5_).\nCross Checks\n\nDischarge/Transfer To code is checked against all the Record Types and age.\nDischarge/Transfer To code is checked against Discharge Type.\nSMR02 - Discharge/Transfer To code is checked against Management of Patient.\nCodes and Values\n\nDeath\n00 - Patient Died (except patients on pass)\n01 - Patient died whilst on pass\n\nInstitution\n20 - Place of Residence - Institution - no additional detail added\n24 - NHS Partnership Hospital\n25 - Care Home\n26 - Intermediate Care\n28 - Place of Residence - Institution - other type\n29 - Place of Residence - Institution - type not known\n\nOther\n60 - Discharge to other types of locations - no additional detail added\n61 - Private Hospital\n62 - Hospice\n68 - Other type of discharge location\n69 - Type of discharge location not known\n70 - Home Birth (SMR02 only)\n\nPrivate Residence\n10 - Private Residence - no additional detail added\n11 - Private Residence - Living alone\n12 - Private Residence - Living with relatives or friends\n14 - Private Residence (supported)\n18 - Private Residence - Other type (e.g. foster care)\n19 - Private Residence - type not known\n\nTemporary\n30 - Temporary Place of Residence - no additional detail added\n31 - Holiday Accommodation\n32 - Student Accommodation\n33 - Legal Establishment, including prison\n34 - No fixed abode\n38 - Other type of temporary residence, includes hospital residences, hotel facilities, foster care)\n39 - Temporary Place of Residence - type not known\n\nTranfer Within the Same Provider\n40 - Transfer within the same Health Board/ Health Care Provider - no additional detail added\n41 - Accident and Emergency Ward\n42 - Surgical Specialty\n43 - Medical Specialty\n44 - Obstetrics/Postnatal Cots\n45 - Paediatrics\n46 - Neonatal Paediatrics\n47 - GP Obstetrics/Postnatal Cots\n48 - Other specialty not separately identified\n49 - Transfer within the same Health Board/ Health Care Provider - Specialty not known\n4A - GP other than Obstetrics\n4B - Geriatrics (except for patient on pass)\n4C - Geriatrics (patient on pass)\n4D - Psychiatry (except patient on pass)\n4E - Psychiatry (patient on pass)\n4F - Orthopaedics\n4G - Learning Disability\n4H - Hospital at Home\n\nTransfer to Another NHS Provider\n50 - Transfer to another Health Board/ Health Care Provider - no additional detail added\n51 - Accident and Emergency Ward\n52 - Surgical Specialty\n53 - Medical Specialty\n54 - Obstetrics/Postnatal Cots\n55 - Paediatrics\n56 - Neonatal Paediatrics\n57 - GP Obstetrics/Postnatal Cots\n58 - Other specialty not separately identified\n59 - Transfer to another Health Board/ Health Care Provider - specialty not known\n5A - GP Other than Obstetrics\n5B - Geriatrics (except for patient on pass)\n5C - Geriatrics (patient on pass)\n5D - Psychiatry (except for patient on pass)\n5E - Psychiatry (patient on pass)\n5F - Orthopaedics\n5G - Learning Disability\n5H - Hospital at Home\n\nSMR Validation - Discharge Transfer To\n\n\nRelated items:\n\nDischarge Type\nManagement of Patient\nTags:\nepisode  care  patient  inpatient  mental  health  pass  discharged  transferred  SMR01  SMR02  SMR04", "name": "Discharge/Transfer To", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n5\n\nPriority\nMandatory\n\nDefinition\nA location is any building or set of buildings where events pertinent to the NHSSCOTLAND take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes and schools. Each location has a location code (Formerly Institution code). This is a five character code which is maintained by ISD.\n\nRecording Rules\nThe Location code should be entered in the fields provided.\n\nThis field records the location where the care is provided. A separate field is available to record provider code. The data record, therefore, captures both the organisation providing the care and where it is being provided.\n\nWhere care is provided at home (i.e. a private Domiciliary address), the Location code D201N should be used. For patients living long term in residential care the Location code should be that of the residential home. A separate set of Location codes should be used for Cancer Registration purposes.\n\nFor healthcare activity occurring at locations for which a code cannot be allocated use code D299N - Location not otherwise coded. This code may be used when a patient contact occurs:\n\nin the street\non the sports field\nat Leisure Centres\nin hotels (if not the patients normal domicile - use D201N if it is the patients normal domicile)\nin railway stations etc\nAnyone wishing to start using D299N in national data returns should notify ISD using the appropriate Reference File Amendment Notification Form.\n\nPoints to Note\n\nIf any new locations arise where NHS healthcare is delivered, please ensure that the Reference Files team at ISD is informed using form LOC-NEW so that a new code may be issued as appropriate.\nFor SMR02 Home Birth Location code D201N should be used\nIn cases of babies Born Before Arrival, the Location code should be completed as though the delivery had in fact occurred in the hospital.\n\nCross Checks\n\nLocation code is used in cross-checks with Record Type, e.g. GP maternity hospital can only be recorded on SMR02 (Maternity).\nLocation code is held on a reference file which links to provider and Specialty. It is important that this file is kept up to date.\nThe Location must be open at the Clinic Date (SMR00), Date of Arrival (SMR30) or Admission Date (all other record types).\nTo request a Location Code or to inform ISD of any changes go to the ISD National Reference Files page for links to forms to complete.\n\nSMR Validation - Location\n\nTags:\nbuilding  NHS  Scotland  hospitals  health  centres  GP  surgeries  clinics  offices  nursing  homes  schools  code  NRS  care  provided  SMR00  SMR01  SMR02  SMR04", "name": "Location", "type": "PrimitiveType"}]}, {"id": "", "description": "Diagnostic Section", "name": "General Clinical Information", "dataElementsCount": 18, "dataElements": [{"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nIn addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded.\n\nFor further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website\n\nPoints to Note\n\nUp to five other significant conditions may be recorded for SMR01 returns.\nOther conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.\nFrom April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.\nPriority changed from Mandatory (where applicable) to Local.\nCross Checks\n\nAs for main condition.\nA main condition must be recorded before the Other Condition fields can be completed.\nSMR Validation - Other Conditions\n\nTags:\naddition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04", "name": "Other Condition/Co-morbidity and Complication ICD10 5", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nIn addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded.\n\nFor further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website\n\nPoints to Note\n\nUp to five other significant conditions may be recorded for SMR01 returns.\nOther conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.\nFrom April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.\nPriority changed from Mandatory (where applicable) to Local.\nCross Checks\n\nAs for main condition.\nA main condition must be recorded before the Other Condition fields can be completed.\nSMR Validation - Other Conditions\n\nTags:\naddition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04", "name": "Other Condition/Co-morbidity and Complication ICD10 6", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nConditional\n\nDefinition\nThis reflects the date the other operation was performed.\n\nRecording Rules\nThe full date should be entered thus: 5 July 2004 = 05/07/04\n\nCross Checks\n\nDate of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.\nSMR Validation - Date of Other Operation\n\nTags:\nperformed  sequence  recorded  SMR00  SMR01  SMR02  SMR06", "name": "Date of Other Operation/Treatment/Intervention/Investigative Procedures 4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThese are the additional procedures performed on an individual patient at a particular time.\n\nPoints to Note\n\nUp to three pairs of procedures, in addition to the main procedure, may be recorded for an inpatient or day case episode on the central return. Therefore, if more than four procedures are performed during an episode of care, the clinicians opinion should be sought on which are the most significant. Local systems may allow more than four procedures to be recorded.\nCross Checks\n\nThese are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.\nSMR Validation - Other Operation\n\nTags:\nadditional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR06", "name": "Other Operation/Treatment/Intervention/Investigative Procedures (4) - OPCS4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nConditional\n\nDefinition\nThis reflects the date the other operation was performed.\n\nRecording Rules\nThe full date should be entered thus: 5 July 2004 = 05/07/04\n\nCross Checks\n\nDate of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.\nSMR Validation - Date of Other Operation\n\nTags:\nperformed  sequence  recorded  SMR00  SMR01  SMR02  SMR05", "name": "Date of Other Operation/Treatment/Intervention/Investigative Procedures 3", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThis is the identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.\n\nPoints to Note\n\nThe \"Clinician Responsible for Main Operation\" is the most senior medical or health care professional in attendance in theatre during the main operation.\nThe code entered may not necessarily be the code of the consultant responsible for the episode of care if, for example, the operation is performed by a doctor in training or in a case where the consultant from another specialty attends the patient on the territory of the admitting specialty for the purposes of carrying out a procedure (e.g. endoscopy).\nFor guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.\nThe 7 digit GMC number allocated to each doctor is used as the clinician code. The GMC number can consist of 7 numeric, L + 6 numeric. The \"L\" format is used for limited registrations, usually overseas doctors, and in time the doctors number could be superseded by a permanent number, usually 7 numeric.\nThe General Dental Council (GDC) Number consists of D + 0 + 5 numeric.\nThe code number of the clinician should be right justified in the character spaces provided.\nCross Checks\n\nIt must be a valid GMC/GDC number.\nClinician Responsible for Main Operation/Treatment/ Investigative Procedure is cross checked against SMR record type. If it is 8 characters, it is a Health Care Professional Identifier and SMR record type must be SMR00, 01 or 02 (7 character General Medical Council/General Dental Council identifiers may appear on all record types).\nSMR Validation - Clinician Responsible for Main Operation\n\nTags:\nidentification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR04", "name": "Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 2", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThis is the identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.\n\nPoints to Note\n\nThe \"Clinician Responsible for Main Operation\" is the most senior medical or health care professional in attendance in theatre during the main operation.\nThe code entered may not necessarily be the code of the consultant responsible for the episode of care if, for example, the operation is performed by a doctor in training or in a case where the consultant from another specialty attends the patient on the territory of the admitting specialty for the purposes of carrying out a procedure (e.g. endoscopy).\nFor guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.\nThe 7 digit GMC number allocated to each doctor is used as the clinician code. The GMC number can consist of 7 numeric, L + 6 numeric. The \"L\" format is used for limited registrations, usually overseas doctors, and in time the doctors number could be superseded by a permanent number, usually 7 numeric.\nThe General Dental Council (GDC) Number consists of D + 0 + 5 numeric.\nThe code number of the clinician should be right justified in the character spaces provided.\nCross Checks\n\nIt must be a valid GMC/GDC number.\nClinician Responsible for Main Operation/Treatment/ Investigative Procedure is cross checked against SMR record type. If it is 8 characters, it is a Health Care Professional Identifier and SMR record type must be SMR00, 01 or 02 (7 character General Medical Council/General Dental Council identifiers may appear on all record types).\nSMR Validation - Clinician Responsible for Main Operation\n\nTags:\nidentification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR04", "name": "Clinician Responsible for Main Operation/Treatment/Investigative Procedure/Intervention", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nIn addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded.\n\nFor further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website\n\nPoints to Note\n\nUp to five other significant conditions may be recorded for SMR01 returns.\nOther conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.\nFrom April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.\nPriority changed from Mandatory (where applicable) to Local.\nCross Checks\n\nAs for main condition.\nA main condition must be recorded before the Other Condition fields can be completed.\nSMR Validation - Other Conditions\n\nTags:\naddition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04", "name": "Other Condition/Co-morbidity and Complication ICD10 4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nMain Operation/Treatment/Investigative Procedure/Intervention are those aspects of clinical care carried out on patients undergoing treatment:\n\nfor the prevention, diagnosis, care or relief of disease\nfor the correction of deformity or deficit, including those performed for cosmetic reasons\nassociated with pregnancy, childbirth or contraceptive or procreative management\nTypically this will be:\n\nsurgical in nature: and/or\ncarries a procedural risk: and/or\ncarries an anaesthetic risk: and/or\nrequires specialist training: and/or\nrequires special facilities or equipment only available in an acute care setting.\nPoints to Note\n\nPlease refer to the general rules for recording operations/procedures.\nCross Checks\n\nA check is made that each Operation Code is valid as defined by the OPCS Classification. If not, an error will be reported.\nA check is made that the use of the OPCS code is actually permitted on the record type. If a discrepancy is found, an appropriate error or query will be reported.\nIf Main Operation is specified, but the Date of Main Operation is not given, an error will be reported.\nEach operation can have one or two codes. Checks are made to ensure that an Approach, Technique, Site or Laterality code is not supplied on its own or with another such code. If it is an error will be reported.\n\nSMR01\nIf a code is recorded in the second field of a pair as well as the first field, checks are made to ensure that either:\nthe two codes are a recognised pair or\nthe code in the second field is from one of the subsidiary Y or Z chapters.\nFor any two consecutive single-coded operations, a check is made to see if these could be combined as one dual-coded operation. If this is possible, a query is reported.\nIf the patient is a Day Case, a further check will be made on each Operation code to ensure that the Operation is appropriate for such cases. If not, an error or query will be reported.\nIf the patient is an Outpatient, a further check will be made on each Operation code to ensure that the Operation is appropriate for such cases. If not, a query will be reported.\nEach Operation code is checked to ensure that it is compatible with the stated Sex.\nIf a discrepancy is found an error or a query will be reported.\nSMR Validation - Main and Other Operation/Treatment/Investigative Procedure\n\nTags:\nclinical  care  patients  code  classification  undergoing  treatment  surgical  anaesthetic  acute  SMR00  SMR01  SMR02  SMR04", "name": "Main Operation/Treatment/Investigative Procedure/Intervention - OPCS4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThis is the identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.\n\nPoints to Note\n\nThe \"Clinician Responsible for Main Operation\" is the most senior medical or health care professional in attendance in theatre during the main operation.\nThe code entered may not necessarily be the code of the consultant responsible for the episode of care if, for example, the operation is performed by a doctor in training or in a case where the consultant from another specialty attends the patient on the territory of the admitting specialty for the purposes of carrying out a procedure (e.g. endoscopy).\nFor guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.\nThe 7 digit GMC number allocated to each doctor is used as the clinician code. The GMC number can consist of 7 numeric, L + 6 numeric. The \"L\" format is used for limited registrations, usually overseas doctors, and in time the doctors number could be superseded by a permanent number, usually 7 numeric.\nThe General Dental Council (GDC) Number consists of D + 0 + 5 numeric.\nThe code number of the clinician should be right justified in the character spaces provided.\nCross Checks\n\nIt must be a valid GMC/GDC number.\nClinician Responsible for Main Operation/Treatment/ Investigative Procedure is cross checked against SMR record type. If it is 8 characters, it is a Health Care Professional Identifier and SMR record type must be SMR00, 01 or 02 (7 character General Medical Council/General Dental Council identifiers may appear on all record types).\nSMR Validation - Clinician Responsible for Main Operation\n\nTags:\nidentification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR05", "name": "Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 3", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nIn addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded.\n\nFor further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website\n\nPoints to Note\n\nUp to five other significant conditions may be recorded for SMR01 returns.\nOther conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.\nFrom April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.\nPriority changed from Mandatory (where applicable) to Local.\nCross Checks\n\nAs for main condition.\nA main condition must be recorded before the Other Condition fields can be completed.\nSMR Validation - Other Conditions\n\nTags:\naddition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04", "name": "Other Condition/Co-morbidity and Complication ICD10 2", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThese are the additional procedures performed on an individual patient at a particular time.\n\nPoints to Note\n\nUp to three pairs of procedures, in addition to the main procedure, may be recorded for an inpatient or day case episode on the central return. Therefore, if more than four procedures are performed during an episode of care, the clinicians opinion should be sought on which are the most significant. Local systems may allow more than four procedures to be recorded.\nCross Checks\n\nThese are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.\nSMR Validation - Other Operation\n\nTags:\nadditional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR04", "name": "Other Operation/Treatment/Intervention/Investigative Procedures (2) - OPCS4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThis is the identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.\n\nPoints to Note\n\nThe \"Clinician Responsible for Main Operation\" is the most senior medical or health care professional in attendance in theatre during the main operation.\nThe code entered may not necessarily be the code of the consultant responsible for the episode of care if, for example, the operation is performed by a doctor in training or in a case where the consultant from another specialty attends the patient on the territory of the admitting specialty for the purposes of carrying out a procedure (e.g. endoscopy).\nFor guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.\nThe 7 digit GMC number allocated to each doctor is used as the clinician code. The GMC number can consist of 7 numeric, L + 6 numeric. The \"L\" format is used for limited registrations, usually overseas doctors, and in time the doctors number could be superseded by a permanent number, usually 7 numeric.\nThe General Dental Council (GDC) Number consists of D + 0 + 5 numeric.\nThe code number of the clinician should be right justified in the character spaces provided.\nCross Checks\n\nIt must be a valid GMC/GDC number.\nClinician Responsible for Main Operation/Treatment/ Investigative Procedure is cross checked against SMR record type. If it is 8 characters, it is a Health Care Professional Identifier and SMR record type must be SMR00, 01 or 02 (7 character General Medical Council/General Dental Council identifiers may appear on all record types).\nSMR Validation - Clinician Responsible for Main Operation\n\nTags:\nidentification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR06", "name": "Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 4", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\n\nPriority\nLocal\n\nDefinition\nIn addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded.\n\nFor further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website\n\nPoints to Note\n\nUp to five other significant conditions may be recorded for SMR01 returns.\nOther conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.\nFrom April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.\nPriority changed from Mandatory (where applicable) to Local.\nCross Checks\n\nAs for main condition.\nA main condition must be recorded before the Other Condition fields can be completed.\nSMR Validation - Other Conditions\n\nTags:\naddition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04", "name": "Other Condition/Co-morbidity and Complication ICD10 3", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nConditional\n\nDefinition\nThis reflects the date the other operation was performed.\n\nRecording Rules\nThe full date should be entered thus: 5 July 2004 = 05/07/04\n\nCross Checks\n\nDate of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.\nSMR Validation - Date of Other Operation\n\nTags:\nperformed  sequence  recorded  SMR00  SMR01  SMR02  SMR04", "name": "Date of Other Operation/Treatment/Intervention/Investigative Procedures 2", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n6\nPriority\nMandatory\n\nDefinition\nThis item should be seen as describing the main medical (or social) condition managed/investigated during the patients stay.\n\nRecording Rules\nThe main condition is the condition, diagnosed at the end of the episode of health care, primarily responsible for the patients need for treatment or investigation. If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected. If no diagnosis was made, the main symptom, abnormal finding, or problem should be selected as the main condition.\n\nPoints to Note\n\nFor patients who have died, the main condition is not necessarily the same as the condition recorded as the cause of death.\nThe main condition should be decided by a senior member of the medical staff and recorded in the agreed place in the case notes, on the appropriate form or computer system.\nIf the main condition is coded to a pair of dagger and asterisk codes, the dagger should be entered as main condition.\nIf the main condition is an injury or other condition due to an external cause, the injury or condition should be entered as main condition with the external cause code following the injury (or injuries).\nIn the case of the admission record for SMR04 the admission diagnosis would be as defined in the recording rules (but as diagnosed at the beginning of the episode of healthcare). Further guidance is given in the SMR04 section of the electronic data manual.\nCross Checks\n\nA check is made that each Diagnosis Code is valid as defined by the ICD classification. If not, an error will be reported.\nA check is made that the use of the code (although listed in the ICD Classification) is actually permitted on the record type. If a discrepancy is found, an appropriate error or query will be reported.\nMain condition is cross-checked against:\nSex\nAge (except SMR02)\nRarity (except SMR00, and SMR02)\nAdmission Type (SMR01)\nLength of Stay (SMR01 and SMR04)\nWaiting Time (SMR01 only)\nDischarge Type (SMR01)\nCondition on Discharge (SMR02 only)\nSMR Validation - Main Condition\n\nTags:\nmedical  social  managed  investigated  patient  stay  diagnosed  treatment  ICD10  classification  code  SMR00  SMR01  SMR02  SMR04", "name": "Main Condition/Principal Diagnosis/Problem Managed - ICD10", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmyy)\n\nField Length\n6\n\nPriority\nConditional\n\nDefinition\nThis reflects the date the main operation was performed.\n\nRecording Rules\nThe full date should be entered thus: 5 July 2004 = 05/07/04\n\nCross Checks\n\nDate of Main Operation is checked to ensure it is in the correct sequence with other dates recorded.\nAn error will be reported if there is a Main Operation recorded but the Date of Main Operation has been omitted.\nAn error will be reported if an entry has been made for Date of Main Operation, but the Main Operation has been omitted.\nSMR Validation - Date of Main Operation/Treatment/Investigative Procedure\n\nTags:\nsequence  reported  performed  SMR00  SMR01  SMR02  SMR04", "name": "Date of Main Operation/Treatment/Investigative Procedure/Intervention", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nConditional\n\nDefinition\nThese are the additional procedures performed on an individual patient at a particular time.\n\nPoints to Note\n\nUp to three pairs of procedures, in addition to the main procedure, may be recorded for an inpatient or day case episode on the central return. Therefore, if more than four procedures are performed during an episode of care, the clinicians opinion should be sought on which are the most significant. Local systems may allow more than four procedures to be recorded.\nCross Checks\n\nThese are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.\nSMR Validation - Other Operation\n\nTags:\nadditional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR05", "name": "Other Operation/Treatment/Intervention/Investigative Procedures (3) - OPCS4", "type": "PrimitiveType"}]}, {"id": "", "description": "An SMR02 is generated for patients receiving care in the Obstetrics Specialties/ Health Professions listed when the following events occur:\n\nInpatients and Day Cases are admitted to NHS hospitals from locations external to the NHS.\nInpatients and Day Cases are admitted to contracted NHS beds in non-NHS institutions.\nInpatients and Day Cases change specialty/health profession (with or without a change of consultant).\nTransfers between Midwifery and Obstetrics specialties are excluded.\n\nAn inpatient transfers to become an Inpatient in Obstetrics or Midwifery in the same hospital.\nInpatient becomes a Day Case in Obstetrics or Midwifery during the inpatient stay.\nA Day Case transfers to become an Inpatient in Obstetrics or Midwifery (except when the Day Case episode is during an Obstetric or Midwifery inpatient stay and the patient is transferring back to the original consultant/midwife).\nA Day Case transfers back to resume an Obstetric or Midwifery Inpatient stay but does NOT transfer back to the original consultant/midwife for medical reasons.\nInpatients and Day Cases transfer from another NHS hospital (including contracted NHS beds in non-NHS institutions).\nInpatients and Day Cases change consultant/midwife for medical reasons within the same specialty.\nAn inpatient transfers as an Inpatient to the care of a different consultant/ midwife for medical reasons in the same specialty in the same hospital.\nAn inpatient becomes a Day Case in the same specialty under a different consultant/midwife for medical reasons during the inpatient stay.\nA Day Case transfers to become an Inpatient under the care of a different consultant in the same specialty for medical reasons (except when the Day Case episode is during an Obstetric or Midwifery inpatient stay and the patient is transferring back to the original consultant/midwife).\nA Day Case transfers back to resume an Inpatient stay in the same specialty but does NOT transfer back to the original consultant/midwife for medical reasons.\nInpatients return to hospital having been on pass for more than 5 days.\nInpatients move into and/or out of one of the valid significant facilities.\nInpatients and Day Cases are admitted to hospital for a postnatal episode, following a planned or unplanned home delivery.\nPlease note\nHome births (planned and unplanned) should be recorded on SMR02.\n\nNote: Items in bold denote the patient type of the further SMR record generated by the transfers described in these categories.", "name": "Maternity Inpatient and Day Case", "dataElementsCount": 58, "dataElements": [{"id": "", "description": "Field Length\n6\n\nPriority\nConditional\n\nDefinition\nThe date on which the baby is delivered.\n\nRecording Rules\nThe Date of Delivery should be entered thus:\n\n10 November 2004\n\n1\t0\t1\t1\t0\t4\nPoints to Note\n\nFor multiple births, the date of the first delivery should be entered.\nCross Checks\n\nAll dates on SMR02 are checked to ensure that they are in the correct sequence. In this case, the Date of Delivery must be the same or before the Date of Discharge.\nDate of Delivery is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).\nSMR Validation - Delivery Date\n\n\nRelated items:\n\nCondition on Discharge\nTags:\nbirth  baby  SMR02", "name": "Date of Delivery", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThis denotes the type of location to which the patient is re-designated for delivery following a change of type of location in her DELIVERY PLAN.\n\nPoints to Note\n\nEmergencies causing:\n\u00b7 a transfer from the original hospital to another during labour\n\u00b7 emergency admissions because of premature labour to another hospital\n\ndo not fall into the category of a Booking Change and Code 8 should be recorded for these cases.\nCross Checks\n\nBooking Change - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).\nBooking Change - Place is cross-checked with all other Proposals for Delivery fields.\nCodes and Values: Location Code - SMR02 (Code order)\n0 Home Birth\n1 Consultant Unit\n2 GP Unit\n3 Midwife Unit\n7 No change\n8 Not booked/Other\n9 Not known\n\nSMR Validation - Booking Change - Place\n\n\nRelated items:\n\nCondition on Discharge\nDelivery Plan - Place\nOriginal Booking\nTags:\nlocation  type  patient  transfer  hospital  labour  delivery  plan  SMR02  consultant  GP  midwife  unit", "name": "Booking change - Place", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinition\nNumber of units of alcohol consumed in the course of a typical week. One unit is defined as half a pint of normal beer or one pub measure of spirits or one small glass of wine or one glass of sherry.\n\nRecording Rules\nEnter the number of units as follows:\n\n00\tNone\n01-97\tActual number of units consumed\n98\t98 or more units consumed\n99\tNot known\n\nThe number of units should be recorded as a two-digit number, right-justified, with leading zeroes as appropriate. For example:\n\n5 units recorded as\t05\n9 units recorded as\t09\n15 units recorded as\t15\n102 units recorded as\t98\n\nPoints to Note\n\nAlcohol consumption by the mother during pregnancy may have adverse effects on the baby.\nMidwives undertaking the antenatal booking appointment are asked to record in the Scottish Woman Held Maternity Record (SWHMR) the number of units of alcohol that the woman states she has drunk \"in an average week\". Concern has been raised that simply considering the week prior to the booking appointment will not capture whether a woman was drinking very early in pregnancy, possibly before confirmation of pregnancy.\n\nThe revised current advice for midwives in Scotland from April 2013 is to ask women about their average weekly consumption of alcohol over the three months prior to booking. Midwives are asked to record the womans answer in the SWHMR maternity information system so it can be reported on SMR02. If the woman says she has not drunk any alcohol at all over the last three months, number of units should be recorded as 0. If the woman states that she has consumed an average of 0 to 1 unit per week over the three months code as 1. Otherwise code as nearest number averaged over the three months.\nCross Checks\nNone.\n\nSMR Validation - Typical Weekly Alcohol Consumption\n\nTags:\nnumber  units  consumed  during  pregnancy  scottish  woman  held  maternity  record  SWHMR  SMR02", "name": "Typical Weekly Alcohol Consumption", "type": "PrimitiveType"}, {"id": "", "description": "An SMR02 is raised for each Inpatient and Day Case admission for care in the Obstetrics specialties listed below (including non-delivery admissions), and completed at the end of the Inpatient or Day Case episode. An Inpatient or Day Case admission marks the start of an Inpatient or Day Case episode. Inpatient and Day Case admissions include Inpatient and Day Case Transfers-In.\n\nNote: An SMR02 is NOT raised for a change of ward only.\n\n \n\nCodes and Values:\nFor specific Significant Facility Codes valid for SMR02 - see the SMR02 CRIB Sheet\n\nGeneric Definition\nSignificant Facility", "name": "Significant Facilities for SMR02", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nWhether or not a midwife was present at the delivery.\n\nPoints to Note\n\nA midwife will always be present at a delivery - except for circumstances such as a birth in the ambulance on the way to hospital (Born Before Arrival - BBA) or other unattended or emergency delivery. The only likely circumstance in which a doctor (but not a midwife) is present at a delivery is one that takes place in an Accident and Emergency Department.\nCross Checks\n\nThis field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).\nCodes and Values: Midwife present (Code order)\n0 No\n1 Yes\n9 Not Known\n\nSMR Validation - Midwife Present at Delivery\n\n\nRelated items:\n\nCondition on Discharge\nTags:\nbirth  ambulance  hospital  emergency  born  before  arrival  SMR02", "name": "Midwife Present at Delivery", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe treatment given to a woman who has an abortion.\n\nRecording Rules\nThis field must be completed if Type of Abortion has been coded, otherwise it should be blank.\n\nPoints to Note\n\nIf an attempt at therapeutic abortion has completely failed and the patient is still pregnant when another, successful method is used, the successful method must be coded.\nIf a therapeutic abortion, using prostaglandins is partially successful, but some retained products remain, being subsequently removed by D & C, the appropriate code is 4 (not A).\nAntiprogestagens (e.g. RU486) are a relatively new method of termination of pregnancy. RU486 is normally administered as an outpatient (SMR00) and a planned day case is arranged for 48 hours later for the administration of prostaglandins. It is at this stage that a SMR02 should be completed and the Management of Abortion should be coded as 4.\nCross Checks\n\nManagement of Abortion MUST be completed when Condition on Discharge = 2.\nManagement of Abortion is cross-checked with Type of Abortion e.g. if management is code 3 (Hysterotomy) then Type of Abortion must be coded to 4 (Therapeutic Abortion) or 9 (Unspecified).\nSee table below.\nThe use of codes 8 and 9 will always be queried.\n\nManagement of Abortion\tType of Abortion\n0\tConservative/Expectant\t1,5 or 9\nA\tDilation & Cureltage(D&C) or Vacuum Aspiration\t1-5,8 or 9\n3\tHystertomy\t4 or 9\n4\tMedical\t1-4, 8 or 9\nB-E\tEctopic Laparoscopy / Laparotomy\t6\n8 or 9\tUse of these codes will be queried\t\n\nCodes and Values: Abortion (Code order)\n0 Conservative/expectant management\n3 Hysterotomy\n4 Medical (includes Misoprostol and Prostaglandin)\n8 Other (incl. Methotrexate)\n9 Management not stated\nA Dilatation and Curettage (D & C) or vacuum aspiration\nB Ectopic Laparoscopic Salpingectomy\nC Ectopic Laparoscopic Salpingostomy\nD Ectopic Laparotomy & Salpingectomy\nE Ectopic Laparotomy & Salpingostomy\n\nSMR Validation - Management of Abortion\n\n\nRelated items:\n\nCondition on Discharge\nType of Abortion\nTags:\nwoman  type  treatment  coded  therapeutic  antiprogestagens  outpatient  termination  recording  laparotomy  laparoscopic  salpingectomy  salpingostomy  hysterotomy    SMR02", "name": "Management of Abortion", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nPresentation at delivery is the part of the fetus which is lowest in relation to the position within the maternal pelvis.\n\nPoints to Note\n\nWhere the position is changed by operative intervention (e.g. rotation of the head by forceps) the presentation to be entered should be the presentation before the operation began.\nVarious initials may summarise the presentation, e.g. OP may also be POP, persistent occipito-posterior; LOL or ROL, left or right Occipito-Lateral. Face to pubis should be coded to 2 Occipito-Posterior.\nOccipito-transverse (OT) should be coded to Occipito-lateral (OL). Occipito-sacral (OS) should be coded to Occipito-posterior (OP).\nProvision is made for the coding of presentation in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank.\nThe fourth and subsequent babies in quadruplet and high order pregnancies should not be coded.\nWhen midwives complete the presentation field on SWHMR, if the presentation (at delivery) is recorded as \u2018cephalic\u2019 or \u2018cephalic vertex\u2019 what the person completing the SMR02 actually needs to know is the fetal head position.\nThe quality of the data recorded for this SMR02 data item could be vastly improved if midwives could also record the position of the fetal head at the time of delivery where the presentation was cephalic vertex, e.g. Cephalic vertex OA. If the fetal head position is not noted in a cephalic vertex delivery, it can be assumed to be OA.\nCross Checks\n\nPresentation is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nPresentation at Delivery is cross-checked against Mode of Delivery.\nSee checks under Outcome of Pregnancy.\nCodes and Values: Presentation at delivery (Code order)\n1 Occipito-Anterior (OA)\n2 Occipito-Posterior (OP)\n3 Occipito-Lateral (OL)\n4 Breech\n5 Face/brow\n6 Shoulder\n7 Cord\n8 Other\n9 Not Known\n\nSMR Validation - Presentation at Delivery\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nOutcome of Pregnancy - Babies 1 to 3\nTags:\npart  fetus  lowest  maternal  pelvis  operative  breech  intervention  occipito-anterior  occipito-posterior  occipito-lateral  midwives  SMR02", "name": "Presentation at delivery (or at start of operative delivery) - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinition\nThe number of previous INPATIENT or DAY CASE ADMISSIONS to any specialty in any hospital during the current pregnancy, but excluding the current EPISODE of CARE.\n\nRecording Rules\nThe actual number of events should be entered as follows:\n\n00-97 = none to 97 actual events\n98 = 98 or more events\n99 = Not Known\n\nIf there are less than 10 previous admissions, preceding zeros should be entered.\nPoints to Note\n\nThe previous admissions should include inpatient episodes and day cases in any specialty in any hospital.\nNormal deliveries can be coded (O80.0) even if there have been previous INPATIENT or DAY CASE ADMISSIONS to any specialty in any hospital during the current pregnancy.\nCross Checks\nNone.\n\nSMR Validation - Previous Admissions this Pregnancy\n\nTags:\ninpatient  day  case  specialty  current  SMR02", "name": "Previous Admissions to Hospital This Pregnancy", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nMother\u2019s status of diabetes.\n\nPoints to Note\n\nIn addition to the completion of this field the appropriate ICD10 code should be recorded.\nSee coding guidelines under Other Conditions in the Diagnostic Section.\nCross Checks\nNone.\n\nCodes and Values: Diabetes (Code order)\n1 Yes, pre-existing diabetes (diagnosed before pregnancy)\n2 Yes, Gestational diabetes (diagnosed during pregnancy)\n3 Yes, time of diagnosis unknown\n4 No (no diabetes during this pregnancy)\n9 Not Known\n\nSMR Validation - Diabetes\n\nTags:\nICD10  code  recorded  guidelines  conditions  diagnostic  mother  pre-existing  gestational  SMR02", "name": "Diabetes", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe state of being male or female in a new born baby.\n\nPoints to Note\n\nProvision is made for coding the sex of three babies. In singleton pregnancies only the first field should be completed.\n\u20180\u2019 - Sex not known - The sex of the person cannot be determined for physical reasons, e.g. a new born baby.\n\u20189\u2019 - Sex not specified - The sex of the person is not provided in the personal details i.e. the data has not been supplied and sex cannot be ascertained from the data provided\n\u2018Intersex\u2019 should be recorded under code \u20180\u2019 \u2013 not known\nCross Checks\n\nSex is cross-checked with Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).\nSee checks under Outcome of Pregnancy.\nPoints to Note\n0 Not Known (i.e. indeterminate sex, includes \u2018Intersex\u2019)\n1 Male\n2 Female\n9 Not Specified (includes not stated by patient, or not recorded)\n\nSMR Validation - Sex\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\npersonal  details  outcome  pregnancy  codes  male  female  new  born  baby  intersex  SMR02", "name": "Sex (Gender) - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nOptional\n\nDefinition\nThe length of the baby from its head to its heels when the legs are fully extended.\n\nRecording Rules\nEnter the measurement in centimetres.\n\nPoints to Note\n\nIn some units, the crown-rump measurement is recorded (length of the baby from head to base of spine). This measurement MUST NOT BE USED in the Crown-heel field.\nCross Checks\n\nCrown Heel is cross-checked with Condition on Discharge, and MAY ONLY be present if Condition on Discharge = 3.\nSee checks under Outcome of Pregnancy.\nFor stillbirths this field should be left blank\nThe record will be queried if Crown-heel length for Birthweight falls outwith the following ranges (unless Crown-heel = 99 and/or Birthweight = 9999).\n\nCrown-heel (cm)\tBirthweight (g)\n26-42\t<1000\n30-48\t1000-1499\n34-50\t1500-1999\n38-52\t2000-2499\n41-54\t2500-2999\n44-56\t3000-3499\n44-58\t3500-3999\n46-60\t4000-4499\n46-62\t4500-9998\n\nSMR Validation - Crown - Heel\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nlength  baby  head  heel  measurement  centimetres  birthweight  SMR02", "name": "Crown-Heel - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n10\n\nPriority\nOptional\n\nDefinition\nThe Community Health Index (CHI) is a population register which is used for health care purposes. The CHI number uniquely identifies a person on the index.\n\nPoints to Note\n\nMost babies now have their CHI number allocated at birth. For a minority of cases there is a short lag (usually no more than 3 months) between birth and the baby CHI number being fed through into the national CHI database. An example would be a home birth or a birth in a remote community. Often there is no immediate CHI-allocation/registration facility available in such circumstances.\nOnce the CHI number becomes available on the Master Patient Record it is important that these numbers should be added to all SMR returns. The CHI is critical for record linkage, linking this record to the infant SBR or SMR01, and for data-sharing.\n\nProvision is made for coding Baby CHI number for three babies if required. In the commonest circumstances (singleton pregnancies) only the first field should be completed.\nCross Checks\n\nSee checks under Outcome of Pregnancy.\nFurther Information\nSee - CHI Number\n\n\nSMR Validation - Baby CHI Number\n\n\nRelated items:\n\nOutcome of Pregnancy - Babies 1 to 3\nTags:\ncommunity  health  index  population  register  identification  confidentiality  babies  SMR02 \n\nb", "name": "Baby CHI - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nConditional\n\nDefinition\nA score based on assessment of 5 variables in the baby, each rated from 0-2 (0 worst, 2 best).\n(A = Appearance, P = Pulse, G = Grimace, A = Activity, R = Respiration)\n\nRecording Rules\nThe appropriate code should be entered for a live birth as follows:\n\nNR not recorded\n00-10 actual Apgar score at 5 minutes (or death before 5 minutes)\nRR Baby being actively resuscitated at the 5 minute check (therefore Apgar score cannot be accurately taken)\nPoints to Note\n\nThe Apgar score is the common scoring method of the babys well being after the birth, and is based on a combination of the heartbeat, respiration, skin colour, muscle tone and movement.\nFor stillborn babies the field should be left blank or recorded as 00.\nFor liveborn babies who just live for one or two minutes a score should be entered; it may be 00 or 01.\nIf the baby is receiving active resuscitation (intubation) the Apgar score is probably not valid and the boxes should be infilled with \u2018RR\u2018.\nProvision is made for coding the Apgar score of three babies. In singleton pregnancies only the first field should be completed.\nCross Checks\n\nApgar score is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nSee checks under Outcome of Pregnancy.\nApgar score is cross-checked with Resuscitation e.g. if Apgar = RR then Resuscitation must = 2-6 or 8.\nSMR Validation - APGAR at 5 mins\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nResuscitation - Babies 1 to 3\nTags:\nassessment  variables  baby  code  live  birth  resuscitated  stillborn  liveborn  condition  discharge  pregnancy  SMR02", "name": "Apgar Score - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinitions\nThe total number of live babies born prior to the current pregnancy who died within the first 28 days of life.\n\nRecording Rules\nThe appropriate number of Previous neonatal deaths should be entered. If there are less than 10 previous neonatal deaths preceding zeros should be entered.\n\nPoints to Note\nNone.\n\nCross Checks\n\nIf total Previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.\nSMR Validation - Previous Neonatal Deaths\n\nTags:\nlive  babies  prior  current  pregnancy  died  number  28  days  life  SMR02", "name": "Previous Neonatal Deaths", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nConditional\n\nDefinition\nThe number of completed weeks of pregnancy, as judged by the clinician (doctor or midwife), usually on the basis of an ultrasound measurement.\n\nRecording Rules\nEnter the Estimated Gestation in the boxes provided. If the Estimated Gestation is not known enter 99 however, as gestation is only required for delivery and abortion episodes, this should be very uncommon\n\nPoints to Note\n\nThis field should be completed for Delivery and Abortion episodes and may be completed for Other (includes missed abortion) episodes, otherwise it should be left blank.\nFor episodes that involve the delivery of a stillborn infant, the gestation recorded should be the gestation at delivery (not the gestation at confirmation of intrauterine death, which may be earlier)\nRecords staff must not base this Estimated Gestation simply on the interval between the dates of LMP and delivery. The clinicians estimate will take account of other factors, including scans.\nCross Checks\n\nEstimated Gestation MUST be present if Certainty of Gestation is present.\nThe record will be queried if the Estimated Gestation falls outwith the range 01-45 weeks.\nGestation is cross-checked with Birthweight.\nGestation is cross-checked with Outcome of Pregnancy.\nGestation is cross-checked with Condition on Discharge and MUST be completed if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).\nSMR Validation - Estimated Gestation\n\n\nRelated items:\n\nBirthweight - Babies 1 to 3\nCertainty of Gestation (Based on the Scan)\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nnumber  completed  weeks  pregnancy  clinician  ultrasound  measurement  LMP  delivery  SMR02", "name": "Estimated Gestation", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThis denotes the pattern of obstetric care planned.\n\nPoints to Note\n\nThere is great interest, not only in the choice of where the woman will deliver, but also in the planned management of her care.\nCross Checks\n\nThis item MUST ONLY be present if Condition on Discharge = 2 or 3 (abortion or delivery episode).\nDelivery Plan - Management is cross-checked with other Proposals for Delivery fields.\n\nOriginal Booking\tDelivery Plan - Place\tDelivery Plan - Management\nHome Birth\tD201N\t0\t0\nConsultant, GP or Midwife Unit\tHospital Code\t1,2 or 3\t3\nNot Booked\t00000\t8\t8\nNot Known\t99999\t9\t9\n\nCodes and Values: Delivery Plan - Codes (Code order)\n0 Home\n3 Inpatient\n8 Not booked/other\n9 Not Known\n\nSMR Validation - Delivery Plan - Management\n\nTags:\ncare  planned  obstetric  home  inpatient  SMR02", "name": "Delivery plan - Management", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nWhether or not the mother has been given a course of antenatal steroids where it is anticipated the baby will be delivered at less than 36 weeks gestation.\n\nRecording Rules\n\nIt is important in cases where the baby is delivered at less than 36 weeks gestation, that the mother has a course of antenatal steroids. This helps to mature the babys lungs reducing the risk of respiratory distress syndrome.\nThe obstetricians have requested that this is recorded, as it helps with auditing care of premature labour.\nPoints to Note\n\nThis field should be completed for delivery episodes only.\nIf gestation is greater than 35 weeks and there has been a threat of early delivery in a previous episode, it is correct to enter a value of 0 or 1 in this field, but the record will be queried.\nCross Checks\n\nAntenatal steroids MUST ONLY be present if Condition on Discharge = 3.\nAntenatal steroids are cross-checked with Estimated gestation. Antenatal steroids should = 0,1 or 9 if Estimated gestation < 36 weeks. If Estimated gestation > 35 weeks and Antenatal Steroids is not 8, the record will be queried.\nCodes and Values: Antenatal Steroids (Code order)\n\n0 Antenatal steroids not given\n1 Antenatal steroids given (complete 48hr course); or Incomplete (less than 48hr course)\n8 Not applicable (gestations of 36 weeks or over with no previous threat of delivery)\n9 Not known whether given or not\nSMR Validation - Antenatal Steroids\n\nTags:\nbaby  gestation  delivered  mother  premature  SMR02", "name": "Antenatal Steroids", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n5\n\nPriority\nConditional\n\nDefinitions\nOriginal Booking is the location at which the patient originally intended to deliver her baby. (Please note that it is not necessarily the location of the booking clinic).\n\nPoints to Note\n\nCode 99999 should only be used as a last resort. An example of when it could be used is when a visitor to Scotland comes in as an emergency, in premature labour and delivers while on holiday. However, there is a dummy hospital code that you can use - E999H - if you know that she was booked for hospital delivery elsewhere in the UK.\nHome delivery has a single Domiciliary Code D201N and this should be used for all home births in Scotland.\nCross Checks\n\nThis item MUST be present if Condition on Discharge = 2 or 3 (abortion or delivery episode).\nOriginal Booking is cross-checked with Condition on Discharge\nOriginal Booking is cross-checked with Booking Date.\nOriginal Booking is cross-checked with all other Proposals for Delivery fields.\nCodes and Values: Original Booking\n00000 - Not booked\n99999 - Not known if booked\nD201N - Home delivery\nE888H - Hospital outwith UK\nE999H - UK hospital outwith Scotland\nLocation code - Scottish Hospital\n\nSMR Validation - Original Booking\n\n\nRelated items:\n\nBooking Change - Management\nBooking Change - Place\nBooking Date\nCondition on Discharge\nDelivery Plan - Management\nDelivery Plan - Place\nTags:\nlocation  patient  deliver  baby  intended  planned  SMR02", "name": "Original Booking", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nLength of admission (or non admission) to a neonatal unit following delivery.\n\nPoints to Note\n\nA Neonatal Unit is a nursery in which the accommodation, equipment, staffing, spacing, temperature, and other support facilities are such as to permit the care of babies who require a level of care above that associated with healthy babies.\nCode 0 should be used if the hospital has no Neonatal Unit, even if it is known that the baby was ill.\nIf it is not clear from the maternal record whether the baby remained in Neonatal Unit for up to or more than 48 hours, and the baby and mother went home at an appropriate time, Code 1 should be used.\nCode 9 should only be used rarely when there is doubt whether the baby was admitted to Neonatal Care Unit or not.\nProvision is made for coding Neonatal Unit for three babies. In the commonest circumstances (Singleton Pregnancies) only the first field should be completed.\nCross Checks\n\nNeonatal Indicator is cross-checked with Condition on Discharge, and MUST ONLY be present if Condition on Discharge = 3\nSee checks under Outcome of Pregnancy.\nFor Stillbirths this field should be left blank.\nCodes and Values: Admission (Code order)\n\n0 Not admitted\n1 Admitted - for up to 48 hours\n2 Admitted - for more than 48 hours\n9 Not Known\nSMR Validation - Neonatal-Indicator\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nlength  admission  unit  delivery  admitted  SMR02", "name": "Neonatal Indicator - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinition\nThe total number of pregnancies experienced by the woman, prior to the current one including ectopic pregnancy and pregnancies ending in therapeutic or spontaneous abortion.\n\nRecording Rules\nA pregnancy with multiple births should be COUNTED AS ONE.\n\nThe code entered should include ALL previous pregnancies even though some may have ended early in therapeutic abortion or miscarriage. If there are less than 10 previous pregnancies preceding zeros should be entered.\n\nPoints to Note\n\nOne pregnancy may result in more than one delivery - but, nevertheless, the event must be COUNTED AS ONE pregnancy.\nCross Checks\n\nIf total previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.\nSMR Validation - Previous Pregnancies\n\nTags:\nnumber  prior  delivery  current  pregnancy  ectopic  therapeutic  spontaneous  abortion  SMR02", "name": "Previous Pregnancies", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinition\nThe total number of pregnancies prior to the current one which ended spontaneously with the loss of a non-registerable Fetus.\n\nRecording Rules\nThe appropriate number of previous spontaneous abortions (miscarriages) should be entered. If there are less than 10 previous spontaneous abortions preceding zeros should be entered.\n\nPoints to Note\n\nPrevious missed abortions, ectopic pregnancies and molar pregnancies should be included in Previous Spontaneous Abortions.\nCross Checks\n\nIf total previous pregnancies is equal to \u201800\u2019, then the following fields must be equal to \u201800\u2019: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.\nSMR Validation - Previous Spontaneous Abortions\n\nTags:\nnumber  pregnancies  loss  missed  non-registerable  fetus  ectopic  molar  SMR02", "name": "Previous Spontaneous Abortions", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nOptional\n\nDefinition\nA measure of accuracy of gestation.\n\nPoints to Note\n\nThis field should only be entered for abortion or delivery episodes, when the Estimated Gestation is also completed.\nCode 1 should only be used when the completed date of the LMP is known and the clinician believes that the clinical and scan findings correspond to the gestation based on the Scan. If there is no routine recording of this item in the antenatal record Code 1 should be used, if all indications are that gestation based on Scan is accurate.\nCode 2 should be used either when:\n- the date of the LMP is unknown or the woman is unsure of her dates; or\n- the date of the LMP is certain, but the clinician has reason to believe that it does not reflect the true length of gestation. This is likely to happen with women who have an irregular cycle, or in cases of post-pill amenorrhea.\nCode 9 should only be used rarely, for example, in the case of a woman transferred from another hospital, and the previous notes are not available.\nIf the date of the last menstrual period has been forgotten by the patient or if the menstrual cycle is markedly different from the normal 28 days, the Certainty of Gestation should be coded Uncertain 2.\nThis information is usually noted most extensively in the medical record when there is uncertainty about dates, but notes on the reliability of the LMP and the consequent calculation of gestation are usually recorded as a routine at the first antenatal visit.\nThe calculated number of weeks between the LMP and Date of Delivery is a derived item held on computer; the quality of that item can be judged by the Certainty of Gestation based on the LMP.\nCross Checks\n\nCertainty of Gestation must not be present if Condition on Discharge is not equal to 2 or 3 or 8.\nCodes and Values\n1 Certain\n2 Uncertain\n3 No scan given\n9 Not known\n\nSMR Validation - Certainty of Gestation\n\n\nRelated items:\n\nCondition on Discharge\nTags:\nmeasure  accuracy  certain  scan  uncertain  delivery  abortion  LMP  antenatal  inpatient  hospital  SMR02", "name": "Certainty of Gestation (Based on the Scan)", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinition\nThe definition of \u2018illicit drugs\u2019 includes illegal drugs (e.g. heroin), solvents and gases (e.g. butane), drugs prescribed for someone else\u2018s use (i.e. \u2018street use\u2019). Also include drugs prescribed to the woman by a doctor as a substitute for the drug(s) of addiction (e.g. prescribed methadone) or to alleviate the symptoms of withdrawal (e.g. prescribed diazepam).\n\nRecording Rules\n\nList any illicit drugs, or drugs prescribed for the treatment of drug misuse/dependence, used in this pregnancy.\nWhere data on the type of drug(s) used is not available, code 99 should be recorded.\nWhere the mother is drug free, code 00 should be recorded.\nPoints to Note\n\nCodes containing the description \u2018prescribed only\u2019 should be used where the drug has been prescribed for the woman\u2018s personal use. Codes containing the description \u2018other\u2019 should be used if all, or some, of the amount being taken was not prescribed for the woman\u2018s personal use, or if the prescribing details are not known.\nSince there is space only for a maximum of four drugs to be recorded, it may be necessary to make a judgement about which should be recorded. In doing so, it may be helpful to consider whether the mother has changed her drug using behaviour as a result of pregnancy (e.g. from \u2019illicit drugs\u2019 to prescribed alternatives). Where possible, both should be recorded.\nCross Checks\n\nDrugs Used is cross - checked against Drug Misuse.\nCodes and Values: Drugs (illicit)\n\nCannabis\n50 Cannabis\n\nDrug Free\n00 None\n\nHallucinogens (e.g.LSD, ketamine, magic mushrooms)\n40 Hallucinogens\n\nNot Known\n99 N/A\n\nOpiates\n10 Heroin\n11 Morphine\n12 Methadone - prescribed only\n13 Methadone - other\n14 Dihydrocodeine - prescribed only\n15 Dihydrocodeine - other\n16 Dipipanone\n17 Buprenorphine\n19 Other opiates\n\nOther drugs\n70 Other drugs\n\nSedatives\n20 Diazepam - prescribed only\n21 Diazepam - other\n22 Temazepam - prescribed only\n23 Temazepam - other\n24 Nitrazepam\n25 Other benzodiazepines\n29 Other sedatives\n\nSolvents and Gases (e.g. glue, butane, amyl nitrate)\n60 Solvents and gases\n\nStimulants\n30 Amphetamines\n31 Cocaine\n32 Crack cocaine\n33 Ecstacy\n39 Other stimulants\n\nSMR Validation - Drugs Used\n\nTags:\nillicit  illegal  solvents  gases  dependence  misuse  pregnancy  opiates  stimulants  cannabis  SMR02", "name": "Drugs Used", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nSterilisation after delivery indicates the method of sterilisation used.\n\nPoints to Note\n\nSterilisation at the time of Caesarean Section should be coded 3.\nSterilisation except during Caesarean Section is fairly rare, and if there is no statement about sterilisation Code 0 should be used.\nOnly use code 8 if the records only have Sterilisation NOS and the woman has been sterilised, but the method of sterilisation is unknown.\nUse code 0 if it cannot be ascertained from the case notes whether the woman was sterilised.\nCross Checks\n\nSterilisation After Delivery is cross-checked with Condition on Discharge and can only be present when Condition on Discharge = 3 (Delivered).\nSterilisation After Delivery is cross-checked with Mode of Delivery. If Sterilisation After Delivery =3, then Mode of Delivery must = 7 (Elective Caesarean) or 8 (Emergency Caesarean).\nCodes and Values: Sterilisation (Code order)\n0 None\n1 Laparoscopy\n2 Laparotomy\n3 Sterilisation with caesarean section\n7 Other Method\n8 Sterilised, but method not stated\n\nSMR Validation - Sterilisation After Delivery\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nmethod  caesarean  section  code  laparoscopy  laparotomy  method  sterilised  SMR02", "name": "Tears", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nConditional\n\nDefinition\nDuration of labour is the length of time the state of labour lasts from its onset to the delivery of the placenta, expressed as the number of completed hours.\n\nRecording Rules\nEnter the appropriate number of completed hours.\n\nExamples\n\nFirst stage\t12 hours 35 minutes\nSecond stage\t45 minutes\nThird stage\t15 minutes\nTotal\t13 hours 35 minutes = 13\n\nFirst stage\t11 hours 20 minutes\nSecond stage\t40 minutes\nThird stage\t20 minutes\nTotal\t12 hours 20 minutes = 12\n\nPoints to Note\n\nThe Duration of Labour is usually found in the midwifes record in the delivery section of the case note.\nOnly short labour lasting less than one hour should be recorded as 00 hours. This could occur with an elective section, or an emergency section before the onset of labour.\nIf the Duration of Labour has not been recorded in any of the available records, 99 (Not known) should be entered.\nWhen an emergency section has been carried out, duration of stages 1 and 2 must be recorded where applicable.\nCross Checks\n\nDuration of Labour is cross-checked with Condition on Discharge and MUST only be present where Condition on Discharge = 3 (Delivered).\nDuration of Labour is cross-checked with Mode of Delivery.\nSMR Validation - Duration of Labour\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nlength  time  onset  delivery  placenta  number  hours  SMR02", "name": "Duration of Labour", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nMandatory\n\nDefinition\nThe condition of the mother on discharge.\n\nPoints to Note\n\nCondition on Discharge code 8 (Other) can also be used associated with Admission Reason 21 (Abortion), when the Type of Abortion is missed abortion and the woman is discharged without having undergone an evacuation.\nCondition on discharge code 2 (Aborted) should be used for all types of completed abortion, including spontaneous abortions at <24 weeks gestation and terminations of pregnancy at any gestation\nCross Checks\n\nCondition on discharge is cross-checked with admission reason:\n\nCondition on Discharge\tAdmission Reason\n1\t22, 23, 28\n2\t21, 22, 28\n3\t20-26, 28\n4\t25, 26\n5\t28\n8\t21, 22, 28\n\nCondition on Discharge is cross-checked with Management of Patient.\nCertain data items may, must or must not be present depending on the value of the Condition on Discharge code. Click here to view table.\nCodes and Values: Discharge condition\n1 - Still pregnant\n2 - Aborted (all types of completed abortion)\n3 - Delivered\n4 - Postnatal care only\n5 - Pregnancy not confirmed\n8 - Other (includes missed abortion)\n\nSMR Validation - Condition on Discharge\n\n\nRelated items:\n\nAdmission Reason\nManagement of Patient\nTags:\nmother  pregnant  aborted  delivered  postnatal  pregnancy  recording  termination  postnatal  SMR02", "name": "Condition on Discharge", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n3\n\nPriority\nMandatory\n\nDefinition\nThe weight of the woman in kilograms recorded at the booking clinic.\n\nRecording Rules\nThe weight should be specified in kilograms. Preceding zeroes should be entered if the weight is less than 100Kg.\n\nExamples:\n\n65Kg\t065\n101Kg\t101\n55.5Kg\t056\n55.4Kg\t055\nPoints to Note\n\nWeight recorded in stones and pounds must be converted to kilograms.\nWeight held in the case notes as kilograms and grams should be rounded to the nearest kilo, not truncated. (See examples 3 & 4 above).\nIf the mothers weight is not known, enter 999.\nCross Checks\n\nWeights outwith the range 032 - 127 Kg will be queried\nSMR Validation - Weight of Mother at Booking", "name": "Weight of Mother at Booking", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThis indicates the disposal of the baby on the mother\u2018s DISCHARGE.\n\nPoints to Note\n\nCode 2 should be used if a sick baby remains in the Neonatal Unit after the mothers discharge.\nCode 6 should be used for babies who are discharged to a foster home even though the local authority retains legal responsibility (fostering prior to adoption).\nCode 7 should be used when the baby is discharged to an institution under local authority care.\nCode 8 should be used when a healthy baby remains in hospital but not in the Neonatal Unit after the mothers discharge. This might occur when the baby is awaiting adoption, or when the home circumstances do not allow the baby to be taken home at that time.\nFor Stillbirths this field should be coded 9.\nCross Checks\n\nBaby Discharged To is cross-checked with Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).\nSee checks under Outcome of Pregnancy.\nCodes and Values: Baby Discharge To\n1 - Home with mother\n2 - Remaining in neonatal care\n3 - Underwent neonatal care, but home with mother\n4 - Transfer to other hospital\n5 - Other unit in same hospital\n6 - Foster Home\n7 - Local Authority Care\n8 - Healthy baby remaining in hospital after mothers discharge\n9 - Dead\n0 - Other\n\nSMR Validation - Baby Discharged To\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\ndisposal  birth  neonatal  unit  stillbirth  condition  outcome  pregnancy  SMR02", "name": "Baby Discharged To - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n6\n\nPriority\nOptional\n\nDefinition\nThe date on which the last menstrual period before the woman conceived began.\n\nRecording Rules\nThe date on which the LMP started should be entered as DD MM YY.\n\nPoints to Note\n\nIf only the month and year is known, the day should be infilled with zeros.\nIf the LMP is not known the field should be left blank.\nIf the woman has not had a period since her last pregnancy, or since coming off the pill, the field should be left blank.\nIf the woman is not pregnant the field should be left blank. This will occur in postnatal admissions (Condition on Discharge = 4, Postnatal care only) or when the woman was found not to be pregnant (Condition on Discharge = 5, Pregnancy not confirmed).\nBecause the LMP is frequently in the calendar year prior to the year of delivery, please take care to record the CORRECT YEAR when transcribing the date.\nCross Checks\nNone.\n\nSMR Validation - LMP (Last Menstrual Period)\n\nTags:\nSMR02  period  began  date  conceived  woman  pregnant", "name": "LMP(Last Menstrual Period)", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n4\n\nPriority\nConditional\n\nDefinition\nThe weight of the baby at birth specified in grams.\n\nRecording Rules\nThe weight should be specified in grams. Four boxes are provided and preceding zeros should be entered if the weight is less than 1000g.\n\nPoints to Note\n\nIf birthweight is still recorded in pounds and ounces in your hospital, please convert to grams.\nFor pregnancies with an abortive outcome, the weight of the fetus should be recorded if possible.\nIf the baby has not been weighed at birth, the birthweight should be recorded as 9999. This may happen if the baby needs immediate medical attention.\nProvision is made for coding the birthweight of three babies. In singleton pregnancies only the first field should be completed.\nCross Checks\n\nBirthweight is cross-checked against Estimated Gestation and Outcome, and live born babies who appear to be implausibly heavy (or light) for the Gestation will be queried.\nBirthweight is cross-checked against Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).\nSMR Validation - Birthweight - Babies 1 to 3\n\n\nRelated items:\n\nCondition on Discharge\nEstimated Gestation\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nweight  grams  estimated  gestation  outcome  condition  discharge  SMR02", "name": "Birthweight - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nMandatory\n\nDefinition\nDrug misuse at any time during the current pregnancy. Includes use of illegal drugs, solvents and gases, drugs prescribed for someone elses use (i.e. 'street use'). Also included are drugs which are prescribed to the woman by a doctor as a substitute for the drug(s) of addiction (e.g. prescribed methadone) or to alleviate the symptoms of withdrawal (e.g. prescribed diazepam). Excludes tobacco, alcohol or 'over the counter' medicines.\n\nPoints to Note\n\nDrug misuse during pregnancy may cause harm to both mother and baby.\nIf it not known whether there has been any drug misuse code 9 should be used and Drugs Used coded to 99 (Not Known).\nCross Checks\n\nDrug Misuse is cross - checked with Drugs Used. If no drug use has been recorded (code 0), Drugs Used must = 00.\nCodes and Values: Drugs Misuse Codes (Code order)\n0 No\n1 Yes\n9 Not Known\n\nSMR Validation - Drug Misuse During Pregnancy\n\n\nRelated items:\n\nDrugs Used\nTags:\nillegal  solvents  gases  prescribed  substitute  addiction  mother  baby  SMR02", "name": "Drugs Misuse During This Pregnancy", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nAn abortion is a pregnancy which ends spontaneously prior to 24 completed weeks gestation with the delivery of a dead fetus (miscarriage) or which ends following therapeutic abortion at any gestation (termination of pregnancy).\n\nPoints to Note\n\nThe threatened abortion that progresses to a(n) (in)complete abortion should be coded 1.\nA threatened abortion where patient continues with pregnancy : DO NOT complete Type of Abortion.\nCode 2 should be used for missed abortion, which may include the following terms:\ncarneous mole; fleshy mole; haemorrhagic mole.\nCode 3, Trophoblastic disease, should also be used with the following terms:\nmolar pregnancy; cystic mole.\nCode 6 should be used where the pregnancy has ended before 24 weeks in an abdominal pregnancy (with a dead Fetus); and for cervical, infundibular or tubal pregnancy.\nCross Checks\n\nThis field MUST be completed if Condition on Discharge = 2 (Abortion or Other).\nThis field will be cross-checked with Admission Reason 21 (Abortion) and Condition on Discharge, which should be 2 (Aborted, all types of completed abortion).\nType of Abortion is cross-checked with Birthweight.\nType of Abortion is cross-checked with Estimated gestation.\nIf Type of Abortion is completed, Management of Abortion must also be completed.\nCodes and Values: Type of Abortion\n1 Spontaneous or incomplete abortion\n2 Missed abortion\n3 Trophoblastic disease\n4 Therapeutic abortion\n5 Suspected illegal abortion\n6 Ectopic pregnancy\n8 Other abortion\n9 Unspecified\n\nSMR Validation - Type of Abortion\n\n\nRelated items:\n\nAdmission Reason\nBirthweight - Babies 1 to 3\nCondition on Discharge\nEstimated Gestation\nManagement of Abortion\nTags:\npregnancy  24  weeks  gestation  fetus  recording  termination  therapeutic  spontaneous  missed  trophoblastic  disease  ectopic  SMR02", "name": "Type of Abortion", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinitions\nThe total number of Caesarean sections prior to the current pregnancy carried out to effect delivery of the Fetus.\n\nRecording Rules\nThe appropriate number of previous Caesarean Sections should be entered. If there are less than 10 previous caesarean sections preceding zeros should be entered.\n\nPoints to Note\n\nA previous twin pregnancy in which both twins were delivered by Caesarean Section, only counts as 1 Caesarean Section.\nCross checks\n\nThe number of Previous Caesarean Sections, plus Therapeutic Abortions plus Spontaneous Abortions should never equal more than the number of total Previous Pregnancies.\nIf number of Previous Caesarean Sections = 02 or more and Condition on Discharge is 3 (delivered) Mode of Delivery should = 7 or 8 (Caesarean).\nSMR Validation - Previous Caesarean Sections\n\nTags:\nnumber  prior  delivery  fetus  current  pregnancy  SMR02", "name": "Previous Caesarean Sections", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe method of feeding at the time of the mother\u2019s discharge.\n\nPoints to Note\n\nUse code 3 (Not applicable) if the baby has died or is stillborn.\nCross Checks\n\nFeed on Discharge is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nSee checks under Outcome of Pregnancy.\nCodes and Values: Feed on Discharge (Code order)\n1 Breast only\n2 Formula only\n3 Not Applicable\n4 Mixed (Breast and Formula)\n8 Other (non-milk feed)\n9 Not Known\n\nSMR Validation - Feed on Discharge\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nmother  breast  milk  formula  condition  SMR02", "name": "Feed on Discharge - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "For the data items not listed, completion on discharge is mandatory and the code is determined by type of episode.\n\nCondition on Discharge Code\t1\t2\t3\t4\t5\t8\nData Item\tStill Pregnant\tAborted (all types of completed abortion)\tDelivered\tPostnatal care only\tPregnancy not confirmed\tOther (includes missed abortion)\nBooking Date\tMay\tMay\tMust\tMay\tMay\tMay\nBooking change - place\tMust not\tMust\tMust\tMust Not\tMust not\tMust not\nBooking change - management\tMust not\tMust\tMust\tMust Not\tMust not\tMust not\nDelivery plan - place\tMust not\tMust\tMust\tMust Not\tMust not\tMust not\nDelivery plan - management\tMust not\tMust\tMust\tMust Not\tMust not\tMust not\nOriginal booking\tMust not\tMust\tMust\tMust Not\tMust not\tMust not\nAntenatal steroids\tMust not\tMust Not\tMust\tMust Not\tMust not\tMust not\nCertainty of gestation\tMust not\tMay\tMay\tMust Not\tMust not\tMust not\nDiabetes\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nEstimated Gestation\tMust not\tMust\tMust\tMust Not\tMust not\tMay\nManagement of abortion\tMust not\tMust\tMust not\tMust Not\tMust not\tMay\nType of abortion\tMust not\tMust\tMust not\tMust Not\tMust not\tMay\nAnalgesia during labour/delivery\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nDate of delivery\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nDoctor present at delivery\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nDuration of labour\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nEpisiotomy\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nIndication for operative delivery\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nInduction of labour\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nMidwife present at delivery\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nMidwife to consultant transfer\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nNo. of births this pregnancy\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nSterilisation after delivery\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nTear\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nApgar score*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nBaby CHI*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nBaby discharged to*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nBirthweight*\tMust not\tMay\tMust\tMust Not\tMust not\tMust not\nCrown-Heel*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nFeed on discharge*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nFirst feed given*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nMode of delivery*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nNeonatal indicator*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nOFC (occipito-frontal circumference)*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nOutcome of pregnancy*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nPresentation at delivery*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\nResuscitation*\tMust not\tMust not\tMay\tMust Not\tMust not\tMust not\nSex (Gender)*\tMust not\tMust not\tMust\tMust Not\tMust not\tMust not\n\n* see also checks under Outcome of Pregnancy\n\nTags:\nstill  pregnant  aborted  abortion  delivered  postnatal  care  pregnancy  missed", "name": "Condition on Discharge Code Table", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nOptional\n\nDefinition\nThis denotes the patient type and/or pattern of obstetric care to which the patient is re-designated following a change of management under a patients DELIVERY PLAN.\n\nPoints to Note\n\nIn the majority of cases there will be no change in management and code 7 should be used.\n\nLocation (hospcode)\tOriginal Booking\tDelivery Plan Place\tDelivery Plan Management\tBooking Change Place\tBooking Place Management\nT202H\tT202H\t1\t3\t7\t7\n\nIf a woman is discovered to have a fetal abnormality that requires specialist treatment for the baby after delivery and her booking is changed from a GP Obstetric Unit to a Specialist Obstetric Unit at around 32 weeks, the coding will be as follows:\n\nLocation (hospcode)\tOriginal Booking\tDelivery Plan Place\tDelivery Plan Management\tBooking Change Place\tBooking Place Management\nN161H\tN335H\t2\t3\t1\t7\n\nThis type of planned change can be assessed analysing these codes. However, in order to distinguish clearly the potentially more dangerous emergency transfers in labour - for fetal distress perhaps - from the planned antenatal booking changes, booking change place and booking change management should be coded to 8 (See example below).\n\nA woman with a twin pregnancy who had been booked in the consultant unit in Princess Royal Maternity Unit as an inpatient, and who came in in premature labour at 29 weeks and was then transferred to Glasgow Royal Infirmary, (in utero transfer) would be coded by GRI thus:\n\nLocation (hospcode)\tOriginal Booking\tDelivery Plan Place\tDelivery Plan Management\tBooking Change Place\tBooking Place Management\nG107H\tG108H\t1\t3\t8\t8\nCross Checks\n\nBooking Change - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).\nBooking Change - Management is cross-checked with all other Proposals for Delivery fields.\nCodes and Values: Booking Change\n0 - Home Birth\n3 - Inpatient\n7 - No change\n8 - Not booked/Other\n9 - Not known\n\nSMR Validation - Booking Change - Management\n\n\nRelated items:\n\nBooking Change - Place\nCondition on Discharge\nDelivery Plan - Management\nDelivery Plan - Place\nTags:\nobstetric  care  patient  designated  delivery  plan  original  SMR02", "name": "Booking change - Management", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nMandatory\n\nDefinition\nHistory of smoking recorded at the booking clinic.\n\nPoints to Note\n\nCode 9 should only be used if there is no comment on the booking clinic notes about the smoking status.\nIf a woman is admitted as an unbooked emergency for delivery and it is noted on her admission notes that she is a smoker, it may be reasonably inferred that she smoked also at the start of pregnancy and code 1 should be entered.\nThe use of e-cigarettes should be recorded within the following codes:\n- If only e-cigarettes used, this should be recorded as 0 - Never Smoked\n- If a combination of e-cigarettes and traditional cigarettes are used, this should be recorded as 1 - Current Smoker\nCross Checks\nNone.\n\nCodes and Values: Smoking history (Code order)\n0 Never smoked\n1 Current smoker\n2 Former smoker\n9 Not known\n\nSMR Validation - Smoking History at Booking\n\nTags:\ncode  never  smoked  current  smoker  former  e-cigarettes  SMR02", "name": "Smoking History at Booking", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe method by which the baby is delivered.\n\nPoints to Note\n\nCode 0 - The terms used may include, Normal delivery or SVD (spontaneous vertex delivery).\nCode 1 - An abnormal presentation may occur with a spontaneous delivery at term, or more usually perhaps, with a premature delivery when the babys head is small enough to be delivered without assistance. The abnormal presentation may be persistent occipito posterior (POP).\nIf \u2018low\u2019, \u2018mid\u2019 or \u2018high\u2019 cavity is mentioned, this should take priority over the type of forceps.\nCode 2 - should be used when forceps are specified, but no further information is provided (i.e. forceps NOS.); also for Wrigley\u2019s Forceps, where no note of the position of the forceps is available. (Haig-Ferguson forceps will now be considered as usually denoting mid.)\nIf more than one type of forceps is used, only the most resource intensive should be recorded. Code B \u2013 Rotational is most important, followed by A \u2013 Mid cavity and lastly, 2 \u2013 Low forceps, no rotation.\nCode B - should be used for Kiellands forceps rotation and where there has been a manual rotation of the head before forceps are applied.\nCode 5 - should be used for a breech delivery that is specified as spontaneous (usually in a very premature delivery), assisted and with (or without) forceps to the aftercoming head (FACH).\nCodes 7 and 8 - The reason for having two categories of delivery by Caesarean section is to have the capability of comparing the outcome in the best circumstances - i.e. a planned caesarean section (7), during the day with both patient and staff fully prepared, with the less favourable circumstance of an emergency section (8).\n\nNote: A woman for whom a caesarean section is planned may go into labour and require an emergency caesarean section: this is coded to 8.\n\nCode 9 - should rarely be used and will be queried. The only circumstance when a Mode of Delivery is likely to be truly \u2018not known\u2019 is an unattended delivery. But such a delivery must have been spontaneous/unassisted and should be coded to 0.\nProvision is made for the coding of Mode of Delivery in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank. The fourth and subsequent babies in quadruplet and higher order pregnancies should not be coded.\nCross Checks\n\nMode of Delivery is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nMode of Delivery is also cross-checked with the following fields: Tears, Episiotomy, Analgesia During Labour/Delivery, Method of Induction.\nSee checks under Outcome of Pregnancy.\nCodes and Values: Delivery (Code order)\n0 Normal, spontaneous vertex vaginal delivery, occipito-anterior.\n1 Cephalic vaginal delivery, with abnormal presentation of the head at delivery, without instruments, with or without manipulation\n2 Low forceps, no rotation, forceps NOS (incl. Wrigleys).\n5 Breech delivery, spontaneous, assisted or unspecified partial breech extraction.\n6 Breech extraction, NOS. Version with breech extraction.\n7 Elective (planned) caesarean section.\n8 Emergency and unspecified caesarean section.\n9 Other and unspecified method of delivery.\nA Mid cavity forceps, no rotation (incl. Haig Fergusson, Neville-Barnes etc).\nB Rotational forceps (incl Kiellands)\nC Ventouse, no rotation or unspecified\nD Ventouse with rotation\nE Other forceps delivery (includes \u2018high-cavity\u2019, high forceps)\n\nSMR Validation - Mode of Delivery - (Babies 1 to 3)\n\nTags:\nmethod  baby  delivered  normal  abnormal  presentation  premature  SMR02", "name": "Mode of Delivery - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nPain relief given during labour and/or delivery.\n\nRecording Rules\nThis item must be completed for delivery episodes.\n\nPoints to Note\n\nMore than one method of analgesia may be used in labour. The highest method in the following hierarchy should be used for coding this item.\n- General anaesthetic\n- Spinal (includes \u2018combined spinal epidural\u2019)\n- Epidural\n- Pethidine/Morphine or other opiates/opioids\n- Gas/Air\n- None\nCode 8 should be used for other types of analgesia such as TENS, waterbirths and other complementary medicines.\nThere is no requirement to code analgesia in OPCS4.\nIf \u2018combined spinal epidural\u2019 is identified, code to \u20185\u2019 \u2013 Spinal.\nCross Checks\n\nAnalgesia During Labour/Delivery is cross-checked with Condition on Discharge and MUST ONLY be present where Condition on Discharge = 3 (Delivered).\nAnalgesia During Labour/Delivery is cross-checked with Management of Patient.\nCodes and Values: Analgesia (Code order)\n0 None\n1 Pethidine/morphine or other opiates/opioids\n2 Epidural\n3 Gas and air only\n4 General anaesthetic\n5 Spinal (includes \u2018combined spinal epidural\u2019)\n8 Other\n9 Not Known\n\nSMR Validation - Analgesia During Labour and/or Delivery\n\n\nRelated items:\n\nCondition on Discharge\nManagement of Patient\nTags:\npain  relief  analgesia  spinal  epidural  pethidine  morphine  opiates  gas/air  TENS  SMR02", "name": "Analgesia During Labour and/or Delivery", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nOutcome of pregnancy indicates whether the baby was liveborn or stillborn (or fetus was aborted in multiple pregnancy).\n\nRecording Rules\nCoding Examples:\n\nCode 3 - Baby born at 3pm on 6 August dies at 1pm on 13 August = 6 days.\nCode 4 - Baby born at 3pm on 6 August dies at 4pm on 13 August = 7 days.\nCode 4 - Baby born at 3pm on 6 August dies at 2.15pm on 3 September = 27 days.\nCode 5 - Baby born at 3pm on 6 August dies at 5pm on 3 September = 28 days.\n\nPoints to Note\n\nProvision is made for coding the outcome of three babies. In single births the first field only should be coded.\nA live born infant who is still alive at 28 days (to the best of ones knowledge) should be coded to 1; a live born infant who dies within 7 days should be coded 3.\nFor the purposes of recording on SMR02, Outcome of pregnancy code 2 [Stillbirth] is used when a baby is born at ?24 completed weeks of gestation (not following a termination of pregnancy) showing no signs of life. On SMR02, pregnancies ending following termination of pregnancy at any gestation (and those ending following a spontaneous abortion at <24 weeks gestation) are coded to Condition on discharge 2 [Aborted] hence the Outcome of pregnancy variable is not applicable to these records.\nThere are occasions where a multiple pregnancy, ending before 24 completed weeks, has one or more babies born alive and the other(s) dead. In such cases the liveborn(s) should be coded to 1 (or 3, 4 or 5 as appropriate) and the dead fetus(es) should be coded 8.\nCross Checks\n\nOutcome of Pregnancy is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nOutcome of Pregnancy is cross-checked with Baby Discharged To, e.g. if Outcome is 1 (Livebirth) then Baby Discharged To should not be coded 9 (Died).\nOutcome of Pregnancy is cross-checked with Estimated Gestation, e.g. if Outcome is 2 (Stillbirth) then Estimated Gestation should be coded to 24 weeks or over.\nThe following data items can only be present if a delivery is recorded. Although Condition on Discharge (code 3) and Number of Births (>0) are used to determine whether a delivery has occurred, outcome of pregnancy further determines whether or not the record of baby data items may, must or must not be present.\nThese rules apply to Baby 1, 2, 3 where appropriate.\nCodes and Values: Outcome of Pregnancy (Code order)\n1 Livebirth\n2 Stillbirth\n3 Livebirth dying within the first 6 days (early neonatal death).\n4 Livebirth dying on or after the 7th completed day but before the 28th day (late neonatal eath).\n5 Livebirth dying on or after the 28th completed day, but before the end of the first year of life (post-neonatal death).\n8 Abortion of a dead fetus of a multiple pregnancy ending before 24 wks of gestation in which the other babies are live born.\n\nSMR Validation - Outcome of Pregnancy\n\n\nRelated items:\n\nBaby Discharged To - Babies 1 to 3\nCondition on Discharge\nEstimated Gestation\nNumber of Births this Pregnancy\nTags:\nbaby  liveborn  stillborn  aborted  recording  code  born  dies  SMR02", "name": "Outcome of Pregnancy - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nInduction of labour indicates the type of induction used actively to start labour by clinical intervention.\n\nRecording Rules\nSome of the means used to induce labour can also be used to augment pre-existing labour that is not progressing. Induction designed to start labour must not be confused with the augmentation of labour.\n\nPoints to Note\n\nIt is important to note that Induction of Labour is a procedure to start labour off and is usually a planned procedure. The admission reason in these cases will probably be Code 22 (pregnant but not in labour).\nCode 0 should be used when any of these procedures are used to assist or augment labour. Do not confuse induction methods with similar procedures used to assist or augment labour which has already started.\nCross Checks\n\nInduction of Labour is cross-checked with Condition on Discharge and MUST be present where Condition on Discharge = 3 (Delivered).\nInduction of Labour is cross-checked with Mode of Delivery, e.g. if Mode of Delivery is 7 (Planned Caesarean Section) then Induction of Labour must be 0 (None).\nCodes and Values: Induction of Labour (Code order)\n0 None\n1 Artificial rupture of membranes (ARM)\n2 Oxytocics\n3 ARM + Oxytocics\n4 Prostaglandins (includes cervical priming)\n5 Prostaglandins + ARM\n6 Prostaglandins and Oxytocics\n7 Prostaglandins and ARM and Oxytocics\n8 Other\n9 Not Known\n\nSMR Validation - Induction of Labour\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nstart  type  clinical  intervention  induced  planned  procedure  oxytocics  prostaglandins  ARM  SMR02", "name": "Induction of Labour", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinitions\nThe total number of pregnancies prior to the current one terminated under the Abortion Acts (1967 & 1991) by medical or surgical means.\n\nRecording Rules\nThe appropriate number of previous therapeutic abortions should be entered. If there are less than 10 previous therapeutic abortions preceding zeros should be entered.\n\nPoints to Note\nNone.\n\nCross checks\n\nIf total previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.\nSMR Validation - Previous Therapeutic Abortions\n\nTags:\ntotal  number  pregnancies  prior  current  acts  medical  surgical  terminate  SMR02", "name": "Previous Therapeutic Abortions", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nMandatory\n\nDefinition\n\u2018Ever\u2019 been administered illegal drugs (e.g. heroin, amphetamines), by self or by another, using a hypodermic needle/hypodermic syringe. Include also inappropriate injection of prescribed drugs (e.g. diazepam).\n\nPoints to Note\n\nInjecting drug use carries serious risks of infection to both mother and baby. Even if the mother has not injected drugs during the current pregnancy, previous injecting behaviour (and sharing of injecting equipment) may have put them at risk of infection from blood-borne viruses such as HIV and hepatitis B and C.\nCross Checks\nNone.\n\nCodes and Values: Injected drugs (Code order)\n0 No\n1 Yes, during current pregnancy\n2 Yes, prior to current pregnancy\n3 Yes, but it is not known when\n9 Not known\n\nSMR Validation - Ever Injected Illicit Drugs\n\nTags:\nillegal  administered.  hypodermic  needle  injection  prescribed  syringe  mother  baby  SMR02", "name": "Ever Injected Illicit Drugs", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nWhether or not a doctor was present at the delivery.\n\nPoints to Note\n\nDoctors will be present for an assisted delivery but are unlikely to be present for a spontaneous delivery.\nCross Checks\n\nThis field is cross-checked with Mode of Delivery e.g. record will be queried if an assisted delivery and no doctor present at delivery.\nThis field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).\nCodes and Values: Doctor Present (Code order)\n0 No\n1 Yes\n9 Not Known\n\nSMR Validation - Doctor Present at Delivery\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nassisted  spontaneous  SMR02", "name": "Doctor Present at Delivery", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nMandatory (where applicable)\n\nDefinition\nHistory of smoking at any point during pregnancy.\n\nPoints to Note\n\nSmoking during pregnancy is one of the relatively few preventable known risk factors in pregnancy.\nThe two smoking fields were provided as a means of recording the success of anti-smoking health education.\nMost health education is given by midwives who have agreed to make readily available in the case notes whether the woman has smoked throughout pregnancy (code 1) or not (code 0).\nIf the woman has smoked at any point during the pregnancy then this should be recorded as 1 - Yes. This applies even though the woman may have stopped once the pregnancy was confirmed but had been a smoker between LMP and confirmation of pregnancy.\nThe use of e-cigarettes should be recorded within the following codes:\n- If only e-cigarettes used, this should be recorded as 0 - No\n- If a combination of e-cigarettes and traditional cigarettes are used, this should be recorded as 1 - Yes.\nCross Checks\nNone.\n\nCodes and Values: Smoker\n0 -No\n1 -Yes\n9 - Not Known\n\nSMR Validation - Smoker During Pregnancy\n\nTags:\nsmoking  health  education  preventable  risk  factors  e-cigarettes  SMR02", "name": "Smoker during pregnancy", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n3\n\nPriority\nMandatory\n\nDefinition\nThis is the height of the mother measured in centimetres.\n\nRecording Rules\nThe height of the mother should be recorded in centimetres. There is space on the SMR02 for recording the height of the mother in feet and inches, if this is required for local use.\n\nPoints to Note\n\nIf the height is not available in the notes, 999 should be recorded.\nCross Checks\n\nExtremes of the normal height range are checked and heights outwith the range 138-185cm are queried.\nSMR Validation - Height\n\nTags:\nmother  centimetres  measure  SMR02", "name": "Height", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nSterilisation after delivery indicates the method of sterilisation used.\n\nPoints to Note\n\nSterilisation at the time of Caesarean Section should be coded 3.\nSterilisation except during Caesarean Section is fairly rare, and if there is no statement about sterilisation Code 0 should be used.\nOnly use code 8 if the records only have Sterilisation NOS and the woman has been sterilised, but the method of sterilisation is unknown.\nUse code 0 if it cannot be ascertained from the case notes whether the woman was sterilised.\nCross Checks\n\nSterilisation After Delivery is cross-checked with Condition on Discharge and can only be present when Condition on Discharge = 3 (Delivered).\nSterilisation After Delivery is cross-checked with Mode of Delivery. If Sterilisation After Delivery =3, then Mode of Delivery must = 7 (Elective Caesarean) or 8 (Emergency Caesarean).\nCodes and Values: Sterilisation (Code order)\n0 None\n1 Laparoscopy\n2 Laparotomy\n3 Sterilisation with caesarean section\n7 Other Method\n8 Sterilised, but method not stated\n\nSMR Validation - Sterilisation After Delivery\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nmethod  caesarean  section  code  laparoscopy  laparotomy  method  sterilised  SMR02", "name": "Sterilisation after delivery", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nOptional\n\nDefinition\nThe first feed given to the baby immediately following delivery.\n\nPoints to Note\n\nUse code 3 (Not applicable) if the baby is stillborn.\nCross Checks\n\nFirst Feed Given is cross-checked with Condition on Discharge and MAY ONLY be present if Condition on Discharge = 3.\nSee checks under Outcome of Pregnancy.\nCodes and Values: First Feed Given (Code order)\n1 Breast only\n2 Formula only\n3 Not Applicable\n4 Mixed (Breast & Formula)\n8 Other (non milk feed)\n9 Not Known\n\nSMR Validation - First Feed Given\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\ndelivery  breast  formula  milk  condition  discharge  outcome  pregnancy  SMR02", "name": "First Feed Given - Babies 1 - 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nWhen a midwife formally and definitively passes responsibility for a woman\u2018s obstetric care to a consultant during an EPISODE of CARE with no expectation that the midwife will resume responsibility during that episode.\n\nRecording Rules\nSMR02 episodes during which such transfers occur are attributed to the specialty of Obstetrics. Data on the transfers is contained in the SMR02 records for such episodes.\n\nPoints to Note\n\nThis field is another that is designed to help monitor emerging changes in the care of women, along with the more planned changes in the booking plans.\nThis field should be completed for delivery episodes only.\nA Midwife to Consultant Transfer does not generate a further SMR02.\nThis field is used to capture the cases when a mother is transferred from midwifery care to a consultant and should be completed when the HCP Responsible for Care and Specialty are both attributed to a midwife. This transfer can only happen from an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU).\nWhen a transfer has occurred Specialty should NOT be attributed to Obstetrics.\nWhere NO transfer has taken place then this field should be completed with No transfer (mother remains under Midwifery) or Not Applicable (mother remains under Obstetrics).\nCross Checks\n\nThis field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).\nThis field is cross-checked with Delivery Plan - Place.\nThis field is cross-checked with Booking Change - Place.\nCodes and Values: Transfer (Code order)\n0 No transfer - midwife retains responsibility throughout the delivery episode\n1 Midwife to consultant transfer in labour/delivery\n2 Midwife to consultant transfer after delivery\n8 Not applicable\n9 Not known\n\nSMR Validation - Transfer of Responsibility: Midwife to Consultant\n\n\nRelated items:\n\nBooking Change - Place\nCondition on Discharge\nDelivery Plan - Place\nTags:\nepisode  care  obstetric  SMR02  delivery  condition  discharge  alongside  midwifery  unit  freestanding", "name": "Transfer of Responsibility Midwife to Consultant", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe form of resuscitation used.\n\nPoints to Note\n\nIf the baby does not breath spontaneously, or after its mouth is cleared it requires some form of resuscitation to maintain oxygenation until spontaneous breathing starts.\nOxygen may be given by:\n\u00b7 A constant stream via a mask\n\u00b7 Intermittent puffs again by a mask (Intermittent Positive Pressure Ventilation (IPPV))\n\u00b7 A tube inserted into the trachea (Intubation)\nAn injection of a drug to overcome the analgesics given to the mother during labour and which may depress the reflex which starts breathing in the baby.\nCross Checks\n\nResuscitation is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nSee checks under Outcome of Pregnancy.\nCodes and Values: Resuscitation (Code order)\n1 Nil/Facial oxygen (includes \u2018mask only\u2018)\n2 Bag and mask (no drugs)\n3 Bag and mask (with drugs)\n4 Intubation for IPPV (no drugs)\n5 Intubation for IPPV (with drugs)\n6 Drugs only (usually Nalaxone)\n8 Other\n9 Not Known\n\nSMR Validation - Resuscitation - Babies 1 to 3\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\nbreath  spontaneously  oxygen  IPPV  discharge  outcome  pregnancy  codes  SMR02", "name": "Resuscitation - Babies 1 to 3", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThe number of babies delivered this episode.\n\nRecording Rules\nThe number of babies delivered should be entered as follows:\n\nSingle Birth\t1\nTwin Birth\t2\nTriplets\t3\nQuads\t4\nQuins\t5\nSix to Nine\t6-9\nPoints to Note\n\nThere is space to record the details of up to three babies. In the rare circumstances where quads, quins etc. are born, enter the appropriate number of babies born under number of births (4, 5 etc.) and complete the details for the first three babies.\nAlthough up to 9 births can be recorded here there is only space to record further details of up to 3 babies.\nThis field includes stillbirths but excludes abortion of dead Fetus.\nWhere number of births >0, the following items must be present (for Baby 1, 2, 3 as appropriate): Presentation at Delivery, Mode of Delivery, Outcome of Pregnancy, Birthweight, Sex, Baby Discharged To and Feed on Discharge.\nCross Checks\n\nThis field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.\nThis field is checked against all the fields where provision is made for baby 1, baby 2 and baby 3 to be recorded. If the number of births is shown as 2, then all the baby 2 fields must be completed and baby 3 fields completed for number of births 3 or more.\nThis field is cross-checked with Birthweight, e.g. if more than 4 births this delivery the birthweight of babies 1, 2 ,3 should be in the range 0001 - 3000 grams.\nThis field is cross-checked with Estimated Gestation.\nSMR Validation - Number of Births this Pregnancy\n\n\nRelated items:\n\nCondition on Discharge\nTags:\ndelivered  episode  twin  triplets  quads  quins  SMR02", "name": "Number of births this pregnancy", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n6\n\nPriority\nConditional\n\nDefinitions\nThe booking date is the \"Date of booking appointment\" as recorded just below the \"history taken by\" field on page 5 of the Demographic information and EDD page in the SWHMR Combined Pregnancy and Postnatal Record\n\nRecording Rules\nThe date should be entered as in the following example:\n\n11th December 2004 = 11 12 04\nPoints to Note\n\nIf the woman has been referred from another hospital, or from GP/Midwife antenatal care, the Booking Date is the date she originally booked (not the date she was first seen in your hospital).\nThe Booking Date, together with the Estimated Gestation and the Date of Delivery is used to calculate the gestation at booking, which is important in reviewing outcomes such as participation in screening programmes.\nIf the episode is not a delivery episode and if the date of Original Booking is not known, the item should be left blank.\nIf only the month and year of booking is known, the day should be in filled with zeros, for example May 2004 = 00 05 04\nIf the woman is previously unbooked prior to her first hospital antenatal admission and she books during that episode, the actual booking date should be entered and Original Booking coded as \"not Booked\" (00000). If she has an appointment to attend a future booking clinic following discharge, the Booking Date should be left blank.\nIf Condition on Discharge = Delivered and Booking Date is unknown, a Booking Date less than or equal to the Date of Delivery should be entered.\nIf Booking Date is between 294 and 307 days before Date of Delivery record will be queried (Q3502)\nIf Booking Date is more than 307 days before Date of Delivery record will error (E7000)\nCross Checks\n\nAll dates on SMR02 are checked against each other to make sure they are in the correct sequence.\nIf present, Booking Date must be after the date of LMP, and if present it must be before the date of discharge. If the booking date is after the date of admission, the Original Booking field should be not booked (code 1).\nBooking date must be present if Condition on Discharge is \"Delivered\".\nBooking date is cross checked against admission date, delivery date and discharge date.\nSMR Validation - Booking Date\n\nTags:\nappointment  history  taken  demographic  SWHMR  hospital  SMR02", "name": "Booking Date", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThis indicates whether or not this procedure is carried out.\n\nPoints to Note\n\nEpisiotomy is an incision made in the perineum just before the baby is born, in order to facilitate the delivery, and to try to prevent uncontrolled tearing of the tissues around the exit to the birth canal. Episiotomy can co-exist with tears.\nCross Checks\n\nEpisiotomy is cross-checked with Mode of Delivery e.g. record will be queried if assisted delivery and no Episiotomy.\nEpisiotomy is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge =3 (Delivered).\nCodes and Values: Episiotomy (Code order)\n0 No\n1 Yes\n9 Not Known\n\nSMR Validation - Episiotomy\n\n\nRelated items:\n\nCondition on Discharge\nMode of Delivery - Babies 1 to 3\nTags:\nincision  perineum  baby  born  delivery  tearing  tears  tissue  procedure  SMR02", "name": "Episiotomy", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n1\n\nPriority\nConditional\n\nDefinition\nThis denotes the type of location at which the patient is booked to be delivered.\n\nPoints to Note\n\nThe code of the hospital in which the consultant unit, GP unit, or midwife unit is housed will be captured by the item Original Booking.\nCross Checks\n\nDelivery Plan - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or delivery episode).\nDelivery Plan - Place is cross-checked with all other Proposals for Delivery fields.\nCodes and Values: Delivery plan - Locations (Code order)\n0 Home birth\n1 Consultant Unit\n2 GP Unit\n3 Midwife Unit\n8 Not booked/Other\n9 Not Known\n\nSMR Validation - Delivery Plan - Place\n\n\nRelated items:\n\nBooking Change - Management\nBooking Change - Place\nCondition on Discharge\nDelivery Plan - Management\nOriginal Booking\nTags:\nlocation  patient  booked  hospital  consultant  GP  midwife  unit  home  birth  SMR02", "name": "Delivery plan - Place", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n6\n\nPriority\nConditional\n\nDefinition\nThe reason given for an assisted delivery coded to ICD10.\n\nRecording Rules\nOperative deliveries include:\n\nForceps (mode of delivery = 2, A, B or E)\nVentouse (mode of delivery = C or D)\nCaesarean Section (mode of delivery = 7 or 8)\nBreech Deliveries (mode of delivery = 5 or 6)\nUsually the obstetrician will include the indication for an operative delivery in the delivery notes.\n\nPoints to Note\nNone.\n\nCross Checks\n\nAn Indication for Operative Delivery will be expected if the Mode of Delivery is 2, A, B, C, D, E, 7 or 8 and may be present if Mode of Delivery is 5 or 6.\nSMR Validation - Indication for Operative Delivery\n\n\nRelated items:\n\nMode of Delivery - Babies 1 to 3\nTags:\nassisted  forceps  ventouse  caesarean  breech  ICD10  obstetrician  SMR02", "name": "Indication for operative delivery (ICD10)", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n3\n\nPriority\nMandatory\n\nDefinitions\n\nSpecialty\nA Specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties.\n\nClick here for a complete list of Specialties\n\nDiscipline\nA Discipline is a non-medical profession related to healthcare, for which a formal training leading to a recognised professional qualification is undertaken. Examples of disciplines are physiotherapy, nursing, pharmacology.\n\nRecording Rules\nThis field should be coded to the Specialty/Discipline of the consultant/GP/HCP who is in charge of the patient episode. If the consultant is formally recognised and contracted to work in more than one specialty then the patients problem or condition should dictate the specialty.\n\nNote that this is the ONLY rule for completing this field. The designation of the beds is not used.\n\nSpecialty/Discipline comprises four characters, the first three of which are allocated by ISD for each specialty, and is mandatory for completion. For the majority of Specialty/Discipline codes, which are two characters, the 3rd character space must be left blank if the 4th character extension is used. The 4th character is an Optional extension of the code for local special interests.\n\nThe Specialty/Discipline code should be entered in the character spaces provided and left justified.\n\nPoints to Note\n\nA separate SMR record is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds\nGPs: Patients under the care of a GP in a GP hospital must be given the Specialty code E12 (GP other than Obstetrics) regardless of whether the patients are in a short stay or long stay facility.\nStaff Wards: The Specialty recorded is that of the consultant/GP in charge of the patient. Record Significant Facility as 11 (Other: including all Standard Specialty Wards, Clinical Facility 1K, Day Bed Unit 1J).\nYounger Physically Disabled: Record the Specialty of the consultant in charge of the patient, which will usually be geriatric medicine. Record Significant Facility as 18 (Ward for Younger Physically Disabled) or 1E (Long Stay Unit for Care of the Elderly).\nSee additional notes under Significant Facility.\nFor SMR02 records this should reflect the speciality of the person who was responsible for the care for the mother on original admission.\nExample 1- If the mother was originally admitted under the care of a midwife in an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU), then the midwifery specialty should be recorded in this section, irrespective of whether the mother was then transferred to an Obstetric unit during labour/delivery. When a transfer has occurred Speciality should NOT be attributed to Obstetrics.\n\nExample 2 - If the mother was originally admitted under the care of a Consultant in an Obstetric Unit then the Obstetrics specialty should be recorded here.\n\nCross Checks\n\nSpecialty is checked against Location Code.\nSpecialty is checked against Consultant.\nSpecialty is checked against the Patients Age (at Date of Admission).\nSpecialty is checked against Duration of Stay calculated between Date of Admission and Date of Discharge.\nSpecialty is checked against Record Type\nSpecialty is checked against Significant Facility.\nSMR Validation - Specialty/Discipline\n\n\nRelated items:\n\nHCP Responsible for Care\nLocation Code\nSignificant Facility\nSMR Record Type\nTags:\ndivision  medicine  dentistry  clinical  activity  royal  college  faculties  consultant  GP  HCP  patient  episode  alongside  midwifery  unit  AMU  freestanding  FMU  SMR00  SMR01  SMR02  SMR04", "name": "Specialties and Codes for SMR02", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n2\n\nPriority\nMandatory\n\nDefinitions\nThe total number of stillbirths prior to the current pregnancy.\n\nRecording Rules\n\nA stillbirth occurs when a baby is born dead at 24 weeks gestation or over\nAll Previous Stillbirths must be counted. Thus, if triplets in a Previous Pregnancy were all born dead, 3 Previous Stillbirths must be noted.\nThe appropriate number of previous stillbirths should be entered. If there are less than 10 previous stillbirths preceding zeros should be entered.\nPoints to Note\nNone.\n\nCross Checks\n\nIf total Previous Pregnancies is equal to \u201800\u2019, then the following fields must be equal to \u201800\u2019: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.\nSMR Validation - Previous Stillbirths\n\nTags:\nnumber  pregnancy  baby  born  dead  24  weeks  prior  SMR02", "name": "Previous Stillbirths", "type": "PrimitiveType"}, {"id": "", "description": "Field Length\n3\n\nPriority\nOptional\n\nDefinition\nThe circumference of the babys head at the widest part.\n\nRecording Rules\nEnter the measurement in centimetres, (preferably on the third day of life).\n\nPoints to Note\nNone.\n\nCross Checks\n\nOFC is cross-checked with Condition on Discharge, and MAY ONLY be present if Condition on Discharge = 3.\nThe record will be queried if Occipito-Frontal Circumference (OFC) is outwith the range 19.9 - 40.0cm.\nSee checks under Outcome of Pregnancy.\nFor stillbirths this field should be left blank.\nSMR Validation - OFC\n\n\nRelated items:\n\nCondition on Discharge\nOutcome of Pregnancy - Babies 1 to 3\nTags:\noccipito-frontal  circumference  baby  head  measurement  centimetres  SMR02", "name": "OFC - Babies 1 to 3", "type": "PrimitiveType"}]}, {"id": "", "description": "Patient Identification and Demographic Information", "name": "Patient Identification and Demographic Information", "dataElementsCount": 17, "dataElements": [{"id": "", "description": "Field Length\n20\n\nPriority\nMandatory\n\nDefinition\nThe surname of a person represents that part of the name of a person which indicates the family group of which the person is part.\n\nIt should be noted that in Western culture this is normally the latter part of the name of a person. However, this is not necessarily true of all cultures. This will, of course, give rise to some problems in the representation of the name. This is resolved by including with the name a preferred name format indicating amongst other things the order of various parts of the name.\n\nRecording Rules\n\nSurname should be entered in the character spaces provided. CAPITAL LETTERS should be used and the item left justified.\nHyphens or apostrophes occurring within a name should be entered as a separate character (but not as a first character).\nDouble-barrelled surnames should be entered with a hyphen between the two parts of the surname, whether or not the patient normally uses a hyphen.\nIn the very rare circumstances when the surname is not known, the first two character spaces should be filled with \"X\".\n\nExamples\nS\tM\tI\tT\tH\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\nD\tU\tR\tH\tA\tM\t-\tJ\tO\tN\tE\tS\t\t\t\t\t\t\t\t\nO\t-\tH\tA\tR\tA\t\t\t\t\t\t\t\t\t\t\t\t\t\t\nX\tX\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\nPoints to Note\n\nA surname must have at least one alphabetic character.\nSpace for up to 20 characters is provided; it is recommended that the full 20 characters be allowed in use for future systems development.\nWhere a patient requires to remain anonymous, a pseudo-name, such as A N Other, should be used.\n\nBased on UK Government Data Standards Catalogue: BSEN 7372:1993\nCross Checks\nNone.\n\nSMR Validation - Surname", "name": "Surname", "type": "PrimitiveType"}, {"id": "", "description": "ormat\nCharacters\n\nField Length\n4\n\nPriority\nLocal\n\nDefinition\nA health records system identifier is a code which identifies a health records system.\n\nCross Checks\nNone.\n\nSMR Validation - Health Records System Identifier\n\n\nRelated items:\n\nHealth Records System\nTags:\ncode  SMR00  SMR01  SMR02  SMR04", "name": "Health Records System Identifier", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n13\n\nPriority\nOptional\n\nDefinition\nA unique identifier allocated to new referrals to a consultant led service, to enable identification of patient pathways.\n\nPoints to Note\n\nThe UCPN was initiated by the 18 Weeks RTT team and was first used by SCI Gateway Referrals in September 2009.\nA UCPN should be generated for all source referrals made to a Consultant led service.\nWhere referrals are not received via SCI Gateway, local systems should generate a UCPN.\nThe format of the UCPN was defined by the SCI Gateway as SSS999999999C.\n\u201cSSS\u201d is a 3 character alphanumeric System Source Identifiers (SSI), assigned by ISD.\n\u201c999999999\u201d is a 9 digit sequential number.\n\u201cC\u201d is a check digit/character calculated on the preceding 12 characters.\nISD maintains a National Reference File of System Source Identifiers (SSIs) and provides Health Boards with these codes on request.\nWhen one referral is received with more than one referring complaint then the primary referring complaint should keep the UCPN received from SCI Gateway. This should be managed as one pathway. Further referring complaints should each have a UCPN generated by the local system. These should be managed as separate pathways, i.e. that patient has two (or more) concurrent 18 Week RTT pathways.\nOne UCPN may be recorded on a single SMR return.\nThe UCPN will be used to link SMR00 and SMR01 datasets and will enable the tracking of patients as they move between consultants, specialties, hospital settings (outpatient to inpatient) and Health Boards and will not be used by ISD for the purpose of measuring 18wRTT.\nSee the following site for further information: Unique Care Pathway Number (UCPN) - FAQs\nE-Health\nCross Checks\nNone.\n\nSMR Validation - UCPN\n\nTags:\nidentifier  referrals  consultant.  patient  pathway  led  service  system  source  SCI  gateway  ssi  National  Reference  File  SMR00  SMR01  SMR02  SMR04", "name": "Unique Care Pathway Number (UCPN)", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n10\n\nPriority\nMandatory\n\nCommon Name(s)\nPatient Identifier, Case Reference Number, CRN, Hospital Number\n\nMain Source of Standard\nScottish Executive Health Department\n\nDefinition\nA Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS\n\nRecording Rules\nNote: If more than 10 characters are required for the Health Record Identifier, ISD should be contacted for advice.\n\nA Health Record Identifier should be recorded on every record - advice should be sought from your Medical Records Manager if no Health Record Identifier is available.\n\nExample 1: 6 digits or less - The first 6 character spaces should be used. Enter preceding zeros to make the number up to 6 digits e.g. 1234 = 001234\n\nExample 2: 7 digits or more - The number should be entered starting from the left and leaving no spaces between digits. Unused character spaces should be left blank, e.g. PT123432 = PT123432\nPoints to Note\n\nWhere the CHI is used as the HRI, please continue to record this number in both the HRI and CHI fields.\nCross Checks\nNone.\n\nSMR Validation - Patient Health Record Identifier\n\nTags:\npatient  health  number  unique  register  SMR00  SMR01  SMR02  SMR04", "name": "Health Record Identifier", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n20\n\nPriority\nOptional\n\nDefinition\nA second and/or middle name that some people have between their first name and surname.\n\nRecording Rules\n\nIf the patient does not have a second forename, leave this item blank. Otherwise complete exactly as specified for first forename.\nPoints to Note\n\nMade up of Second Initial and Second Forename (remainder).\nCross Checks\nNone\n\nSMR Validation - Second Forename\n\nTags:\nname  middle  surname  patient  identifier  SMR00  SMR01  SMR02  SMR04", "name": "Second Forename", "type": "PrimitiveType"}, {"id": "", "description": "Format\nDate (ddmmccyy)\n\nField Length\n8\n\nPriority\nMandatory\n\nDefinition\nThe date on which a person was born or is officially deemed to have been born as recorded on their birth certificate.\n\nRecording Rules\nDate of birth should be entered thus:\n\n9th February 1942\n0\t9\t0\t2\t1\t9\t4\t2\nAll dates must consist of eight digits by entering preceding zeros for single digits in day, month or year.\n\nPatients age only is available\n- year of birth should be calculated and day and month infilled with zero, thus:\n\nAge 25 (in 1999): therefore year of birth = (1999-25) = 1974\n\n0\t0\t0\t0\t1\t9\t7\t4\nAge not known\n- if all avenues have been explored and neither date of birth nor age is available then the clinicians or nursing staffs estimate of age should be used to calculate year of birth. If this is not possible, refer to your Medical Records Manager\n\nEstimated Age 27 (in 1999): therefore estimated year of birth = (1999-27) = 1972\n\n0\t0\t0\t0\t1\t9\t7\t2\nPoints to Note\n\nThe Date of Birth is allocated 8 digits to record the full year of birth.\nCross checks\n\nAge (and consequently the Date of Birth) is an important data item and is used in a number of cross-checks, e.g.\nSpecialty\nDiagnoses\nAdmission /Transfer From\nDischarge/ Transfer To\nReferral Received Date (SMR00 Only)\nDate of Birth is also checked to be in sequence with the other dates recorded. To view sequence of dates checks please refer to Date Sequences\nDate of Birth must be less than date of admission for all record types (except SMR01, where Date of Birth can equal date of admission when Significant Facility is 11 or 16).\nDate of Birth may equal date of clinic or date of referral for SMR00.\nSMR01 and 04, and age on admission is greater than 100 years, the record will be queried\nIf record is SMR02, and age on admission is less than 10 or greater than 50, the record will be queried.\nIf record is SMR04, and age on admission is less than 1 year, the record will be queried.\nFor SMR01 where specialty is AB (Geriatrics), and age on admission is less than 49 and Significant Facility is not 18, the record will be queried.\nIf record type is SMR01 and Specialty is AF (Paediatrics), CA (Paediatric Surgery) or D8 (Paediatric Dentistry), and age on admission is 18 or over, the record will be queried\nAge is also checked with diagnoses, e.g\nSenile Dementia - The current check will generate a query if the patient is less than 55 years of age.\nSimilarly childhood diagnoses will generate a query if the patient is greater than 16 years of age.\nSMR Validation - Date of Birth\n\nTags:", "name": "Date of Birth", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters (right justified)\n\nField Length\n6\n\nPriority\nMandatory\n\nCommon names\nRegistered GP Practice\n\nDefinition\nRegistered General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and single-handed practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board.\n(Scottish Morbidity Record - NHS Information Services)\n\nRecording Rules\n\nA standard 5 digit numerical code has been developed for the whole of Scotland. It comprises a 4 digit identifying code, which is within an agreed range for each Health Board, and a check digit.\nIt is the Practice Code of the patients registered GP which is recorded in this field\nIt should be noted that the GP Practice code in England is 6 characters long.\nThe General Practice code should be right justified, with the first character a space, unless it is a valid GP Practice Code from outwith Scotland.\nPoints to Note\n\nPractice code will be used to provide information to GMPs on referral activity.\nThe Practice Code on the patients referral or attendance should be record. If a patient changes GP practice between referral and attendance, the new Practice Code should be recorded.\nDummy practice codes are held in the reference files and are hard coded for validation. These codes are:\n99942 - Patients registered with a private practice only\n99957 - Patients not registered with a GP in the UK\n99961 - Patients where practice code is unknown and who are not covered by codes 99942, 99957, 99976, 99981, 99995 and 99961\n99976 - British armed forces patients not registered with a GP in the UK\n99981 - Foreign visitors not registered with a GP in Scotland\n99995 - Patients registered with a GP in England, Wales or Northern Ireland (excluding patients included under code 99942)\nGPPC is not validated for SMR00 or SMR01 records from Dental Hospitals (G106H, S206H, T113H).\nCross Checks\n\nIf it is a Scottish GPPC it must be a valid practice code which is open on the clinic date (SMR00), date of arrival (SMR30) or admission date (all other record types).\nIf it is a practice outwith Scotland it must be a valid code on the \"Rest of UK\" practice reference file.\nFurther Information\nIt should be noted that patients are no longer registered with an individual GP, but with a practice.\n\nIn NHS Scotland, the practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board. ISD maintains a GP Practice code reference file which contains up to date details of address, postcode, telephone number for each GP Practice in Scotland.\n\nIn England and Wales, the field is 6 digits therefore to accommodate cross border patient flows, this should be taken into account.\n\nSMR Validation - General Practitioner Practice Code\nTags:\ngeneral  medical  practitioner  services  registered  GMP  SMR00  SMR01  SMR02  SMR04", "name": "General Practitioner Practice Code (GPPC)", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n8\n\nPriority\nMandatory\n\nDefinition\nThe postcode is a basic unit for identifying geographic locations. A postcode is associated with each address in the UK..\n\nPostcode Format\nA postcode has two component parts. Part one of the postcode is known as the outcode, and part two is known as the incode.\n\nOutcode\nThe outcode identifies the postal area and the postal district. The postal area is represented by 1 or 2 alpha characters and the postal district is represented by 1 or 2 digits. Therefore, part 1 contains 2, 3 or 4 characters.\n\nIncode\nThe incode is of length 3 characters. The postcode sector is represented by the outcode plus the first digit of the incode. The complete postcode represents the postmans walk.\n\nPoints to Note\nPostcodes for Scotland\n\nThe instructions for determining a postcode given at the front of the Postcode Directories should be followed and the Postcodes entered in the spaces provided, and left justified. There should be no embedded blanks.\nPostcodes as written have two parts. The first part, consisting of one or two letters and one or two numbers identifies the Post Town and Postal district. The second part, consisting of one number and two letters, identifies the Postcode Sector and postmans walk.\nThe postcode of the patients usual address should be entered wherever possible. If only a temporary address is known, then this should be coded.\nIf a postcode cannot be found using the Postcode Directory, the appropriate Postcode Enquiry office should be contacted.\nAddress not known. Where a patients address is not known (but the patient is not of \"no fixed abode\"), and all reasonable means of attempting to trace the address have been exhausted, the dummy postcode \"NK01 0AA\" should be used. The use of this postcode will always be queried.\nThe querying of postcodes valid to sector level was discontinued on 1st April 1998. The whole postcode must be valid to be accepted; if not an error will be produced.\nLocal Government District Dummy Postcodes can no longer be entered.\nThe postcode must be recorded in full\nA list of all valid postcodes in Scotland, together with the permitted dummy postcodes, is held on the computer files at ISD.\nIf the full Postcode is not on the reference file, the record will be flagged with an error message and the postcode must be corrected.\nFor patients who are with the armed forces and based in the United Kingdom, use postcode of their base. For British Forces Posted Overseas who return to Scotland and go direct to hospital for treatment, use the dummy postcode BF01 0AA.\nCross Checks (applicable to SMR only)\n\nIf postcode is OS14AA, OS16AA, OS17AA, OS18AA, then Category of Patient should be 4 or 5 (i.e. overseas visitors). If not, the record will be queried.\nFrom 1st April 2000 if postcode is BF01 0AA and the category of patient is not 3 (NHS), the record will be queried.\nSMR Validation - Postcode\n\nTags:\ngeographic  locations  address  outcode  incode  postal  area  district  SMR00  SMR01  SMR02  SMR04", "name": "Postcode", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n10\n\nPriority\nOptional (SMR only)\nMandatory (A&E only)\nMain Source of Standard\nScottish Government.\n\nDefinition\nThe Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index.\n\nPoints to Note\n\nWhere the CHI is used as the Health Record Identifier (Case Reference Number), please continue to record this number in both the HRI and CHI fields.\nCross Checks\nNone.\n\nFurther Information\n\nThe Community Health Index is a register of all patients in NHS Scotland. CHI Index contains details of all Scottish residents and exists to ensure that patients can be correctly identified, and that relevant information pertaining to a patients health is available to providers of care.\n\nThe CHI number is a unique is a 10-character numeric identifier, allocated to each patient on first registration with the system.\n\nThe CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records.\n\nAlthough there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications.\n\nNon-Scottish patients and other temporary residents can have a CHI number allocated if required.\n\nShould it be required patients can contact their GP Surgery in the first instance for their individual CHI Number.\n\nSee also - Baby CHI \u2013 Babies 1 to 3\n\nSMR Validation - Community Health Index\n\nTags:\ncommunity  health  index  population  register  identifier  patient  allocation  status  SMR00  SMR01  SMR02  SMR04  scotland  records  individual  hospital", "name": "Marital Status", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n10\n\nPriority\nLocal\n\nDefinition\nAn alternative patient identifier used locally e.g. Local case note reference for merged case notes..\n\nRecording Rules\nThis is a local item. Local guidance will be given concerning the completion of this field. Examples of use may be in departmental indexing of records.\n\nPoints to Note\n\nThis field may have been used in the past to record a patients CHI number. In the SMR Dataset a separate field is now available to record CHI.\nThis field should NOT be used to record CHI numbers\nCross Checks\nNone.\n\nSMR Validation - No Validation.\n\nTags:\nlocal  guidance  field  indexing  CHI  patient  identifier  SMR00  SMR01  SMR02  SMR04", "name": "Alternative Case Reference Number", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n20\n\nPriority\nMandatory\n\nDefinition\nThe first forename of a person represents that part of the name of a person which after the surname, is the principal identifier of a person\n\nRecording Rules\n\nWhere only the initial letter of the first forename is available this should be entered in the first character space.\nIn the very rare circumstances where the first forename is not known \"X\" should be entered in the first character space.\nWhere the full forename is available the remainder of the forename should be entered in the character spaces provided, using CAPITAL LETTERS.\nHyphens occurring within a forename should be given a separate character space\nNotes\nBased on UK Government Data Standards Catalogue: BSEN 7372:1993\n\nCross Checks\nNone\n\nSMR Validation - First-Forename\n\nRelated items:\n\nPerson Name\nPrevious Name\nPrevious Surname\nSurname\nTags:\nname  surname  principal  identifier  patient  SMR00  SMR01  SMR02  SMR04", "name": "First Forename", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n4\n\nPriority\nLocal\n\nDefinition\nA health records system identifier is a code which identifies a health records system.\n\nCross Checks\nNone.\n\nSMR Validation - Health Records System Identifier\n\n\nRelated items:\n\nHealth Records System\nTags:\ncode  SMR00  SMR01  SMR02  SMR04", "name": "NHS Number", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n2\n\nPriority\nOptional\n\nDefinition\nEthnic group classifies the person according to their own perceived ethnic group and cultural background. (Scotland Census)\n\nPoints to Note\n\nThis is included as an Optional item, but may be made Mandatory at a later date in order to conform to UK-wide requirements.\nThis is the patients perception of his or her own ethnic group, and is intended to assist the monitoring of equality of access to NHS services..\nFor the A&E datamart, please ensure this data item is as complete as possible\nCross Checks\nNone.\n\nNotes\nThe following list is the current ethnicity classification (2011 Census categories). This should be used by NHS Scotland organisations for local and SMR return purposes. Local systems may record more detailed codes as required but these must map to the categories for SMR return purposes.\n\nThe letters that appear in the group headings in the codes and value list refer to positions in the census list and are not valid SMR codes. Please only use the codes in the code list (1A, 1B etc.).\n\nCodes and Values: Ethnic Group (Code order)\n\nGroup A - White\n1A Scottish\n1B Other British\n1C Irish\n1K Gypsy/ Traveller\n1L Polish\n1Z Other white ethnic group\n\nGroup B - Mixed or multiple ethnic groups\n2A Any mixed or multiple ethnic groups\n\nGroup C - Asian, Asian Scottish or Asian British\n3F Pakistani, Pakistani Scottish or Pakistani British\n3G Indian, Indian Scottish or Indian British\n3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British\n3J Chinese, Chinese Scottish or Chinese British\n3Z Other Asian, Asian Scottish or Asian British\n\nGroup D - African\n4D African, African Scottish or African British\n4Y Other African\n\nGroup E - Caribbean or Black\n5C Caribbean, Caribbean Scottish or Caribbean British\n5D Black, Black Scottish or Black British\n5Y Other Caribbean or Black\n\nGroup F - Other ethnic group\n6A Arab, Arab Scottish or Arab British\n6Z Other ethnic group\n\nGroup G - Refused/Not provided by patient\n98 Refused/Not provided by patient\n\nGroup H - Not Known\n99 Not Known\n\nSMR Validation - Ethnic Group\n\nTags:\nethnicity  classification  census  person  perceived  cultural  background  categories  SMR00  SMR01  SMR02  SMR04", "name": "Ethnic Group", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n20\n\nPriority\nOptional\n\nDefinition\nThis is any surname by which a person was previously known.\n\nRecording Rules\n\nIt may be used for Maiden Surname for married females including those widowed, divorced or separated; or for Birth Name and Alternative name, where these are required. Where several surnames are known for a patient, it is recommended that Birth Surname should be entered as previous surname. This item also applies to any person, including males, who have changed their surname (e.g. by deed poll).\nThis data item has been retained primarily for maternity and record linkage purposes until a unique identifier is available.\nPoints to Note\n\nThis information is required to assist in the matching of an individual patients records\nThis item must not be used to record the birth surnames of adopted children.\nFor SMR02 (Maternity) this field should be used to record Maiden Surname.\nCross Checks\nNone.\n\nSMR Validation - Previous Surname\n\nTags:\npreviously  known  maiden  surname  birth  alternative  deed  poll  maternity  patient  identifier  SMR00  SMR01  SMR02  SMR04", "name": "Previous Surname", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n10\n\nPriority\nLocal\n\nDefinition\nThe NHS number is the identifier allocated to an individual to enable unique identification within the UK for NHS health care purposes.\n\nRecording Rules\n\nThis field should be left blank for Scottish Residents until further instructions are issued.\nThis is the new NHS Number which was implemented by the NHS in England and Wales in April 1997 and will be required to be held by Scottish health care systems for English or Welsh patients.\nThe CHI number will eventually be the NHS Number for Scottish patients.\nThe first digit of the NHS Number in England and Wales will be 4 or greater.\nPoints to Note\nNone.\n\nCross Checks\nNone.\n\nSMR Validation - NHS Number\n\nTags:\nidentifier  allocated  individual  unique  health  care  UK  england  wales  SMR00  SMR01  SMR02  SMR04", "name": "Community Health Index (CHI) Number", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters (right justified)\n\nField Length\n8\n\nPriority\nLocal\n\nDefinition\nThe GMC (General Medical Council) number is the personal identification number issued to each doctor in the UK by the General Medical Council.\n\nRecording Rules\n\nIf this item is to be completed, it is the General Medical Council registration number (GMC number) of the referring Doctor or Dentist which should be used.\nThe GMC number can consist of 7 numeric or L + 6 numeric. The L format is used for limited registrations, usually overseas doctors, and in time this number could be changed to a permanent number, usually 7 numeric.\nThe General Dental Council (GDC) Number consists of D + 6 numeric.\nThe 8 digit personal identification number (PIN) allocated to Nurses and other Allied Healthcare Professionals (AHP) is used as the Nurse/AHP code. In the case of a nurse the PIN consists of an 8 character alpha/numeric code, although this format may differ for other AHPs (e.g. Podiatrists).\nThe GMC/GDC/PIN number should be right justified in the eight character spaces provided.\nFrom April 2020 this data item was no longer required for national collection on SMR00.\nPoints to Note\n\nThe referring Doctor may not belong to the patients registered GP Practice.\nCross Checks\nNone.\n\nSMR Validation - GMC Number\n\nTags:\ngeneral  medical  council  personal  identification  doctor  AHP  registered  bodies  number  dentist  nurse  SMR00  SMR01  SMR02  SMR04", "name": "GMC No of Referring Doctor/Dentist/Nurse/Allied Healthcare Professional", "type": "PrimitiveType"}, {"id": "", "description": "Format\nCharacters\n\nField Length\n1\n\nPriority\nOptional\n\nDefinition\nAn indicator to identify the legal marital or civil status of a person.\n\nPoints to Note\n\nCode Y - OTHER should be used for cohabiting or stable relationships.\nCode Z - NOT KNOWN should be reserved for rare occasions such as:-\n* the patient refuses to divulge it\n* the patient has left the hospital before it could be recorded.\nCross Checks\nNone.\n\nCodes and Values: (code order)\n\nA Never married nor registered civil partnership\nB Married\nC Registered civil partnership\nD Separated, but still married\nE Separated, but still in civil partnership\nF Divorced\nG Dissolved civil partnership\nH Widowed\nJ Surviving civil partner\nY Other\nZ Not known\nSMR Validation - Marital Status\n\nTags:\nlegal  person  patient  identifier  married  divorced  civil  partnership  widowed  SMR00  SMR01  SMR02  SMR04", "name": "Sex", "type": "PrimitiveType"}]}]