SMR DATA CHANGE NOTICE (DCN)
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/01
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Height
/ Target Implementation Dateoptional 01/10/10
mandatory 01/04/11
Details of change
Changes requested as a result of the SMR02 Quality Assurance Report - Published April 2010.Current validation is optional to be changed to mandatory.
Change to SMR Validation
Height – Section 1
Current text
1 Height may be present
Above text to be removed
Height – Section 2 (E4200)
Current text
2 If present, Height must be numeric
Error Message: Height invalid
Flag: Height
To be replaced with
1 Height must be present and numeric
Error Message: Height missing/invalid
Flag: Height
http://www.datadictionaryadmin.scot.nhs.uk/isddd/10376.html
ISD USE ONLY
Changes affect:
NHS Health & Social Care Data Dictionary / ü / SMR Definitions and codes / X
SMR Validation / ü / SMR Reference Files / X
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/02
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Weight of Mother at Booking
/ Target Implementation Dateoptional 01/10/10
mandatory 01/04/11
Details of change
Changes requested as a result of the SMR02 Quality Assurance Report - Published April 2010.Current ‘Priority’ is Conditional - to be changed to Mandatory.
Change to SMR Validation:
Weight of Mother at Booking – Section 1 (E4580)
Current text
Weight of Mother at Booking must and can only be present if Condition on Discharge = 3
Error Message: Weight of Mother missing/inappropriate
Flag: Weight of Mother at Booking, Condition on Discharge
Above text to be removed
Weight of Mother at Booking – Section 2 (E4582)
Current text
If present Weight of Mother must be numeric
Error Message: Weight of Mother invalid
Flag: Weight of Mother at Booking
To be replaced with
Weight of Mother at Booking must be present and numeric
Error Message: Weight of Mother missing/invalid
Flag: Weight of Mother at Booking
http://www.datadictionaryadmin.scot.nhs.uk/isddd/10391.html
Changes to SMR Data Manual:
Weight of Mother at Booking
Current text
Priority C
To be replaced with
Priority M
Current text
2. Weight of mother is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).
Above text to be removed
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9645.html
Condition on Discharge Code Table
Delete Weight of mother at booking.
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9626.html
ISD USE ONLY
Changes affect:
NHS Health & Social Care Data Dictionary / ü / SMR Definitions and codes / ü
SMR Validation / ü / SMR Reference Files / X
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/03
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Analgesia During Labour and/or Delivery / Target Implementation Date
mandatory 01/10/10
DETAILS OF CHANGE
Changes requested as a result of the SMR02 Quality Assurance Report - Published April 2010.Additional text for clarification.
Changes to SMR Data Manual:
Analgesia During Labour and/or Delivery
Current text
Points to Note
1. More than one method of analgesia may be used in labour. The highest method in the following hierarchy should be used for coding this item.
General anaesthetic
Spinal
Epidural
Pethidine
Gas/Air
None
2. Code 8 should be used for other types of analgesia such as TENS.
Codes and Values:
0 None
1 Pethidine/morphine
2 Epidural
3 Gas and air only
4 General anaesthetic
5 Spinal
8 Other
9 Not Known
To be replaced with
Points to Note:
1. More than one method of analgesia may be used in labour. The highest method in the following hierarchy should be used for coding this item.
General anaesthetic
Spinal (includes ‘combined spinal epidural’)
Epidural
Pethidine/Morphine or other opiates/opioids
Gas/Air
None
2. Code 8 should be used for other types of analgesia such as TENS, waterbirths and other complementary medicines.
3. There is no requirement to code epidural in OPCS4. This is identified in the data items Analgesia During Labour and/or Delivery.
4. If ‘combined spinal epidural’ is identified, code to ‘5’ – Spinal.
Codes and Values:
0 None
1 Pethidine/morphine or other opiates/opioids
2 Epidural
3 Gas and air only
4 General anaesthetic
5 Spinal (includes ‘combined spinal epidural’)
8 Other
9 Not Known
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9649.html
SMR02 Data Items - Codes - Record of Labour Delivery Data Items
http://www.datadictionaryadmin.scot.nhs.uk/isddd/11051.html
ISD USE ONLY
Changes affect:
NHS Health & Social Care Data Dictionary / ü / SMR Definitions and codes / ü
SMR Validation / X / SMR Reference Files / ü
Update SMR02 Cribsheet
Changes to SMR Lookup tables
SMR look up table: analgesia in labour delivery
SMR look up table: analgesia during labour
SMR look up table: analgesia during delivery
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/04
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Tear / Target Implementation Date
mandatory 01/10/10
DETAILS OF CHANGE
Changes requested as a result of the SMR02 Quality Assurance Report - Published April 2010.Changed and additional text for clarification.
Changes to SMR Data Manual:
Tear
Current text
Points to Note
1. Sometimes tissues within the birth canal, or at its exit, can be torn by the delivery of the baby. Such tears can occur in a spontaneous or assisted vaginal delivery, and may also occur in the presence of an Episiotomy.
2. A first or second degree tear is regarded as part of a normal delivery and need not be coded in the diagnostic section. Tears of greater severity should be coded in the diagnostic section in ICD10, but only code the tear of greatest severity if more than one is recorded. For example, where there is a 3rd degree tear and cervical laceration, the latter should be coded.
Tear 1 (1st Degree) O70.0
Tear 2 (2nd Degree) O70.1
Tear 3 (3rd Degree) O70.2
Tear 4 (4th Degree) O70.3
Vaginal laceration O71.4
Cervical laceration O71.3
Cross-Checks
1. Tears is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge =3 (delivered).
Codes and Values:
0 No (includes intact perineum and minor lacerations)
1 Tear 1 (1st Degree)
2 Tear 2 (2nd Degree)
3 Tear 3 (3rd Degree)
4 Tear 4 (4th Degree)
5 Vaginal lacerations
6 Cervical lacerations
8 Unspecified tear
9 Not known if tear
To be replaced with
Points to Note
1. Sometimes tissues within the birth canal, or at its exit, can be torn by the delivery of the baby. Such tears can occur in a spontaneous or assisted vaginal delivery, and may also occur in the presence of an Episiotomy.
2. A first or second degree tear is regarded as part of a normal delivery and need not be coded in the diagnostic section. Tears of greater severity should be coded in the diagnostic section in ICD10, but only code the tear of greatest severity if more than one is recorded. For example, where there is a 3rd degree tear and cervical laceration, the latter should be coded.
3. Vaginal and cervical lacerations should be coded in the diagnostic section using O71.4 and O71.3 respectively.
4. If there is only a vaginal or cervical laceration and no tear of perineum, record ‘0’ in the data item. See table below.
Tear 1 (1st Degree) O70.0
Tear 2 (2nd Degree) O70.1
Tear 3 (3rd Degree) O70.2
Tear 4 (4th Degree) O70.3
Cross-Checks
1. Tears is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge =3 (delivered).
Codes and Values:
0 No (includes intact perineum and/or vaginal or cervical lacerations)
1 Tear 1 (1st Degree)
2 Tear 2 (2nd Degree)
3 Tear 3 (3rd Degree)
4 Tear 4 (4th Degree)
8 Unspecified tear
9 Not known if tear
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9672.html
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9674.html
SMR02 Data Items - Codes - Record of Labour Delivery Data Items
http://www.datadictionaryadmin.scot.nhs.uk/isddd/11051.html
ISD USE ONLY
Changes affect:
NHS Health & Social Care Data Dictionary / ü / SMR Definitions and codes / ü
SMR Validation / X / SMR Reference Files / ü
Update SMR02 Cribsheet
Changes to SMR Lookup tables
SMR look up table: Tear
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/05
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Mode of Delivery - Babies 1 to 3 / Target Implementation Date
mandatory 01/10/10
DETAILS OF CHANGE
Changes requested as a result of the SMR02 Quality Assurance Report - Published April 2010.Changed and additional text for clarification.
Changes to SMR Data Manual:
Mode of Delivery - Babies 1 to 3
Current text
Points to Note
1. Code 0 - The terms used may include, Normal delivery' or 'SVD' (spontaneous vaginal delivery).
2. Code 1 - An abnormal presentation may occur with a spontaneous delivery at term, or more usually perhaps, with a premature delivery when the baby's head is small enough to be delivered without assistance. The abnormal presentation may be persistent occipito posterior (POP).
3. Code 2 - should be used when forceps are specified, but no further information is provided (i.e. forceps NOS); also for Haig-Ferguson or Wrigley's Forceps.
4. Code B - should be used for Kiellands forceps rotation and where there has been a manual rotation of the head before forceps are applied.
5. Code 5 - should be used for a breech delivery that is specified as spontaneous (usually in a very premature delivery), assisted and with (or without) forceps to the aftercoming head (FACH).
6. Codes 7 and 8 - The reason for having two categories of delivery by Caesarean section is to have the capability of comparing the outcome in the best circumstances - i.e. a planned caesarean section (7), during the day with both patient and staff fully prepared, with the less favourable circumstance of an emergency section (8).
7. Code 9 - should rarely be used and will be queried. The only circumstance when a Mode of Delivery is likely to be truly 'not known' is an unattended delivery. But such a delivery must have been spontaneous/unassisted and should be coded to 0.
8. Provision is made for the coding of Mode of Delivery in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank. The fourth and subsequent babies in quadruplet and higher order pregnancies should not be coded.
Note: A woman for whom a caesarean section is planned may go into labour and require an emergency caesarean section: this is coded to 8.
Codes and Values:
0 Normal, spontaneous vertex vaginal delivery, occipito-anterior.
1 Cephalic vaginal delivery, with abnormal presentation of the head at delivery, without instruments, with or without manipulation
2 Low forceps, no rotation, forceps NOS.
5 Breech delivery, spontaneous, assisted or unspecified partial breech extraction.
6 Breech extraction, NOS. Version with breech extraction.
7 Elective (planned) caesarean section.
8 Emergency and unspecified caesarean section.
9 Other and unspecified method of delivery.
A Mid cavity forceps, no rotation
B Rotational forceps (incl Kiellands)
C Ventouse, no rotation or unspecified
D Ventouse with rotation
To be replaced with
Points to Note:
1.Code 0 - The terms used may include, Normal delivery' or 'SVD' (spontaneous vertex delivery).2.Code 1 - An abnormal presentation may occur with a spontaneous delivery at term, or more usually perhaps, with a premature delivery when the baby's head is small enough to be delivered without assistance. The abnormal presentation may be persistent occipito posterior (POP).
3. If ‘low’, ‘mid’ or ‘high’ cavity is mentioned, this should take priority over the type of forceps.
4.Code 2 - should be used when forceps are specified, but no further information is provided (i.e. forceps NOS.); also for Wrigley’s Forceps, where no note of the position of the forceps is available. (Haig-Ferguson forceps will now be considered as usually denoting mid.)
5. If more than one type of forceps is used, only the most resource intensive should be recorded. Code B – Rotational is most important, followed by A – Mid cavity and lastly, 2 – Low forceps, no rotation.
6.Code B - should be used for Kiellands forceps rotation and where there has been a manual rotation of the head before forceps are applied.
7.Code 5 - should be used for a breech delivery that is specified as spontaneous (usually in a very premature delivery), assisted and with (or without) forceps to the aftercoming head (FACH).
8.Codes 7 and 8 - The reason for having two categories of delivery by Caesarean section is to have the capability of comparing the outcome in the best circumstances - i.e. a planned caesarean section (7), during the day with both patient and staff fully prepared, with the less favourable circumstance of an emergency section (8). Note: A woman for whom a caesarean section is planned may go into labour and require an emergency caesarean section: this is coded to 8.
9.Code 9 - should rarely be used and will be queried. The only circumstance when a Mode of Delivery is likely to be truly ‘not known’ is an unattended delivery. But such a delivery must have been spontaneous/unassisted and should be coded to 0.
10. Provision is made for the coding of Mode of Delivery in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank. The fourth and subsequent babies in quadruplet and higher order pregnancies should not be coded.
Codes and Values:
0 Normal, spontaneous vertex vaginal delivery, occipito-anterior.
1 Cephalic vaginal delivery, with abnormal presentation of the head at delivery, without instruments, with or without manipulation
2 Low forceps, no rotation, forceps NOS. (incl. Wrigleys)
5 Breech delivery, spontaneous, assisted or unspecified partial breech extraction.
6 Breech extraction, NOS. Version with breech extraction.
7 Elective (planned) caesarean section.
8 Emergency and unspecified caesarean section.
9 Other and unspecified method of delivery.
A Mid cavity forceps, no rotation (incl. Haig Fergusson, Neville-Barnes etc.)
B Rotational forceps (incl Kiellands)
C Ventouse, no rotation or unspecified
D Ventouse with rotation
http://www.datadictionaryadmin.scot.nhs.uk/isddd/9694.html
SMR02 Data Items - Codes - Record of Baby Data Items
http://www.datadictionaryadmin.scot.nhs.uk/isddd/11052.html
ISD USE ONLY
Changes affect:
NHS Health & Social Care Data Dictionary / ü / SMR Definitions and codes / ü
SMR Validation / X / SMR Reference Files / ü
Update SMR02 Cribsheet
Changes to SMR Lookup tables
SMR look up table: mode of delivery
SPECIFICATION OF SMR CHANGE / SMR Change Ref. No.
1008/06
Classification
Record Type /
Data Item(s) Applicable To / SMR02
Apgar Score - Babies 1 to 3 / Target Implementation Date
mandatory 01/10/10
Details of change