Sexual Health Protocol and Templates
This is set up as a protocol with multiple choice access to all sexual health screens. Entry of choice takes you to the relevant template and back to this screen on filing. The codes underlying the template are shown below the screen shots.
Registration data
The Registration data template should be completed by admin staff as patient is booked in as well as recording other registration data as usual on clinical system. It collects data needed as part of CDSSH (Common Data Set for Sexual Health), and data that will enable us to identify those patients seen as part of the SH service as opposed to GMS / PMS and data to determine the type of service eg 1st or F/U which affects charging.
Coding
Date 1st encounter: first SH encounter this episode EMISNQCD2
Date subsequent enc: current SH encounter EMISNQCD1
Phone enc: Entry here if phone (1st or FU) 9N31
*Consulting HCP* Seen by general practitioner 9N21
Seen by practice nurse 9N22
Seen by GP registrar 9N2O
Seen by nurse practitioner 9N2l
Seen by health support worker 9N2o
Seen by health care assistant 9N2s
(Above choice placed in several templates to ensure we can identify performer of the particular service for charging and service monitoring purposes. These should be dated the same date as the encounter, preferably by the HCP as they provide the service)
Foll-up: Entry here if this is a FU 9NV
1st apt attempt: Enter date 0f 1st attempt 2 make appt EMISNQCD3
1st appt offer: Enter date of the first apt offered EMISNQCD4
Referred: source of referral to SH vice Various
Ethnicity: 9i…
Registration second screen
Patient reg. data unknown ie pt refuses to give correct name 916
GP practice text is national GP code 9b1F
PCT of patient: Record PCT to handle out of area pts 915E
Failed encounter – DNA of SHACC 9N4
Consent to share data with GP 9NdG
No Consent to share data with GP 9NdH
Consent withdrawn 9NdJ
Place of birth 13d…
Obstetric History
The data coding here is required by CDSSH and only at first contact for each episode and no more freq than every 6m.
Prompt Age & Sex Coded Subsets
H/O: full term delivery (1545) 0-140 F
H/O: premature delivery (1546) 0-140 F
H/O: miscarriage (1542) 0-140 F Non-Induced Abortion
No history of miscarriage) (15421)
H/O: 1 miscarriage)(15422)
H/O: 2 miscarriages)(15423)
H/O: 3 miscarriages)(15424)
H/O: 4 miscarriages)(15425)
H/O: 5 miscarriages)(15426)
H/O: 6 miscarriages)(15427)
H/O: miscarriage NOS)(1542Z)
H/O: abortion (1543) 0-140 F Induced Abortion
No history of abortion)(15431)
H/O: 1 abortion)(15432)
H/O: 2 abortions)(15433)
H/O: 3 abortions)(15434)
H/O: 4 abortions)(15435)
H/O: 5 abortions)(15436)
H/O: 6 abortions)(15437)
H/O: abortion NOS)(1543Z)
H/O: ectopic pregnancy(1544) 0-140 F
H/O: stillbirth (1541) 0-140 F
H/O: perinatal fetal loss(15A8) 0-140 F
(OLD CODING _ IGNORE
Total Live birth: enter number of live births in toto EMISNQCD9
Total prev preg: EMISNQCD8
CDSSH pilot - total number of non-induced abortions EMISNQCD10 CDSSH pilot - total number of induced abortions EMISNQCD11
CDSSH pilot - total number of ectopic pregnancies EMISNQCD14
CDSSH pilot - total number of still births EMISNQCD12
CDSSH pilot - total number of neonatal deaths EMISNQCD13
)
Sexual history
As per CDSSH and only at first contact for each episode
Coding
Sexual orientation: Bisexual(13m0)
Heterosexual(13m1)
Male homosexuality(E2200)
Female homosexuality(E2201-1)
Sex Abroad with non-UK resident 1 year: enter country: EMISNQSE14 / 1ABZ
Two or more sexual partners in the last year: EMISNQTW1 / 13N5
New sexual partner in last 3 months EMISNQNE15 / ?
Free text the sex of the new partner
Number sexual partners past year: Enter number & sex 1P70
H/O previous STI: 1415
Pt ad notify sexual partners of STI 8CAd
HIV risk lifestyle 13N5
Pt advised about risks of HIV 8CAE
Contraceptive sheath use Options
Uses contraceptive sheath 6171
Stopped using sheath 6173
Contraceptive sheath NOS 617Z (No by convention)
Spermicidal contraceptive 61C
Sex History Second Screen
Investigations
Coding
Urine pregnancy test: Options are subcodes 465..
Cervical smear result Options are subcodes 4K2..
Chlamydia test: Options are: Eye swab taken 4JE
Throat swab taken 4JF4
Anal swab taken 4JH62
FEMALE Endocervical chlamydia swab 4JK9
LVS for chlamydia taken by pt 4JKD
Urine screen for chlamydia 68K7
MALE Penile swab taken 4JK8
Urethral chlamydia swab 4JKA
Urine screen for Chlamydia 68K7
Refuses chlamydia screen: Chlamydia screening declined 8I3T
Can free text comment here
Chlamydia result: Options: Chlamydia PCR positive 43U4
Chlamydia PCR negative 43U5
Chlamydia test equivocal 43U7
GC test: Options are: Gonococcal cervical swab 4JKB F
Gonococcal urethral swab 4JKC F
Endocervical swab taken EMISHGT44 F
Gonococcal urethral swab 4JKC M
Gonorrhoea Result Options: Gonorrhoea test negative 4JQ8
Gonorrhoea test equivocal 4JQ9
Gonorrhoea test positive 4JQA
Other Swab: Options: Throat swab taken 4JF4
Mouth swab 4JH5
Anal swab taken 4JH62
Urethral swab taken 4JK1
High vaginal swab taken 4JK2
Low vaginal swab taken 4JK3
Vulval swab taken 4JK4
Cervical swab taken 4JK5
Penile swab taken 4JK8
HSV isolated 4J3C
Syphilis serology 4389
Syphilis result: Options: Syphilis titre test negative 4381
Syphilis titre test positive 4382
Investigation second screen
HIV screen: Options are: HIV screening test 4JR7
HIV screening counseling 677N
HIV screening declined 8I3p
HIV screening offered 9Op0
HIV results: Options are: HTLV-3 antibody positive 43C3
[V]HIV negative ZV018
(no simple HIV pos / neg read codes)
Diary for rpt HIV test: HIV serology 4JDT
Hepatitis B screening 6828
Hepatitis B surface antibody level 43d8
Hepatitis B core antibody level 43dB
Hepatitis B viral load 4J3D
Hepatitis C screening 6829
Hepatitis C result: Options Hepatitis C antibody test positive 43X3
Hepatitis C antibody test negative 43X4
Hepatitis C PCR 43h3
Contraception
Contraception : Options General contraceptive advice 611
Oral contraceptive 614
Intra-uterine contr. Device 615
Contraceptive diaphragm 616
Contraceptive sheath 617
Rhythm method contraception 618
Withdrawal contraception 619
Post-coital contraception 61A
Depot contraceptive 61B
Spermicidal contraceptive 61C
Sympto-thermal contraception 61E
Contraception: vasectomy 61G
Contraception: female sterilis 61H
Subcutaneous contraceptive 61K
Transdermal contraceptive 61N
Advice options: Contraception counselling 6777
Oral contraceptive advice 614E
Emergency contraception advice 614F
Counsel for contracep implant 677D
Depot contraceptive given 61B1
Depot contraceptive NOS : due diary 61BZ
Depot contraceptive – problem 61B4
Systolic blood pressure 2469
Diastolic blood pressure 246A
O/E - height 229
O/E - weight 22A
Body Mass Index 22K
Tobacco consumption Options: Never smoked tobacco 1371
Pipe smoker 137H
Passive smoker 137I
Cigar smoker 137J
Current non-smoker 137L
Rolls own cigarettes 137M
Cigarette smoker 137P
Current smoker 137R
Ex smoker 137S
Smoking cessation advice 8CAL
Referral to stop-smoking clinic 8HTK
Health ed. - breast exam. 6795
PVaginal exam :Options O/E - bi-manual VE - NAD) 2681
O/E - VE - uterine enlargement) 2682
O/E - VE - uterine swelling)
(2683)
O/E - VE - gravid uterus)
(2684)
O/E - VE - uterus anteverted)
(2685)
O/E - VE - uterus retroverted)
(2686)
O/E - VE - ovarian swelling)
(2687)
O/E - VE - pelvic mass NOS)
(2688)
O/E-VE-cervical excit.present)
(2689)
O/E-VE-cervical excit.absent)
(268A)
O/E - VE - uterine tenderness)
(268B)
O/E - bi-manual VE - NOS)
(268Z)
O/E - vaginal speculum exam.
(269) 0-140 F
O/E-vaginal speculum exam. NAD)
(2691)
O/E - speculum = cervical abn.)
(2692)
O/E-speculum=bleeding thro' os)
(2693)
O/E - speculum=vag. wall. abn.)
(2694)
Uterine cervix visualised)
(2695)
360 deg sweep cervix performed)
(2696)
360 deg sweep cx not performed)
(2697)
Lesion of cervix)(2698)
O/E -vaginal speculum exam.NOS)
(269Z)
IUD checked - no problems
(6154) 0-140
IUD checked - no problems
(6154)
IUD checked - problems(6155)
Endocervical chlamydia swab
(4JK9) 0-140 F
Cervical swab taken (4JK5) 0-140
High vaginal swab taken
(4JK2) 0-140
Chlamydia antigen test
(43U) 0-140
Chlamydia PCR positive(43U4)
Chlamydia PCR negative(43U5)
Chlamydia test negative(43U6)
Chlamydia test equivocal
(43U7)
Chlamydia test positive(43U8)Contraception (second screen)
Contraception (third screen)
Contraception (fourth screen)
IUCD
IUCD (2nd)
IUCD (3rd)
Coding For Intra-uterine contr. device
Prompt Age & Sex Coded Subsets
Intra-uterine contr. device
(615) 0-140
IUD fitted)(6151)
IUD removed)(6152)
IUD re-fitted)(6153)
IUD checked - no problems)
(6154)
IUD checked - problems)(6155)
IUD - defaulted from check)
(6156)
IUD fitting awaited)(6157)
IUD removal awaited)(6158)
IUD change due)(6159)
IUD check due)(615A)
IUD expelled)(615B)
IUD failure - pregnant)(615C)
IUD partially expelled)(615D)
IUD threads lost)(615E)
IUD check)(615F)
IUD in situ)(615G)
Breast feeding problem)(615H)
IUD - NOS)(615Z)
Oral contraception NOS
(614Z) 12-140 F
Contraception counselling
(6777)
Emergency contraception advice
(614F)
Parity status (152) 0-140 F
Nulliparous)(1521)
Para 1)(1522)
Para 2)(1523)
Para 3)(1524)
Para 4)(1525)
Para 5)(1526)
Para 6)(1527)
Para 7)(1528)
Parity NOS)(152Z)
Oth exam female genital tract
O/E - bi-manual vaginal exam.
(268) 0-140 F
O/E - bi-manual VE - NAD)
(2681)
O/E - VE - uterine enlargement)
(2682)
O/E - VE - uterine swelling)
(2683)
O/E - VE - gravid uterus)
(2684)
O/E - VE - uterus anteverted)
(2685)
O/E - VE - uterus retroverted)
(2686)
O/E - VE - ovarian swelling)
(2687)
O/E - VE - pelvic mass NOS)
(2688)
O/E-VE-cervical excit.present)
(2689)
O/E-VE-cervical excit.absent)
(268A)
O/E - VE - uterine tenderness)
(268B)
O/E - bi-manual VE - NOS)
(268Z)
O/E - vaginal speculum exam.
(269) 0-140 F
O/E-vaginal speculum exam. NAD)
(2691)
O/E - speculum = cervical abn.)
(2692)
O/E-speculum=bleeding thro' os)
(2693)
O/E - speculum=vag. wall. abn.)
(2694)
Uterine cervix visualised)
(2695)
360 deg sweep cervix performed)
(2696)
360 deg sweep cx not performed)
(2697)
Lesion of cervix)(2698)
O/E -vaginal speculum exam.NOS)
(269Z)
Endocervical chlamydia swab
(4JK9) 0-140
Cervical swab taken (4JK5) 0-140
Chlamydia antigen test
(43U) 0-140
Chlamydia antigen by ELISA)
(43U0)
Chlamydia antigen ELISA positive)
(43U1)
Chlamydia antigen ELISA negative)
(43U2)
Chlamydia trachomatis antigen test)
(43U3)
Chlamydia PCR positive)(43U4)
Chlamydia PCR negative)(43U5)
[V]Intraut.contrac.dev.present
(ZV455) 0-140
Intra-uterine contr. device
(615)
""Morning after"" IUCD fitted
(61F2)
Menorrhagia(K5920)
IUCD procedure (7E09) 12-140 F
IUCD introduction)(7E090)
IUCD replacement)(7E091)
IUCD removal NEC)(7E092)
Displaced IUCD removal)(7E093)
Introduction of Mirena coil)
(7E094)
Removal of Mirena coil)(7E095)
IUCD procedure OS)(7E09y)
IUCD procedure NOS)(7E09z)
IUCD removal NEC (7E092) 12-140 F
IUD checked - problems
(6155) 12-140 F
IUD expelled(615B)
IUD failure - pregnant(615C)
IUD partially expelled(615D)
IUD threads lost(615E)
Post-coital IUCD failure
(61F4)
Removal IUCD pouch of Douglas
(7D1E4)
Acute uterine inflamm.disease
(K410)
Fetus+IUCD damage(L257)
[D]Vasovagal attack(R0022)
Mech.comp.-IUD(SP032)
AR - surface/infiltrat.anaesth
(TJ85)
Implant
Implant (2nd)
Coding For Subcutaneous contraceptive
Template For Subcutaneous contraceptive Classification Code Appears in ()
Prompt Age & Sex Coded Subsets
Subcutaneous contraceptive
(61K) 12-140 F
Insert subcut contraceptive)
(61KA)
Check of subcut contraceptive)
(61KB)
Subcutaneous contraceptive in situ)
(61KD)
Subcutaneous contraceptive NOS)
(61KZ)
Removal of subcutaneous contraceptive)
(EMISNQRE18)
Counsel for contracep implant
(677D) 12-140 F
Systolic blood pressure
(2469) 0-140
Diastolic blood pressure
(246A) 0-140
O/E - height (229) 0-140
O/E - weight (22A) 0-140
Body Mass Index (22K) 0-140
Insertion subcut contraceptive
(7G2AB) 12-140 F
Check of subcut contraceptive
(61KB)
Insertion subcut contraceptive
(7G2AB)
Removal of Norplant(7G2H5)
Removal subcut contraceptive
(7G2H7)
Removal subcut contraceptive
(7G2H7) 12-140 F
Other procedure complic.NEC
(SP2) 12-140 F
[D]Vasovagal attack(R0022)
Post-operative haematoma formation
(SP212)
Postop. wound infection,unspec
(SP255)
AR - surface/infiltrat.anaesth
(TJ85)
Cervical Smear
Template For Cervix smear screening
Prompt Age & Sex Coded Subsets
Cervical smear taken (7E2A2) 15-75 F
Last menstrual period -1st day
(1513) 0-140
H/O: abnormal uterine bleeding
(158) 0-140
H/O: post-coital bleeding)
(1581)
H/O: inter-menstrual bleeding)
(1582)
H/O: post-menopausal bleeding)
(1583)
Heavy episode of vaginal bleeding)
(1584)
H/O:abnormal uterine bleed NOS)
(158Z)
[D]Pelvic and perineal pain
(R090G) 0-140
Presence of chaperone
(9NP) 0-140
Chaperone offered)(9NP0)
Chaperone present)(9NP1)
Chaperone refused)(9NP2)
Nurse chaperone)(9NP3)
Chaperone not available)(9NP4)
IUD checked - no problems
(6154) 0-140
IUD checked - no problems
(6154)
IUD checked - problems(6155)
Cervical smear result
(4K2) 0-140
Cervical smear:inadequate spec)
(4K21)
Cervical smear: negative)
(4K22)
Cerv.smear: mild dyskaryosis)
(4K23)
Cerv.smear: severe dyskaryosis)
(4K24)
Cerv.smear:severe dysk.?inv.ca)
(4K25)
Cervical smear: ? gland neopl.)
(4K26)
Cervical smear:atrophic change)
(4K27)
Cerv.smear: mod.dyskaryosis)
(4K28)
Cerv.smear: borderline changes)
(4K29)
Cerv smear endocerv cells pres)
(4K2A)
Cerv smear endocerv cells abs)
(4K2B)
Smear NAD - no endocervical cells)
(4K2C)
Cerv smear trans zon cell pres)
(4K2D)
Cerv smear trans zon cells abs)
(4K2E)
Cervical smear result NOS)
(4K2Z)
Abnormal Metaplastic Cells)
(SAFFRAB2)
Atypical Metaplastic Cells)
(SAFFRAT1)
Pregnancy Screen
Template For Termination of pregnancy NEC Classification Code Appears in ()
Prompt Age & Sex Coded Subsets
Last menstrual period -1st day
(1513) 10-60 F
Urine pregnancy test (465) 0-140
Urine pregnancy test negative
(4652)
Urine pregnancy test equivocal
(4653)
Urine pregnancy test positive
(4654)
Gravida status (153) 0-140
Gravida 0)(1531)
Gravida 1)(1532)
Gravida 2)(1533)
Gravida 3)(1534)
Gravida 4)(1535)
Gravida 5)(1536)
Gravida 6)(1537)
Gravida 7)(1538)
Gravida 8)(1539)
Gravida 9)(153A)
Gravida 10)(153B)
Gravida NOS)(153Z)
Parity status (152) 0-140
Nulliparous)(1521)
Para 1)(1522)
Para 2)(1523)
Para 3)(1524)
Para 4)(1525)
Para 5)(1526)
Para 6)(1527)
Para 7)(1528)
Parity NOS)(152Z)
ABO blood grouping (431) 0-140
Blood sent for grouping)(4311)
Blood group A)(4312)
Blood group B)(4313)
Blood group AB)(4314)
Blood group O)(4315)
ABO blood grouping NOS)(431Z)
Rhesus blood grouping
(432) 0-140
Rhesus negative(4321)
Rhesus positive(4322)
Preg. termination counselling
(6776) 0-140
Requests pregnancy termination
(8M6) 0-140
Reason for terminatn pregnancy
(9Ea) 0-140
Endocervical chlamydia swab
(4JK9) 0-140
Endocervical chlamydia swab
(4JK9)
LVS for chlamydia taken by pt
(4JKD)
Urine screen for chlamydia
(68K7)
Haemoglobin estimation
(423) 0-140
Cervical smear taken (7E2A2) 0-140
Refer to other provider
Refer on (2nd)
Coding For Referred on
Prompt
Referral to genitourinary clinic
(8HTa) 0-140
Gynaecological referral
(8H58) 0-140
Referral to fertility clinic
(8HTB) 0-140
Refer to TOP counselling
(8H7W) 0-140
Ref for termination pregnancy
(8HHV) 0-140
Referral to male urology clinic
(8HTb) 0-140
Referral to vasectomy clinic
(8HTf) 0-140
Referral to psychosexual clinic
(8HTc) 0-140
Dermatological referral
(8H43) 0-140
Vasectomy
Template For [V]Sterilisation Classification Code Appears in ()
Prompt Age & Sex Coded Subsets
Contraception: vasectomy
(61G) 0-140
Vasectomy requested(8M00)
Reversal vasectomy requested
(8M10)
Sterilisation counselling