Appendix D
Health Protection Agency Centre for Infections
British Association for Sexual Health and HIV
GUMCAD(2)
Genitourinary Medicine Clinic Activity Dataset
Guidance to clinic staff
Authors
:
Revision date
ESHSs Update
:
:
Version
Implementation
completion date
:
:
Dr. Gwenda Hughes, Dr. Immy Ahmed,
Ms. Geraldine Leong, Dr Mary Poulton
23rd June 2010
Jordana Peake (Oct 2010 and July
2011)
Re-issue with SHHAPT codes (V11)
31st December 2011
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Implementation completion date: 31 December 2011
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Appendix D
Contents
1
Document control .................................................................................. 3
2
Introduction ........................................................................................... 4
3
Collection and recording guidance ........................................................ 5
Patient registration details at first attendance ........................................ 5
Attendance type ..................................................................................... 6
Attendance date ..................................................................................... 7
Clinical details and SHHAPT (KC60)/READ coding .......................... 8
Other guidance ...................................................................................... 9
4
Reporting and transmitting data to the HPA ....................................... 10
Description .......................................................................................... 10
Running extracts .................................................................................. 10
Extract format ...................................................................................... 10
Reporting time period.......................................................................... 11
Frequency of reporting ........................................................................ 11
Transmission of the data extract to the HPA....................................... 11
Overlap with the Sexual and Reproductive Health Activity Dataset 11
5
How the HPA uses the data ................................................................. 12
Purpose of the GUMCAD return ........................................................ 12
Types of output.................................................................................... 12
Reporting time period.......................................................................... 13
Frequency of reporting ........................................................................ 13
Report format ...................................................................................... 13
Presentation of local area data ............................................................. 13
Recipients of routine reports ............................................................... 13
Distribution of reports ......................................................................... 13
6
Confidentiality and anonymity ............................................................ 14
7
Contact information for support and guidance .................................... 16
8
Appendix 1: Data items collected on the GUMCAD return ............... 17
9
Appendix 2: Summary of format and available coding options for
data items collected on the GUMCAD return ..................................... 18
10
Appendix 3: SHHAPT codes, suffixes and definitions ....................... 21
11
Appendix 4: Reduced list of READ codes .......................................... 29
12
Appendix 5: Full Sexual Health READ code list ................................ 31
13
Appendix 6: GUMCAD and SRHAD mapping .................................. 32
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Implementation completion date: 31 December 2011
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Appendix D
1
Document control
Document
control topic
Current
version
Current status
Authors
Reviewers
Issued to
Details
Document intended to provide guidance to front line staff
responsible for capturing and entering GUMCAD data into
systems and reporting to the HPA.
Draft revision
Author name
Section amended/
Date
added
amended
Gwenda Hughes
All
14/04/10
Gwenda Hughes
4,6,7,9
15/04/10
Gwenda Hughes
Mary Poulton
Gwenda Hughes
Code names updated 13/05/10
3,6
14/06/10
Appendices
23/06/10
Jordana Peake
Mandy Yung
Jordana Peake
GUMCAD2 update
GUMCAD2 update
GUMCAD2 update
27/10/10
28/10/10
20/07/11
Reviewer name
Section reviewed
Geraldine Leong
All
Date
reviewed
15/04/10
Person(s) issued to
Date issued
File reference
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Implementation completion date: 31 December 2011
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Appendix D
2
Introduction
2.1
This document is intended for front line NHS staff responsible for the collection and
recording of data used to generate the Genitourinary Medicine Clinic Activity Dataset
(GUMCAD) and to those responsible for reporting the data to the Health Protection
Agency (HPA).
2.2
The GUMCAD return includes patient demographic details collected at patient
registration at their first attendance, and clinical and risk factor data collected during
the patient consultation. Collection of patient registration details is usually led by data
entry clerks, front desk staff including receptionists, information technology,
administrative or secretarial staff. Clinical coding and the collection of risk factor
information is usually led by clinical staff supported by the above staff. Running and
transmitting reports for the HPA is usually led by administrative staff supported by
information technology staff.
2.3
The GUMCAD data support the monitoring and reporting of STIs including historical
trend data. From April 2008, the structure of the return has been revised to include
additional data items which will improve the public health utility of the data and will
facilitate robust assessment of local service needs. This enables informed planning and
allocation of resources at national, regional and local levels and is important in the
drive to reduce the level of Sexually Transmitted Infections (STIs) nationally. The
more informed the planning and decision-making process, the better the allocation of
limited resource to effective treatment of STIs.
2.4
This document will provide staff with a guidance explaining how to collect and record
each data item. It also provides detailed instructions on how and when to report the
return to the HPA.
2.5
This guidance focuses on the items needed only for GUMCAD reporting. For
reporting of other data-sets, such as GUM Access Monthly Monitoring, please refer to
the appropriate guidance (DSCN 39/2007; www.isb.nhs.uk).
2.6
The GUMCAD return is electronic rather than paper-based. The data items collected
on the GUMCAD return are shown in Appendix 1. The required format and coding
options for these data items are given in Appendices 2 and 3.
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Appendix D
3
Collection and recording guidance
3.1
This section covers what to record when and deals with some of the common
problems which may be encountered. Local systems and processes vary so the
application of this guidance should be checked with your manager, software provider
or with staff at the HPA if any issues arise.
3.2
The guidance covers the collection and recording of data relevant to the GUMCAD
return, and includes:
Patient registration details at the patient‟s first attendance
Attendance type when the booking is made
Attendance date when the patient attends for the appointment
Clinical details and SHHAPT (KC60)/READ coding during and after the clinical
consultation
3.3
The remainder of this section details what needs to be collected and recorded at each
of these points.
Patient registration details at first attendance
3.4
When a patient attends the clinic for a booked appointment or to a walk-in service, the
patient should be registered and standard demographic details collected. Some patients
may already have provided some basic registration information when calling to make
the appointment.
3.5
Some of the registration details are also required for the GUMCAD return. This
section provides some additional guidance on recording the GUMCAD specific
registration details.
3.6
To generate the GUMCAD return, the following items need to be collected from, or
created for, all patients during patient registration at their first attendance:
Postcode of residence
Date of Birth
Gender
Ethnicity
Country of Birth
Unique Patient Identifier number
3.7
The various options that can be recorded for each of these data items are summarised
in Appendix 2.
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Appendix D
3.8
Postcode of residence: The postcode of residence enables most systems to generate
Primary Care Trust and Lower Super Output area of residence, both of which are
required for the GUMCAD return. If the patient does not provide their postcode, the
patient should be asked to provide their PCT or borough of residence. Otherwise, the
post code should be recorded as „Not known‟ (however this is recorded on your clinic
system) or left blank. The post code of the clinic should not be entered.
3.9
Date of birth: Date of birth allows the system to generate the age of the patient at the
date of attendance. Age at the date of attendance is required for the GUMCAD return.
3.10
Gender: Gender should be specified by the patient. „Not Specified‟ should be
recorded where gender cannot be classified as either male or female and „Not Known‟
where the patient does not provide the information.
3.11
Ethnicity: Ethnicity should be specified by the patient from the standard list. „Not
stated‟ should be recorded where the patient does not provide the information.
3.12
Country of Birth: Country of birth should be selected from the standard list.
3.13
Unique Patient Identifier: Most systems will automatically generate a unique Patient
Identifier number at patient registration.
3.14
Some patients may not provide all these details. This should not prevent them being
registered and accessing the service. If not all these details are collected at the first
attendance, it may be possible to collect some further information at subsequent
patient attendances.
Attendance type
3.15
When the booking is made the attendance type must be recorded. The GUMCAD
return requires information on the type of the appointment to distinguish new and
follow-up patient attendances, and whether these are face-to-face or
telephone/telemedicine consultations. The national categories, as defined by the NHS
Data Dictionary, are as follows:
First attendance face-to-face
Follow-up attendance face-to-face
First telephone or telemedicine consultation
Follow-up telephone or telemedicine consultation.
A first face-to-face attendance refers to a patient at the start of any new episode of
care. A follow-up face-to-face attendance refers to a patient attending a follow-up
appointment for a pre-existing condition. The same definitions apply to telephone or
telemedicine consultations.
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Appendix D
3.16
The coding options for attendance type categories are given in Appendix 2.
3.17
In most clinic software systems, first patient attendances are further distinguished as
either new or re-book attendances. A new patient attendance refers to patients at the
start of a new episode who are being registered and seen at the clinic for the first time,
and a re-book patient attendance to patients at the start of a new episode who were
registered at the clinic during a previous episode. Criteria for booking new or re-book
appointments are as follows: (1) The patient has never before attended the service (2)
the reason for attendance is not related to any previous visit by that patient, and (3) the
patient was discharged following their last visit or was not required to attend for a
follow-up visit. New and re-book attendances are not distinguished on the GUMCAD
return. However, for local patient management and commissioning purposes it is
advisable to continue to record attendance information in this way on your clinic
system if possible.
3.18
Please note the recording of first and follow-up attendances may be automated in your
system. Attendances by a patient within 26 weeks of their last attendance will usually
be classified as a follow-up attendance by clinic software. Attendances by a patient 26
weeks or more after their last attendance will usually be classified as a first or re-book
attendance by clinic software. However, patients will frequently return to the clinic
within 26 weeks with a new episode or problem and these patients should be reregistered and coded as a first (re-book) attendance. In order to invoke a re-book
attendance you must close the previous episode by discharging the patient or make it
very clear in the case records that no further follow up is planned. Consequently, you
should manually change the attendance type details in the clinic software if an episode
is closed within, or should extend beyond, the 26 week default interval. If you are
unsure, please check with clinical staff to determine exactly how these items are to be
recorded.
3.19
Information from patients with a booked appointment but who did not attend (DNAs)
is not included in the GUMCAD return.
Attendance date
3.20
When the patient attends for the appointment the Attendance Date must be recorded.
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Appendix D
Clinical details and SHHAPT (KC60)/READ coding
3.21
During the clinical consultation, the following items need to be recorded for all
patients:
Sexual orientation
Sexual Health and HIV Activity Property Type (SHHAPT)1 or READ code
3.22
Data may be recorded directly onto the system by the clinician during the consultation
or written in the clinical notes. The data entry process may therefore vary by clinic i.e.
it may be entered by the clinician or transcribed later from clinical notes by
administrative or other staff.
Sexual Orientation:
3.23
Patients will have a sexual history taken during the clinical consultation. Detailed
guidelines on taking a sexual history have been developed by BASHH and should be
followed closely („National Guideline for Consultations requiring Sexual History
Taking‟, BASHH 2005). For the GUMCAD return, it is necessary to determine and
record the Sexual Orientation of the patient2. The system default should be set as
„Unknown‟ but it is important to record specific and accurate information whenever
possible. Sexual orientation should be collected for both males and females.
3.24
The coding options for sexual orientation are given in Appendix 2.
SHHAPT/READ codes:
3.25
Each item of service provided or diagnosis made in a GUM clinic and in some ESHSs
is described by a SHHAPT code. Enhanced general practices and sexual and
reproductive health (SRH) services using GP software, will use the national READ
coding system. At least one SHHAPT/READ code must be recorded for each first
patient attendance. A SHHAPT/READ code may also be appropriate at certain followup attendances. Where possible, the SHHAPT/READ code should be recorded on the
system or in the clinical notes during or immediately after the consultation. For those
situations where this is not possible e.g. where the results from tests are awaited, codes
should be recorded as soon as this is possible.
3.26
All SHHAPT/READ codes should be used only once per patient episode. The
exception is the SHHAPT code H2 which should be used every time a patient attends
for HIV related care (i.e. it is attendance based). This is because H2 codes may be
used to extract information for SOPHID (Survey of Prevalent HIV Infections
Diagnosed) patients.
1
Previously known as KC60 codes.
Sexual orientation is collected because route of transmission („How acquired‟) is not appropriate for service
provision codes such as „sexual health screen‟.
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2
Appendix D
SHHAPT codes with descriptions and guidance on how they should be used are given in
Appendix 3. A reduced list of READ codes has been developed by the HPA and is included in
Appendix 4; a more comprehensive list is included in Appendix 5. However, this list is not
exhaustive and is subject to change due to the release of new READ codes. Any national
sexual health READ code may be submitted by clinics using READ codes.
Other guidance
3.27
Supportive arrangements should be made where necessary for patients who do not
have English as a first language, or who are visually impaired or have other disabilities
that may affect their ability to complete the form e.g. literacy.
3.28
Patients should be made aware that the questions on the registration form and at sexual
history taking are designed to help manage their care.
3.29
Clinics should be aware that some patients will have questions regarding these items.
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Appendix D
4
Reporting and transmitting data to the HPA
Description
4.1
Each GUM clinic and ESHS is required by law to produce a quarterly electronic data
extract of all patient attendances and diagnoses at GUM clinics/ESHSs with associated
patient information for the GUMCAD statistical return. These extracts are submitted
to the Health Protection Agency (HPA) Centre for Infections for processing and
analysis. The data items collected on the GUMCAD return are shown in Appendix 1.
All specified fields are mandatory and must be reported1.
Running extracts
4.2
In the majority of cases, the clinic‟s computer software will have a routine query tool
to run the GUMCAD extract. This process is likely to vary according to the software
your clinic uses, so please refer to your software provider‟s training material for
specific guidance where necessary.
4.3
A Morbidity Information Query and Export Syntax (MIQUEST) query is currently
under development and will be distributed to all ESHSs that are using GP software.
The tool will automate extraction for these services and the extraction is dependant
upon all information collected during a sexual health consultation being recorded in a
designated template.
Extract format
4.4
Once you have run the query, the GUMCAD extract report should be formatted into a
single comma delimited CSV file2. The format of the CSV file is presented in
Appendix 1. 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. If you think the format
of your extract differs from the one below, please contact your software provider for
further advice. Files that do not match this format cannot be uploaded into the
database at the HPA.
Example of CSV format for GUMCAD2 for services using SHHAPT codes for one row of data
ClinicID,PatientID,KC60,Gender,Age,Sex_Ori,Ethnicity,Country_Birth,PCT,LSOA,First_Attendance,AttendanceDate
RCC25,PAT123,C10A,1,16,1,A0,GBR,5K9,E01000001,1,2007-10-31
Example of CSV format for GUMCAD2 for services using READ codes for one row of data
ClinicID,PatientID,READ,Gender,Age,Sex_Ori,Ethnicity,Country_Birth,PCT,LSOA,First_Attendance,AttendanceDate
RCC25,PAT123,A98z.11,1,16,1,A0,GBR,5K9,E01000001,1,2007-10-31
1
The only exception is that a SHHAPT code need not be supplied for follow-up attendances.
HPA are working with software providers towards changing GUMCAD files to XML format to be compliant
with eGIF standards.
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2
Appendix D
Reporting time period
4.5
Each GUMCAD extract should cover one calendar quarter.
Frequency of reporting
4.6
Reports should be run quarterly, at least seven days after the end of the calendar
quarter but no later than six weeks after the end of the calendar quarter. You must
therefore ensure that patient records have been updated with the appropriate
SHHAPT/READ codes (except in the minority of cases where results are delayed) and
that these have been entered onto your computer system within 6 weeks of the end of
the quarter. The GUMCAD Team at the HPA will send you a reminder two weeks
before the deadline. Failure to meet the deadline will result in a null return for your
clinic‟s data in quarterly feedback reports to the Department of Health and Trust
managers. If you have concerns that you are unlikely to be able to meet this deadline
please contact the GUMCAD Team at the HPA for advice as soon as possible.
Transmission of the data extract to the HPA
4.7
GUMCAD data extracts must be submitted to the HPA through the HIV/STI web
portal. This portal enables organisations to distribute files to previously identified
users in a secure manner across the Internet. Use of the portal requires a login account
name and password, which will be provided to you by the GUMCAD Team at the
HPA Centre for Infections. Requests for user accounts should be sent to:
[email protected]. The web portal can be found at:
https://www.hpawebservices.org.uk/HIV_STI_Webportal/
Overlap with the Sexual and Reproductive Health Activity Dataset
(SRHAD)
4.8
Sexual and reproductive health services are also expected to submit SRHAD to the
NHS Information Centre. SRHAD provides data on contraception provision and other
SRH activities carried out at SRH services. A number of data items within SRHAD
and GUMCAD overlap (see Appendix 6), SRH services are not expected to complete
these data items twice, but to continue to record the information routinely into their IT
system. It is down to the development of the software to extract the relevant
information to the specific dataset. Both SRHAD and GUMCAD data items comply
with NHS Data Dictionary formatting and conditions.
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Appendix D
5
How the HPA uses the data
Purpose of the GUMCAD return
5.1
The GUMCAD data are collected and analysed to monitor trends in new diagnoses of
sexually transmitted infections (STI) and other sexual health problems and to
determine which specific groups are at particular risk. For example, the data can be
used to identify (1) emerging syphilis outbreaks in particular localities, (2) increasing
gonorrhoea transmission among certain ethnic groups, or (3) HIV or other STI risk in
specific immigrant populations.
This information is used to inform the public health response by:
Improving the planning and management of services.
Developing, adapting and refining interventions.
Monitoring the effectiveness of sexual health policies.
Types of output
5.2
In addition to the HPA‟s main annual publication on HIV and Sexually Transmitted
Infections, the agency aims to produce timely routine outputs of data at the local,
regional and national level.
The HPA has launched a GUMCAD data reporting tool available on the HIV/STI web
portal. The tool enables clinic, PCT, SHA and HPA staff to run summary reports of
aggregated data at the clinic or PCT level. These reports can be accessed at
https://www.hpawebservices.org.uk/HIV_STI_Webportal/ using your user name and
password.
5.3
The following reports are available or are in development:
Phase 1
•
Numbers of Selected STI Diagnoses
•
Sexual Health Screens
•
HIV Test Offer and Uptake
•
Patient Flow for Each PCT and SHA
•
Rates of Selected STI Diagnoses
Phase 2
•
Numbers of All Diagnoses and Services Provided
•
Data Completion/Data Quality
•
Yearly Trends for Selected STI Diagnoses
•
Reporting compliance
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Appendix D
Reporting time period
5.4
HPA output reports will cover quarterly and annual periods.
Frequency of reporting
5.5
The HPA will update the data for running reports quarterly. Data from clinics should
be received by HPA within 6 weeks after the calendar quarter. HPA aims to make
updated reports available 2 weeks thereafter.
Report format
5.6
Automated reports will be produced in pdf and Microsoft Excel format.
Presentation of local area data
5.7
Following recent guidance issued by the Office of National Statistics on the risk of
deductive disclosure in small area statistics, the HPA has agreed with the Department
of Health (DH) that clinic and LSOA level STI data tables will not be published by the
HPA, in hard copy or on the website. Some PCT level data may be published in tables
provided that these have been assessed and considered not to be at risk of deductive
disclosure.
5.8
Clinic, PCT and Local Authority level data tables will be distributed in confidence to
relevant organisations within the NHS, DH, local government and HPA.
5.9
When PCT or clinic level data are requested by other organisations (such as for
Freedom of Information requests or Parliamentary Questions), then all cell sizes with
counts of between 1 and 4 inclusive, and any associated „Totals‟ columns that would
allow these cells to be deduced, will be blanked out (unless these have previously been
assessed and considered suitable for publication).
5.10
Maps of STI rates by area of residence, where rates are grouped into categories, may
be published in reports and on the HPA website.
Recipients of routine reports
5.11
Reports will be made available to all clinics, PCTs, SHAs, Health Protection Units,
Local Authorities, and the Department of Health.
Distribution of reports
5.12
Reports will be made available across the HIV/STI web portal and will require a valid
user name and password for access.
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Appendix D
6
Confidentiality and anonymity
6.1
Wherever possible, due to the sensitive nature of the data collected, system controls
should be put in place to ensure that only those individuals for whom it is necessary to
see certain patient information, are able to see it. EMIS LV is the biggest software
supplier for enhanced general practice and there are system controls in place which
means that clinicians have the highest level of access and are able to see all patient
data and system administrators will only be able to see certain patient data.
6.2
Some patients may express concern regarding supplying their data and it being
reported to the HPA. If so, the following approach should be taken:
Explain the uses to be made of the data i.e. what they are consenting to, which is to
allow information to be recorded and reported to improve the service and to
protect public health. This will reassure the vast majority of patients. When
necessary, patients should be reassured that their personal data are held in strict
confidence and that no personally identifiable information will be reported to the
HPA. Patients can also be provided with the HPA leaflet “Information and the
Health Protection Agency” for further information. These leaflets have been
distributed to your clinic but can also be accessed on the HPA website here:
http://www.hpa.org.uk/ProductsServices/InfectiousDiseases/ServicesActivities/Sur
veillance/SafeguardingTheConfidentiality/
If there are still on-going concerns, systems allow for the use of aliases. Whilst
this is not ideal it is preferable to not recording the data at all. This should then
allow for the reporting of data for these patients.
If a patient‟s data has been submitted to the HPA and the patient later objects, you
should contact the GUMCAD Team at HPA with the patient‟s unique ID number
and your clinic code so that HPA staff can delete the relevant patient‟s records on
the database.
6.2
The HIV/STI web portal enables organisations to distribute any type of files to
previously identified users in a secure manner across the Internet. The HIV/STI web
portal can be found at: https://www.hpawebservices.org.uk/HIV_STI_Webportal/. Use
of the portal requires a login account name and password, which will be available
from the project administrator at the Centre for Infections. The portal supports the
Secure Sockets Layers (SSL) method of communication.
6.3
All staff within the HPA have a legal duty to keep patient information confidential.
All records are kept securely in compliance with the Caldicott Guidelines. The HPA
stores personal health information on secure servers and all databases are password
protected. Access to the data is strictly controlled and limited to those directly
involved in the collation of the data. Disaggregated data are retained for a maximum
of 8 years from the date of patients‟ last attendance.
6.4
Following recent guidance issued by the Office of National Statistics on the risk of
deductive disclosure in small area statistics, the HPA has agreed with the DH that
clinic and LSOA level STI data tables will not be published by the HPA, in hard copy
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Appendix D
or on the website. Some PCT level data may be published in tables provided that these
have been assessed and considered not to be at risk of deductive disclosure. Clinic,
PCT and Local Authority level data tables will be distributed in confidence to relevant
organisations within the NHS, DH, local government and HPA. When PCT or clinic
level data are requested by other organisations (such as for Freedom of Information
requests or Parliamentary Questions), then all cell sizes with counts of between 1 and
4 inclusive, and any associated „Totals‟ columns that would allow these cells to be
deduced, will be blanked out (unless these have previously been assessed and
considered suitable for publication). Maps of STI rates by area of residence, where
rates are grouped into categories, may be published in reports and on the HPA
website.
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Appendix D
7
Contact information for support and guidance
7.1
Further guidance on collecting, recording and reporting data for the GUMCAD return
is available from:
GUMCAD Reporting Team, STI Section
Department of HIV and STIs
Health Protection Agency Centre for Infections
61 Colindale Avenue
London
NW9 5EQ
Tel: 020 8327 7469
Fax: 020 8200 7868
[email protected]
http://www.hpa.org.uk/gumcad
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Appendix D
8
Position
*
Appendix 1: Data items collected on the
GUMCAD return
Field Name
Description
1
ClinicID
Clinic ID code
2
PatientID
Local patient identifier
number
3
KC60
SHHAPT code
4
READ
Sexual Health/HIV
READ code
5
Gender
Gender
6
Age
Age at attendance date
in years
7
Sex_Ori
Sexual orientation
8
Ethnicity
9
Country_Birth
10
PCT
PCT of residence code
11
LSOA
Lower Super Output
Area of residence code
12
First_Attendance
Attendance type
13
AttendanceDate
Date of attendance
Patient‟s ethnic
category
Patient‟s country of
birth
NHS Data Dictionary
Data Element
SITE CODE (OF
TREATMENT)
LOCAL PATIENT
IDENTIFIER
SEXUAL HEALTH AND
HIV ACTIVITY
PROPERTY TYPE
DIAGNOSTIC OR
PROCEDURE CODING
(SEXUAL HEALTH AND
HUMAN
IMMUNODEFICIENCY
VIRUS RELEVANT
READ CODE
PERSON GENDER
CURRENT
AGE AT ATTENDANCE
DATE
SEXUAL
ORIENTATION
(CURRENT)
ETHNIC CATEGORY
COUNTRY CODE
(BIRTH)
ORGANISATION CODE
(PCT OF RESIDENCE)
LOWER LAYER SUPER
OUTPUT AREA
(RESIDENCE)
FIRST ATTENDANCE
ATTENDANCE DATE
Variable
Length≠
Example±
AN(5)
RCC25
AN(10)
PAT123
AN(5)
C10A
AN(7)
A78A.00
N(1)
1
N(3)
16
N(1)
1
AN(2)
A0
A(3)
GBR
AN(3)
5K9
AN(9)
E01000001
N(1)
N(10) CCYYMM-DD
1
2007-10-31
*Refers to the horizontal position of the field within CSV format
≠
AN = Alpha-numeric, N = Numeric, A = Character. Number in brackets denotes the string length.
±
Example of field content, also used to illustrate extract format expected
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Appendix D
9
Appendix 2: Summary of format and available
coding options for data items collected on the
GUMCAD return
Data item
Format and coding options
Clinic ID
Format/length: an5
PatientID
Format/length: an10
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.
KC60/SHHAPT
Format/length: an5
National Codes: The national SHHAPT codes and their definitions are given in sections 4.4 – 4.6
Notes: SEXUAL HEALTH AND HIV ACTIVITY PROPERTY TYPE renamed from
GENITOURINARY EPISODE TYPE
Format/length: an7
National Codes: A reduced list of national READ codes and their definitions are given in appendix
4 and a fuller list in appendix 5.
Notes: ESHSs will either supply their diagnostic/clinical codes in the form of SHHAPT codes
under the data item “KC60” as SHHAPT codes or as READ codes under the data item “READ”.
READ codes can be mapped to SHHAPT codes nationally at the HPA to allow reporting of
combined GUMCAD and GUMCAD2 data.
READ
Gender
Format/length: n1
National Codes:
0 Not Known - means that the gender of the person has not been recorded.
1 Male
2 Female
9 Not Specified – means indeterminate, i.e. unable to be classified as either male or female
Age
Format/length: n3
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, i.e. date of birth not known and age cannot be estimated
Sex_Ori
Format/length: n1
National Codes:
1 Heterosexual
2 Homosexual
3 Bi Sexual
9 Unknown
Ethnicity
Format/length: an2
National Codes:
White
A British
B Irish
C Any other White background
Mixed
D White and Black Caribbean
E White and Black African
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Appendix D
Data item
Format and coding options
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
Country_Birth
Format/length: A(3)
Refer to the International Standard of Organisation (ISO) 3166-1 standard for actual list of
alphabetic codes and countries. Where country of birth in unknown please record this as ZZZ
Note: The 2-char alphabetic code must not be used.
Max 3 Characters
Reference: http://www.iso.org/iso/home.htm
PCT
Format/length: an3
Notes: PCT OF RESIDENCE is the same as the attribute ORGANISATION CODE.
Derived from POSTCODE using mapping from the National Administrative Codes Service
(NACS).
There is a PCT (or equivalent) for each postcode in England, Wales, Scotland and Northern
Ireland. Records where the patient‟s postcode has not been provided to generate PCT of residence
should be allocated to „not known‟ and coded "Q99". Postcodes outside the UK (overseas visitors)
should be allocated to „not applicable‟ and coded as “X98”.
http://www.connectingforhealth.nhs.uk/technical/standards/nacs
LSOA
Attend_type
Format/length: an9
List of English Lower Super Output Area codes available at
http://www.statistics.gov.uk/geography/soa.asp
http://neighbourhood.statistics.gov.uk/dissemination/Info.do?page=SOAConstitutions.htm
There is a Lower Layer Super Output Area for each postcode in England and Wales. Postcodes in
Scotland, Northern Ireland, Channel Islands or Isle of Man should be coded “Z99999999”.
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”.
Format/length: n1
The National Codes for „FIRST ATTENDANCE‟ 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
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Appendix D
Data item
Format and coding options
AttendanceDate
Format/length: n10 – ccyy-mm-dd
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Appendix D
10 Appendix 3: SHHAPT codes, suffixes and
definitions
A.
DIAGNOSIS OF INFECTION, CONDITION OR DISEASE
SHHAPT code
Description
Definition and guidance
A1
Primary syphilis
This refers to primary infectious syphilis. Laboratory confirmation is required.
A2
Secondary syphilis
This refers to secondary infectious syphilis. Laboratory confirmation is
required.
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.
A4
Cardiovascular syphilis
This refers to cardiovascular syphilis
A5
Neurosyphilis
This refers to syphilis of the nervous system.
A6
All other late and latent
syphilis
This refers to latent syphilis after the first two years of infection and all other
latent syphilis.
Congenital syphilis
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.
A7A
This includes all cases of complicated and uncomplicated gonorrhoea (preand post-pubertal) involving any site.
B
Gonorrhoea
Persistent/recurrent gonorrhoea:
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, antibiotics not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner) within 6 weeks.
Patients who are thought to be newly infected after a previous episode of
gonorrhoea should be regarded as a new GUM episode and be investigated,
treated and diagnosed/coded accordingly.
Rectal and pharyngeal site suffix codes may be added. The X suffix may be
added where the patient is known to have been diagnosed with this infection
episode at another non-GUM clinic health setting.
C1
Chancroid
Laboratory confirmation is essential for this condition.
C2
Lymphogranuloma
venereum
Laboratory confirmation is essential for this condition.
Rectal or pharyngeal site suffix codes may be added.
C3
Donovanosis
Laboratory confirmation is essential for this condition.
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Appendix D
SHHAPT code
Description
Definition and guidance
Chlamydial infection
This includes all cases of complicated and uncomplicated Chlamydia
trachomatis infections (diagnosed by culture or antigen detection) involving
any site.
Persistent/recurrent chlamydia:
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, antibiotics not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner) within 6 weeks.
Patients who are thought to be newly infected after a previous episode of
chlamydia should be regarded as a new GUM episode and be investigated,
treated and diagnosed/coded accordingly.
Rectal or pharyngeal site suffix codes may be added. The X suffix may be
added where the patient is known to have been diagnosed with this infection
episode at another non-GUM clinic health setting.
C4N
Non-specific genital
infection
This includes all cases of complicated and uncomplicated NSGI. Proctitis
should be coded C4N with the rectal site suffix code i.e. 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 are also to be
coded C4N.
Persistent/recurrent urethritis:
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, antibiotics not taken correctly) and those who have had sexual
intercourse with an untreated partner (not a new partner) within 6 weeks.
Patients who are thought to be newly infected after a previous episode of nonspecific infection should be regarded as a new GUM episode and be
investigated, treated and diagnosed/coded accordingly.
C5A
Pelvic inflammatory
disease and
epididymitis
This includes all cases of pelvic inflammatory disease and all cases of
epididymitis associated with chlamydial, gonococcal or non-specific infections.
Can be used with the relevant infection code, where appropriate. Other
complications should be coded D2B.
C5B
Opthalmia neonatorum
This includes all cases of opthalmia neonatorum. Can be used with the
relevant infection code.
C6A
Trichomoniasis
If associated with bacterial vaginosis then code C6A only should be used.
C6B
Anaerobic/bacterial
vaginosis and
anaerobic balanitis
Diagnosis of bacterial vaginosis 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. Other and nonconfirmed anaerobic balanitis should be coded as C6C. Asymptomatic
patients who do not require treatment should not be coded C6B.
C6C
Other
vaginosis/vaginitis/
balanitis
C4
C7
C8
Anogenital candidosis
This is diagnosed only when there is microscopic or culture evidence of
Candida infection. If no microbiological evidence then case should be coded
as C6C. Asymptomatic patients who do not require treatment should be
coded D3.
Scabies
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.
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Appendix D
SHHAPT code
Description
Definition and guidance
Pediculosis pubis
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.
C10A
Anogenital Herpes
simplex: first episode
An episode should be recorded here only if the patient has never (as far as
can be ascertained) previously had a confirmed diagnosis with anogenital
herpes. Laboratory confirmation is essential.
C10B
Anogenital Herpes
simplex: recurrence
This should include all other episodes of anogenital herpes. If there has been
previous confirmation, then clinical judgement is enough for this diagnosis.
Anogenital warts
infection: first episode
An episode should be recorded here only if the patient has never (as far as
can be ascertained) been previously treated for anogenital warts.
C11A diagnosis refers to macroscopic warts, not acetowhite patches or
abnormalities revealed by acetowhite staining, nor is the cytological finding of
wart virus change sufficient to use this code.
C9
C11A
C11D
C12
Anogenital warts
infection: recurrence
This should include all other episodes of anogenital warts and should only be
used once per episode.
C11D diagnosis refers to macroscopic warts, not acetowhite patches or
abnormalities revealed by acetowhite staining, nor is the cytological finding of
wart virus change sufficient to use this code.
Molluscum
contagiosum
C13
Viral hepatitis B (HbsAg
positive): First
diagnosis
C13 records a first diagnosis of antigen positive hepatitis B. Known carriers of
hepatitis B who present at a clinic for the first time should also be coded as
C13.
All subsequent presentations of hepatitis B that require management should
be coded as D2B. Subsequent attendances by carriers that are unrelated to
hepatitis B management should not be coded.
C14
Viral hepatitis C: First
diagnosis
This code records the first diagnosis of hepatitis C, defined as anti-HCV
positive or HCV RNA positive.
C15
Viral hepatitis A: acute
infection
This code records a diagnosis of acute hepatitis A, defined as detection of
hepatitis A virus specific IgM antibodies.
D2A
Urinary tract infection
Includes all patients with a positive culture, otherwise patients should be
coded D2B.
D2B
Other conditions
requiring treatment at
GUM clinic
H
H1
H1A
HIV positive
This code is to be use for first (new or re-book) attendances in patients who
are known to have previously been diagnosed with HIV infection in any clinical
setting but who are not attending specifically for HIV-related care.
Codes H, H1, H1A, H1B and H2 are all mutually exclusive.
New HIV diagnosis
This includes all new HIV diagnoses. Codes H, H1, H1A, H1B and H2 are all
mutually exclusive.
The X suffix may be added where the patient is known to have been
diagnosed with HIV at another non-GUM clinic health setting.
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 (e.g. RITA assay, RNA, neutralisable p24 antigen and
antibody negative), or
c) evidence of seroconversion illness.
Codes H, H1, H1A, H1B and H2 are all mutually exclusive.
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Appendix D
SHHAPT code
H1B
Description
New HIV diagnosis:
Late
Definition and guidance
This includes all new HIV diagnoses which have a clinical AIDS diagnosis
within three months of their HIV diagnosis.
Codes H, H1, H1A, H1B and H2 are all mutually exclusive.
Attendance for HIVrelated care
This includes all attendances relating to HIV care.
Codes H, H1, H1A, H1B and H2 are all mutually exclusive.
Once defined, standardised BASHH codes will enable stage of infection to be
determined and thereby support reporting to the Survey of Prevalent HIV
Infections Diagnosed (SOPHID) and for calculating PbR tariffs.
P4A
Cervical cytology: minor
abnormality
Includes smears showing lower grades (i.e. “borderline” or “mild”) of
dyskaryosis on cytological examination.
P4B
Cervical cytology: major
abnormality
Includes smears showing moderate or worse (i.e. “moderate” or “severe”)
dyskaryosis on cytological examination.
H2
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Appendix D
B.
SERVICES PROVIDED
New
SHHAPT
code
Description
Definition and guidance
T1
Chlamydia test
T1 should be used for patients tested for chlamydia but who are not tested for
gonorrhoea or syphilis.
T1 is mutually exclusive of T2, T3 and T4 but may be used with P1A, P1B and
P1C.
T2
Chlamydia and
gonorrhoea tests
T2 should be used to code a sexual health screen which includes gonorrhoea
and chlamydia testing but excludes syphilis testing.
T2 is mutually exclusive of T1, T3 and T4 but may be used with P1A, P1B and
P1C.
T3
Chlamydia,
gonorrhoea and
syphilis tests
T3 should only be used to code a sexual health screen which includes
gonorrhoea, chlamydia and syphilis testing but excludes HIV testing.
T3 is mutually exclusive of T1, T2, T4 and P1A but may be used with P1B and
P1C.
T4
Full sexual health
screen including HIV
antibody test
T4 is used to code a full sexual health screen including gonorrhoea, chlamydia,
syphilis and HIV testing.
T4 is mutually exclusive of T1, T2, T3, P1A, P1B and P1C.
HIV antibody test
This code is to be used for any HIV antibody testing done which is not part of a
full sexual health screen as described by code T4.
P1A is mutually exclusive of T3, T4, P1B and P1C but may be used with T1 and
T2.
HIV antibody test
offered and refused
This code refers to all patients offered an HIV test who decline the test even
though the clinician believes there is some possible HIV risk that could be
screened by testing on that day. The code is used regardless of whether a pretest discussion or counselling was given, or whether the patient intends to test in
the future.
P1B is mutually exclusive of T4, P1A and P1C.
P1C
HIV test inappropriate
This code is used to describe a patient attendance where an HIV test was not
offered because it was not appropriate or was offered but after discussion it was
deemed not appropriate e.g. where the patient has been recently tested, is in the
„window‟ period, is already known to be HIV positive etc.
P2A
Hepatitis B
st
vaccination: 1 dose
P1A
P1B
st
Only the 1 dose of any new Hepatitis B vaccination course should be included.
This would include those patients who may have been vaccinated some time in
the past but are now receiving the first dose of a new course of vaccination.
Subsequent doses should be coded P2B/P2C and boosters should be coded as
D2B.
P2B
Hepatitis B
nd
vaccination: 2 dose
Includes only the second dose of a Hepatitis B vaccination course, including
those who are known to have received a first dose at another clinic.
P2C
Hepatitis B
rd
vaccination: 3 dose
Includes only the third dose of a Hepatitis B vaccination course, including those
who are known to have received a first and/or second dose at another clinic.
P2I
Hepatitis B immune
Includes patients who are ineligible for hepatitis B vaccination because they are
already immune. This should only be recorded once, the first time a patient
attends a particular clinic, or when first known to be immune.
P4
Cervical cytology
done
Includes all patients who had cervical cytology done, regardless of outcome.
W1
HPV vaccination: 1
dose
Only the 1 dose of any new human papillomavirus vaccination course should be
included. This would include those patients who may have been vaccinated
some time in the past but are now receiving the first dose of a new course of
vaccination. Subsequent doses should be coded W2/3.
The Q suffix can be added if the quadrivalent vaccine is used.
W2
HPV vaccination: 2
dose
st
st
nd
Includes only the second dose of a HPV vaccination course, including those who
are known to have received a first dose at another clinic.
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Appendix D
New
SHHAPT
code
Description
Definition and guidance
rd
W3
HPV vaccination: 3
dose
Includes only the third dose of a HPV vaccination course, including those who
are known to have received a first and/or second dose at another clinic.
PN
Partner notification
initiated
For use in Level 2 & Level 1 services only: Partner notification has been initiated
for this patient by this clinic.
PNC
Partner notificationrelated attendance:
Chlamydia
This should be used for those presenting as a partner of an index case
diagnosed with chlamydia (at this or any setting). If the partner is found to be
infected with chlamydia he/she should also be coded C4.
PNG
Partner notificationrelated attendance:
Gonorrhoea
This should be used for those presenting as a partner of an index case
diagnosed with gonorrhoea (at this or any setting). If the partner is found to be
infected with gonorrhoea he/she should also be coded B.
PNS
Partner notificationrelated attendance:
Syphilis
This should be used for those presenting as a partner of an index case
diagnosed with syphilis (at this or any setting). If the partner is found to be
infected with syphilis he/she should also be coded A1, A2 or A3.
PNH
Partner notificationrelated attendance:
HIV
This should be used for those presenting as a partner of an index case
diagnosed with HIV (at this or any setting). If the partner is found to be infected
with HIV he/she should also be coded H1, H1A or H1B.
PEPS
Post exposure
prophylaxis after
sexual exposure
(PEPSE)
Used for patients given HIV prophylaxis following sexual exposure
Contraception
(excluding condom
provision)
This code will be used to record contraception (females only), including
prescribing and family planning advice, and excluding condom provision.
Condom provision should not be included.
This code should not be used in sexual health services where SHRAD coding is
in use.
Other episodes not
requiring treatment
D3 is used to code any new patient episode where no treatment is given,
whether or not a sexual health screen and/or an HIV test are/is performed. D3
can therefore be used to record an episode where a patient tests negative for all
tests done, or where testing the patient is not indicated and otherwise no
treatment is given.
D3 may also be used to record any other contact with a patient for clinical
purposes but which does not result in treatment. Patients who do not attend
appointments may be coded D3 if a) they have already been triaged, or b) they
have had contact with a health advisor. Otherwise patients who do not attend
should not be coded D3.
D3 can be used only once per patient episode.
Prisoner
The „Z‟ code is used to code the provision of a service to a patient known to be a
current prisoner.
Sex worker
The „SW‟ code is used to code the provision of a service to a patient known to be
a current sex worker.
P3
D3
Z
SW
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Appendix D
C.
SUFFIXES TO CODES
For a number of conditions it is useful to record additional information about the patient’s presentation or service
given. This will be collected through the use of suffixes which can be appended to certain SHHAPT codes. Where
appropriate, multiple suffixes can be used on the same SHHAPT code, however, for site of infection suffixes R
and O, only one suffix should be used to describe an infection episode. Where multiple suffixes are used, they
should be ordered R or O followed by X, M. (A complete list of permissible code permutations using suffixes is
given in Table D).
Suffix
Description
R
Rectal infection
O
Pharyngeal infection
X
Diagnosed previously
elsewhere
M
Medication given
Q
Quadrivalent HPV
vaccine
SHHAPT codes to
be used with
Definition and guidance for use
The „R‟ suffix is added where a diagnosis includes infection of
the anorectum. Where the patient is infected at multiple sites
including the anorectum the patient need only be coded once
using the root SHHAPT code and the „R‟ suffix.
The „O‟ suffix is added where a diagnosis includes a pharyngeal
infection but excludes anorectal and genital infections.
1
For use in Level 3 services only: The „X‟ suffix is added where a
patient is known to have been diagnosed with their presenting
condition at another non-level 3 (non-GUM clinic) health setting
in the UK before this attendance.
2
For use in Level 2 & level 1 services only: The patient was
given/prescribed treatment at this setting for the presenting
condition. The M suffix should be used whether or not the patient
is then referred for further management.
The „Q‟ suffix is added where a patient being immunised against
HPV receives the quadrivalent vaccine.
B, C4, C2, C4N
B, C4, C2
B, C4, H1, H1A,
H1B
B, C4, C10A,
C10B, C11A,
C11D.
W1, W2, W3
1
Level 3 service = Specialist Sexual Health and HIV (or genitourinary medicine clinic) service
Level 1 and level 2 services = Other commissioned sexual health services
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Appendix D
D. PERMISSIBLE CODE PERMUTATIONS USING SUFFIXES
Permissible combinations of SHHAPT codes and their suffixes are shown below:
SHHAPT
Code & Suffix
Combinations
BR
BO
BX
BM
BRX
BRM
BOX
BOM
C4R
C4O
C4X
C4M
C4RX
C4RM
C4OX
C4OM
C2R
C2O
C4NR
H1X
H1AX
H1BX
C10AM
C10BM
C11AM
C11DM
W1Q
W2Q
W3Q
1
Description
LGV
NSGI
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
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
Proctitis
HIV
Diagnosed previously elsewhere
HSV
Medication given
Warts
Medication given
HPV vaccine
Quadrivalent vaccine
Gonorrhoea
Chlamydia
1
Service type
All
All
L3
L1,L2
L3
L1,L2
L3
L1,L2
L1,L2,L3
L1,L2,L3
L3
L1,L2
L3
L1,L2
L3
L1,L2
L1,L2,L3
L1,L2,L3
L1,L2,L3
L3
L3
L3
L1,L2
L1,L2
L1,L2
L1,L2
L1,L2,L3
L1,L2,L3
L1,L2,L3
L1 and L2 = Level 1 and level 2 commissioned sexual health services; L3 = Specialist Sexual Health and HIV
(or genitourinary medicine clinic) services
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Appendix D
11 Appendix 4: Reduced list of READ codes
A.
DIAGNOSIS OF INFECTION, CONDITION OR DISEASE
READ code
READ code description
A78A.00
Chlamydial infection
K420900
Chlamydia cervicitis
A78A200
Chlamydial infection of anus and rectum
A98z.11
Gonorrhoea
A987100
Gonococcal rectal infection
A980100
Acute gonococcal urethritis
A981500
Acute gonococcal cervicitis
A910.00
Primary genital syphilis
A919.00
Unspecified secondary syphilis
A92..00
Latent early syphilis
A96..00
Late latent syphilis
A90..00
Congenital syphilis
A781200
Genital warts
7D03311
Cauterisation of vulval warts
7D03500
Painting of vulval warts
7732300
7732500
Cauterisation of perianal warts NEC
Painting of perianal warts
7732400
Cryotherapy to perianal warts
A541.00
Genital herpes simplex
43C3.11
HIV positive
65VE.00
Notification of AIDS
K44..00
Female gonococcal pelvic inflammatory disease
A981.00
Acute gonorrhoea upper GUT
K40y100
Female chlamydial pelvic inflammatory disease
K241600
Chlamydial epididymitis
K4...00
Female pelvic inflammatory diseases
K241.00
Epididymitis
A984011
Ophthalmia neonatorum - gonococcal
Q406713
Ophthalmia neonatorum - chlamydial
A94..00
Neurosyphilis
A990.00
Chancroid
A991.00
Lymphogranuloma venereum
A992.11
Donovanosis
A994.00
Nonspecific urethritis
AD1..00
Trichomoniasis - trichomonas
K421911
Bacterial vaginosis
AD22.12
Pediculus pubis - pubic lice
A780.00
Molluscum contagiosum
AD30.00
Scabies
K190.00
Urinary Tract Infection, site not specified
AB21.00
Candidal vulvovaginitis
GUMCAD: Behavioural and Organisational Guidance 21.07.11;
st
Implementation completion date: 31 December 2011
Page 29 of 32
Appendix D
READ code
READ code description
43B4.00
Hepatitis B surface antig +ve
43X3.00
Hepatitis C antibody test positive
A701.00
Viral (infectious) hepatitis A
B.
SERVICES PROVIDED
READ code
READ code description
8I3T.00
Chlamydia screening declined
43jK.00
Chlamydia DNA detection
68K7.00
Urine screen for chlamydia
4JK9.00
Endocervical chlamydia swab
4JKA.00
Urethral chlamydia swab
4JKD.00
Low vaginal swab for chlamydia taken by patient
4JF42.00
Throat swab for chlamydia
4JH63.00
Anal swab for chlamydia
4JF43.00
Throat swab for gonorrhoea
4JH64.00
43U6.00
Anal swab for gonorrhoea
Chlamydia test negative
8I3o.00
Gonorrhoea screening declined
4JLA.00
Gonococcal swab
4JKB.00
Gonococcal cervical swab
4JKC.00
Gonococcal urethral swab
4JQ8.00
Gonorrhoea test negative
43jA.00
Neisseria gonorrhoeae nucleic acid detection
8I3t.00
4381.00
Syphilis screening declined
Syphilis titre test negative
438..00
Syphilis infectious titre test
62K..00
Antenatal syphilis screen
4JR7.00
HIV screening test
62b..00
Antenatal HIV screening
8I3p.00
HIV screening declined
43C2.11
HIV negative
43M..00
Hepatitis A test
43B..00
SH-antigen (hepatitis B) test
43X2.00
Hepatitis C antibody test
65X..00
Contact tracing
6151.00
IUD fitted
614..11
Oral contraception
61B..00
Depot contraceptive
61Z..00
Contraception NOS
8B2L.11
Condom issued
GUMCAD: Behavioural and Organisational Guidance 21.07.11;
st
Implementation completion date: 31 December 2011
Page 30 of 32
Appendix D
12 Appendix 5: Full Sexual Health READ code list
Please click on the link below:
Final READ code list
for GUMCAD2 sites_200711.xlsx
Clinics using Clinical Terms version 3 will also be able to submit these and a full list
corresponding to the version 2 list will be sent out imminently. Although READ codes of
length AN(7) have been listed here, READ codes of length AN(5) will also be accepted.
GUMCAD: Behavioural and Organisational Guidance 21.07.11;
st
Implementation completion date: 31 December 2011
Page 31 of 32
Appendix D
13 Appendix 6: GUMCAD and SRHAD mapping
DATASETS: GUMCAD (&2)
Responsible Organisation:
Data Submitted By:
HPA
GUM & ESHSs
SRHAD
NHS IC
SRH services
DATA ITEMS
Patient Registration/Clinic Information
Organisation ID
Clinic ID
Patient ID
Gender
Age
Ethnicity
Country of Birth
PCT of Residence
LSOA of Residence
Responsible PCT
First Attendance
Date of Attendance
Initial Contact
Location Type








Attendance Information









*




Clinical Details
Sexual Orientation
KC60 (code)
READ (code)
Contraception Method Status
Contraception Main Method
Contraception Other Method (1&2)
Contraception Method Post Coital (1&2)
SRH Care Activity








*Proposed addition of LSOA of Residence to SRHAD to ensure data is available for a static geographical boundary
due to possible changes to PCT boundaries. Application to add this data item into SRHAD is currently being
considered by ISB.
GUMCAD: Behavioural and Organisational Guidance 21.07.11;
st
Implementation completion date: 31 December 2011
Page 32 of 32