GUMCADv2
Genitourinary Medicine Clinic Activity Dataset (version 2)
Technical guidance and extract
specification for data extract
GUMCADv2 Technical guidance and extract specification for data extract
About Public Health England
Public Health England exists to protect and improve the nation's health and wellbeing,
and reduce health inequalities. It does this through world-class science, knowledge and
intelligence, advocacy, partnerships and the delivery of specialist public health services.
PHE is an operationally autonomous executive agency of the Department of Health.
Public Health England
Wellington House
133-155 Waterloo Road
London SE1 8UG
Tel: 020 7654 8000
www.gov.uk/phe
Twitter: @PHE_uk
Facebook: www.facebook.com/PublicHealthEngland
HIV/STI Department
Public Health England
61 Colindale Avenue
London NW9 5EQ
Tel: 020 8200 4400
Current Version: (v23) re-issued 01/12/2015 following enhancements to guidance and
SHHAPT coding (all associated changes are highlighted in green).
Previous Version: (v22) re-issued 02/04/2015 following the publication of the
Information Standards Notice on 12 November 2014 for amendments to SHHAPT
coding, gender coding, patient geography and data item (column) names (all
associated changes are highlighted in blue).
© Crown copyright 2015
You may re-use this information (excluding logos) free of charge in any format or
medium, under the terms of the Open Government Licence v3.0. To view this licence,
visit OGL or email [email protected]. Where we have identified any third
party copyright information you will need to obtain permission from the copyright
holders concerned. For queries relating to this document please contact:
[email protected]
Published: 01/12/2015
PHE publications gateway number: 2015003
2
GUMCADv2 Technical guidance and extract specification for data extract
Contents
About Public Health England
2
Contents
3
1. Introduction
5
2. Data extract specification
Description
Time period
Frequency
Format
Transmission
Coding and formatting
Definition of a sexual health and HIV episode (NHS Data Dictionary)
Rules for specific GUMCADv2 items
6
6
6
6
6
7
7
7
8
3. Other sexual and reproductive health data reporting
GUMCADv2 Shared Data Items
GUMCADv2 and CTAD
GUMCADv2 and HARS
GUMCADv2 and SRHAD
11
12
12
13
14
Appendix 1: Data items collected in GUMCADv2
16
Appendix 2: Example of CSV format for GUMCADv2
18
Appendix 3: Coding specification for GUMCADv2 extract
19
Appendix 4: SHHAPT codes and notes
A. SHHAPT codes
B. SHHAPT code suffixes
C. Permissible SHHAPT/suffix combinations
D. HIV/STI test code combinations
27
27
43
45
46
Appendix 5: READ codes and definitions
READ Code Version 2
READ Code Clinical Terms Version 3 (CTV3)
48
48
48
3
GUMCADv2 Technical guidance and extract specification for data extract
Document control
Current version
Current status
Authors
Reviewers
Issued to
To provide guidance and specifications to providers of
software to Level 3 (GUM) and Level 2 (non-GUM)
sexual health services for the recording and extraction of
GUMCADv2 data.
Published
Author name
Section
Date
amended/ added amended
Previous changes not documented
Holly Mitchell
All
20/02/13
Stephen Duffell
All
25/02/13
Mandy Yung
All
25/02/13
08/04/13
Stephen Duffell
All
01/10/14
Stephen Duffell
SHHAPT coding
01/09/15
Reviewer name
Section reviewed Date
reviewed
Hamish
All
27/03/13
Mohammed
Gwenda Hughes
All
10/06/13
Danielle Mercey
All
12/03/15
David Philips
All
12/03/15
Hamish
All
12/03/15
Mohammed
Danielle Mercey
SHHAPT coding
01/09/15
David Philips
SHHAPT coding
01/09/15
Hamish
SHHAPT coding
01/09/15
Mohammed
Person(s) issued to
Date issued
Software Providers (public)
01/10/2015
File reference
4
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
1. Introduction
The Department of Health (DH) requires information on diagnoses made and services
provided by Level 3 specialist sexual health and HIV services/genitourinary medicine
(GUM) clinics and Level 2 commissioned sexual health (non-GUM) services. This data
is submitted to Public Health England, which has responsibility for collating the data
and providing epidemiological and public health updates on diagnoses of sexually
transmitted infections (STIs) and the provision of STI related services to the DH, local
authorities and all those involved in health protection. These data are referred to as the
Genitourinary Medicine Clinic Activity Data Set (GUMCADv2) (ISB 0139) and are
provided as anonymised, patient-level electronic data.
Diagnoses made and services provided by the majority of Level 2 and 3 sexual health
services are currently coded using Sexual Health and HIV Activity Property Type
(SHHAPT) codes1. These codes are used by services for patient management and
audit, and for coding the data which are reported to PHE. They are therefore the means
through which specific activities within clinics are described and monitored. GPs and
some Level 2 sexual health services using a GP clinical information system are able to
report using national READ codes – Version 2 and Clinical Terms Version 3 (CTV3).
Comprehensive behavioural guidance on completing and transmitting the GUMCADv2
return for GUM and non-GUM staff is available at https://www.gov.uk/genitourinarymedicine-clinic-activity-dataset-gumcadv2.
1
Previously known as KC60 codes
5
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
2. Data extract specification
Description
Every Level 2 (non-GUM) and Level 3 (GUM) sexual health service is required, by law,
to generate a quarterly GUMCADv2 extract of patient attendances* and associated STI
tests and diagnoses relating to a Sexual Health and HIV episode of care. The list of
GUMCADv2 data items and related coding specifications are shown in Appendix 1.
* Integrated sexual health services should include all attendances in their GUMCADv2
extract ie attendances solely for SRH services should be included in the extract (please
see new ‘SRH’ SHHAPT code – Appendix 4).
Time period
The extract will cover one calendar quarter:




Q1: 1 January to 31 March
Q2: 1 April to 30 June
Q3: 1 July to 30 September
Q4: 1 October to 31 December
Frequency
Reports will be run quarterly, six weeks after the end of the quarter.
Format
Data extracts should be formatted into a single comma delimited CSV file2. The format
of the CSV file and an example of the field content is shown in Appendix 2.
Please note the following:


2
the name and content of the ‘PCT’ (PCT of residence) data item has now been
changed to the ‘LA’ (local authority of residence) data item – see section 3 and
Appendices 1, 2 and 3 for further details
the name (not the content) of the ‘KC60/READ’ data item has now been changed to
the ‘Episode_Activity’ data item – see Appendices 1, 2 and 3 for further details
PHE is working towards changing GUMCADv2 files to XML format to be compliant with e-GIF standards
6
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Transmission
Electronic files will be transmitted to PHE. Data must be submitted to the GUMCAD
team at PHE through the secure HIV and STI Web Portal (HSWP). Use of the portal
requires a username and password which can be obtained from the GUMCAD team at
PHE Colindale. The portal supports the Transport Layer Security (TLS) method of
communication.
Requests for user accounts should be sent to: [email protected].
The HSWP can be found at:
www.hpawebservices.org.uk/HIV_STI_WebPortal/Login.aspx.
Coding and formatting
The coding and formatting of the data items required are presented in Appendices 1, 2
and 3. The full list of SHHAPT codes (and suffixes) is provided in Appendix 4. A list of
permissible READ codes is available in Appendix 5. All fields specified are defined
using the NHS data dictionary.
Please note that the SHHAPT code list is held and maintained by the GUMCAD team
at PHE (not the NHS data dictionary).
Please note that new SHHAPT codes were released on 1 January – see Appendix 4 for
further details.
Definition of a sexual health and HIV episode (NHS Data Dictionary)
http://www.datadictionary.nhs.uk/data_dictionary/HIVSTIEpisode
A Sexual Health and HIV Episode is an ACTIVITY GROUP. A Sexual Health and HIV
Episode is an episode of care, under one Health Care Provider, comprising of one or
more attendances, where a CONSULTANT has overall responsibility for the PATIENT
who attends for screening, diagnosis and management of sexually transmissible
infections and related conditions. The patient may be seen by other CARE
PROFESSIONALS, during the same care episode, who are working on behalf of the
consultant. The episode starts on the date the patient first sees or is in contact with a
care professional in respect of a REFERRAL REQUEST from either a health care
provider or a self-referral. The episode ends when either the patient is formally
discharged or has not had face to face contact with the SERVICE for at least six
months. Each Sexual Health and HIV Episode may be for one or more SEXUAL
HEALTH AND HIV ACTIVITY PROPERTY TYPES (SHHAPT) code and each SHHAPT
code is recorded at a first attendance. The only exception to this is where the patient
7
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
attends for HIV-related care in which case the relevant SHHAPT code should be
recorded at every attendance.
Rules for specific GUMCADv2 items
Attendance type
The GUMCADv2 return requires information on the attendance type to distinguish
between new and follow-up patient attendances and whether they are face-to-face or
telephone/telemedicine consultations. All attendance types are reported in the
First_Attendance field. The national categories, as defined by the NHS Data Dictionary,
are as follows:



First attendance face-to-face: All attendances relating to a new Sexual Health
and HIV episode of care where the patient is registered at the service for the first
time (new) or where the previous episode was discharged/closed (re-book). All
attendances by an existing patient with a new episode 26 weeks (or more) after the
last attendance should be routinely classified as a re-book attendance (which can
be manually altered by service staff as required). All first attendances face-to-face
should be reported with an STI code (SHHAPT/READ) in the KC60 field
Follow-up attendance face-to-face: All attendances relating to an existing Sexual
Health and HIV episode of care. Attendances within 26 weeks of the last
attendance should be routinely classified as a follow-up attendance (which can be
manually altered by service staff as required). The majority of follow-up
attendances face-to-face would be reported without an STI code (SHHAPT/READ)
as the episode would have been coded at the first attendance face-to-face ie the
KC60 field would remain blank. However, if a new diagnosis is made at a follow-up
attendance the attendance type should be updated to reflect the new episode of
care ie the attendance type becomes a first attendance face-to-face (re-book) and
should be reported with an STI (SHHAPT/READ) code
First telephone or telemedicine consultation: All telephone or telemedicine
consultations relating to a new Sexual Health and HIV episode of care where the
patient is registered at the service for the first time (new) or where the previous
episode was discharged (re-book) All attendances by an existing patient with a new
episode 26 weeks (or more) after the last attendance should be routinely classified
as a re-book telephone or telemedicine consultation (which can be manually altered
by service staff as required). All first telephone or telemedicine consultations should
be reported without an STI code (SHHAPT/READ) ie testing/diagnosis cannot be
made over the phone.
8
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Episode activity – STI codes (SHHAPT/READ)
STI codes (SHHAPT/READ) for diagnoses and services should only be used once per
patient episode. However, the following SHHAPT codes are attendance based and can
be used as often as required.





H – Patient is known HIV positive
H2 - Attendance for HIV related care
SRH – Attendance for SRH related care only
SW - Patient is a sex worker
Z - Patient is a prisoner
Please note that new SHHAPT codes were released 01/01/2015. A full list of SHHAPT
codes is given in Appendix 4.
A reduced list of READ codes has been developed by the GUMCAD team at PHE
(Appendix 5). This will help to ensure accurate and consistent recording of data across
all applicable sites. At present, any READ code relating to sexual health may be
submitted by sites using READ codes (ie Level 2 (non-GUM) services). However, the
GUMCAD team at PHE does not manage the READ code list and it is therefore subject
to change (in relation to the release of new codes.
Allocation of local authority of residence
Following the abolition of PCTs (from 01/04/2013), the PCT (of residence) data item
has now been replaced by LA (local authority district of residence).
There is an LA (or equivalent – as defined by ONS) for each postcode in the UK*. LA
(of residence) should be generated from the patient postcode (using the same patient
postcode used to generate LSOA of residence). Records where the patient’s postcode
has not been provided to generate LA (of residence) should be allocated to ‘not known’
and coded "X99999999". Postcodes outside the UK (overseas visitors) should be
allocated to ‘not applicable’ and coded as “X99999998” – see Appendix 3 for further
details.
PHE can provide postcode/LA data (updated once per quarter) to facilitate mapping
LSOA (of residence) from patient postcode.
*UK includes, England, Wales, Scotland, Northern Ireland, Channel Islands and Isle of
Man.
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GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Allocation of LSOA of residence
There is a Lower Layer Super Output Area (LSOA) (or equivalent – as defined by ONS)
for each postcode in the UK*. LSOA (of residence) should be generated from the
patient postcode (using the same patient postcode used to generate LA of residence).
Records where the patient’s postcode has not been provided to generate LSOA (of
residence) should be allocated to ‘not known’ and coded “X99999999”. Postcodes
outside the UK (overseas visitors) should be allocated to ‘not applicable’ and coded
“X99999998” – see Appendix 3 for further details.
PHE can provide postcode/LSOA data (updated once per quarter) to facilitate mapping
LSOA (of residence) from patient postcode.
*UK includes, England, Wales, Scotland, Northern Ireland, Channel Islands and Isle of
Man.
Allocation of changing patient residence
A single patient should only ever have one LSOA and one LA throughout a quarterly
data extract (the most recent information should be reported).
Allocation of changing patient details
A single patient should only ever have one gender, ethnic group and country of birth
throughout a quarterly data extract (the most recent information should be reported).
A single patient may have more than one age or sexual orientation throughout a
quarterly data extract. However, a single patient must not have more than one sexual
orientation within the same episode of care eg patients cannot be recorded as
‘heterosexual’ for one diagnosis and ‘homosexual’ for another diagnosis within the
same episode of care.
Recoding sexual orientation
Clinical staff taking sexual histories are advised to enter accurate information during the
clinical consultation or as soon as possible thereafter. Patient software systems (PSSs)
should default to ‘Not known’ (they should not default to ‘heterosexual’). To improve the
quality of sexual orientation information recorded, PSSs should prevent completion of
data entry until sexual orientation has been recorded. A single patient must not have
more than one sexual orientation within the same episode of care eg patients cannot
be recorded as ‘heterosexual’ for one diagnosis and ‘not known’ for another diagnosis
within the same episode of care.
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GUMCADv2 Technical Guidance and Extract Specification for Data Extract
3. Other sexual and reproductive health
data reporting
Sexual health services that are required to report GUMCADv2 (Level 3 GUM and Level 2 nonGUM) may also be required to report other mandatory sexual and reproductive health datasets
to PHE or HSCIC – outlined in the tables below.
Mandatory sexual and reproductive health datasets
Dataset
Information
Collected
Services Affected
Responsible
Organisation
CTAD
Chlamydia
Testing Activity
Dataset
Chlamydia tests &
diagnoses
All laboratories
commissioned to provide
chlamydia testing
Public Health England
(PHE)
GUMCADv2
Genitourinary
Medicine Clinic
Activity Dataset
STI diagnoses &
services provided
Level 2 (non-GUM) &
Level 3 (GUM) sexual
health services
Public Health England
(PHE)
HARS
HIV & AIDS
Reporting System
HIV outpatient
service provision
HIV outpatient services
Public Health England
(PHE)
Contraceptive
service provision
Settings offering
contraceptive services
(excluding general
practice)
Health & Social Care
Information Centre
(HSCIC)*
Sexual &
Reproductive
SRHAD
Health Activity
Dataset
*SRHAD is sponsored by PHE
Reporting requirements of mandatory sexual and reproductive health datasets
Sexual Health Service Type
General Practice
Service Level
1 (non-GUM)
2 (non-GUM)
GUM
3 (GUM)
Integrated GUM & SRH
3 (GUM)
Other Sexual Health Services
(e.g. Outreach, CSO, TOP)
1 (non-GUM)
SRH
Young People's Services
2 (non-GUM)
1 (non-GUM)
2 (non-GUM)
1 (non-GUM)
2 (non-GUM)
CTAD










GUMCADv2










HARS
SRHAD




















Key
Submission is required
Submission may be required (determined by the nature of the services provided)
Data are collated and submitted by Laboratories (Sexual Health Services are not
required to submit CTAD data)
 Submission is not required

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GUMCADv2 Technical Guidance and Extract Specification for Data Extract
3.1.
GUMCADv2 Shared Data Items
Some data items in GUMCADv2 overlap with data items in CTAD, HARS and SRHAD
e.g. ‘Gender’. The table below provides a summary of the GUMCADv2 data items that
are shared with CTAD, HARS and SRHAD – all reports use the same NHS Data
Dictionary terminology and coding, however, the data item name may differ across
datasets e.g. ‘Clinic ID’ in GUMCADv2 is named ‘Venue Code’ in CTAD, ‘Site Code’ in
HARS and ‘Clinic ID’ in SRHAD.
GUMCADv2 data items shared with CTAD, HARS & SRHAD
GUMCADv2 Data Items
CTAD¹ HARS² SRHAD³



Clinic ID



Patient ID
Episode Activity (SHHAPT or READ


code)



Gender


Sexual Orientation



Age



Ethnicity

Country of Birth




LA of Residence



LSOA of Residence

Attendance Type




Attendance Date
¹Reported to PHE by all laboratories commissioned to provide chlamydia testing
²Reported to PHE by all HIV outpatient services
³Reported to the HSCIC by all sexual and reproductive health services (excluding GPs)
GUMCADv2 and CTAD
The Chlamydia Testing Activity Dataset (CTAD) is a quarterly disaggregate dataset of all
chlamydia tests carried out using nucleic acid amplification (NAAT) testing, from all age groups
and from all testing venues, which are undertaken by publicly commissioned laboratories in
England. CTAD is an approved mandatory dataset that is reported directly to PHE by the
laboratories.
All GUMCADv2 reporters (Level 3 GUM and Level 2 non-GUM) contribute to the CTAD report
indirectly via the information they send to laboratories with their chlamydia samples (sexual
health services are not required to submit CTAD data directly to PHE).
National reporting of chlamydia data comprises of a combination of data sourced from CTAD
and GUMCADv2. CTAD data reported via Level 3 GUM services does not include patient
residence data (via postcode) for reasons of patient confidentiality, therefore the patient
12
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
residence data from CTAD is supplemented with (equivalent) patient residence data from
GUMCADv2 (via LSOA). It is therefore essential that Level 3 GUM services report data
consistently as ‘Level 3 GUM’ to GUMCADv2 and to CTAD** (via the laboratories) to enable
accurate reporting – please see the table below.
Samples sent to the lab should be correctly identified using the GUMCADv2 ‘ClinicID’ code and
the corresponding Level 3 GUM or Level 2 non-GUM service type – which is reported via
CTAD’s ‘Testing Service Type’ code shown below.
GUMCADv2 Sexual Health Services and CTAD Testing Service Type
GUMCADv2 Sexual Health Services
CTAD Testing Service Type (TST) Code
GUM (Level 3)
GUM (01)
Integrated GUM & SRH (Level 3)
GUM (01)
SRH Services (Level 2)
Community Sexual Health Services (02)
Young People’s Services (Level 2)
Community Sexual Health Services (02)
Enhanced General Practices (Level 2)
General Practice (03)
Internet services (06)
Other services (XX)
Other (Level 2)
Further information on the CTAD dataset can be found here:
http://www.chlamydiascreening.nhs.uk/ps/info-management.asp.
[email protected]
GUMCADv2 and HARS
The HIV and AIDS Reporting System (HARS) is a quarterly disaggregate dataset that collects
information on patients diagnosed with HIV infection attending HIV outpatient care.
HARS is an approved mandated dataset that is reported directly to PHE by HIV outpatient
services.
GUMCADv2 Level 3 (GUM) services that provide specialist HIV treatment and care will also be
required to report HARS.
Some episode activity collected in GUMCADv2 overlaps with care activity collected in
HARS e.g. new HIV diagnosis - please see table below.
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GUMCADv2 Technical Guidance and Extract Specification for Data Extract
GUMCADv2 and HARS shared episode activity
SHHAPT
HARS Data
SHHAPT Description
Code
Item
H1
New HIV Diagnosis
H1A
New HIV Diagnosis - Acute
Dx_UK_date
New HIV Diagnosis - AIDS
H1B
defined
H2
HIV related care
HIV_care_date
SW
Sex worker
Sex_worker
Z
Prisoner
Prisoner
HARS Description
HIV diagnosis date in the UK
Consultation date for HIV care
Sex worker
Prisoner
Please note the episode activity coding required in GUMCADv2 may not be the same
as the equivalent care activity coding in HARS.
Further information on the HARS dataset can be found here:
https://www.gov.uk/guidance/hiv-surveillance-systems#hiv-and-aids-reporting-system-hars
[email protected]
GUMCADv2 and SRHAD
The Sexual and Reproductive Health Activity Dataset (SRHAD) is an annual
disaggregate dataset that collects information on contraceptive service provision and
other reproductive health activities from all sexual and reproductive health (SRH)
services. SRHAD is an approved mandatory dataset that is reported directly to the
Health and Social Care Information Centre (HSCIC).
Some GUMCADv2 reporters (Level 3 GUM and Level 2 non-GUM) will also be required to
report SRHAD (depending on the level of SRH services provided).
Some episode activity collected in GUMCADv2 overlaps with care activity collected in
SRHAD e.g. sexual assault – please see table below.
14
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
GUMCADv2 and SRHAD shared episode activity
SHHAPT
Code
40
41
P3*
P4
SRH*
All
SHHAPT
codes
SHHAPT
Description
Sexual assault Acute
Sexual assault Non-acute
Contraception
Cervical cytology
performed
SRH patient only
SRHAD Data Items
SRHAD Description
SRH Care Activity: 40
Sexual assault - Acute
Sexual assault – Nonacute
Contraception Method Status, SRHAD contraception
Contraception Main Method,
related data items
Contraception Other Method,
Contraception Method Post
Coital.
SRH Care Activity:11
Cervical Screening
SRH Care Activity: 41
All Contraception related
items and SRH Care Activity
Attendances related SRH Care Activity: 34
to STI care only i.e.
no SRH related care
provided
Attendances related to
SRH care only i.e. no
STI related care
provided
STI related care
* These SHHAPT codes relate to multiple care activities in SRHAD.
Please note the episode activity coding required in GUMCADv2 may not be the same
as the equivalent care activity coding in SRHAD.
Further information on the SRHAD dataset can be found here:
www.hscic.gov.uk/datacollections/srhad
[email protected]
15
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Appendix 1: Data items collected in
GUMCADv2
Position¹ Field Name
1
2
3
Description
ClinicID
Clinic (service) ID
code
PatientID
Local patient identifier
number
Episode_Acti SHHAPT code
vity
NHS Data
Dictionary
Data element
Site code (of
treatment)
Local patient
identifier
Sexual health and
HIV activity
property type
Variable
Length
(Maximum)²
AN(9)
Example³
AN(20)
PAT123
AN(6)
C10A
Diagnostic or
procedure coding
(sexual health and
human
immunodeficiency
virus relevant read
code)
Person stated
gender code
Age at attendance
date
Sexual orientation
(current)
Ethnic category
AN(7)
9Oq0.00
N(1)
1
N(3)
16
N(1)
1
AN(2)
A
Country code
(birth)
Ons local
government
geography code
(local authority
district)
Lower layer super
output area
(residence)
A(3)
GBR
AN(3) or
AN(9)
95A
or
E060000
01
AN(8) or
AN(9)
95AA01S
1 or
E010000
01
RCC25
OR
(previously
‘KC60’ or
‘READ’)
READ code
4
Gender
Gender
5
Age
6
Sex_Ori
Age at attendance
date in years
Sexual orientation
7
Ethnicity
8
9
10
Patient’s ethnic
category
Country_Birth Patient’s country of
birth
LA
Local Authority
District (LA) code of
(previously
patient residence
‘PCT’)
LSOA
Lower Layer Super
Output Area of
residence code
16
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
11
12
First_Attenda Attendance type
nce
AttendanceD Date of attendance
ate
First attendance
N(1)
1
Attendance date
N(10)
CCYY-MMDD
2007-1031
¹Refers to the horizontal position of the field within CSV format
²AN = Alpha-numeric, N = Numeric, A = Character. Number in brackets denotes the
string length. Code entries which are shorter than the string length should not include
leading/trailing zeroes or spaces
³Example of field content, also used to illustrate extract format expected
17
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Appendix 2: Example of CSV format for
GUMCADv2
An example of the field content for one row of data is shown below and is used to
illustrate how the data should appear in the CSV file. Files that do not comply with the
required format will be rejected when submitted to PHE.
SHHAPT or READ: CSV Example (one row of data)
ClinicID,PatientID,Episode_Activity,Gender,Age,Sex_Ori,Ethnicity,Country_Birth,LA,LSOA,First_Attendance,
AttendanceDate
RCC25,PAT123,C10AM,1,16,1,A,GBR,E06000001,E01000001,1,2014-10-31
18
GUMCADv2 Technical guidance and extract specification for data extract
Appendix 3: Coding specification for GUMCADv2 extract
Data item
NHS Data Dictionary
name
Definition/comments
ClinicID
SITE CODE (OF
TREATMENT)
Format: AN(9)
An identifier for a CLINIC OR FACILITY.
An Organisation Data Service (ODS) Code should be entered. This code can be ascertained
direct from ODS: http://www.connectingforhealth.nhs.uk/systemsandservices/data/ods
PatientID
LOCAL PATIENT
IDENTIFIER
Format: AN(20)
Note: This is a number used to identify a PATIENT uniquely within a Health Care Provider. It
may be different from the Patient’s case note number and may be assigned automatically by the
computer system.
Episode_Activity
SEXUAL HEALTH
AND HIV ACTIVITY
PROPERTY TYPE
Format/length: AN(6)
National Codes: The national SHHAPT codes and their definitions are given in Appendix 4.
Notes: SEXUAL HEALTH AND HIV ACTIVITY PROPERTY TYPE renamed from
GENITOURINARY EPISODE TYPE
(previously ‘KC60’
or ‘READ’)
DIAGNOSTIC OR
PROCEDURE
CODING (SEXUAL
HEALTH AND
HUMAN
IMMUNODEFICIENCY
VIRUS RELEVANT
READ CODE)
Format/length: (AN(7)
National Codes: A list of national sexual health related READ codes (including a reduced list of
recommended codes) and their definitions are given in Appendix 5.
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GUMCADv2 Technical guidance and extract specification for data extract
Data item
NHS Data Dictionary
name
Definition/comments
Gender
PERSON STATED
GENDER CODE
Format/length: N(1)
National Codes:
1 Male
2 Female
9 Not Specified/indeterminate, ie unable to be classified as either male or female or gender is not
known.
Please note there is no longer a separate code for ‘Not Known’ (previously code ‘0’)
Age
AGE AT
ATTENDANCE DATE
Format/length: N(3)
This is usually derived as the number of completed years between the PERSON BIRTH DATE of
the PATIENT and the ATTENDANCE DATE .
However, age can be manually entered in the absence of patient date of birth.
Not known = 999, ie date of birth not known and age cannot be estimated
Sex_Ori
SEXUAL
ORIENTATION
(CURRENT)
Format/length: N(1)
See SEXUAL ORIENTATION CODE for the National Codes. The current SEXUAL
ORIENTATION of a PERSON
National Codes:
1 Heterosexual
2 Gay/Lesbian
3 Bi-sexual
9 Not Known
20
GUMCADv2 Technical guidance and extract specification for data extract
21
GUMCADv2 Technical guidance and extract specification for data extract
Ethnicity
ETHNIC CATEGORY
Format/length: AN(2)
The ethnicity of a PERSON, as specified by the PERSON.
National Codes:
White
A British
B Irish
C Any other White background
Mixed
D White and Black Caribbean
E White and Black African
F White and Asian
G Any other mixed background
Asian or Asian British
H Indian
J Pakistani
K Bangladeshi
L Any other Asian background
Black or Black British
M Caribbean
N African
P Any other Black background
Other Ethnic Groups
R Chinese
S Any other ethnic group
Z Not stated
Note: ETHNIC CATEGORY is the classification used for the 2001 census, replacing ETHNIC
GROUP in the flows through the NHS-wide Clearing Service.
22
GUMCADv2 Technical guidance and extract specification for data extract
Country_Birth
COUNTRY CODE
(BIRTH)
LA
ONS LOCAL
GOVERNMENT
GEOGRAPHY CODE
(LOCAL AUTHORITY
DISTRICT)
(previously PCT)
Format/length: A(3)
This is the country where the PATIENT was born.
COUNTRY CODE (BIRTH) is the same attribute COUNTRY CODE
Refer to the ISO 3166-1 standard for actual list of alphabetic codes and countries. The alphabetic
code to be used is the 3-char alphabetic code available on the International Organisation for
Standardisation website http://www.iso.org/iso/home.htm
Note: The 2-char alphabetic code must not be used.
Refer to the ISO 3166-1 standard for actual list of alphabetic codes and countries. Where country
of birth is unknown please record this as ZZZ
Notes: UK Government Data Standards Catalogue (GDSC), Version 2.0, Agreed 01.01.02.
GDSC:
http://www.govtalk.gov.uk/gdsc/html/default.htm
Max 3 Characters
Reference: http://www.iso.org/iso/home.htm
Format/length: AN(3) or AN(9) - Please note LA codes for Northern Ireland (DCA) are 3 digits –
all other codes are 9 digits.
ONS LOCAL GOVERNMENT GEOGRAPHY CODE (LOCAL AUTHORITY DISTRICT is the
LOCAL AUTHORITY DISTRICT code derived from the PATIENT's POSTCODE OF USUAL
ADDRESS, where they reside within the boundary of a:






local authority district (LAD) – in England or Wales
unitary authority (UA) – in England
metropolitan district (MD) – in England
London borough (LB) – in England
council area (CA) – in Scotland
district council area (DCA) – in Northern Ireland
There is an LA for each postcode in the UK* (or equivalent – as defined by ONS). Records where
the patient’s postcode has not been provided to generate LA of residence should be allocated to
23
GUMCADv2 Technical guidance and extract specification for data extract
‘not known’ and coded "X99999999". Postcodes outside the UK (overseas visitors) should be
allocated to ‘not applicable’ and coded as “X99999998”.
Please contact PHE for a current postcode mapping file: [email protected]
24
GUMCADv2 Technical guidance and extract specification for data extract
LSOA
LOWER LAYER
SUPER OUTPUT
AREA
(RESIDENCE))
Format/length: AN(8) or AN(9) - Please note LSOA codes for Northern Ireland (SOA) are 8 digits
– all other codes are 9 digits.
Notes: the Lower Layer Super Output Area for where the PATIENT is resident. This is the
GEOGRAPHIC AREA CODE where the GEOGRAPHIC AREA TYPE is classification Lower
Layer Super Output Area.
There is a Lower Layer Super Output Area (or equivalent – as defined by ONS**) for each
postcode in the UK*. Records where the patient’s postcode has not been provided to generate
LSOA of residence should be allocated to ‘not known’ and coded “X99999999”. Postcodes
outside the United Kingdom should be allocated to ‘not applicable’ and coded “X99999998”.
Lower Layer Super Output Areas are a geographic hierarchy designed to improve the reporting of
small area statistics. Lower Layer Super Output Areas are built from groups of contiguous Output
Areas and have been automatically generated to be as consistent in population size as possible,
and typically contain from four to six
E01000001 – E01033768 = England
W01000001 – W01001958 = Wales
S01000001 – S01006505 = Scotland (**data zone)
95AA01S1 – 95ZZ16S2 = Northern Ireland (**SOA)
L99999999 (pseudo) = Channel Islands
M99999999 (pseudo) = Isle of Man
X99999998 = Outside the UK
X99999999 = Not known
Please contact PHE for a current postcode mapping file: [email protected]
25
GUMCADv2 Technical guidance and extract specification for data extract
First_Attendance
FIRST
ATTENDANCE.
Format/length: N(1)
The National Codes for ‘FIRST ATTENDANCE’ (denoting attendance type) in the NHS Data
Dictionary are:
1 First attendance face to face
2 Follow-up attendance face to face
3 First telephone or telemedicine consultation
4 Follow up telephone or telemedicine consultation
Notes:
This indicates whether a patient is making a first or follow-up attendance. For Genitourinary Clinic
Attendances a FIRST ATTENDANCE is the first in a series, or the only attendance by a PERSON
at a Consultant Clinic.
AttendanceDate
ATTENDANCE
DATE
Re-book should still be collected locally. It is used to identify frequently repeat attendees recurring
infections which are of significance in managing individual patient care and for protecting public
health.
Format/length: N(10) – ccyy-mm-dd
ATTENDANCE DATE is the same as attribute ACTIVITY DATE of ACTIVITY DATE TIME where
the ACTIVITY DATE TIME TYPE is National Code 33 'Attendance Date'
UK Government Data Standards Catalogue (GDSC), Version 1.0, Agreed 01.01.02. GDSC:
http://www.govtalk.gov.uk/gdsc/html/default.htm
This is the e-GIF standard that should be used for all new and developing systems and for XML
messages
*UK includes, England, Wales, Scotland, Northern Ireland, Channel Islands and Isle of Man.
26
GUMCADv2 Technical Guidance and Extract Specification for Data Extract
Appendix 4: SHHAPT codes and notes
A. SHHAPT codes
SHHAPT Description
code
Diagnosis Codes
40
Sexual Assault
(Acute
Presentation)
Definition and guidance
The time between sexual assault and medical examination is
within 7 days.
 this code is shared with the SRHAD report. Please speak to
your software provider to determine if coding is required for
GUMCAD and SRHAD ie this may need to be coded twice in
order to appear in both reports
41
Sexual Assault
(Non-acute
Presentation)
http://www.hscic.gov.uk/datacollections/srhad.
The time between sexual assault and medical examination is
more than 7 days.
 this code is shared with the SRHAD report. Please speak to
your software provider to determine if coding is required for
GUMCAD and SRHAD ie this may need to be coded twice in
order to appear in both reports
A1
Primary syphilis
http://www.hscic.gov.uk/datacollections/srhad.
This refers to primary infectious syphilis. Laboratory
confirmation is required.
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A1X)*
A2
*see tables D and E for further details on using suffixes.
Secondary syphilis This refers to secondary infectious syphilis. Laboratory
confirmation is required.
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A2X)*
*see tables D and E for further details on using suffixes.
GUMCADv2 Technical guidance and extract specification for data extract
A3
Early latent
syphilis
This refers to patients who acquired syphilis in the preceding 2
years who have no signs of primary or secondary syphilis. Proof
of negative serology within the preceding 2 years is required.
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A3X)*
A4
Cardiovascular
syphilis
*see tables D and E for further details on using suffixes.
This refers to cardiovascular syphilis
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A4X)*
A5
Neurosyphilis
*see tables D and E for further details on using suffixes.
This refers to syphilis of the nervous system.
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A5X)*
A6
All other late and
latent syphilis
*see tables D and E for further details on using suffixes.
This refers to latent syphilis after the first two years of infection
and all other latent syphilis.
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A6X)*
A7A
Congenital
syphilis
*see tables D and E for further details on using suffixes.
Serological evidence of syphilis in an infant or child and clinical
signs consistent with congenital syphilis, for example:
 early (<2 years): snuffles, skin and mucous membrane
lesions, lymphadenopathy, hepatosplenomegaly
 late (>2 years): gummatous ulcers, interstitial keratitis, optic
atrophy, sensorineural deafness, Hutchinson’s incisors
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (A7AX)*
*see tables D and E for further details on using suffixes.
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GUMCADv2 Technical guidance and extract specification for data extract
B
Gonorrhoea
This includes all cases of complicated and uncomplicated
genital gonorrhoea (pre- and post-pubertal).
 NAAT-positive or culture confirmed.
 Genital gonorrhoea would include urethral and cervical
urethral infections.
 The O and R suffixes can be added to report pharyngeal (BO)
and rectal infections (BR).*
 The X suffix can be added where the current episode is known
to have been diagnosed at another sexual health service.
(BX)*
 Patients thought to be newly infected after a previous episode
should be regarded as a new episode and investigated,
treated and diagnosed/coded accordingly.
 Treatment failures should not be given a new diagnosis.
Treatment failures include those in whom first line antibiotics
have failed (for example, symptoms not resolved or antibiotics
not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner)
within 6 weeks.
C1
C2
C3
C4
*see tables D & E for further details on using suffixes..
Chancroid
Laboratory confirmation is required for this condition.
Lymphogranuloma Laboratory confirmation is required for this condition.
venereum (LGV)
 the O and R suffixes can be added to report pharyngeal (C2O)
and rectal infections (C2R)*
Donovanosis
Chlamydia
*see tables D and E for further details on using suffixes.
Laboratory confirmation is required for this condition.
This includes all cases of complicated and uncomplicated
genital chlamydia trachomatis infections (diagnosed by culture
or antigen detection).
 genital chlamydia would include urethral and cervical urethral
infections
 the O and R suffixes can be added to report pharyngeal (C4O)
and rectal infections (C4R)*
 the X suffix can be added where the current episode is known
to have been diagnosed at another sexual health service.
(C4X)*
 patients thought to be newly infected after a previous episode
should be regarded as a new episode and investigated,
29
GUMCADv2 Technical guidance and extract specification for data extract
C4N
Non-specific
genital infection
(NSGI)
C5A
Pelvic
inflammatory
disease (PID) and
epididymitis
C5B
Ophthalmia
neonatorum
C6A
Trichomoniasis
treated and diagnosed/coded accordingly
 treatment failures should not be given a new diagnosis.
Treatment failures include those in whom first line antibiotics
have failed (for example, symptoms not resolved or antibiotics
not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner)
within 6 weeks
*see tables D and E for further details on using suffixes.
This includes all cases of complicated and uncomplicated NSGI.
 the R suffix can be added to report Proctitis (C4NR)*
 in males, NSGI is diagnosed in the absence of gonorrhoea
and laboratory confirmed chlamydia and the presence of
polymorphonuclear leucocytes at >5 per high power field
 females being treated for non-specific mucopurulent cervicitis
should be coded C4N
 patients thought to be newly infected after a previous episode
should be regarded as a new episode and investigated,
treated and diagnosed/coded accordingly
 treatment failures should not be given a new diagnosis.
Treatment failures include those in whom first line antibiotics
have failed (for example, symptoms not resolved or antibiotics
not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner)
within 6 weeks
*see tables D and E for further details on using suffixes.
This includes all cases of pelvic inflammatory disease and all
cases of epididymitis
 C5A should be reported with B for gonococcal infections and
with C4 for chlamydial infections
 all other complications should be coded D2B
This includes all cases of ophthalmia neonatorum.
 C5B should be reported with B for gonococcal infections and
with C4 for chlamydial infections.
Diagnosis of trichomoniasis associated with bacterial vaginosis
(BV) should only be coded C6A (for trichomoniasis) ie do not
also code C6B (for BV).
 the X suffix can be added where the current episode is known
to have been previously diagnosed at another sexual health
service (C6AX)*
30
GUMCADv2 Technical guidance and extract specification for data extract
*see tables D and E for further details on using suffixes.
C6B
C6C
C7
C8
C9
Anaerobic/
bacterial vaginosis
(BV) and
anaerobic
balanitis
Diagnosis of bacterial vaginosis (BV) is generally based on
microscopy, pH vaginal fluid and the amine test.
 this diagnosis is very rarely appropriate in males and used
only if the patient has confirmed anaerobic balanitis
 all other / non-confirmed anaerobic balanitis should be coded
C6C
This includes 'other' and non-confirmed anaerobic balanitis.
Other
vaginosis/vaginitis/
balanitis
Anogenital
This is diagnosed only when there is microscopic or culture
candidosis
evidence of candida infection.
Scabies
Pediculosis pubis
C10A
Anogenital Herpes
simplex: 1st
episode
C10B
Anogenital Herpes
simplex:
recurrence
 if there is no microbiological evidence then infection should be
coded C6C
 asymptomatic patients who do not require treatment should be
coded D3
This includes cases treated on either a clinical or
epidemiological basis.
 treatment failures should not be given a new diagnosis.
Patients who are thought to be re-infected should be regarded
as new cases, and investigated, treated and diagnosed/coded
accordingly
This includes cases treated on either a clinical or
epidemiological basis.
 treatment failures should not be given a new diagnosis.
Patients who are thought to be re-infected should be regarded
as new cases, and investigated, treated and diagnosed/coded
accordingly.
A first episode of anogenital herpes should only be recorded if
the patient has never previously had a confirmed diagnosis (at
any sexual health service). Laboratory confirmation is required
for this condition.
This includes all subsequent episodes of anogenital herpes. If
there has been previous laboratory confirmation, then clinical
judgement is enough for this diagnosis.
31
GUMCADv2 Technical guidance and extract specification for data extract
C11A
C11D
C12
C13
C14
C15
C16
D2A
Anogenital warts
infection: 1st
episode
Anogenital warts
infection:
recurrence
Molluscum
contagiosum
Viral hepatitis B
(HbsAg positive):
first diagnosis
Viral hepatitis C:
1st diagnosis
Viral hepatitis A:
acute infection
Mycoplasma
genitalium
Urinary tract
infection
A first episode of anogenital warts should only be recorded if the
patient has never previously received treatment for the condition
(at any sexual health service).
 diagnosis refers to macroscopic warts. It does not refer to
acetowhite patches, abnormalities revealed by acetowhite
staining nor the cytological finding of a wart virus change ie
these should not be coded C11A
This includes all subsequent episodes of anogenital warts.
 diagnosis refers to macroscopic warts. It does not refer to
acetowhite patches, abnormalities revealed by acetowhite
staining nor the cytological finding of a wart virus change ie
these should not be coded C11D
Diagnosis refers to presence of characteristic lesions, or
characteristic histopathological features if biopsy has been
performed.
This includes 1st diagnoses of antigen positive hepatitis B only.
 subsequent attendances for hepatitis B management and/or
other STI services should not be coded C13 (hepatitis B
management should be coded D2B)
First diagnoses of hepatitis C, defined as anti-HCV positive or
HCV RNA positive.
Diagnoses of acute hepatitis A, defined as detection of hepatitis
A virus specific IgM antibodies.
Laboratory confirmation is required for this condition.
This includes patients where any of the following conditions are
met (otherwise patients should be coded D2B):
i. Culture positive UTI.
ii. Moderately to highly likely UTI based on clinical and
dipstick* criteria.
iii.Treated for UTI based on moderate/severe symptoms of UTI
without culture or dipstick*
D2B
Other conditions
requiring
services/treatment
at Sexual Health
services
* LE or Nitrite positive.
This includes any new episode where an STI service and/or
treatment was required for a condition that is not covered by
any other SHHAPT code.
32
GUMCADv2 Technical guidance and extract specification for data extract
H
H1
HIV positive
New HIV
diagnosis
For known HIV positive patients who are attending for STI care
only (and can be coded as often as required within an episode).
 patient attending for HIV care should be coded H2 (not H)
 cannot be reported on the same date as H1, H1A, H1B or H2
This includes all new HIV diagnoses (that are not defined as
'acute' or AIDS related).
 the X suffix can be added where the patient is known to have
been previously diagnosed with HIV (at any other clinical
setting) and has not previously accessed HIV care (H1X)*
 known HIV positive patients transferring their existing HIV
care to a new service should be coded H2
 H can be coded at each associated attendance within a single
episode.
 cannot be reported on the same date as H or H2.
 cannot be reported in the same patient history as H1A or H1B
*see tables D and E for further details on using suffixes.
H1A
New HIV
diagnosis: Acute
This includes all new HIV diagnoses which have evidence of
one or more of the following in the last 6 months:
a) a documented negative HIV test.
b) laboratory evidence (eg RITA assay, RNA, neutralisable p24
antigen and antibody negative).
c) evidence of seroconversion illness.
 the X suffix can be added where the patient is known to have
been previously diagnosed with HIV (at any other clinical
setting) and has not previously accessed HIV care (H1X)*
 known HIV positive patients transferring their existing HIV
care to a new service should be coded H2
 cannot be reported on the same date as H or H2
 cannot be reported in the same patient history as H1 or H1B
*see tables D and E for further details on using suffixes.
33
GUMCADv2 Technical guidance and extract specification for data extract
H1B
H2
New HIV
diagnosis: Late
(AIDS defined)
Attendance for
HIV-related care
This includes all new HIV diagnoses which have a clinical AIDS
diagnosis within 3 months of initial HIV diagnosis.
 the X suffix can be added where the patient is known to have
been previously diagnosed with HIV (at any other clinical
setting) and has not previously accessed HIV care (H1BX).*
 known HIV positive patients transferring their existing HIV
care to a new service should be coded H2
 cannot be reported on the same date as H or H2
 cannot be reported in the same patient history as H1 or H1A
*see tables D and E for further details on using suffixes.
This includes all attendances relating to HIV care.
Cervical cytology:
minor abnormality
Cervical cytology:
major abnormality
Pregnant 1-12
weeks
 H2 can be coded at each associated attendance within a
single episode
 cannot be reported on the same date as H, H1, H1A or H1B
Includes smears showing lower grades (ie “borderline” or “mild”)
of dyskaryosis on cytological examination.
Includes smears showing moderate or worse (ie “moderate” or
“severe”) dyskaryosis on cytological examination.
For those known to be in the 1st trimester of pregnancy (only
required once per pregnancy).
Pregnant 13-28
weeks
 cannot be reported on the same date as PR2 or PR3
For those known to be in the 2nd trimester of pregnancy (only
required once per pregnancy).
Pregnant 29
weeks – full term
 cannot be reported on the same date as PR1 or PR3
For those known to be in the 3rd trimester of pregnancy (only
required once per pregnancy).
SG1
Shigella flexneri
 cannot be reported on the same date as PR1or PR2
Laboratory confirmation is required for this condition.
SG2
Shigella sonnei
Laboratory confirmation is required for this condition.
SG3
Shigella other /
unspecified
Laboratory confirmation is required for this condition.
P4A
P4B
PR1
PR2
PR3
34
GUMCADv2 Technical guidance and extract specification for data extract
Service Codes
D3
Other episodes
not requiring
treatment
P1A
HIV antibody test
This includes any new episode where no STI services and/or
treatment were required ie no other SHHAPT code is
appropriate.
 D3 can be used to code negative HIV/STI tests (P1A and T1T7) although this is not strictly necessary ie negative HIV/STI
tests can be reported without D3
 D3 can be used in conjunction with 'prisoner' (Z) and 'sex
worker' (SW) codes
 D3 can be used to code patients who have been triaged or
have seen a health advisor but have 'walked-out' before
seeing a clinician
 patients who do not attend should not be coded D3
 D3 can be used only once per episode
For those receiving an HIV antibody test which is not part of a
full sexual health screen (as described by code T4).
 Cannot be reported on the same date as P1B, P1C, T3, T4 or
T7.*
P1B
P1C
HIV antibody test
offered and
refused
HIV test not
appropriate
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those offered an HIV antibody test who decline the test.
 Including where a clinician believes there is a HIV risk that
could be tested on that day, where a pre-test
discussion/counselling has taken place or where the patient
intends to test in the future.
 Cannot be reported on the same date as P1A, P1C, T4 or
T7.*
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those accessing STI services who were not offered an HIV
test because the clinician deemed it was not appropriate eg the
patient has recently tested or is still inside the HIV ‘window’
period.
 Patients already known to be HIV positive do not need to be
coded P1C – they should be coded H or H2 (as appropriate).
 It may be more appropriate to code some patients SRH
instead of P1C e.g. patients attending for continued
contraceptive care where HIV testing is not relevant to the
consultation.
35
GUMCADv2 Technical guidance and extract specification for data extract
 Cannot be reported on the same date as P1A, P1B, T4 or
T7.*
P2A
P2B
P2C
P2D
P2E
P2I
P3
Hepatitis B
vaccination: 1st
dose
*see section ‘F’ for further details on HIV/STI test code
combinations.
The 1st dose of any new hepatitis B vaccination course
(including patients who may have been previously vaccinated
but are now receiving the 1st dose of a new vaccination
course).
Hepatitis B
vaccination: 2nd
dose
 cannot be reported on the same date as P2B, P2C, P2D or
P2E
The 2nd dose of a hepatitis B vaccination course (including
those who are known to have received a 1st dose at another
service).
Hepatitis B
vaccination: 3rd
dose
 cannot be reported on the same date as P2A, P2C, P2D or
P2E
The 3rd dose of a hepatitis B vaccination course (including
those who are known to have received a prior dose at another
service).
Hepatitis B
vaccination: 4th
dose
 cannot be reported on the same date as P2A, P2B, P2D or
P2E
The 4th dose of a hepatitis B vaccination course (including
those who are known to have received a prior dose at another
service).
Hepatitis B
vaccination:
Booster
Hepatitis B
immune
Contraception
(excluding
condom provision)
 cannot be reported on the same date as P2A, P2B, P2C or
P2E
For hepatitis B vaccination boosters (including those who are
known to have been vaccinated at another service).
 cannot be reported on the same date as P2A, P2B, P2C or
P2D
Includes patients who have natural immunity and vaccinated
immunity.
For females only: to be used to record the provision of
contraception and family planning advice. The provision of
condoms is not included.
 this code is related to multiple activities in the SRHAD report.
Please speak to your software provider to determine if
36
GUMCADv2 Technical guidance and extract specification for data extract
P4
PEPS
PN
PNC
PNG
PNH
PNN
PNP
PNS
Cervical cytology
done
Post exposure
prophylaxis:
Sexual exposure
Partner
notification
initiated
Partner
notification:
chlamydia contact
Partner
notification:
gonorrhoea
contact
Partner
notification: HIV
contact
Partner
notification: nonspecific genital
infection (NSGI)
contact
Partner
notification: PID /
epididymitis
contact
Partner
separate coding is required for GUMCADV2 and SRHAD ie
this may need to be coded twice in order to appear in both
reports
 integrated services should use code SRH where the patient
only accessed SRH services without accessing STI services
See http://www.hscic.gov.uk/datacollections/srhad.
Includes all patients having a cervical cytology, regardless of
outcome.
For patients given HIV prophylaxis following sexual exposure
(PEPSE).
Partner notification has been initiated for this patient by this
service.
 for use in non-GUM Level 2 and Level 1 services only
This includes those presenting as a partner of an index case
diagnosed with chlamydia (at this or any other service).
 If the partner is found to be infected with chlamydia they
should also be coded C4.
This includes those presenting as a partner of an index case
diagnosed with gonorrhoea (at this or any other service).
 If the partner is found to be infected with gonorrhoea they
should also be coded B.
This includes those presenting as a partner of an index case
diagnosed with HIV (at this or any other service).
 If the partner is found to be infected with HIV they should also
be coded H1, H1A or H1B.
This includes those presenting as a partner of an index case
diagnosed with NSGI (at this or any other service).
 If the partner is found to be infected with NSGI they should
also be coded C4N.
This includes those presenting as a partner of an index case
diagnosed with PID / epididymitis (at this or any other service).
 If the partner is found to be infected with PID /epididymitis
they should also be coded C5A.
 Can be reported on the same date as PNC or PNG.
This includes those presenting as a partner of an index case
37
GUMCADv2 Technical guidance and extract specification for data extract
notification:
syphilis contact
PNT
REF1
REF2
REF3
Partner
notification:
trichomoniasis
contact
Referred from
chlamydia
screening
programme
Referred to GUM
(Level 3) Sexual
Health Services
Referred from
home testing /
sampling service
diagnosed with syphilis – of any stage (at this or any other
service).
 if the partner is found to be infected with syphilis they should
also be coded A1, A2 A3, A4, A5, A6 or A7A
This includes those presenting as a partner of an index case
diagnosed with trichomoniasis (at this or any other service).
 if the partner is found to be infected with trichomoniasis they
should also be coded C6A
To identify those referred from the chlamydia screening
programme - self referral is sufficient.
 REF1 should be reported with supplementary STI test and/or
diagnosis codes
For Level 2 & Level 1 sexual health services to identify those
being referred to Level 3 GUM services.
 For use in non-GUM Level 2 & Level 1 services only
 REF2 should be reported with supplementary STI test and/or
diagnosis codes.
To identify those referred from home testing / home sampling
services with a reactive test result - self referral is sufficient.
 home testing/home sampling services would include services
accessed outside of a normal clinic setting eg outreach, over
the counter or internet testing
 REF2 should be reported with supplementary STI test and/or
diagnosis codes
38
GUMCADv2 Technical guidance and extract specification for data extract
SRH
Sexual
reproductive
health patient
(only)
To identify those attending for SRH services where a full sexual
health screen / HIV testing was not relevant to the consultation ie
those not coded P1A, P1B, P1C, T4 or T7.
Please review BHIVA guidelines on HIV testing to determine whether
HIV testing is relevant to the SRH consultation (see section 4 of the
guidelines).
http://www.bhiva.org/documents/guidelines/testing/glineshivtest08.pdf
SW
T1
Sex worker
Chlamydia test
 patients coded SRH do not need to be coded P1C (HIV testing not
appropriate) or T9 (STI testing not required/appropriate)
 this code will identify patients that should be excluded from
calculations to measure HIV test coverage/uptake
 SRH can be coded at each associated attendance within a single
episode
 this code is related to multiple activities in the SRHAD report.
Please speak to your software provider to determine if separate
coding is required for GUMCADV2 and SRHAD, ie this may need
to be coded twice in order to appear in both reports
For the provision of services to a patient known to be a current sex
worker.
SW can be coded at each associated attendance within a single
episode.
For those tested for chlamydia (but are not tested for gonorrhoea or
syphilis).
 Cannot be reported on the same date as T2, T3 or T4.*
T2
T3
*see section ‘F’ for further details on HIV/STI test code
combinations.
Chlamydia and For those given a sexual health screen which only includes
chlamydia and gonorrhoea testing (and excludes syphilis testing).
gonorrhoea
tests
 Cannot be reported on the same date as T1, T3, T4 or T7.*
Chlamydia,
gonorrhoea
and syphilis
tests
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those given a sexual health screen which only includes
chlamydia, gonorrhoea and syphilis testing (and excludes HIV
testing).
 Cannot be reported on the same date as P1A, T1, T2, T4, T7 or
T9.*
39
GUMCADv2 Technical guidance and extract specification for data extract
T4
T5
T6
T7
T8
T9
Full sexual
health screen
(chlamydia,
gonorrhoea,
syphilis and
HIV tests)
Herpes
simplex virus
(HSV) test
Hepatitis
A/B/C test
Syphilis and
HIV antibody
test
Self sampling
(chlamydia,
gonorrhoea or
HIV) without
HCW
consultation
STI testing not
required /
appropriate
(chlamydia,
gonorrhoea or
syphilis)
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those given a full sexual health screen including chlamydia,
gonorrhoea, syphilis and HIV testing.
 Cannot be reported on the same date as P1A, P1B, P1C, T1, T2,
T3, T7 or T9.*
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those tested for the herpes simplex virus (HSV).*
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those tested for hepatitis A, B or C.*
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those tested for syphilis and HIV (and excludes chlamydia and
gonorrhoea testing).
 Cannot be reported on the same date as P1A, P1B, P1C, T2, T3 or
T4.*
*see section ‘F’ for further details on HIV/STI test code
combinations.
Self sampling of STIs without ‘face to face’ health care worker (HCW)
consultation.
 Can be reported on its own or in conjunction with other test codes –
P1A, T1, T2, T3, T4, T5, T6 or T7.*
 This code will identify patients that do not have a consultation /
sexual health history taken.
 Self sampling includes urine specimens (commonly known as 'pee
& go'), swabs (vaginal, anal or pharyngeal) or blood specimens.
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those accessing STI services where testing for chlamydia,
gonorrhoea or syphilis is not required, appropriate or is declined.
 P1B or P1C should be coded when HIV testing is refused/not
appropriate.
 Patients only attending for SRH care (and not STI care) should be
coded SRH instead of T9.
 Cannot be reported on the same date as T3 or T4.*
*see section ‘F’ for further details on HIV/STI test code
combinations.
40
GUMCADv2 Technical guidance and extract specification for data extract
T10
TS
TT
W1
Rapid testing –
same-day
results
(chlamydia,
gonorrhoea or
HIV)
Microscopy
(gonorrhoea or
syphilis)
3 site testing
(chlamydia or
gonorrhoea)
HPV
vaccination:
1st dose
For those receiving at least 1 rapid test (same-day results) for
chlamydia, gonorrhoea or HIV.*
 Should be reported in conjunction with other test codes - P1A, T1,
T2, T3, T4 or T7.
*see section ‘F’ for further details on HIV/STI test code
combinations.
For use with any test where microscopy is undertaken.*
 Can be reported on its own or in conjunction with other test codes T2, T3, T4 or T7.
*see section ‘F’ for further details on HIV/STI test code
combinations.
For those receiving 3 site testing (genital, pharyngeal and rectal) for
chlamydia or gonorrhoea.*
 Should be reported in conjunction with other test codes - T1, T2, T3
or T4.
*see section ‘F’ for further details on HIV/STI test code
combinations.
The 1st dose of any new human papillomavirus vaccination course
(including patients who may have been previously vaccinated but are
now receiving the 1st dose of a new vaccination course).
 the Q suffix can be added if the quadrivalent vaccine is used
(W1Q)*
 cannot be reported on the same date as W2 or W3
W2
HPV
vaccination:
2nd dose
*see tables D and E for further details on using suffixes.
The 2nd dose of a human papillomavirus vaccination course
(including those who are known to have received the 1st dose at
another service).
 the Q suffix can be added if the quadrivalent vaccine is used
(W2Q)*
 cannot be reported on the same date as W1 or W3
W3
HPV
vaccination:
3rd dose
*see tables D and E for further details on using suffixes.
The 3rd dose of a human papillomavirus vaccination course
(including those who are known to have received a prior dose at
another service).
41
GUMCADv2 Technical guidance and extract specification for data extract
 the Q suffix can be added if the quadrivalent vaccine is used
(W3Q)*
 cannot be reported on the same date as W1 or W2
Z
Prisoner
*see tables D and E for further details on using suffixes.
For the provision of services to a patient known to be a current
prisoner.
 Z can be coded at each associated attendance within a single
episode
Unspecified Codes
O11O99
Unspecified
Codes
All codes from O11 to O99 are reserved by PHE for use with
future national reporting requirements in response to newly
identified sexual health issues.
 PHE will notify services as and when codes are officially
released for use in GUMCAD reporting ie codes O11-O99
should not be used unless notified by PHE
A range of unspecified (‘dummy’) codes have been devised to allow a more timely
response to future infection outbreaks. The codes will be released by PHE as and when
an appropriate need for new surveillance is identified (at which time detailed guidance
will be given).
The unspecified (‘dummy’) codes range from O11 to O99 inclusive (O11, O12, O13 etc.)
– this range of codes should be reserved in software systems and should not be used
for any other surveillance (national or local) until notified otherwise by PHE.
42
GUMCADv2 Technical guidance and extract specification for data extract
B. SHHAPT code suffixes
Suffix
Description
Definition and Guidance
M
Medication
given
For use in Level 2 services*: the 'M'. Suffix is
added to the primary SHHAPT code where
treatment is given/prescribed for the presenting
condition (including patients referred to Level 3
GUM services for further management).
O
Pharyngeal
infection
Q
Quadrivalent
HPV vaccine
R
Rectal
infection
 patients referred to Level 3 GUM* should also
be coded REF2
 level 3 GUM* services provide treatment for all
diagnoses as standard and are therefore not
required to use the 'M' suffix
See table E for further details on using suffixes.
The ‘O’ suffix is added to the primary SHHAPT
code where diagnosis includes a pharyngeal
infection.
Compatible
SHHAPT
Codes
B, C4, C10A,
C10B, C11A,
C11D.
B, C4, C2
 where the patient has a multiple site infection
(genital, rectal and /or pharyngeal) each site of
infection should be coded eg a 3 site infection of
gonorrhoea should be coded B (genital), BO
(pharyngeal) and BR (rectal)
See table E for further details on using suffixes.
The ‘Q’ suffix is added to the primary SHHAPT
W1, W2, W3
code for those receiving the quadrivalent vaccine
for HPV.
See table E for further details on using suffixes.
The ‘R’ suffix is added to the primary SHHAPT
B, C4, C2,
code where diagnosis includes a rectal infection.
C4N
 where the patient has a multiple site infection
(genital, rectal and /or pharyngeal) each site of
infection should be coded eg a 3 site infection of
gonorrhoea should be coded B (genital), BO
(pharyngeal) and BR (rectal)
See table E for further details on using suffixes.
43
GUMCADv2 Technical guidance and extract specification for data extract
X
Diagnosed
previously
elsewhere
The ‘X’ suffix is added to the primary SHHAPT
code where a patient is known to have been
recently diagnosed with their presenting condition
at another health setting in the UK before this
attendance.
A1, A2, A3,
A4, A5, A6,
A7A, B, C4,
C6A, H1,
H1A, H1B
This includes:
 diagnoses of chlamydia, gonorrhoea or syphilis
that were made in the last 6 weeks
 diagnoses of HIV where the patient has not
previously accessed HIV care (this may include
diagnoses made more than 6 weeks ago)
See table E for further details on using suffixes.
Please note: When an episode is diagnosed with a multi-site infection (genital,
pharyngeal or rectal), the episode should be coded with each site of infection code eg
genital, pharyngeal and rectal gonorrhoea should be coded B, BO and BR (the
previously required hierarchy has been abolished).
44
GUMCADv2 Technical guidance and extract specification for data extract
C. Permissible SHHAPT/suffix combinations
SHHAPT/
Description
Suffix
combinations
A1X
Syphilis
A2X
A3X
A4X
A5X
A6X
A7AX
BR
BO
BX
BM
BRX
Gonorrhoea
BRM
BOX
BOM
C2R
C2O
C4R
C4O
C4X
C4M
C4RX
C4RM
C4OX
C4OM
LGV
Chlamydia
Service type*
Primary syphilis, diagnosed
previously elsewhere
Secondary syphilis, diagnosed
previously elsewhere
Early latent syphilis, diagnosed
previously elsewhere
Cardiovascular syphilis, diagnosed
previously elsewhere
Neurosyphilis, diagnosed previously
elsewhere
Other late/latent syphilis, diagnosed
previously elsewhere
Congenital syphilis, diagnosed
previously elsewhere
Rectal infection
Pharyngeal infection
Diagnosed previously elsewhere
Medication given
Rectal infection, diagnosed
previously elsewhere
Rectal infection, medication given
Pharyngeal infection, diagnosed
previously elsewhere
Pharyngeal infection, medication
given
Rectal infection
Pharyngeal infection
Rectal infection
Pharyngeal infection
Diagnosed previously elsewhere
Medication given
Rectal infection, diagnosed
previously elsewhere
Rectal infection, medication given
Pharyngeal infection, diagnosed
previously elsewhere
Pharyngeal infection, medication
45
All services
All services
All services
All services
All services
All services
All services
All services
All services
All services
Level 2 services
All services
Level 2 services
All services
Level 2 services
All services
All services
All services
All services
All services
Level 2 services
All services
Level 2 services
All services
Level 2 services
GUMCADv2 Technical guidance and extract specification for data extract
C4NR
C6AX
C10AM
C10BM
C11AM
C11DM
H1X
H1AX
H1BX
W1Q
W2Q
W3Q
given
NSGI
Proctitis
Trichomoniasis Trichomoniasis, diagnosed
previously elsewhere
Herpes
Medication given
Warts
Medication given
HIV
Diagnosed previously elsewhere
HPV vaccine
Quadrivalent vaccine
*Level 2 service: commissioned sexual health (non-GUM) services
46
All services
All services
Level 2 services
Level 2 services
Level 2 services
Level 2 services
All services
All services
All services
All services
All services
All services
GUMCADv2 Technical guidance and extract specification for data extract
D. HIV/STI test code combinations
SHAPPT codes for HIV/STI testing should be used in the appropriate way to ensure coding
provides an accurate reflection of the services provided. The table below illustrates the 1-to-1
relationship between each HIV/STI code and highlights whether the combination is ‘Accepted’,
‘Incomplete’ or ‘Rejected’.
SHHAPT Code
P1A: HIV antibody test
P1B: HIV test offered &
refused
P1C: HIV test not
appropriate
P1A


P1B


P1C
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
TS
TT
            
            


T1: Chlamydia test


T2: Chlamydia &
gonorrhoea tests
T3: Chlamydia,
gonorrhoea & syphilis
tests
T4: Full sexual health
screen (chlamydia,
gonorrhoea, syphilis & HIV
tests)



 


  


   
T5: Herpes simplex virus
(HSV) test


            
T6: Hepatitis A / B / C test


     
T7: Syphilis & HIV
antibody test


T8: Self sampling of STIs



       
T9: STI testing not
required/appropriate
(chlamydia, gonorrhoea or
syphilis)


        
T10: Rapid testing – same
day results (chlamydia,
gonorrhoea or HIV)


         
TS: Microscopy


          
TT: 3 site testing
(chlamydia or gonorrhoea)




           
          

         

        

       

      
     
    

   

  

 

           


HIV/STI test code combinations – key
 Accepted: code combination can be reported together.

Incomplete: code combination can only be reported together when accompanied by a 3rd code (or 4th
code etc.).
e.g. T6 & TT cannot be reported on their own - because 3 site testing isn’t conducted when testing for
Hepatitis A /B/C. However, combining T6 & TT with a 3rd code, such as T2, would complete the coding
combination – such as reporting T6, TT & T2 for testing of Hepatitis A /B/C and 3 site testing for
chlamydia/gonorrhoea.
 Rejected: code combination cannot be reported together
47
GUMCADv2 Technical guidance and extract specification for data extract
Appendix 5: READ codes and definitions
READ Code Version 2
The MS Excel Workbook embedded below contains all permissible READ Version 2
codes for GUMCADv2. Demographic and Attendance related READ codes are provided
in the separate tabs.
GUMCADv2 READ CODE v2_230315.xlsx
READ Code Clinical Terms Version 3 (CTV3)
A number of sites submitting GUMCADv2 will be submitting codes using READ CTV3
codes. The MS Excel Workbook embedded below contains all permissible READ CTV3
codes. Demographic and Attendance related READ codes are provided in the separate
tabs.
GUMCADv2 READ_CODE_CTV3_230315.xlsx
The sexual health related READ codes are available as:
1. Recommended List of READ Codes
The recommended list of READ codes is a shortened list of READ codes that are
compatible with the SHHAPT codes used by other Level 2 and 3 sexual health services.
We recommend that this list be adopted to standardise data collection. The GUMCAD
team and the main GP PSSs are developing standard data collection templates to aid
collection of GUMCADv2 which is based on this list of codes. Once the templates are
available we will contact the relevant services.
2. All Permitted READ Codes
This provides the full list of all sexual health related READ codes permitted in
GUMCADv2.
48