Section 3 describes the scope of the standard i.e. which type of project the standard may apply to, and the associated timescales; Section 3.4 contains the detail of the standard; Section 4 describes the sign off process for the standard. Scope Overview The recognises this as a National requirement and includes all NHS Scotland Boards. Input was sought directly from: NHS Greater Glasgow and (Lead Board) NHS Dumfries and Galloway NHS Grampian NHS Tayside SCIMP NHS National Services Scottish Government – eHealth Division Applicable systems All clinical systems in particular those sharing information across Health Boards for example:- Clinical Portals SCI Store Letters Systems Clinical Systems GP Systems (EMIS & INPS) TrakCare Timescales The standard should to be implemented in accordance with eHealth and local Health Board strategies. Contents of standard Following on from workshops held, consultations and reviews, the current standards have been updated to reflect the discussion points and agreement reached with the stakeholders. The proposed document type standards are as follows:- REVISED DOCUMENT INDEXING STANDARDS (April 2018) DST Code Document Type/Subtype Description (examples where applicable) SNOMED Code AL Alerts & Risks AL01 Allergies and Adverse Reactions Any allergy or adverse reaction noted at a point in time 163221000000102
AL02 Alerts Any alert noted at a point in time 37341000000109 AS Assessments AS01 Nursing assessment tool Any tool used by nursing staff for recording an assessment. 819981000000101 AS02 AHP Assessment Any assessment completed by an AHP 819991000000104 AS03 CAF assessment Common Assessment Framework - a standard approach to conducting assessments of children's additional 820011000000105 AS04 SSA assessment Single Shared Assessment - and more streamlined approach led by a single professional with other specialist involvement where appropriate. 820021000000104 AS05 CPA assessment Care Programme Approach. 820031000000102 AS07 Multidisciplinary assessment Any assessment completed by various clinical staff groups 820041000000106 AS08 Scored Assessment Any completed scored assessment. 823571000000103 AS10 Pre-admission assessment Any assessment completed prior to any admission. 820071000000100 AS11 Self-assessment form Any assessment completed by a patient 820081000000103 AS12 Medical assessment Any assessment completed by medical staff 820091000000101 AS13 Theatre Patient Checklist Intervention/Procedure check prior to theatre 823591000000104 AS14 Social Services Assessment. Any assessment completed for or by social services 820101000000109 AS15 Pre Op Assessment Any assessment completed prior to an intervention/ procedure 823561000000105 AS16 Nursing Profile Any profile used by nursing staff to assess a patient. 819981000000101 AS34 Risk Assessment Self-explanatory 886831000000103 AS35 Gait Analysis Assessment Record This is a structured assessment of an individual’s gait which may include graphs and 927061000000101
charts, images of the objective findings. AS99 Assessment Not Specified or for bulk scanning 325931000000109 CA Care Plans CA03 Clinical Care Plan Any care plan involving clinicians and/or social services which may or may not be integrated. Also includes Care Pathway. 325661000000106 CA04 MDT Plan Any care plan involving multi disciplinary staff groups for example Lung MDT Plan 823581000000101 CA05 Discharge Plan Any care plan used for discharge planning including nursing 820121000000100 CA06 Anticipatory Care Plan (ELT) End of Life Treatment decisions 935921000000102 CA07 Anticipatory Care Plan (ITG) Individualised Treatment Guidelines for a patient with an unusual condition or difficulty treating a condition 962891000000106 CA99 Care Plan Not Specified or for bulk scanning 325661000000106 CH Observations CH03 Fluid Balance Chart Any chart, form or document used to record fluid balance 526591000000108 CH04 Fundal height Any chart, form or document used to record fundal height 820141000000107 CH05 Growth Chart Any chart, form or document used to record growth 820161000000108 CH06 ITU & ICU chart Any form or document used to record intensive care or intensive therapy observations 823601000000105 CH07 Partogram A graphical record of key data (maternal and fetal) during labour for example Cervical Dilatation 820191000000102 CH08 Temperature Chart Any chart, form or document used to record temperature 824231000000100 CH09 Patient Safety Checklist Any chart, form or document used for this purpose 820211000000103
CH10 Vital Signs Chart Any chart, form or document used to vital signs 823611000000107 CH11 Weight Any chart, form or document used to record weight 820441000000103 CH99 Observation Not specified or for bulk scanning 823621000000101 CL Clinical Notes CL03 Inpatient medical note Any inpatient information recorded by medical staff 820221000000109 CL04 Inpatient nursing note Any inpatient information recorded by nursing staff 829201000000105 CL05 Medical note Any information recorded by medical staff 820451000000100 CL06 Multidisciplinary note Any information recorded by multiple staff groups 820461000000102 CL07 Nursing note Any information recorded by nursing staff including community notes 820471000000109 CL08 OOH note Any information recorded by Out of Hours service 823631000000104 CL09 Outpatient nursing note Any outpatient information recorded by nursing staff 820481000000106 CL10 Outpatient medical note Any outpatient information recorded by medical staff 820491000000108 CL11 AHP note Any information recorded by an AHP e.g.. Dietetic Record Card 823641000000108 CL13 Telephone Consultation Any clinical information pertaining to a telephone consultation 24681000000104 CL14 Consultation Any clinical information pertaining to a video consultation 325921000000107 CL15 Summary record Any clinical summary noted at a point in time 824321000000109 CL16 ED Card Emergency department clinical note e.g.. AE Card 445300006 CL99 Clinical note Not Specified or for bulk scanning and remote notes including patient contacts by telephone and email. 823651000000106 CO Correspondence CO02 Outpatient Letter Created as a result of an out patient clinic attendance e.g.. clinic letter 823681000000100
IN04 Endoscopy record Record of endoscopic intervention 820511000000100 IN05 Interventional radiology record Record of radiological intervention e.g. Drainage of abscess radiological guidance, coiling of aneurysm under radiological guidance, biopsy of tissue under radiological guidance 820251000000104 IN06 AHP therapy record Record of AHP therapy 823831000000103 IN07 Operation note Record of surgical intervention 823661000000109 IN08 Radiotherapy record Record of radiotherapy treatment 823841000000107 IN09 UVA / PUVA Treatment Record Intervention involving ultraviolet light therapy, often as an outpatient treatment 962901000000107 IN10 Record of Implantation of cardiac electronic device Record of initial or revision implant procedure including the procedure note and any initial programming or setup to the device itself. 1054141000000102 IN11 Record of Percutaneous Coronary Intervention Record of intervention to a coronary artery e.g. stenting, balloon angioplasty, mechanical thrombectomy. Does not include reports for diagnostic only procedures where intervention does not occur. 1067211000000108 IN99 Intervention Not specified or for bulk scanning 826491000000106 LA Labs LA01 Biochemistry Report Any result from a test performed in a Biochemistry lab 4311000179106 LA02 Combined laboratory report A summarised view of location/patient results 1076911000000107 LA03 Haematology Report Any result from a test performed in a haematology lab 4321000179101 LA04 Cellular Pathology Report Any result from a test performed in a cellular pathology lab, Includes Histopathology & Cytology 1054291000000102
LA05 Virology Report Any result from a test performed in a virology lab 1054281000000104 LA06 Immunology Report Any result from a test performed in an immunology lab 4331000179104 LA07 Microbiology Report Any result from a test performed in a microbiology lab, including MSSU, MRSA Screening 4341000179107 LA08 Blood transfusion Report Any result from a test performed in a blood transfusion lab 1054181000000105 LA09 Histocompatibility & Immunogenetics Report Renal, Cardiac, Stem Cell transplant H&I investigations and HLA disease associations 909871000000100 LA20 Genetics Report Any results from genetic investigations are to be filed here. Examples include: cytogenetics, clinical genetics, biochemical and molecular. 1054161000000101 LA99 Laboratory Report Not specified or for bulk scanning 371528001 ME Medication ME01 Controlled drugs dispensing Any form or document recording the dispensing of controlled drugs e.g., Morphine, Diamorphine 820261000000101 ME03 Drug administration chart Any record of the administration of medicine for example Insulin or Warfarin 824781000000106 ME07 Medication record Any medication record including Prescription records and repeat prescriptions. 163111000000100 ME08 Prescription and administration record Any record for the prescribing and administration of medicine, for example Kardex as used in some Health Boards. 824791000000108 ME09 Chemotherapy record Record of chemotherapy treatment for cancer 820271000000108 ME10 Medication review Any communication or record of a medication review (includes level reviews) and / or New Code Request
used where details of the Adverse Event are not recorded elsewhere – e.g. within a Study Visit Document. Sponsors’ SAE/ SUSAR Forms, etc., are stored in the CRF rather than the medical notes. RE05 Research Study withdrawal / un-blinding Any study document completed as a result of withdrawal or un-blinding of a study participant 1054071000000109 RE99 Research Study Document – not otherwise specified Any other study-specific document that does not fit into any of the above categories or for bulk scanning 1054061000000102 RP Reports RP02 ECG For example ECG 827711000000108 RP05 Pulmonary Investigation For example, PFT, Sleep tests 822771000000101 RP08 Vascular Investigation For example, Carotid, DVT 822781000000104 RP09 Gastro Investigation For example, Breath tests, PH studies 822801000000103 RP11 Cardiac Investigation All Cardiac tests except those in ECG & Echos e.g. Ambulatory BP 822791000000102 RP12 Urodynamics For example, Urethral function test, Cystometry 827721000000102 RP13 Neuro Investigation For example, Carpal tunnel, EEG & nerve conduction studies 822811000000101 RP29 Ambulance Patient Report Form For example ePRF (Electronic Patient Report Form) 824861000000106 RP30 Radiology For example, X-ray, CT 371527006 RP31 Echo For example, Echocardiogram 822821000000107 RP32 Audiology Investigation For example, Hearing Aids, Tinnitus 822831000000109 RP33 AHP Investigation For example, balance test, swallowing 823891000000102 RP34 ETT Exercise Tolerance Test report 914861000000106 RP35 Ambulatory ECG monitoring report For example 24 hour ECG 914851000000108 RP36 Implanted Device Maintenance Report For example maintenance can include device check, replacement of leads, 918401000000103
commonly used to assess gastrointestinal, abdominal and lung related pathology but possibly utilised in other areas. Excludes EBUS – Endobronchial Ultrasound Report. RP47 Endobronchial Ultrasound Report EBUS - A report on a technique that uses ultrasound with a bronchoscope to visualise the airway wall and adjacent structures. 1083341000000106 RP48 Combined Upper and Lower GI endoscopy Report A single report on a combined upper and lower GI endoscopic investigation. E.g. combined upper GI endoscopy plus sigmoidoscopy report, combined upper GI endoscopy plus colonoscopy report 1095251000000101 RP49 Cystoscopy Report A report on an inspection of the urethra and bladder. 1095241000000104 RP99 Report Not specified or for bulk scanning 229059009 TH Third party documents TH01 Non-Statutory provider document Any document from a non-statutory organisation for example, local authority information 823901000000101 TH02 Private provider note Any document from private health care provision 823931000000107 TH99 party document Not specified or for bulk scanning 823941000000103 Document Types = 17 & Document Sub Types = 166 Guidance Notes have been produced which provide further clarity when applying the indexing standards to documents and act as a quick reference to ensure there is an agreed and consistent approach for storing and retrieving electronic clinical documentation. Data items Data items are not applicable as this is a document management standard. Document approval and sign-off