The Mental Health Inpatient and Day Case dataset (SMR04) collects episode level data on patients who are receiving care at psychiatric hospitals at the point of both admission and discharge.

ADR  > Mental Health Inpatient and Day Case - Scottish Morbidity Record (SMR04) @ 85

https://www.researchdata.scot/media/ljgfchjt/mental-health-inpatient-and-day-case-scottish-morbidity-record-smr04-variables.pdf

The dataset contains a wide variety of information such as patient characteristics, mental health diagnosis, length of stay, destination on discharge, whether they are admitted under Mental Health Legislation and any previous psychiatric care. Patient identifiers such as name, date of birth, Community Health Index number, NHS number, and postcode are included together with a wide variety of geographical measures. This includes the Scottish Index of Multiple Deprivation and Carstairs measures, census output area, NHS Board, Electoral Ward and Parliamentary constituency.

Scottish Health Data

National Services Scotland;,;Public Health Scotland

Format
Characters

Field Length
3

Priority
Mandatory

Definitions

Specialty
A 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.

Click here for a complete list of Specialties

Discipline
A 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.

Recording Rules
This 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.

Note that this is the ONLY rule for completing this field. The designation of the beds is not used.

Specialty/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.

The Specialty/Discipline code should be entered in the character spaces provided and left justified.

Points to Note

A separate SMR record is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds
GPs: 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.
Staff 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).
Younger 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).
See additional notes under Significant Facility.
For SMR02 records this should reflect the speciality of the person who was responsible for the care for the mother on original admission.
Example 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.

Example 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.

Cross Checks

Specialty is checked against Location Code.
Specialty is checked against Consultant.
Specialty is checked against the Patients Age (at Date of Admission).
Specialty is checked against Duration of Stay calculated between Date of Admission and Date of Discharge.
Specialty is checked against Record Type
Specialty is checked against Significant Facility.
SMR Validation - Specialty/Discipline


Related items:

HCP Responsible for Care
Location Code
Significant Facility
SMR Record Type
Tags:
division  medicine  dentistry  clinical  activity  royal  college  faculties  consultant  GP  HCP  patient  episode  alongside  midwifery  unit  AMU  freestanding  FMU  SMR00  SMR01  SMR02  SMR04

Specialty/Discipline

Episode Management Data

Format
Characters

Field Length
8

Priority
Mandatory

Definition
The healthcare professional responsible for care (HCP) is the clinician who has overall clinical responsibility for a patients’ 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.

Points to Note

A separate SMR record is submitted when a patient changes Specialty, Significant Facility or Consultant/Health Care Professional Responsible for Care on medical grounds.
Each 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.
A 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.
A 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.

Further clarification on points 3&4

A SMR should be attributed to the person who is clinically responsible for care (not just for an outpatient appointment).
Where 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.
However, 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.

For example
If 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
If 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

It is important to continue recording this data item in this way to allow for comparison/trends across the years.
A 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.

These two data items will then complement each other, but measure two types of activity.

It 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.
SMR00s must not be completed:-
- Where a Midwifery clinic is overseen by an obstetrician
- Where a nurse is carrying out routine nursing work such as bloods, dressings etc
For SMR02 records this should reflect the person who was responsible for the care of the mother on original admission to the unit.
Example 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.
Example 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.
Recording Rules

It is the Hospitals responsibility to register individuals on the National Reference Files that meet the definition of Consultant/HCP Responsible for Care as above.

The 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.

The 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).

Recording GMC/GDC/PIN
The code number of the HCP who had clinical responsibility for the patient during the episode should be right justified in the character spaces provided.

Cross Checks

Consultant 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 .
The GMC/HCP number must be on the reference file at clinic date (record type SMR00) or Admission Date (record type SMR01, 02 and 04).
If the record type is SMR02 and an 8 digit HCP code is used, Specialty/Discipline must be T2 or T21 (midwife).
SMR Validation - HCP Responsible for Care

Related terms: Healthcare professional

Tags:
professional  healthcare  episode  consultant  nurse  AHP  midwife  GP  GMC  SMR00  SMR01  SMR02  SMR04

Consultant/HCP Responsible for Care

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional for SMR01 and 04
Not applicable for SMR00 and 02

Definition
Waiting 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.

Recording Rules

The 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.
Points to Note

The 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.
The field should be left blank for Not on Waiting List (Waiting List Type 8).
Rejected 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.
When 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.
As 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.
Cross Checks

Waiting 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.
Date Placed on Waiting List is checked to be in sequence with the other dates recorded on the record.
Waiting 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.
Waiting List Date is checked against Date of Admission and if both are the same, the record is queried, unless Admission Type = 12.
SMR Validation - Waiting-List-Date

Tags:
decision  patient  smr01  smr04  elective  admission  list  placed  healthcare  professional  responsible  care

Waiting List Type

Format
Characters

Field Length
2

Priority
Mandatory

Definition
Discharge 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.

Recording Rules
Priority is C for SMR04

Points to Note

The 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.
ALL Regular Discharges are on clinical advice, or with clinical consent.
Transfers to other consultants within the same Significant Facility in the same Specialty in the same NHS Board (code 12) must be for medical reasons.
Code 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).
A 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.
SMR01 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.
SMR04 - 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.
Cross Checks

Discharge Type is cross-checked against Record Type.
Discharge Type is cross-checked with Discharge/Transfer To,e.g.
If Discharge Type is 40, 41 or 42, then Discharge Transfer To must equal 00.
If Discharge Type is 12, then Discharge Transfer To must be 4_.
If Discharge Type is 13, then Discharge/Transfer To must be 2_, 5_ or 6_.
From 1 April 2000 if Discharge Type is 43 then Discharge/Transfer To must be 01.
The use of codes 19 and 29 will always be queried.
Discharge Type is cross checked against Management of Patient.
Codes and Values: Discharge type

Death
40 - Death, no additional detail added
41 - Death - Post Mortem
42 - Death - No Post Mortem
43 - Death - whilst on pass

Irregular Discharge
20 - Irregular Discharge, no additional detail added
21 - Patient discharged himself/herself against medical advice
22 - Patient discharged by relative
23 - Patient absconded from detention (SMR04 only)
28 - Other type of irregular discharge
29 - Irregular discharge, type not known

Regular Discharge
10 - Regular discharge, no additional detail added
11 - Discharge from NHS inpatient/day case care
12 - Transfer within the same Health Board/Health Care Provider
13 - Transfer to another Health Board/Health Care Provider
18 - Other type of regular discharge
19 - Regular discharge, type not known
70 - Home Birth (SMR02 only)

SMR Validation - Discharge Type


Related items:

Discharge/Transfer To
Patient on Pass
Tags:
inpatient  day  case  episode  regular  irregular  self-discharge  death  SMR01  SMR02  SMR04

Discharge Type

Format
Characters

Field Length
2

Priority
Mandatory

Definition
Healthcare 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.

Recording Rules

This data item will allow the separate datasets to be identifiable within a comprehensive general SMR dataset.
Specialty 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.
Points to Note

If you complete SMR paper forms, this data item will be hard-coded on the form.
Cross Checks

Record type will be cross-checked against:
* Specialty
* Significant Facility
* Diagnosis
* Location
Codes and Values: SMR Record Type

Hospital Activity SMRs
00 - Outpatient Attendance (exc. A&E Attenders, Ward Attenders and Bedside Consultations)
01 - General/Acute Inpatient & Day Case
02 - Maternity Inpatient & Day Case
04 - Mental Health Inpatient & Day Case

Other SMRs
06 - Cancer Registration
25 - Scottish Drugs Misuse Database

SMR Validation - SMR Record Type

Tags:
healthcare  data  individual  patient  episode  specialty  significant  facility  diagnosis  location  SMR00  SMR01  SMR02  SMR04

SMR Record Type

Format
Characters

Field Length
5

Priority
Mandatory

Definition
A 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.

Recording Rules
The Location code should be entered in the fields provided.

This 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.

Where 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.

For 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:

in the street
on the sports field
at Leisure Centres
in hotels (if not the patients normal domicile - use D201N if it is the patients normal domicile)
in railway stations etc
Anyone wishing to start using D299N in national data returns should notify ISD using the appropriate Reference File Amendment Notification Form.

Points to Note

If 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.
For SMR02 Home Birth Location code D201N should be used
In cases of babies Born Before Arrival, the Location code should be completed as though the delivery had in fact occurred in the hospital.

Cross Checks

Location code is used in cross-checks with Record Type, e.g. GP maternity hospital can only be recorded on SMR02 (Maternity).
Location code is held on a reference file which links to provider and Specialty. It is important that this file is kept up to date.
The Location must be open at the Clinic Date (SMR00), Date of Arrival (SMR30) or Admission Date (all other record types).
To 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.

SMR Validation - Location

Tags:
building  NHS  Scotland  hospitals  health  centres  GP  surgeries  clinics  offices  nursing  homes  schools  code  NRS  care  provided  SMR00  SMR01  SMR02  SMR04

Location

Format
Characters

Field Length
2

Priority
Mandatory

Definition
An 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.

Notes

Routine Admission
A routine admission occurs when a patient is admitted as planned.

Urgent Admission
An 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.

An 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.

Note 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.

Emergency Admission
An emergency admission occurs when, for clinical reasons, a patient is admitted at the earliest possible time after seeing a doctor.

Note 1: The patient may or may not be admitted through Accident & Emergency.
Note 2: Emergency admissions from a waiting list can be identified from the patients Waiting List Type code

Other Admission
Other 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.

Points to Note

Routine Admission (Code 10)
This code should be used for patients being admitted for respite care and for patients routinely re-admitted having exceeded their pass period.
Routine 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.
Emergency - 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.
The use of codes 19 and 39 will always be queried.
Codes 40 & 48 are not valid on SMR01.
Emergency - Road Traffic Accident (Code 32)
In 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.
Emergency - Home Incident (includes accidental poisoning) (Code 33)
This 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.
Emergency - Work Incident (includes accidental poisoning) (Code 34)
This 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.
Emergency - Other Injury (includes accidental poisoning) (Code 35)
This 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.

Example 1
An 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.

Example 2
A 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.

Example 3
A 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.

Example 4
A patient admitted following an assault which took place in the home should be given Admission Type Code 33.

Patient Non-Injury (Code 36)
This 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.
Other Emergency Admission (Code 38)
An example of the use of this code is an emergency admission for respite care and a patient awaiting routine admission whose condition deteriorates.
Cross Checks

Admission Type is cross-checked against Management of Patient codes, e.g. Day Cases cannot be emergency admissions.
SMR01 - Admission Type is cross-checked against Admission Reason (when present).
Admission Type is cross-checked against Record Type.
Admission Type is cross-checked against Waiting List Type.
Codes and Values: Admission Type (Code order)

Emergency Admission
30 - Emergency Admission, no additional detail added
31 - Patient Injury - Self Inflicted (Injury or Poisoning)
32 - Patient Injury - Road Traffic Accident (RTA)
33 - Patient Injury - Home Incident (including Assault or Accidental Poisoning in the home)
34 - Patient Injury - Incident at Work (including Assault or Accidental Poisoning at work)
35 - Patient Injury - Other Injury (inc. Accidental Poisoning other than in the home) - not elsewhere classified
36 - Patient Non-Injury (e.g. stroke, MI, Ruptured Appendix)
38 - Other Emergency Admission (including emergency transfers)
39 - Emergency Admission, type not known

Other Admission
40 - Other admission types, no additional detail added
41 - Home Birth (SMR02 only)
42 - Maternity Admission (SMR02 only)
48 – Other

Routine Admission
10 - Routine Admission, no additional detail added
11 - Routine elective (i.e. from waiting list as planned, excludes planned transfers)
12 - Patient admitted on day of decision to admit, or following day, not for medical reasons, but because suitable resources are available
18 - Planned transfers
19 - Routine Admission, type not known

Urgent Admission
20 - Urgent Admission, no additional detail added
21 - Patient delay (for domestic, legal or other practical reasons)
22 - Hospital delay (for administrative or clinical reasons e.g. arranging appropriate facilities, for test to be carried out, specialist equipment, etc.)

SMR Validation - Admission Type


Related items:

Inpatient Admission
Waiting List Admission
Management of Patient
SMR Record Type
Waiting List Type
Tags:
inpatient  emergency  urgent  routine  other  category  clinical  condition  patient  assessed  receiving  consultant  SMR01  SMR02  SMR04

Admission Type

Format
Date (ddmmyy)

Field Length
6

Priority
Mandatory

Definition
Admission Date is the date on which an inpatient or day case admission occurs.

Recording Rules
The full date should be entered thus: 2 December 2004=
0	2	1	2	0	4
Points to Note
None.

Cross Checks

Date of Admission is checked to be in sequence with the other dates recorded.
The Patient’s Age is calculated between Date of Birth and Date of Admission, and is used in cross-checks with:
* Specialty
* Diagnosis
Duration of Stay (Stay) is calculated as the time between Date of Admission and Date of Discharge, and is used in cross-checks involving
* Management of Patient
* Significant Facility
* Diagnosis
SMR01 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.
SMR01 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.
SMR02,SMR04 and SMR50 - Admission Date must not equal Date of Birth.
Admission Date is checked against Waiting List Date and, if both dates are the same, the record is queried.
SMR Validation - Admission-Date


Related items:

Day Case Admission
Inpatient Admission
Tags:
inpatient  day  case  sequence  SMR01  SMR02  SMR04

Admission Date

Format
Characters

Field Length
2

Priority
Mandatory (excluding SMR00 and A&E which is Optional)

Definition
A Significant Facility is a type of clinical facility which is identified for clinical and/or costing purposes.

Recording Rules
With 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.

A separate SMR record type is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds.

Note: For outpatients, a change in significant outpatient facility attended on its own does NOT generate a new SMR outpatient episode.

Points to Note

Other (including Standard Specialty Wards)
This 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.
Neonatal Unit
SMR01 should not be completed in any circumstances. Babies readmitted to a Neonatal Unit after initial discharge will have a SBR completed.
ICU (Intensive Care Unit)
If 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:
a. SMR - Specialty = C1 (General Surgery) and Significant Facility = 11 (Standard Specialty Ward)
b. SMR - Specialty = C3 (Anaesthetics) and Significant Facility = 13 (ICU)
CCU (Cardiac Care Unit, formerly Coronary Care Unit)
If 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:
a. SMR - Specialty = A2 (Cardiology) and Significant Facility = 14 (CCU)
b. SMR - Specialty = A2 (Cardiology) and Significant Facility = 11 (Standard Specialty Ward)
A & E
If 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:
a. SMR - Specialty = C8 (Trauma & Orthopaedic Surgery) and Significant Facility = 17 (A & E Ward)
b. SMR - Specialty = C8 (Trauma & Orthopaedic Surgery) and Significant Facility = 11 (Standard Specialty Ward)
See also notes under Specialty/Discipline.

Priority is Optional for outpatients..

For A&E datamart, please only use codes 32, 39 and 40.
Cross Checks

Significant facility is cross-checked against age.
Example: Patient in Younger Physically Disabled unit must have age less than 65 years.
Significant facility is cross-checked against Record Type.
Example: Significant Facility must be present for Record Types 01, 02 and 04.
Significant facility is cross-checked against Specialty.
Example: Secure Psychiatric Inpatient Facility (1Q) is only valid for Mental Health Specialties.
Significant Facilities 1A, 1D, 1E and 18 are cross-checked against length of stay.
Codes and Values:
11 - Other (inc. the Clinical Facilities of Standard Specialty Ward 1K, Day Bed Unit 1J)
13 - Intensive Care Unit
14 - Cardiac Care Unit
16 - Childrens Unit
17 - Accident & Emergency (A&E) Ward
18 - Ward for Younger Physically Disabled
19 - Spinal Unit
1A - Geriatric Orthopaedic Rehabilitation Unit (GORU)
1B - Rehabilitation Ward (except GORU)
1C - Burns Unit
1D - Geriatric Assessment Unit
1E - Long Stay Unit for Care of the Elderly
1F - Convalescent Unit
1G - Palliative Care Unit
1H - High Dependency Unit
1L - Adolescent Unit
1M - Transplant Unit
1N - Mother and Baby Unit
1P - Stroke Unit
1Q - Secure Psychiatric Inpatient Facility
1R - Intensive Psychiatric Care Unit (IPCU)
1S - Long Stay Unit - Mental Health
1T - Psychiatric Rehabilitation Unit (PRU)
31 - Outpatient Department
32 - Accident & Emergency Department
33 - Day Hospital
34 - Health Centre
35 - GP Surgery Premises
36 - Patients home
37 - Other Community Premises
38 - Rapid Access Chest Pain Clinic
39 - Ambulatory Emergency Care Unit
40 - Acute Assessment Unit (AAU)

SMR Validation - Significant-Facility

Tags:
clinical  costing  inpatient  day  case  healthcare  episode  SMR00  SMR01  SMR02  SMR04

Significant Facility

Format
Characters

Field Length
6

Priority
Local

Definition
This is the identification number taken from the GPs referral letter.

Points to Note
This is a 6 digit number.

Cross Checks
None.

SMR Validation - GP-Referral-Letter-Number

Tags:
general  practitioner  identification  SMR00  SMR01  SMR02  SMR04

GP Referral Letter Number

Format
Characters

Field Length
10

Priority
Local

Definition
A 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.

Recording Rules

During 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.
The 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).
An Optional 10 digit data item is therefore included for such future use
Points to Note

This data item may be defined locally by the provider.
Cross Checks
None.

SMR Validation - Spell/Care Package Identifier

Tags:
healthcare  condition  SMR  episode  inpatient  outpatient  day  patient  clinical  reasons  SMR00  SMR01  SMR02  SMR04

Spell/Care Package Identifier

Format
Characters

Field Length
2

Priority
Mandatory for SMR02 only

Definition
Admission reason indicates the primary reason why a patient is admitted for inpatient or day case care.

Recording Rules
Priority is Mandatory for SMR02

Points to Note

The 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.
SMR02
Code 22 should be used when a patient is admitted in false labour and discharged still pregnant, or admitted for a threatened abortion.
Code 25 should be used for patients delivered at home as planned but who require admission to a maternity hospital after the delivery.
Code 28 should be used for incomplete abortions following a complete abortion episode and missed abortions.
Care must be taken to ensure that the Admission Reason code entered is compatible with the Condition on Discharge code.
Cross Checks

Reason for Admission is cross-checked against Record Type.
SMR02 - Admission Reason is cross-checked against:
Type of Abortion
Management of Abortion
Condition on Discharge
Management of Patient
Mode of Delivery
Location
Codes and Values: Admission Reason

Code	Maternity Admission Reason (Codes for SMR02 only)
20	20 Home Birth (Not Admitted) To be used only for a completed Home Birth
21	Abortion (includes ectopic pregnancy)
22	Pregnant but not in labour (includes threatened abortion)
23	In labour
24	Born before Arrival
Maternity Admission where the baby was born before arrival at the hospital
25	Admitted after delivery at home
Admission following a home birth
26	Admitted after delivery in any hospital
Transfer of mother where the birth occurred in another hospital
28	Other type of maternity admission (including doubtfully pregnant and incomplete abortion following complete abortion episode)
SMR Validation - Admission Reason

Tags:
primary  patient  admitted  inpatient  day  case  SMR  codes  values  care  SMR01  SMR02  SMR04

Admission Reason

Format
Date (ddmmyy)

Field Length
6

Priority
Optional

Definition
Ready-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.

Recording Rules
The full date should be entered thus:
2 August 2004 =

0	2	0	8	0	4
Notes

“A more appropriate care setting” covers all appropriate destinations outwith short-stay specialties and outwith the NHS (patient’s home, nursing home etc).
From a service provider’s perspective an “appropriate care setting” can be defined as a place that:

Meets the particular care needs of a person.
Meets those needs cost effectively.

If 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.
Points to Note

This 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.
ICD10 codes can be used in the clinical section to indicate reason for delay in discharge, e.g. living alone - Z60.2.
SMR02 - 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.
Cross Checks

Ready for Discharge Date is checked to be in sequence with other dates.
Ready for Discharge Date must not be present for all types of day cases.
SMR Validation - Ready for Discharge Date


Related items:

Delayed Discharge
Discharge
Discharge Date
Inpatient
Inpatient Episode
Tags:
inpatient  responsible  consultant  multi-discipline  team  MDT  episode  GP  agencies  patient  transfer  hospital  bed  duration  of  delay  SMR01  SMR02  SMR04  appropriate  care  setting

Ready for Discharge Date

Definition
This 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.

41/51 Accident & Emergency
C2 - Accident & Emergency

42/52 Surgical specialty
C1 - General Surgery
C11 - General Surgery (excludes Vascular)
C12 - Vascular Surgery
C13 - Oral & Maxillofacial Surgery
C31 - Pain Management
C3 - Anaesthetics
C4 - Cardiothoracic Surgery
C41 - Cardiac Surgery
C42 - Thoracic Surgery
C5 - Ear, Nose & Throat (ENT)
C51 - Audiological Medicine
C6 - Neurosurgery
C7 - Ophthalmology
C9 - Plastic Surgery
C91 - Cleft Lip and Palate Surgery
CB - Urology
D3 - Oral Surgery
F2 - Gynaecology
R11 - Surgical Podiatry

43/53 Medical specialty
A1 - General Medicine
A11 - Acute Medicine
A2 - Cardiology
A3 - Clinical Genetics
A6 - Infectious Diseases [Communicable Diseases]
A7 - Dermatology
A8 - Endocrinology & Diabetes
A81 - Endocrine
A82 - Diabetes
A9 - Gastroenterology
AA - Genito-Urinary Medicine
AC - Homeopathy
AD - Medical Oncology
AG - Renal Medicine
AH - Neurology
AK - Occupational Medicine (SMR Data Manual, Version 1.4, July 2003)
AM - Palliative Medicine
AP - Rehabilitation Medicine
AQ - Respiratory Medicine
AR - Rheumatology
AV - Clinical Neurophysiology
AW - Allergy
D4 - Oral Medicine
H2 - Clinical Oncology
J3 - Chemical Pathology
J4 - Haematology
J5 - Immunology

44/54 Obstetrics/Postnatal cots
F3 - Obstetrics
F31 - Obstetrics Antenatal
F32 - Obstetrics Postnatal
T2 - Midwifery
T21 - Community Midwifery

45/55 Paediatrics
AF - Paediatrics
CA - Paediatric Surgery

46/56 Neonatal Paediatrics
AF - Paediatrics
E12 - GP Other than Obstetrics

47/57 GP Obstetrics/Postnatal cots
E11 - GP Obstetrics

48/58 Other Specialty not separately identified
D1 - Community Dental Practice
D5 - Orthodontics
D6 - Restorative Dentistry
D8 - Paediatric Dentistry
H1 - Clinical Radiology [Diagnostic Radiology]

4A/5A GP Non Obstetrics
E12 - GP Other than Obstetrics

4B/4C/5B/5C Geriatrics
AB - Geriatric Medicine
E12 - GP Other than Obstetrics

4D/4E/5D/5E Psychiatry
G1 - General Psychiatry (Mental Illness)
G2 - Child & Adolescent Psychiatry
G21 - Child Psychiatry
G22 - Adolescent Psychiatry
G3 - Forensic Psychiatry
G4 - Psychiatry of Old Age
G6 - Psychotherapy
G61 - Behavioural Psychotherapy
G62 - Child & Adolescent Psychotherapy
G63 - Adult Psychotherapy

4F/5F Orthopaedics
C8 - Trauma & Orthopaedic Surgery [Orthopaedics]

4G/5G Learning Disability
G5 - Learning Disability

Specialty Groupings for Admission/Discharge/Transfer

Format
Characters

Field Length
2

Priority
Mandatory

Definition
Admission/transfer from indicates the source of admission, or type of location from which a patient has been admitted.

Points to Note

The 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.
Patients 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.
If 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).
Patients 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.
Code 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.
Codes 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.
Cross Checks

Admit/Transfer from is cross-checked with Record Type.
Admit/Transfer from is cross-checked with age.
Codes and Values: Admission/Transfer From

Institution
20 Place of Residence - Institution, no additional detail added
24 NHS Partnership hospital
25 Care home
26 Intermediate Care
28 Place of Residence - Institution - other type
29 Place of Residence - Institution - type not known

Other
60 Admission from other types of location etc - no additional detail added
61 Private Hospital
62 Hospice
68 Other type of location
69 Type of location - not known
70 Home Birth (SMR02 only)

Private Residence
10 - Private Residence - No additional detail given
11 - Private Residence - Living alone
12 - Private Residence - Living with relatives or friends
14 - Private Residence - (supported)
18 - Private Residence - Other type (e.g.Foster Care)
19 - Private Residence - Type not known

Temporary
30 - Temporary place of residence, no additional detail needed
31 - Holiday Accomodation
32 - Student Accomodation
33 - Legal establishment, including prison
34 - No fixed abode
38 - Other type of temporary residence (includes hospital residences, hotel facilities)
39 - Temporary place of residence - type not known

Transfer from another NHS provider
50 - Transfer from another Health Board/Health Care Provider - no additional detail addedTransfer from another NHS provider
50 - Transfer from another Health Board/Health Care Provider - no additional detail added
51 - Accident and Emergency Ward
52 - Surgical specialty
53 - Medical specialty
54 - Obstetrics/Postnatal Cots
55 - Paediatrics
56 - Neonatal Paediatrics
57 - GP Obstetrics/Postnatal cots
58 - Other Specialty not seperately identified
59 - Transfer from another Health Board/ Health Care Provider - specialty not known
5A - GP Non Obstetrics
5B - Geriatrics (except for patient on pass)
5C - Geriatrics (patient on pass)
5D - Psychiatry (except for patient on pass)
5E - Psychiatry (patient on pass)
5F - Orthopaedics
5G - Learning Disability
5H - Hospital at Home

Transfer within the same provider
40 - Transfer within the same Health Board/Health Care Provider - no additional detail added
41 - Accident and Emergency Ward
42 - Surgical specialty
43 - Medical specialty
44 - Obstetrics/Postnatal Cots
45 - Paediatrics
46 - Neonatal Paediatrics
47 - GP Obstetrics/Postnatal cots
48 - Other Specialty not separately identified
49 - Transfer within the same Health Board/ Health Care Provider - specialty not known
4A - GP Non Obstetrics
4B - Geriatrics (except for patient on pass)
4C - Geriatrics (patient on pass)
4D - Psychiatry (except for patient on pass)
4E - Psychiatry (patient on pass)
4F - Orthopaedics
4G - Learning Disability
4H - Hospital at Home

SMR Validation - Admission Transfer From


Related items:

Admission
Patient on Pass
Specialty/Discipline
Tags:
source  type  location  patient  codes  pass  mental  health  long  stay  specialty  acute  episode  SMR01  SMR02  SMR04

Admission/Transfer From

Format
Characters

Field Length
2

Priority
Mandatory

Definition
Discharge/Transfer to gives the type of location to which a patient is discharged or transferred following an episode of care.

Recording Rules
Priority is C for SMR04.

Points to Note

The 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.
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.
SMR01 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.
Please refer to Specialty Groupings for Transfers (Codes 4_ & 5_).
Cross Checks

Discharge/Transfer To code is checked against all the Record Types and age.
Discharge/Transfer To code is checked against Discharge Type.
SMR02 - Discharge/Transfer To code is checked against Management of Patient.
Codes and Values

Death
00 - Patient Died (except patients on pass)
01 - Patient died whilst on pass

Institution
20 - Place of Residence - Institution - no additional detail added
24 - NHS Partnership Hospital
25 - Care Home
26 - Intermediate Care
28 - Place of Residence - Institution - other type
29 - Place of Residence - Institution - type not known

Other
60 - Discharge to other types of locations - no additional detail added
61 - Private Hospital
62 - Hospice
68 - Other type of discharge location
69 - Type of discharge location not known
70 - Home Birth (SMR02 only)

Private Residence
10 - Private Residence - no additional detail added
11 - Private Residence - Living alone
12 - Private Residence - Living with relatives or friends
14 - Private Residence (supported)
18 - Private Residence - Other type (e.g. foster care)
19 - Private Residence - type not known

Temporary
30 - Temporary Place of Residence - no additional detail added
31 - Holiday Accommodation
32 - Student Accommodation
33 - Legal Establishment, including prison
34 - No fixed abode
38 - Other type of temporary residence, includes hospital residences, hotel facilities, foster care)
39 - Temporary Place of Residence - type not known

Tranfer Within the Same Provider
40 - Transfer within the same Health Board/ Health Care Provider - no additional detail added
41 - Accident and Emergency Ward
42 - Surgical Specialty
43 - Medical Specialty
44 - Obstetrics/Postnatal Cots
45 - Paediatrics
46 - Neonatal Paediatrics
47 - GP Obstetrics/Postnatal Cots
48 - Other specialty not separately identified
49 - Transfer within the same Health Board/ Health Care Provider - Specialty not known
4A - GP other than Obstetrics
4B - Geriatrics (except for patient on pass)
4C - Geriatrics (patient on pass)
4D - Psychiatry (except patient on pass)
4E - Psychiatry (patient on pass)
4F - Orthopaedics
4G - Learning Disability
4H - Hospital at Home

Transfer to Another NHS Provider
50 - Transfer to another Health Board/ Health Care Provider - no additional detail added
51 - Accident and Emergency Ward
52 - Surgical Specialty
53 - Medical Specialty
54 - Obstetrics/Postnatal Cots
55 - Paediatrics
56 - Neonatal Paediatrics
57 - GP Obstetrics/Postnatal Cots
58 - Other specialty not separately identified
59 - Transfer to another Health Board/ Health Care Provider - specialty not known
5A - GP Other than Obstetrics
5B - Geriatrics (except for patient on pass)
5C - Geriatrics (patient on pass)
5D - Psychiatry (except for patient on pass)
5E - Psychiatry (patient on pass)
5F - Orthopaedics
5G - Learning Disability
5H - Hospital at Home

SMR Validation - Discharge Transfer To


Related items:

Discharge Type
Management of Patient
Tags:
episode  care  patient  inpatient  mental  health  pass  discharged  transferred  SMR01  SMR02  SMR04

Discharge/Transfer To

Format
Characters

Field Length
1

Priority
Mandatory

Definition
Patient (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.

Points to Note

An 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).
An 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.

Note
Trusts have a statutory duty to identify overseas visitors and make charges in accordance with section 98 of the Act.
An overseas visitor may opt to become a private patient.

Overseas 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.
An overseas visitor may opt to become a private patient.
If an overseas visitor has opted to become a private patient, code 2 should be used.
Code 2 should be used where patients pay for all or part of their treatment.
Patients referred by a court for NHS psychiatric assessment where the court pays should be recorded as NHS code 3 rather than Paying code 2.
Cross Checks

Category 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.
Category of Patient is cross-checked with Record Type.
For SMR00 the Patient Category must not be 1 (Amenity). (01/04/2000)
For SMR04 the Patient Category must not be 1 (Amenity). (01/04/2008)
Codes and Values: Patient category (Code order)
1 Amenity
2 Paying
3 NHS
4 Overseas visitor - liable to pay for treatment
5 Overseas visitor - not liable to pay (reciprocal arrangements)
8 Other (including Hospice)

SMR Validation - Patient Category

Tags:
administrative  status  payment  NHS  charges  overseas  visitor  private  amenity  SMR00  SMR01  SMR02  SMR04

Patient Category

Format
Characters

Field Length
5

Priority
Optional

Definition
Admission/transfer from - location gives the location code, where appropriate, of the location from where a patient is admitted.

Each 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’s homes and schools. The code is a five character code and is maintained by ISD.

Recording Rules
Where applicable, enter the Location code as follows:

Example:
Ninewells Hospital =

T	1	0	1	H
Points to Note
None.

Cross Checks

Admission/Transfer From - Location must be a valid Location code.
The Location must be open at the Admission Date.
SMR Validation - Admission Transfer From Location


Related items:

Location
Location Code
Tags:
patient  code  admitted  hospitals  health  centres  clinics  nursing  homes  schools  SMR01  SMR02  SMR04

Admission/Transfer From - Location

Format
Date (ddmmyy)

Field Length
6

Priority
Mandatory

Definition
Discharge date is the date on which a patient is discharged from an episode of care.

Recording Rules
The full date should be entered thus:
12 June 2004 =

1	2	0	6	0	4
Points to Note

SMR01 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.
When 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.
SMR04 If a patient is transferred to another hospital, general or psychiatric and there is intention to return, treat as if on pass.
Priority is C for SMR02, SMR04.
For 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.
Cross Checks

Discharge Date is checked to be in sequence with the other dates recorded.
Duration of Stay is calculated by subtracting Date of Admission from Discharge Date and is used in cross checks involving:
Management of Patient
Significant Facility
Diagnosis
SMR02 and 04 - Discharge Date must not equal Date of Birth.
SMR01 - If Discharge Date equals Date of Birth this record will always be queried.
SMR01 - If Discharge Date equals Date of Birth then Significant Facility must equal 11 (Other), 12 (Postnatal Cot), 15 (Neonatal Unit) or 16 (Childrens Unit).
SMR Validation - Discharge Date


Related items:

Episode of Care
Tags:
episode  care  patient  discharged  SMR01  SMR02  SMR04

Discharge Date

Format
Characters

Field Length
1

Priority
Mandatory

Definition
Management of Patient indicates the patient type and the pattern of bed use of a patient for SMR Record Types 01, 02, and 04.

Points to Note

Rules for the generation of each of the SMR record types are to be found at the beginning of each Specialty Specific Section.
Management of Patient codes: 2,4,6 are all types of Day Case.
Management of Patient codes: 1,3,5,7, A and B are all types of Inpatient.
Where 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).
Code 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.
Where 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).
Cross Checks

Management of Patient is cross-checked with Record Type.
Example: Codes 1-7, A and B are valid on SMR01
Management of Patient is cross-checked with Length of Stay.
Example: Codes 2, 4, 6 and A must have a length of stay = 0 days
Management of Patient is cross-checked with Admission Reason.
Example: If Admission Reason 21, Management of Patient must be Codes 1-7 or A
Management of Patient is crosschecked with Record Type.
Example: MoP must be blank if Record Type = 00
Codes and Values: Management of Patient (Code order)

0 - Home Birth SMR02
1 - Inpatients (except for categories 3,5,7 and A below)
2 - Day Case in Day Bed Unit (except where retained overnight or longer)
3 - Inpatient originally admitted as a Day Case in Day Bed Unit, then moved to Inpatient Ward for intended overnight retention or longer
4 - Day Case in Inpatient Ward (except where retained overnight or longer)
5 - Inpatient originally admitted as Day Case in Inpatient Ward and retained overnight or longer
6 - Day Case - Other than in Day Bed Unit or Inpatient Ward (except where retained overnight or longer)
7 - Inpatient originally admitted as Day Case Other, then moved to Inpatient Ward for intended overnight retention or longer
A - Inpatient admitted to and discharged from a Day Bed Unit on the same day
B - Hospital at Home

SMR Validation - Management of Patient


Related items:

Admission Reason
Admission Type
Day Bed Unit
Day Case
Inpatient
Tags:
admission  record  reason  type  pattern  bed  use  day  case  hospital  at  home  inpatient  ward  overnight  retained  SMR01  SMR02  SMR04

Management of Patient

Format
Characters

Field Length
5

Priority
Mandatory

Definition
This 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.

Points to Note

When completing the provider code on ISD returns, the code of the Health Board/Health Care Provider which actually provides clinical services must be recorded.
Example
If 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.

If 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.

Cross Checks

Must be valid provider code.
Tags:
health  board  services  legal  provision  location  hospital  national  identifier    SMR00  SMR01  SMR02  SMR04

Provider Code

Format
Characters

Field Length
5

Priority
Optional

Definition
Discharge/transfer to - location gives the location code, where appropriate, of a patient's destination following discharge from an episode of care.

Each 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.

Recording Rules
Where applicable, enter the Location code as in the following example:
Ninewells Hospital =

T	1	0	1	H
Cross Checks

Discharge/Transfer To - Location must be a valid Location code.
The Location must be open at the Discharge Date.
SMR Validation - Discharge-Transfer-To-Location


Related items:

Discharge
Episode of Care
Location
Location Code
Tags:
code  patient  destination  episode  care  SMR01  SMR02  SMR04

Discharge/Transfer To - Location

Format
Characters

Field Length
1

Priority
Mandatory (where applicable)

Definition
Waiting 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.

Points to Note

Code 8 should be used for emergency and urgent admissions who are not on a waiting list for the condition prompting admission.
Code 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.
If code 8 is used, Admission Type should not = 10, 12 or 19.
Cross Checks

Waiting List Type is cross checked against Record Type. It is not applicable to SMR02 and SMR00.
Waiting 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.
If Waiting List Type is 8, Admission Type must not = 11 (Elective Admission)
Codes and Values: Waiting List Type (Code order)
1 True waiting list
2 Planned repeat waiting list
8 Not on waiting list (see points to note)
9 Not known (this is allowed locally as a holding code until the correct code is assigned and is not valid centrally)

SMR Validation - Waiting List Type


Related items:

Admission
Tags:
patient  inpatient  day  case  admission  true  repeat  condition  SMR01  SMR04

Waiting List Date

Field Length
6

Priority
Conditional

Definition
Other medical conditions which contributed to the decision to admit the patient or which were identified on admission as requiring management.

Points to Note

For detailed instructions on ICD10 coding please refer to General Clinical Section.
For specific instructions relating to Psychiatric conditions please refer to the Diagnostic Section.
Cross Checks

The ICD10 codes recorded must be valid codes and in the correct format.
There must be an entry in Main condition if any of the Other conditions fields are completed.
The ICD10 codes are checked against Sex and Age on Admission.
SMR Validation - Admission - Other Conditions/Co-morbidity and Complications


Related items:

Main Condition/Principal Diagnosis/Problem Managed - SMR04
Tags:
medical  condition  patient  management  ICD10  diagnostic  admission  SMR04

Other Conditions/Comorbidity & Complications - SMR04

An SMR04 is generated for patients receiving care in Mental Health Specialties when the following events occur. Part 1 of the record containing admission details is completed and submitted; on discharge Part 2 is completed and submitted.

Inpatients and Day Cases are admitted to NHS hospitals from locations external to the NHS.
Inpatients and Day Cases are admitted to contracted NHS beds in non-NHS institutions.
Inpatients and Day Cases change specialty (with or without a change of consultant):
An inpatient transfers to become an Inpatient in another specialty in the same hospital
An inpatient becomes a Day Case in another specialty during the inpatient stay
A day case transfers to become an Inpatient in another specialty (except when the day case episode during an inpatient stay and the patient is transferring back to the original consultant)
A day case transfers back to resume an Inpatient stay but DOES NOT transfer back to the original consultant for medical reasons
Inpatients and Day Cases transfer from another NHS hospital (including contracted NHS beds in non-NHS institutions).
Inpatients and Day Cases change consultant for medical reasons within the same specialty:
An inpatient transfers as an Inpatient to the care of a different consultant for medical reasons in the same specialty in the same hospital
An inpatient becomes a Day Case in the same specialty under a different consultant for medical reasons during the inpatient stay
A 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 inpatient stay and the patient is transferring back to the original consultant)
A day case transfers back to resume an Inpatient stay in the same specialty but DOES NOT transfer back to the original consultant for medical reasons
Inpatients move into and/or out of one of the significant facilities listed in this section.
Note: The General Definition of Psychiatric is now referred to as Mental Health.

Mental Health Inpatient and Day Case

Definition

An SMR04 is raised at the outset of each Inpatient Admission and of each Day Case Admission for care in the specialties below in a psychiatric hospital or unit, or facility treating people with learning difficulties, whereby Part 1 of the record containing admission details is completed and submitted.

The termination of an Inpatient Episode or of a Day Case Episode within these facilities then raises a completion of the SMR04 record (Part 2) which is a copy of the original record with the inclusion of transfer/discharge/disposal details.

An Inpatient or Day Case admission marks the start of an Inpatient or Day Case episode.
Inpatient admissions include Inpatient Transfers-In to Inpatients and Day Case Transfers-In to Inpatients.
Day Case admissions include Inpatient Transfers-In to Day Cases.
Codes and Values:
For specific Significant Facility Codes valid for SMR04 - see the SMR04 CRIB Sheet

Significant Facilities for SMR04

Field Length
3

Priority
Mandatory

Definitions

Specialty
A 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.

Click here for a complete list of Specialties

Discipline
A 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.

Recording Rules
This 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.

Note that this is the ONLY rule for completing this field. The designation of the beds is not used.

Specialty/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.

The Specialty/Discipline code should be entered in the character spaces provided and left justified.

Points to Note

A separate SMR record is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds
GPs: 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.
Staff 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).
Younger 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).
See additional notes under Significant Facility.
For SMR02 records this should reflect the speciality of the person who was responsible for the care for the mother on original admission.
Example 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.

Example 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.

Cross Checks

Specialty is checked against Location Code.
Specialty is checked against Consultant.
Specialty is checked against the Patients Age (at Date of Admission).
Specialty is checked against Duration of Stay calculated between Date of Admission and Date of Discharge.
Specialty is checked against Record Type
Specialty is checked against Significant Facility.
SMR Validation - Specialty/Discipline


Related items:

HCP Responsible for Care
Location Code
Significant Facility
SMR Record Type
Tags:
division  medicine  dentistry  clinical  activity  royal  college  faculties  consultant  GP  HCP  patient  episode  alongside  midwifery  unit  AMU  freestanding  FMU  SMR00  SMR01  SMR02  SMR04

Field Length
1

Priority
Mandatory

Definition
The status of the patient at the time of admission to the episode with respect to the Mental Health (Care and Treatment) (Scotland) Act of 2003.

Recording Rules
The appropriate code should be entered from the codes and value list

Points to Note

“Formal” refers to patients who have been detained under the provisions of the Mental Health (Care and Treatment) (Scotland) Act of 2003. “Informal” refers to voluntary Mental Health admissions.
Informal Holiday/ Respite admissions are no longer recorded by Status on Admission. Such admissions can be identified by Admission Reason “5B - Respite/holiday care”.
Respite care patients can also be identified by using the ICD10 code Z75.5 - Holiday relief care in the Main Condition field. This should be followed by the code(s) to indicate the condition from which the patient suffers. Please refer to Coding Standards No. 2, July 2013 for further information.
Cross Checks
None.

Codes and Values: Status on Admission
3 Formal
4 Informal

SMR Validation - Status on Admission

Tags:
patient  episode  mental  health  respite  care  main  condition  formal  informal  SMR04

Status On Admission

Field Length
2

Priority
Optional

Definition
The total number of Electro Convulsive Therapy treatments given during this episode of care.

Recording Rules
Enter the number of treatments given.

Points to Note
None.

Cross Checks

If ECT is recorded a diagnosis in the range of F25_, F31_ to F33_ must be present.
SMR Validation - ECT Treatments - Number This Episode


Related items:

Main Condition/Principal Diagnosis/Problem Managed - SMR04
Other Conditions/Comorbidity & Complications - SMR04
Tags:
electro  convulsive  therapy  episode  care  total  discharge  SMR04

ECT Treatments - Number This Episode

Field Length
1

Priority
Mandatory

Definition
The source of the patient‘s referral on admission to the episode.

Points to Note

Code 3 - Direct Transfer from other psychiatric inpatient care. This should be used for patients who transfer from another consultant, psychiatric specialty or significant facility within the same or another Health Board/ Health Care Provider.
Code B - Self, Relations, Friends or Carers - should only be used if sole source of referral.
Code D - General Practitioner - should only be used if no other medical, judicial, social or community services are involved.
Cross Checks

Admission/Referral From is cross-checked against Admission/Transferred From, e.g. If Admission - Referral From is 6 (Prison) then Admission/Transfer From must be 33 (Legal Establishment).
Codes and Values: Referral Codes (SMR04) (Code order)
1 Mental Health Outpatients
3 Direct Transfer from other Psychiatric Inpatient Care
4 Referral from Non-Psychiatric Clinical Ward
6 Prison/Penal establishment (including Police Station)
7 Judicial (Court)
8 Local Authority/Voluntary Agency
9 Other
A Community Mental Health Services
B Self Referral
C Domiciliary Visit
D GP
E From Community Care Order
F Accident & Emergency Department
G Crisis Service

SMR Validation - Admission Referral From

Tags:
patient  admission  episode  transfer  psychiatric  significant  facility  GP  SMR04

Referral From (SMR 04)

Field Length
6

Priority
Optional

Definition
The date of the first Electro Convulsive Therapy treatment in this episode of care.

Recording Rules
Enter the date the first treatment was given, for example the 16th of July 2004 would be entered as 16/07/04

Points to Note
None.

Cross Checks

The date entered must be equal to or after the Date of Admission and before or equal to Date of Discharge.
If the date field is completed, ECT treatments - number this episode must be greater than 0.
SMR Validation - ECT First Treatment Date

Tags:
electro  convulsive  therapy  episode  care  discharge  SMR04

ECT First Treatment - Date

Field Length
1

Priority
Optional

Definition
Whether a care programme approach is in place for the patient on discharge.

Recording Rules
The appropriate code should be entered from the codes and value list

Points to Note
None.

Cross Checks
None.

Codes and Values
1 - Yes
2 - No

SMR Validation - Care Programme Approach

Tags:
patient  discharge  code  SMR04

Care Programme Approach

Field Length
1

Priority
Mandatory

Definition
This is the planned arrangements for aftercare which the patient will receive on discharge.

Points to Note

Up to four codes can be recorded.
If the patient dies leave this field blank.
If the patient transfers directly to another psychiatric inpatient consultant, specialty or significant facility, code C should be used.
Cross Checks

Where Discharge Transfer To = 00 or 01 (Died) arrangements for after care should be blank.
Codes and Values: Aftercare Codes
1 GP
2 Psychiatric Day Hospital
3 Community Care Team
4 Key Worker
5 Statutory Guardianship
6 Outpatient Clinic
7 Social Work
8 Other
9 Not Known
A Voluntary agency/group (e.g. AA, Cruse, Relate)
B None
C Direct Transfer to Other Psychiatric Inpatient Care

SMR Validation - Arrangements for Aftercare

Tags:
discharge  patient  psychiatric  inpatient  specialty  significant  facility  social  work  community  GP  SMR04

Arrangements for After Care

Field Length
1

Priority
Mandatory

Definition
Whether or not the patient has had previous psychiatric hospital care.

Recording Rules
The appropriate code should be entered from the codes and value list

Points to Note

Readmitted following break in inpatient/day case care refers to previous care being provided in any psychiatric institution as an inpatient and the break being of any duration.
Direct transfer refers to patients who have had no intervening stay elsewhere and patients transferred from another consultant, specialty or significant facility in the same psychiatric hospital.
Only enter Not Known if there is no information available either from patient or medical records.
Cross Checks

Previous Psychiatric Inpatient Care is cross-checked against Admission - Referral From

a) If Previous psychiatric inpatient care is code 3 or 9, then Admission-referral from must not be 3 or 5 (Direct Transfer or Extended Pass)

or

b) If Admission Referral From is coded 3 (Direct Transfer), Previous Psychiatric Inpatient Care must be coded 2 (Direct Transfer).
Codes and Values
1 - YES - readmitted following break from inpatient care
2 - YES - direct transfer from or within a psychiatric hospital
3 - NO - first admission to any psychiatric hospital
9 - Not Known

SMR Validation - Previous Psychiatric Inpatient Care


Related items:

Referral From (SMR 04)
Tags:
patient  hospital  care  readmitted  direct  transfer  institution  admission  SMR04

Previous Psychiatric Inpatient Care

Field Length
6

Priority
Mandatory (where applicable)

Definition
The main medical problem which the patient is experiencing at the time of admission.

Points to Note

For detailed instructions on ICD10 coding please refer to General Clinical Section.
Main condition should come from the ICD10 Chapter V (Mental and Behavioural Disorders), or selected Z codes from Chapter XXI (Factors influencing health status and contact with health services).
Main condition is Optional on Admission submissions and Mandatory on Discharge submissions.
Cross Checks

The ICD10 codes recorded must be valid codes and in the correct format.
Any ICD10 codes other than those from Chapter V and selected Z codes from Chapter XXI will be queried or errored.
The ICD10 codes are checked against Sex and Age on Admission.
SMR Validation - Admission - Main Condition/Principal Diagnosis/Problem Managed

Tags:
medical  problem  admission  patient  ICD10  SMR04

Main Cond/Principal Diag/Problem Managed - SMR04

Field Length
1

Priority
Optional

Definition
The main type of care the patient has received during this episode of psychiatric care.

Points to Note

It is the main type of care the patient has received during the episode which is recorded. It is recommended that the clinician responsible for the patient assists with the completion of this data item.
Cross Checks
None.

Codes and Values: Psychiatric Care Codes (Code order)
1 Assessment
2 Cognitive/Behaviour
3 Crisis Management
4 Explorative Psychotherapy
5 Family Work
6 Group Work
7 Medication
8 Observation only
9 Other
A Supportive Psychotherapy
B Advice
C Care for Substance Misuse

SMR Validation - Type Of Psychiatric Care Provided

Tags:
patient  episode  clinician  code  assessment  cognitive/behaviour  crisis  management  explorative  psychotherapy  family  group  medication  observation.  supportive  advice  substance  misuse  discharge  SMR04

Type of Psychiatric Care Provided

Format
Characters

Field Length
20

Priority
Optional

Definition
This is any surname by which a person was previously known.

Recording Rules

It 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).
This data item has been retained primarily for maternity and record linkage purposes until a unique identifier is available.
Points to Note

This information is required to assist in the matching of an individual patients records
This item must not be used to record the birth surnames of adopted children.
For SMR02 (Maternity) this field should be used to record Maiden Surname.
Cross Checks
None.

SMR Validation - Previous Surname

Tags:
previously  known  maiden  surname  birth  alternative  deed  poll  maternity  patient  identifier  SMR00  SMR01  SMR02  SMR04

Previous Surname

Patient Identification and Demographic Information

Format
Date (ddmmccyy)

Field Length
8

Priority
Mandatory

Definition
The date on which a person was born or is officially deemed to have been born as recorded on their birth certificate.

Recording Rules
Date of birth should be entered thus:

9th February 1942
0	9	0	2	1	9	4	2
All dates must consist of eight digits by entering preceding zeros for single digits in day, month or year.

Patients age only is available
- year of birth should be calculated and day and month infilled with zero, thus:

Age 25 (in 1999): therefore year of birth = (1999-25) = 1974

0	0	0	0	1	9	7	4
Age not known
- 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

Estimated Age 27 (in 1999): therefore estimated year of birth = (1999-27) = 1972

0	0	0	0	1	9	7	2
Points to Note

The Date of Birth is allocated 8 digits to record the full year of birth.
Cross checks

Age (and consequently the Date of Birth) is an important data item and is used in a number of cross-checks, e.g.
Specialty
Diagnoses
Admission /Transfer From
Discharge/ Transfer To
Referral Received Date (SMR00 Only)
Date 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
Date 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).
Date of Birth may equal date of clinic or date of referral for SMR00.
SMR01 and 04, and age on admission is greater than 100 years, the record will be queried
If record is SMR02, and age on admission is less than 10 or greater than 50, the record will be queried.
If record is SMR04, and age on admission is less than 1 year, the record will be queried.
For 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.
If 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
Age is also checked with diagnoses, e.g
Senile Dementia - The current check will generate a query if the patient is less than 55 years of age.
Similarly childhood diagnoses will generate a query if the patient is greater than 16 years of age.
SMR Validation - Date of Birth

Tags:

Date of Birth

Format
Characters

Field Length
1

Priority
Optional

Definition
An indicator to identify the legal marital or civil status of a person.

Points to Note

Code Y - OTHER should be used for cohabiting or stable relationships.
Code Z - NOT KNOWN should be reserved for rare occasions such as:-
* the patient refuses to divulge it
* the patient has left the hospital before it could be recorded.
Cross Checks
None.

Codes and Values: (code order)

A Never married nor registered civil partnership
B Married
C Registered civil partnership
D Separated, but still married
E Separated, but still in civil partnership
F Divorced
G Dissolved civil partnership
H Widowed
J Surviving civil partner
Y Other
Z Not known
SMR Validation - Marital Status

Tags:
legal  person  patient  identifier  married  divorced  civil  partnership  widowed  SMR00  SMR01  SMR02  SMR04

Format
Characters

Field Length
10

Priority
Optional (SMR only)
Mandatory (A&E only)
Main Source of Standard
Scottish Government.

Definition
The 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.

Points to Note

Where 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.
Cross Checks
None.

Further Information

The 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.

The CHI number is a unique is a 10-character numeric identifier, allocated to each patient on first registration with the system.

The CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records.

Although there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications.

Non-Scottish patients and other temporary residents can have a CHI number allocated if required.

Should it be required patients can contact their GP Surgery in the first instance for their individual CHI Number.

See also - Baby CHI – Babies 1 to 3

SMR Validation - Community Health Index

Tags:
community  health  index  population  register  identifier  patient  allocation  status  SMR00  SMR01  SMR02  SMR04  scotland  records  individual  hospital

Marital Status

Format
Characters

Field Length
2

Priority
Optional

Definition
Ethnic group classifies the person according to their own perceived ethnic group and cultural background. (Scotland Census)

Points to Note

This is included as an Optional item, but may be made Mandatory at a later date in order to conform to UK-wide requirements.
This 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..
For the A&E datamart, please ensure this data item is as complete as possible
Cross Checks
None.

Notes
The 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.

The 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.).

Codes and Values: Ethnic Group (Code order)

Group A - White
1A Scottish
1B Other British
1C Irish
1K Gypsy/ Traveller
1L Polish
1Z Other white ethnic group

Group B - Mixed or multiple ethnic groups
2A Any mixed or multiple ethnic groups

Group C - Asian, Asian Scottish or Asian British
3F Pakistani, Pakistani Scottish or Pakistani British
3G Indian, Indian Scottish or Indian British
3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British
3J Chinese, Chinese Scottish or Chinese British
3Z Other Asian, Asian Scottish or Asian British

Group D - African
4D African, African Scottish or African British
4Y Other African

Group E - Caribbean or Black
5C Caribbean, Caribbean Scottish or Caribbean British
5D Black, Black Scottish or Black British
5Y Other Caribbean or Black

Group F - Other ethnic group
6A Arab, Arab Scottish or Arab British
6Z Other ethnic group

Group G - Refused/Not provided by patient
98 Refused/Not provided by patient

Group H - Not Known
99 Not Known

SMR Validation - Ethnic Group

Tags:
ethnicity  classification  census  person  perceived  cultural  background  categories  SMR00  SMR01  SMR02  SMR04

Ethnic Group

Field Length
20

Priority
Mandatory

Definition
The surname of a person represents that part of the name of a person which indicates the family group of which the person is part.

It 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.

Recording Rules

Surname should be entered in the character spaces provided. CAPITAL LETTERS should be used and the item left justified.
Hyphens or apostrophes occurring within a name should be entered as a separate character (but not as a first character).
Double-barrelled surnames should be entered with a hyphen between the two parts of the surname, whether or not the patient normally uses a hyphen.
In the very rare circumstances when the surname is not known, the first two character spaces should be filled with "X".

Examples
S	M	I	T	H															
D	U	R	H	A	M	-	J	O	N	E	S								
O	-	H	A	R	A														
X	X																		
Points to Note

A surname must have at least one alphabetic character.
Space for up to 20 characters is provided; it is recommended that the full 20 characters be allowed in use for future systems development.
Where a patient requires to remain anonymous, a pseudo-name, such as A N Other, should be used.

Based on UK Government Data Standards Catalogue: BSEN 7372:1993
Cross Checks
None.

SMR Validation - Surname

Surname

Format
Characters

Field Length
10

Priority
Local

Definition
The NHS number is the identifier allocated to an individual to enable unique identification within the UK for NHS health care purposes.

Recording Rules

This field should be left blank for Scottish Residents until further instructions are issued.
This 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.
The CHI number will eventually be the NHS Number for Scottish patients.
The first digit of the NHS Number in England and Wales will be 4 or greater.
Points to Note
None.

Cross Checks
None.

SMR Validation - NHS Number

Tags:
identifier  allocated  individual  unique  health  care  UK  england  wales  SMR00  SMR01  SMR02  SMR04

Community Health Index (CHI) Number

Format
Characters

Field Length
20

Priority
Optional

Definition
A second and/or middle name that some people have between their first name and surname.

Recording Rules

If the patient does not have a second forename, leave this item blank. Otherwise complete exactly as specified for first forename.
Points to Note

Made up of Second Initial and Second Forename (remainder).
Cross Checks
None

SMR Validation - Second Forename

Tags:
name  middle  surname  patient  identifier  SMR00  SMR01  SMR02  SMR04

Second Forename

Format
Characters

Field Length
20

Priority
Mandatory

Definition
The 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

Recording Rules

Where only the initial letter of the first forename is available this should be entered in the first character space.
In the very rare circumstances where the first forename is not known "X" should be entered in the first character space.
Where the full forename is available the remainder of the forename should be entered in the character spaces provided, using CAPITAL LETTERS.
Hyphens occurring within a forename should be given a separate character space
Notes
Based on UK Government Data Standards Catalogue: BSEN 7372:1993

Cross Checks
None

SMR Validation - First-Forename

Related items:

Person Name
Previous Name
Previous Surname
Surname
Tags:
name  surname  principal  identifier  patient  SMR00  SMR01  SMR02  SMR04

First Forename

Format
Characters

Field Length
10

Priority
Local

Definition
An alternative patient identifier used locally e.g. Local case note reference for merged case notes..

Recording Rules
This 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.

Points to Note

This 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.
This field should NOT be used to record CHI numbers
Cross Checks
None.

SMR Validation - No Validation.

Tags:
local  guidance  field  indexing  CHI  patient  identifier  SMR00  SMR01  SMR02  SMR04

Alternative Case Reference Number

Format
Characters (right justified)

Field Length
6

Priority
Mandatory

Common names
Registered GP Practice

Definition
Registered 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.
(Scottish Morbidity Record - NHS Information Services)

Recording Rules

A 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.
It is the Practice Code of the patients registered GP which is recorded in this field
It should be noted that the GP Practice code in England is 6 characters long.
The General Practice code should be right justified, with the first character a space, unless it is a valid GP Practice Code from outwith Scotland.
Points to Note

Practice code will be used to provide information to GMPs on referral activity.
The 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.
Dummy practice codes are held in the reference files and are hard coded for validation. These codes are:
99942 - Patients registered with a private practice only
99957 - Patients not registered with a GP in the UK
99961 - Patients where practice code is unknown and who are not covered by codes 99942, 99957, 99976, 99981, 99995 and 99961
99976 - British armed forces patients not registered with a GP in the UK
99981 - Foreign visitors not registered with a GP in Scotland
99995 - Patients registered with a GP in England, Wales or Northern Ireland (excluding patients included under code 99942)
GPPC is not validated for SMR00 or SMR01 records from Dental Hospitals (G106H, S206H, T113H).
Cross Checks

If 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).
If it is a practice outwith Scotland it must be a valid code on the "Rest of UK" practice reference file.
Further Information
It should be noted that patients are no longer registered with an individual GP, but with a practice.

In 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.

In England and Wales, the field is 6 digits therefore to accommodate cross border patient flows, this should be taken into account.

SMR Validation - General Practitioner Practice Code
Tags:
general  medical  practitioner  services  registered  GMP  SMR00  SMR01  SMR02  SMR04

General Practitioner Practice Code (GPPC)

Format
Characters (right justified)

Field Length
8

Priority
Local

Definition
The GMC (General Medical Council) number is the personal identification number issued to each doctor in the UK by the General Medical Council.

Recording Rules

If 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.
The 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.
The General Dental Council (GDC) Number consists of D + 6 numeric.
The 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).
The GMC/GDC/PIN number should be right justified in the eight character spaces provided.
From April 2020 this data item was no longer required for national collection on SMR00.
Points to Note

The referring Doctor may not belong to the patients registered GP Practice.
Cross Checks
None.

SMR Validation - GMC Number

Tags:
general  medical  council  personal  identification  doctor  AHP  registered  bodies  number  dentist  nurse  SMR00  SMR01  SMR02  SMR04

GMC No of Referring Doctor/Dentist/Nurse/Allied Healthcare Professional

Format
Characters

Field Length
8

Priority
Mandatory

Definition
The postcode is a basic unit for identifying geographic locations. A postcode is associated with each address in the UK..

Postcode Format
A postcode has two component parts. Part one of the postcode is known as the outcode, and part two is known as the incode.

Outcode
The 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.

Incode
The 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.

Points to Note
Postcodes for Scotland

The 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.
Postcodes 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.
The postcode of the patients usual address should be entered wherever possible. If only a temporary address is known, then this should be coded.
If a postcode cannot be found using the Postcode Directory, the appropriate Postcode Enquiry office should be contacted.
Address 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.
The 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.
Local Government District Dummy Postcodes can no longer be entered.
The postcode must be recorded in full
A list of all valid postcodes in Scotland, together with the permitted dummy postcodes, is held on the computer files at ISD.
If the full Postcode is not on the reference file, the record will be flagged with an error message and the postcode must be corrected.
For 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.
Cross Checks (applicable to SMR only)

If 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.
From 1st April 2000 if postcode is BF01 0AA and the category of patient is not 3 (NHS), the record will be queried.
SMR Validation - Postcode

Tags:
geographic  locations  address  outcode  incode  postal  area  district  SMR00  SMR01  SMR02  SMR04

Postcode

ormat
Characters

Field Length
4

Priority
Local

Definition
A health records system identifier is a code which identifies a health records system.

Cross Checks
None.

SMR Validation - Health Records System Identifier


Related items:

Health Records System
Tags:
code  SMR00  SMR01  SMR02  SMR04

Health Records System Identifier

Format
Characters

Field Length
10

Priority
Mandatory

Common Name(s)
Patient Identifier, Case Reference Number, CRN, Hospital Number

Main Source of Standard
Scottish Executive Health Department

Definition
A 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

Recording Rules
Note: If more than 10 characters are required for the Health Record Identifier, ISD should be contacted for advice.

A 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.

Example 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

Example 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
Points to Note

Where the CHI is used as the HRI, please continue to record this number in both the HRI and CHI fields.
Cross Checks
None.

SMR Validation - Patient Health Record Identifier

Tags:
patient  health  number  unique  register  SMR00  SMR01  SMR02  SMR04

Health Record Identifier

Format
Characters

Field Length
13

Priority
Optional

Definition
A unique identifier allocated to new referrals to a consultant led service, to enable identification of patient pathways.

Points to Note

The UCPN was initiated by the 18 Weeks RTT team and was first used by SCI Gateway Referrals in September 2009.
A UCPN should be generated for all source referrals made to a Consultant led service.
Where referrals are not received via SCI Gateway, local systems should generate a UCPN.
The format of the UCPN was defined by the SCI Gateway as SSS999999999C.
“SSS” is a 3 character alphanumeric System Source Identifiers (SSI), assigned by ISD.
“999999999” is a 9 digit sequential number.
“C” is a check digit/character calculated on the preceding 12 characters.
ISD maintains a National Reference File of System Source Identifiers (SSIs) and provides Health Boards with these codes on request.
When 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.
One UCPN may be recorded on a single SMR return.
The 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.
See the following site for further information: Unique Care Pathway Number (UCPN) - FAQs
E-Health
Cross Checks
None.

SMR Validation - UCPN

Tags:
identifier  referrals  consultant.  patient  pathway  led  service  system  source  SCI  gateway  ssi  National  Reference  File  SMR00  SMR01  SMR02  SMR04

Unique Care Pathway Number (UCPN)

Format
Characters

Field Length
4

Priority
Local

Definition
A health records system identifier is a code which identifies a health records system.

Cross Checks
None.

SMR Validation - Health Records System Identifier


Related items:

Health Records System
Tags:
code  SMR00  SMR01  SMR02  SMR04

NHS Number

Definition

Priority Optional (up to four allowed, two on forms)

The consultative process indicated that Optional provision should be allowed for the future recording of lifestyle factors of interest to particular Specialties.

These 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.

Up to four such factors have been included, with up to six characters per factor, to allow for the use of ICD10 or Read codes.

Lifestyle Factors

Development Data

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.

This may be used for local purposes, and for agreed national projects.

Development Data Section

Definition

Priority Optional (up to four allowed, two on forms)

Interest 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.

For 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.

With 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.

Provision 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.

Dependency Measures

Definition

Priority Optional

Patient 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.

It 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.

Up 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.

Clinical Problem Identifier for Spell/Care Package

Definition

Priority Optional (up to four allowed, two on forms)

Some 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.

They 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.

Severity Measures

Definition

Priority Local

This is the charge applicable to this patient episode.

The 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.

Contract Charge

Definition

Priority Local

A 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.

This 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.

This data item may be of value for specific clinical or contracting purposes within certain Specialties.

Chronic Sick/Disabled

Definition

Priority Local

Diagnostic 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.

Iso-resource Group

Definition

Priority Optional (up to four allowed, two on forms)

During 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:

"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.)
"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.
"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.
The 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.

Optional 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.

Outcome Measures

Definition

Priority (as below)

A contract identifier is a code which identifies each health care contract. It is a three part code:

Provider code
Purchaser code
Contract number which uniquely identifies the contract between the contracting parties


Provider Code (5 characters) - Priority Mandatory

This 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.

Points to Note

When completing the provider code on ISD returns, the code of the Health Board/Health Care Provider which actually provides clinical services must be recorded.
Example
If 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.

If 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.

Cross Checks

Must be valid provider code.

Purchaser Code (5 characters) - Priority Optional

This 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.

Points to Note

This field may be blank.
Cross Checks

If Purchaser Code is present, then it must be a valid code and will be validated against the organisation reference file.

Contract Number (6 characters) - Priority Local

This is an alphanumeric code which uniquely identifies the contract between the contracting parties.

Points to Note

This field may be blank.
Contract Identifier
Contract Identifier (which consists of 16 characters) should be entered thus:

Provider (first 5 digits), Purchaser (next five digits), Contract Number (final six digits).

Contract Identifier

Definition

Priority Local

This 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.

Contract Service Number

Definition

Priority Local

These fields together uniquely identify the invoice and the line within that invoice into which the charge for this patient has been aggregated.

Invoice Number and Invoice Line

Format
Characters

Field Length
8

Priority
Conditional

Definition
This 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.

Points to Note

The "Clinician Responsible for Main Operation" is the most senior medical or health care professional in attendance in theatre during the main operation.
The 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).
For guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.
The 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.
The General Dental Council (GDC) Number consists of D + 0 + 5 numeric.
The code number of the clinician should be right justified in the character spaces provided.
Cross Checks

It must be a valid GMC/GDC number.
Clinician 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).
SMR Validation - Clinician Responsible for Main Operation

Tags:
identification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR04

Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 2

General Clinical Information

Format
Characters

Field Length
6

Priority
Local

Definition
In 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.

For 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

Points to Note

Up to five other significant conditions may be recorded for SMR01 returns.
Other conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.
From April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.
Priority changed from Mandatory (where applicable) to Local.
Cross Checks

As for main condition.
A main condition must be recorded before the Other Condition fields can be completed.
SMR Validation - Other Conditions

Tags:
addition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04

Other Condition/Co-morbidity and Complication ICD10 4

Format
Characters

Field Length
8

Priority
Conditional

Definition
These are the additional procedures performed on an individual patient at a particular time.

Points to Note

Up 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.
Cross Checks

These are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.
SMR Validation - Other Operation

Tags:
additional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR05

Other Operation/Treatment/Intervention/Investigative Procedures (3) - OPCS4

Other Condition/Co-morbidity and Complication ICD10 5

Other Condition/Co-morbidity and Complication ICD10 2

Other Condition/Co-morbidity and Complication ICD10 6

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the other operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.
SMR Validation - Date of Other Operation

Tags:
performed  sequence  recorded  SMR00  SMR01  SMR02  SMR05

Date of Other Operation/Treatment/Intervention/Investigative Procedures 3

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the other operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.
SMR Validation - Date of Other Operation

Tags:
performed  sequence  recorded  SMR00  SMR01  SMR02  SMR04

Date of Other Operation/Treatment/Intervention/Investigative Procedures 2

Format
Characters

Field Length
6
Priority
Mandatory

Definition
This item should be seen as describing the main medical (or social) condition managed/investigated during the patients stay.

Recording Rules
The 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.

Points to Note

For patients who have died, the main condition is not necessarily the same as the condition recorded as the cause of death.
The 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.
If the main condition is coded to a pair of dagger and asterisk codes, the dagger should be entered as main condition.
If 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).
In 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.
Cross Checks

A check is made that each Diagnosis Code is valid as defined by the ICD classification. If not, an error will be reported.
A 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.
Main condition is cross-checked against:
Sex
Age (except SMR02)
Rarity (except SMR00, and SMR02)
Admission Type (SMR01)
Length of Stay (SMR01 and SMR04)
Waiting Time (SMR01 only)
Discharge Type (SMR01)
Condition on Discharge (SMR02 only)
SMR Validation - Main Condition

Tags:
medical  social  managed  investigated  patient  stay  diagnosed  treatment  ICD10  classification  code  SMR00  SMR01  SMR02  SMR04

Main Condition/Principal Diagnosis/Problem Managed - ICD10

Clinician Responsible for Main Operation/Treatment/Investigative Procedure/Intervention

Format
Characters

Field Length
8

Priority
Conditional

Definition
These are the additional procedures performed on an individual patient at a particular time.

Points to Note

Up 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.
Cross Checks

These are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.
SMR Validation - Other Operation

Tags:
additional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR04

Other Operation/Treatment/Intervention/Investigative Procedures (2) - OPCS4

Other Condition/Co-morbidity and Complication ICD10 3

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the main operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Main Operation is checked to ensure it is in the correct sequence with other dates recorded.
An error will be reported if there is a Main Operation recorded but the Date of Main Operation has been omitted.
An error will be reported if an entry has been made for Date of Main Operation, but the Main Operation has been omitted.
SMR Validation - Date of Main Operation/Treatment/Investigative Procedure

Tags:
sequence  reported  performed  SMR00  SMR01  SMR02  SMR04

Date of Main Operation/Treatment/Investigative Procedure/Intervention

Format
Characters

Field Length
8

Priority
Conditional

Definition
This 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.

Points to Note

The "Clinician Responsible for Main Operation" is the most senior medical or health care professional in attendance in theatre during the main operation.
The 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).
For guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.
The 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.
The General Dental Council (GDC) Number consists of D + 0 + 5 numeric.
The code number of the clinician should be right justified in the character spaces provided.
Cross Checks

It must be a valid GMC/GDC number.
Clinician 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).
SMR Validation - Clinician Responsible for Main Operation

Tags:
identification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR05

Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 3

Format
Characters

Field Length
8

Priority
Conditional

Definition
This 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.

Points to Note

The "Clinician Responsible for Main Operation" is the most senior medical or health care professional in attendance in theatre during the main operation.
The 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).
For guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.
The 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.
The General Dental Council (GDC) Number consists of D + 0 + 5 numeric.
The code number of the clinician should be right justified in the character spaces provided.
Cross Checks

It must be a valid GMC/GDC number.
Clinician 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).
SMR Validation - Clinician Responsible for Main Operation

Tags:
identification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR06

Clinician Responsible for Other Operation/Treatment/Intervention/Investigative Proc 4

Format
Characters

Field Length
8

Priority
Conditional

Definition
Main Operation/Treatment/Investigative Procedure/Intervention are those aspects of clinical care carried out on patients undergoing treatment:

for the prevention, diagnosis, care or relief of disease
for the correction of deformity or deficit, including those performed for cosmetic reasons
associated with pregnancy, childbirth or contraceptive or procreative management
Typically this will be:

surgical in nature: and/or
carries a procedural risk: and/or
carries an anaesthetic risk: and/or
requires specialist training: and/or
requires special facilities or equipment only available in an acute care setting.
Points to Note

Please refer to the general rules for recording operations/procedures.
Cross Checks

A check is made that each Operation Code is valid as defined by the OPCS Classification. If not, an error will be reported.
A 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.
If Main Operation is specified, but the Date of Main Operation is not given, an error will be reported.
Each 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.

SMR01
If a code is recorded in the second field of a pair as well as the first field, checks are made to ensure that either:
the two codes are a recognised pair or
the code in the second field is from one of the subsidiary Y or Z chapters.
For 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.
If 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.
If 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.
Each Operation code is checked to ensure that it is compatible with the stated Sex.
If a discrepancy is found an error or a query will be reported.
SMR Validation - Main and Other Operation/Treatment/Investigative Procedure

Tags:
clinical  care  patients  code  classification  undergoing  treatment  surgical  anaesthetic  acute  SMR00  SMR01  SMR02  SMR04

Main Operation/Treatment/Investigative Procedure/Intervention - OPCS4

Format
Characters

Field Length
8

Priority
Conditional

Definition
These are the additional procedures performed on an individual patient at a particular time.

Points to Note

Up 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.
Cross Checks

These are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.
SMR Validation - Other Operation

Tags:
additional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR06

Other Operation/Treatment/Intervention/Investigative Procedures (4) - OPCS4

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the other operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.
SMR Validation - Date of Other Operation

Tags:
performed  sequence  recorded  SMR00  SMR01  SMR02  SMR06

Mental Health Inpatient and Day Case - Scottish Morbidity Record (SMR04)

Summary

Documentation

Coverage

Spatial

Temporal

Provenance

Access and Governance

Usage

Access

Format and Standards

Observations

Origin