DATA SET CHANGE CONTROL PROCEDURE

Transcription

1 DSC Notice: 07/99/P04 Date of Issue: June, 1999 CRIR Committee for Regulating Information Requirements Subject: Data Standards: Community Contacts,, and Implementation date: Immediate DATA SET CHANGE CONTROL PROCEDURE This paper gives notification of changes approved by CRIR which will be included in the NHS Data Dictionary, the NHS Data Manual and the NHS CDS Manual in due course. Summary of change: CLINIC ATTENDANCE: FAMILY PLANNING FACE TO FACE CONTACT COMMUNITY CARE FAMILY PLANNING DOMICILIARY VISIT NURSE OR MIDWIFE CONTACT Change entity type attributes Change entity type attributes Change attribute name and description Summary of impact: None: clarification of Data Standards Change Proposal Reference No: CP07/08/06/99 Please address enquiries about this DSCN to the CRIR Secretariat, NHS Information Authority, 15 Frederick Road, Birmingham B15 1JD (Tel: ) or to the nominated enquiry point. Data Set Change Notices are located on the Internet at and on the NHSnet at : DSCN numbering format = sequence number/year of issue/service identifier and service sequence number. The service identifier and sequence number enables you to check that you have a complete set of service-specific DSCNs. Key to Service Identifier: A = All Services P = Patient (Hospital, Community, Cross Sector Services) F = Finance E = Estates W = Workforce T = Transport

2 DATA SET CHANGE NOTICE 07/99/P04 Reference: Subject: Type of Change: Effective Date: Reason for Change: CP07/99 - DG814/05/99 CP08/99 - DG821/05/99 CP06/99 - DG806/05/99 Community Contacts, and FAMILY PLANNING CLINIC Changes to NHS Data Standards Immediate Clarification Background: Community Contacts The KC Central Returns require a count of face to face contacts but specify that group activity, for example where general advice is given to several patients at the same time, should not be recorded as a contact. This needs specifying in FACE TO FACE CONTACT COMMUNITY CARE. Contacts recorded for KC56, KC57 and KC58 include those made by community support workers (nursing) as well as qualified nurses, although a qualified nurse will always be responsible for the contact. This needs specifying in NURSE OR MIDWIFE CONTACT. In addition, NURSE OR MIDWIFE CONTACT contained a reference to DOMICILIARY VISIT FAMILY PLANNING, whereas the entity type is actually named FAMILY PLANNING DOMICILIARY VISIT, and this has been rectified. The NHS Data Dictionary attribute related only to CLINIC ATTENDANCES: FAMILY PLANNING and FAMILY PLANNING DOMICILIARY VISITS. In most other cases in the NHS Data Dictionary sex is recorded as a CHARACTERISTIC of PERSON; however it is not possible to use CHARACTERISTIC for this attribute, since PERSON is not recorded for family planning contacts. It has been agreed to change the name and description of the attribute to make it clear that it applies only to family planning contacts. It has also been agreed to remove the classification 'Not Specified' since its use is highly unlikely in this context. DSCN 27/98/P19 changed the description of a as follows: This includes non-nhs organisation clinics from which family planning services are commissioned purchased by a HEALTH AUTHORITY. Page 2 of 6

3 The change should not have obscured the fact that these are family planning services commissioned by the NHS. Summary of Changes: CLINIC ATTENDANCE: FAMILY PLANNING Change entity type attributes FACE TO FACE CONTACT COMMUNITY CARE FAMILY PLANNING DOMICILIARY VISIT Change entity type attributes NURSE OR MIDWIFE CONTACT Change attribute name and description CHANGES Change Type: Change entity type attributes CLINIC ATTENDANCE: FAMILY PLANNING Attributes of this entity type are: FAMILY PLANNING: OF PATIENT The remaining attributes are unchanged Change Type: FACE TO FACE CONTACT COMMUNITY CARE A contact which is made by one or more nurses or community support workers (nursing) with a PATIENT or his/her proxy during a COMMUNITY EPISODE. The contact occurs when a PATIENT or their proxy attends a clinic or when the nurse or community support worker (nursing) makes a domiciliary visit to see the PATIENT. A proxy contact is a single occasion involving contact between a proxy and one or more members of a COMMUNITY NURSE STAFF GROUP within a NURSING IN THE COMMUNITY PROGRAMME. Contacts with proxies only count if the contact is in lieu of the contact with the PATIENT, and the proxy is able more effectively than the PATIENT to ensure that the specified advice/treatment devised for the PATIENT is followed. This is most likely to be the case where the PATIENT is unable to communicate effectively say for an infant, or for a person who is mentally ill or has learning disabilities. One or more nurses or community support workers (nursing) in the same or different NURSING IN THE COMMUNITY PROGRAMMES may be in contact with a PATIENT at Page 3 of 6

4 the same time. Contacts should be recorded as follows: a. If one or more nurses or community support workers (nursing) ancillary staff from the same programme are in contact with one patient at the same time, this should be recorded as one face-to-face contact b. If one or more nurses or community support workers (nursing) ancillary staff from different programmes are in contact with one patient at the same time, this should be recorded as one contact for each programme involved c. For contacts at a DAY CARE FACILITY, where repeated contacts may occur during the course of a day, this should be recorded as one contact for each programme involved d. If two nurses of different disciplines but both classed in the OTHER NURSE STAFF GROUP, such as stomatherapist and a continuing care nurse, are in contact with one patient at the same time, this should be recorded as two face-to-face contacts, one for each discipline Group activity, where, for example, general advice is given to several patients at the same time should not be recorded as NURSE OR MIDWIFE CONTACTS. A FACE TO FACE CONTACT COMMUNITY CARE may involve activities attributable to a STRUCTURED PROGRAMME, such as the following: a. SCREENING TEST b. GROUP SESSION c. HEALTH PROMOTION OTHER ACTIVITY d. EDUCATIONAL ASSESSMENT e. TEST OF IMMUNITY f. IMMUNISATION DOSE GIVEN g. FACE TO FACE CONTACT SURVEILLANCE For such activities they must be recorded as part of the respective STRUCTURED PROGRAMME as well as attributed to the NURSING IN THE COMMUNITY PROGRAMME. The attributes and relationships are unchanged Change Type: A type of OUT-PATIENT CLINIC. A clinic specifically to provide family planning services. This includes non-nhs organisation clinics from which family planning services are commissioned by the Page 4 of 6

5 NHS. Clinics run by CONSULTANTS are included under CONSULTANT CLINIC. It should be noted that work in GMP surgeries or GMP work on hospital premises is excluded. Change Type: Change entity type attributes FAMILY PLANNING DOMICILIARY VISIT Attributes of this entity type are: FAMILY PLANNING: OF PATIENT The remaining attributes are unchanged Change Type: NURSE OR MIDWIFE CONTACT A contact, attendance or visit as defined in each of the following: a. FACE TO FACE CONTACT COMMUNITY CARE b. CLINIC ATTENDANCE: MIDWIFE c. CLINIC ATTENDANCE: NURSE d. PROFESSIONAL ADVICE/SUPPORT CONTACT e. MATERNITY DOMICILIARY VISIT f. CLINIC ATTENDANCE: FAMILY PLANNING g. DOMICILIARY VISIT FAMILY PLANNING DOMICILIARY VISIT h. FACE TO FACE CONTACT SURVEILLANCE i. WARD ATTENDANCE There must be only one NURSE OR MIDWIFE CONTACT recorded for an actual face to face contact, classified in the above list, whether it be at a clinic or any other location. Nursing contacts may actually be made either by qualified NURSES or by community support workers (nursing). However, A a named NURSE or MIDWIFE must be responsible for each NURSE OR MIDWIFE CONTACT. The attributes and relationships are unchanged Change Type: Change attribute name and description FAMILY PLANNING: OF PATIENT Page 5 of 6

6 Sex of PERSON, EMPLOYEE or PATIENT. The sex of a PATIENT who makes a CLINIC ATTENDANCE: FAMILY PLANNING or receives a FAMILY PLANNING DOMICILIARY VISIT. Classification: a. Male b. Female c. Not specified References: The Data Manual, Workforce Module, Version 4.0: Section C1 Page 6 of 6