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Queensland Health Data Dictionary

The following list is an inventory of data items maintained by Queensland Health to meet data requirements for National Minimum Data Sets about health care provision. The inventory is currently under review, which may result in some changes.

If you would like to obtain more information about the inventory, please contact the Health Statistics Centre for advice.

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Index

Data Item Name Page Number Account class .............................................................................................................................................7 Action of concern associated with the taking of alcohol.....................................................................8 and/or other drugs ...................................................................................................................................8 Actual place of birth .................................................................................................................................9 Additional diagnoses..............................................................................................................................10 Address line .............................................................................................................................................11 Address of usual residence....................................................................................................................13 ADL score.................................................................................................................................................15 ADL (activity of daily living) tool type...............................................................................................16 ADL (activity of daily living) tool sub-type ........................................................................................17 Admission ................................................................................................................................................19 Admission date - episode ......................................................................................................................20 Admission date - formal ........................................................................................................................21 Admission time .......................................................................................................................................22 Admission weight - neonate..................................................................................................................23 Apgar score (5 minutes) .........................................................................................................................24 Australian South Sea Islander ...............................................................................................................25 Australian State/Territory Identifier ...................................................................................................27 Band ..........................................................................................................................................................29 Behavioural issue potentially related to alcohol and/or ..................................................................30 other drug usage .....................................................................................................................................30 Birth order ................................................................................................................................................31 Birth plurality ..........................................................................................................................................32 Birth weight .............................................................................................................................................33 Birth-birth status .....................................................................................................................................34 Care type ..................................................................................................................................................35 Census date ..............................................................................................................................................39 Chargeable status ....................................................................................................................................40 Compensable/eligibility status for non-admitted patients ..............................................................41 Condition present on admission indicator..........................................................................................43 Contact for feedback indicator ..............................................................................................................44 Contract flag ............................................................................................................................................46 Contract leave ..........................................................................................................................................47 Contract role ............................................................................................................................................48 Contract service .......................................................................................................................................49 Contract type ...........................................................................................................................................51 Country of birth.......................................................................................................................................53 Current accommodation type ...............................................................................................................54 Date not ready for care ...........................................................................................................................58 Date of birth .............................................................................................................................................59 Date of confinement................................................................................................................................61 Date of formal separation ......................................................................................................................62 Date of starting leave ..............................................................................................................................63 Date of transfer (ward) ...........................................................................................................................64 Date returned from contract leave........................................................................................................65

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Date returned from leave .......................................................................................................................66 Date transferred for contract leave .......................................................................................................67 Delayed assessed separation event ......................................................................................................68 Delayed assessed separation event - end date....................................................................................70 Delayed assessed separation event - proposed service .....................................................................71 Delayed assessed separation event - proposed setting .....................................................................75 Delayed assessed separation event - stage of care .............................................................................78 Delayed assessed separation event - start date...................................................................................79 Delayed assessed separation event - waiting period .........................................................................80 Delayed assessed separation event - waiting reason .........................................................................81 Department of Veterans' Affairs card type .........................................................................................84 Department of Veterans' Affairs file number .....................................................................................85 Diagnosis ..................................................................................................................................................86 Diagnosis code type................................................................................................................................87 Diagnosis related group (Facility calculated) .....................................................................................88 Diagnosis related group (HSC calculated) ..........................................................................................89 Diagnostic code (ICD-10-AM)...............................................................................................................90 Discharge status - mother\baby ...........................................................................................................91 Elective care .............................................................................................................................................92 Elective patient status.............................................................................................................................93 Elective surgery .......................................................................................................................................95 Elective surgery specialty ......................................................................................................................96 Elective surgery waiting list episode-waiting list removal...............................................................97 date ............................................................................................................................................................97 Elective surgery waiting time (at census date) ...................................................................................98 Elective surgery waiting time (at removal date) ................................................................................99 Emergency department stay-physical departure date ....................................................................101 Emergency department stay-physical departure time ....................................................................102 Employment - work hours per week .................................................................................................103 Employment status (patient) ...............................................................................................................104 Episode number ....................................................................................................................................105 Episode of care ......................................................................................................................................106 Episode of Care - Contracting Hospital Identifier ...........................................................................107 Episode of care-funding eligibility indicator (Department ............................................................108 of Veterans Affairs) ...............................................................................................................................108 Episode of care-number of psychiatric care days.............................................................................109 Episode of residential care end ...........................................................................................................111 Episode of residential care end date ..................................................................................................112 Episode of residential care end mode ................................................................................................113 Episode of residential care start date .................................................................................................114 Episode of residential care start mode ...............................................................................................115 Episode of treatment for alcohol and other drugs-cessation ..........................................................116 reason......................................................................................................................................................116 Episode of treatment for alcohol and other drugs-client type .......................................................119 Episode of treatment for alcohol and other drugs-treatment.........................................................120 cessation date.........................................................................................................................................120 Episode of treatment for alcohol and other drugs-treatment.........................................................121 commencement date .............................................................................................................................121 Establishment - organisation identifier (Australian) .......................................................................122

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Establishment - organisational identifier (state/territory) .............................................................123 Expected principal source of funds for the episode.........................................................................124 External cause ........................................................................................................................................126 Facility contracted to ............................................................................................................................127 Facility identifier ...................................................................................................................................128 Facility transferred from ......................................................................................................................129 Facility transferred to ...........................................................................................................................130 Facility type............................................................................................................................................131 Family name ..........................................................................................................................................136 First admission for palliative care treatment ....................................................................................138 First admission for psychiatric treatment..........................................................................................139 Geographical Location of Service Delivery Outlet...........................................................................140 Gestational age ......................................................................................................................................141 Given name ............................................................................................................................................142 Health condition of concern - self reported ......................................................................................144 Health professional-area of clinical practice (principal) .................................................................145 Health professional-establishment type (employment), .................................................................147 industry code .........................................................................................................................................147 Health professional-hours worked (in all jobs), total ......................................................................149 Health professional-labour force status.............................................................................................150 Health professional-occupation ..........................................................................................................152 Health professional-principal role......................................................................................................154 Hepatitis B infection indicator - self reported positivity................................................................156 indicator..................................................................................................................................................156 Hepatitis C infection indicator - self reported positivity ................................................................157 indicator..................................................................................................................................................157 Hospital insurance (patient) ................................................................................................................158 Hospital unit ..........................................................................................................................................159 Hospital waiting list .............................................................................................................................160 Human Immunodeficiency Virus (HIV) infection indicator ..........................................................161 -self reported positivity ........................................................................................................................161 Indicator procedure - national ............................................................................................................162 Indicator procedure - site.....................................................................................................................164 Indigenous status ..................................................................................................................................165 Injecting drug status .............................................................................................................................167 Injecting drug use frequency within the last three months ............................................................168 Intended length of stay ........................................................................................................................169 Inter-hospital contracted patient status .............................................................................................170 Interpreter service required.................................................................................................................171 Labour onset type .................................................................................................................................172 Leave .......................................................................................................................................................173 Listing date on waiting list ..................................................................................................................174 Main treatment type for alcohol and other drugs ............................................................................175 Major diagnostic category (Facility calculated) ................................................................................177 Comment:Major diagnostic category (HSC calculated) ..................................................................177 Major diagnostic category (HSC calculated).....................................................................................178 Marital status .........................................................................................................................................179 Medical practitioner-hours on-call, total ...........................................................................................180 Medical practitioner-hours worked (in direct patient care), ..........................................................181

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total..........................................................................................................................................................181 Medical practitioner-hours worked, total .........................................................................................182 Medicare eligibility ...............................................................................................................................183 Medicare number ..................................................................................................................................185 Mental health legal status indicator ...................................................................................................186 Method of birth .....................................................................................................................................187 Method of use for principal drug of concern ....................................................................................188 Mode of separation ...............................................................................................................................190 Multidisciplinary care plan date.........................................................................................................191 Multidisciplinary care plan indicator ................................................................................................192 Non-admitted patient care - outpatient clinic type code ................................................................193 Non-admitted patient ED service episode-episode end date .........................................................201 Non-admitted patient ED service episode-episode end status ......................................................202 Non-admitted patient ED service episode-episode end time.........................................................203 Non-admitted patient ED service episode - service.........................................................................204 commencement date .............................................................................................................................204 Comment:Non-admitted patient ED service episode - service ......................................................204 Non-admitted patient ED service episode - service.........................................................................205 commencement time.............................................................................................................................205 Comment:Non-admitted patient ED service episode-service episode ...........................................205 Non-admitted patient ED service episode-service episode ............................................................206 length ......................................................................................................................................................206 Non-admitted patient ED service episode-transport mode ...........................................................207 (arrival) ...................................................................................................................................................207 Non-admitted patient ED service episode-triage category.............................................................208 Non-admitted patient ED service episode-triage date ....................................................................209 Non-admitted patient ED service episode-triage time....................................................................210 Non-admitted patient ED service episode-type of visit ..................................................................211 Not ready for care .................................................................................................................................212 Number of acute (qualified)/unqualified days for..........................................................................213 newborns ................................................................................................................................................213 Number of days of hospital-in-the-home care..................................................................................214 Number of leave days ..........................................................................................................................215 Other Drug of Concern ........................................................................................................................216 Other treatment type for alcohol and other drugs ...........................................................................217 Overnight-stay patients........................................................................................................................219 Palliative phase type.............................................................................................................................220 Patient - presentation time...................................................................................................................222 Patient days............................................................................................................................................223 Pension status ........................................................................................................................................224 Person identifier ....................................................................................................................................225 Person-sex ..............................................................................................................................................226 Place of occurrence of external cause of injury.................................................................................228 Planned accommodation status ..........................................................................................................229 Postcode - Australian............................................................................................................................230 Postcode of usual residence.................................................................................................................232 Pre-admission clinic..............................................................................................................................233 Preferred language................................................................................................................................234 Presentation of baby .............................................................................................................................235

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Previous specialised non-admitted palliative care treatment ........................................................236 Previous specialised non-admitted treatment ..................................................................................237 Primary reason for induction ..............................................................................................................238 Principal diagnosis................................................................................................................................239 Principal Drug of Concern...................................................................................................................240 Procedure ...............................................................................................................................................241 Qualification status ...............................................................................................................................243 Queensland Ambulance Service patient event identifier................................................................244 Ready for care days since last category escalation - census............................................................245 Reason for removal from waiting list (admitted patient) ...............................................................246 Referral from specialised mental health residential care ................................................................247 Referral to further care (psychiatric) ..................................................................................................248 Same-day patient...................................................................................................................................249 Second name ..........................................................................................................................................250 Separation...............................................................................................................................................251 Separation date ......................................................................................................................................252 Separation time......................................................................................................................................253 Service delivery mode ..........................................................................................................................254 SNAP care type .....................................................................................................................................256 SNAP end date ......................................................................................................................................260 SNAP episode number .........................................................................................................................261 SNAP group classification ...................................................................................................................262 Social issue potentially related to alcohol and/or other drug........................................................265 usage .......................................................................................................................................................265 Source of referral ...................................................................................................................................266 Standard unit code................................................................................................................................267 Standard ward code..............................................................................................................................268 State of usual residence ........................................................................................................................269 Statistical Local Area (SLA) .................................................................................................................271 Suburb/town/locality of usual residence.........................................................................................272 Surname..................................................................................................................................................273 Time of starting leave ...........................................................................................................................274 Time of transfer (ward) ........................................................................................................................275 Time returned from leave ....................................................................................................................276 Total waiting time .................................................................................................................................277 Treatment delivery setting for alcohol and other drugs .................................................................278 Type of non-admitted patient care .....................................................................................................280 Type of non-admitted patient care .....................................................................................................283 Type of usual accommodation ............................................................................................................287 Ward .......................................................................................................................................................288

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Account class

Data Element ID: 040165 Version Number: 1 Type: DATA ELEMENT Status: CURRENT

15/01/1998 Definition: Account codes used in HBCIS (derived from band, chargeable status and compensable status). Context: Institutional health care Datatype: Character Representational Form: TEXT Representation Layout: A(12) Minimum Size: 3 Maximum Size: 12 Data Domain: Corporate reference file as listed in Appendix I of the current version of the QHAPDC manual. Guide for Use: Verification Rules: Related Data References: is derived from Band QHLTH 040059 version 1 is derived from Chargeable status QHLTH 040050 version 1 is derived from Compensable status QHLTH 040051 version 3 Source Document: Source Organisation: Comment: Item used in HBCIS. Contains all information on account class, chargeable status and compensable status. Used to derive these individual items which are transmitted to DSU.

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Action of concern associated with the taking of alcohol and/or other drugs

Data Element ID: 040874 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: Action of concern that in the clinician's opinion is associated with the client's current alcohol and/or other drug use. Context: Queensland Health Minimum Data Set - Alcohol and Other Drug Treatment Services Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Overdose 02 Polydrug use 03 Sharing injecting equipment 04 Binge drinking 05 Drink driving 06 Drug driving 98 Other 99 Not stated/inadequately described Guide for Use: Multiple domain items may be recorded as required. Code 01: Refers to the intentional or unintentional taking of an excessive dose of drug(s). Code 02: Refers to the taking of more than one drug at once. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Actual place of birth

Data Element ID: 040752 Version number: 2 Type: DATA ELEMENT Status: CURRENT 14/11/2003 Definition: The actual place of birth where the birth occurred. Context: Perinatal statistics: Used to analyse the risk factors and outcomes by place of birth. While most deliveries occur within hospitals, an increasing number of births now occur in other settings. It is important to monitor the births occurring outside hospitals and to ascertain whether or not the actual place of delivery was planned. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Hospital, excluding birth centre 2 Birth Centre, attached to hospital 3 Birth Centre, free standing 4 Home 8 Other 9 Not Stated Guide for Use: This is to be recorded for each baby the mother delivers from this pregnancy. Code 4 Home - should be reserved for those births that occur at the home intended. Code 8 Other - used when birth occurs at a home other than that intended. - may also include a community health centre or be used for babies "born before arrival” Verification Rules: Related Data References: supersedes previous data element Actual place of birth, QHLTH 040752 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

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Additional diagnoses

Data Element ID: 040245 Version number: 3 Type: DATA ELEMENT Status: CURRENT 07/12/2005 Definition: A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care or attendance at a health care establishment. Context: Additional diagnoses give information on factors which result in increased length of stay, more intensive treatment or the use of greater resources. They are required for casemix analyses relating to the severity of illness and for correct classification of patients into Australian National Diagnosis Related Groups. Data type: Alphabetic Representational form: CODE Representation layout: ANN.NNN Minimum Size: 1 Maximum Size: 6 Data Domain: Valid ICD-10-AM Guide for Use: Additional diagnoses should be interpreted as additional conditions that affect patient care in terms of requiring any of the following: - Therapeutic treatment - Diagnostic procedures - Increased nursing care and or monitoring Record each additional diagnosis relevant to the episode of care in accordance with the ICD-10-AM Australian Coding Standards. Generally, external cause, place of occurrence and activity codes will be included in the string of additional diagnosis codes. In some data collections these codes may also be copied into specific fields. The diagnosis can include a disease, condition, injury, poisoning, sign, symptom, abnormal finding, complaint, or other factor influencing health status. Verification Rules: Related Data References: relates to the data element Diagnosis code type, QHLTH 040099, version 3 relates to the data element Principal diagnosis, QHLTH 040244 version 1 supersedes previous data element Additional diagnoses, QHLTH 040245 version 2 Source Document: Source Organisation: Comment: Additional diagnoses are significant for the allocation of Australian Refined Diagnosis Related Groups. The allocation of patient to major problem or complication and co-morbidity Diagnosis Related Groups is made on the basis of the presence of certain specified additional diagnoses. Additional diagnoses should be recorded when relevant to the patient's episode of care and not restricted by the number of fields on the morbidity form or computer screen.

External cause codes, although not diagnosis of condition codes, should be sequenced together with the additional diagnosis codes so that meaning is given to the data for use in injury surveillance and other monitoring activities.

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Address line

Data Element ID: 040814 Version Number : 1 Type: DATA ELEMENT Status: CURRENT

25/01/2004 Definition: A composite of one or more standard address components that describes a low level of

geographical/physical description of a location that, used in conjunction with the other high-level address components i.e. 'Suburb/town/locality', 'Postcode', 'State/Territory', and 'Country', forms a complete geographical/physical Address.

Context: Datatype: Alphanumeric Representational Form: TEXT Representation Layout: AN(180) Minimum Size: 1 Maximum Size: 180 Data Domain: A composite of one or more standard address components. Guide for Use: A high-level address component is defined as a broad geographical area that is capable of containing more than one specific physical location. Some examples of a broad geographical area are: - Suburb, town or locality - Postcode - Australian or international - State, Territory, local government area, electorate, statistical local area - Postal delivery point identifier - Countries, provinces, etc other than in Australia These components of a complete address do not form part of the Address line. When addressing an individual physical Australian location, the following standard data elements may be concatenated to form the Address line: - Building/complex sub-unit type - abbreviation - Building/complex sub-unit number - Building/property name - Floor/level number - Floor/level type - House/property number - Lot/section number - Street name - Street type code - Street suffix code One complete identification/description of a location/site of an address can comprise one or more than one instance of address line. Instances of address lines are commonly identified in electronic information systems as Address-line 1, Address-line 2, etc. The format of data collection is less important than consistent use of conventions in the recording of address data. Hence, address may be collected in an unstructured manner but should ideally be stored in a structured format. Where Address line is collected as a stand-alone item, software may be used to parse the Address line details to separate the sub-components. Multiple Address lines may be recorded as required.

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Address line

Verification Rules: Related Data References: relates to the data element concept Address QHLTH 040813 version 1 relates to the data element Address - country identifier QHLTH 040404 version 1 is equivalent to Address line NHIG 000786 version 1 relates to the data element Address type QHLTH 040906 version 1 relates to the data element Australian State/Territory Identifier QHLTH 040394 version 2 relates to the data element Building/complex sub-unit number QHLTH 040815 version 1 relates to the data element Building/complex sub-unit type - abbreviation QHLTH 040816 version 1 relates to the data element Building/property name QHLTH 040817 version 1 relates to the data element Floor/level number QHLTH 040818 version 1 relates to the data element Floor/level type QHLTH 040820 version 1 relates to the data element House/property number QHLTH 040819 version 1 relates to the data element Lot/section number QHLTH 040821 version 1 relates to the data element Postcode - Australian QHLTH 040395 version 2 relates to the data element Postcode - international QHLTH 040919 version 1 relates to the data element Street name QHLTH 040825 version 1 relates to the data element Street suffix code QHLTH 040826 version 1 relates to the data element Street type code QHLTH 040827 version 1 relates to the data element Suburb/town/locality name QHLTH 040859 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

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Address of usual residence

Data Element ID: 040079 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Number and street of usual residential address of person or equivalent in rural areas. Context: Used with other elements to determine the Statistical Local Area (SLA) of usual residence. This enables: - comparison of the use of services by persons residing in different geographical areas, - characterisation of catchment areas and populations for facilities for planning purposes, and - documentation of the provision of services to residents of States or Territories other than Queensland. Data type: Character Representational form: TEXT Representation layout: A(50) Minimum Size: 1 Maximum Size: 50 Data Domain: Guide for Use: Record the building number and street name of the usual residential address of the patient. The usual residential address is the place where the patient lives. For example, it is not the address where the patient might be staying temporarily before or after the period of hospitalisation. Post office box numbers/mail service numbers should not be recorded. Use a building number and street name wherever possible. Even country properties have access roads which have names. EXAMPLE "Emohruo Homestead", Dusty Road Use the postcode as an indicator. For example, If the patient states the address is "Emohruo Homestead", off Dusty Road, Elbow Valley, via Warwick, and both Elbow Valley and Warwick have postcodes, record the property name and access road name in this field. Record Elbow Valley as the suburb/town of usual residence. Warwick need not be entered at all. Do not enter the word "via". If Elbow Valley had no postcode, then the property name and the access road (Dusty Road) only should be entered in this field. Warwick is recorded as the suburb/town of usual residence (Elbow Valley should not be recorded). UNKNOWN NUMBER AND STREET OF USUAL RESIDENCE If the number and street of the usual address are unknown (e.g. an unconscious patient is unable to provide the information), leave blank.

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Address of usual residence TEMPORARY RESIDENCE If the patient is temporarily resident with relatives, in a hotel or place other than his/her home, do not use the temporary address in this field, but attempt to ascertain his/her usual residential address. BABY FOR ADOPTION If the patient is a baby for adoption, use the address of the hospital. Verification Rules: Related Data References: is used in conjunction with Postcode of usual residence, QHLTH 040081 version 4 is used in conjunction with State of usual residence, QHLTH 040078 version 2 is used in conjunction with Suburb/town/locality of usual residence, QHLTH 040080 version 2 is used in the calculation of Statistical Local Area (SLA), QHLTH 040082 version 6 Source Document: Source Organisation: Comment:

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ADL score

Data Element ID: 040604 Version Number: 1 Type: DATA ELEMENT Status: CURRENT

01/07/1999 Definition: Numerical rating from the ADL (activity of daily living) tool used to measure the patient's functional ability. Context: Activity of daily living data is collected for all SNAP patients. Datatype: Numeric Representational Form: QUANTITATIVE VALUE Representation Layout: N(3) Minimum Size: 3 Maximum Size: 3 Data Domain: Guide for Use: More than one ADL score per SNAP episode can be collected, however only the first ADL score recorded at the start of the SNAP episode will be supplied to Data Services Unit.

The HoNOS requires 3 ADL scores to be reported, the FIM tool requires 2 ADL scores to be reported, while the remaining tools require only a single score.

Verification Rules: BAR, MOT (Barthel (Motor)) valid values between 0 & 20; HON, BEH (HoNOS (Behaviour)) valid values between 0 & 4; HON, ADL (HoNOS (Activity of daily living)) valid values between 0 & 4; HON, TOT (HoNOS (Total)) valid values between 0 & 48; MBI, MOT (Modified Barthel (Motor)) valid values between 0 & 100; RUG, MOT (Resource Utilisation Group (Motor)) valid values between 4 & 18; FIM, MOT (FIM (Motor)) valid values between 13 & 91; FIM, COG (FIM (Cognitive)) valid values between 5 & 35.

Related Data References: is used in conjunction with ADL (activity of daily living) tool type QHLTH 040602 version 1 relates to the data element ADL (activity of daily living) date QHLTH 040605 version 1 is used in conjunction with ADL (activity of daily living) tool sub-type QHLTH 040603 version 1 Source Document : Source Organisation : Comment:

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ADL (activity of daily living) tool type

Data Element ID: 040602 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: The type of scoring tool used to measure the physical, psychosocial, vocational and cognitive functions of an individual with a disability. Context: Activity of Daily Living data is collected for all SNAP patients. Data type: Character Representational form: CODE Representation layout: A(3) Minimum Size: 3 Maximum Size: 3 Data Domain: BAR Barthel FIM Functional independence measure HON Health of the nation outcome scales (HoNOS) MBI Modified Barthel index RUG Resource utilisation group Guide for Use: Verification Rules: Related Data References: is used in conjunction with ADL (activity of daily living) tool sub-type, QHLTH 040603 version 1 is used in conjunction with ADL score, QHLTH 040604 version 1 relates to the data element ADL (activity of daily living) date, QHLTH 040605 version 1 Source Document: Source Organisation: Comment:

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ADL (activity of daily living) tool sub-type

Data Element ID: 040603 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A description of the aspect of activity of daily living (ADL) being assessed. Context: Activity of daily living data is collected for all SNAP patients. Data type: Character Representational form: CODE Representation layout: A(3) Minimum Size: 3 Maximum Size: 3 Data Domain: ADL Activity of daily living (HoNOS) BEH Behaviour (HoNOS) COG Cognitive (FIM) MOT Motor (FIM, MBI, BAR, RUG) TOT Total (HoNOS) Guide for Use: Two of the ADL tools require more than one score to be reported, so more than one ADL sub-type needs to be coded. The Health of the Nation Outcome Scale (HoNOS) requires the reporting of a behaviour score, an activity of daily living score and a total score. The Functional Independence Measure (FIM) requires the reporting of a cognition score and a motor score. All of the remaining ADL tools require only a motor score to be reported, so only one ADL sub-type needs to be coded. The HoNOS tool requires the collection of the total HoNOS score and two of the individual items to allow for the assignment to a psychogeriatric care type. For ADL type = HON record 3 ADL subtypes BEH = Behaviour ADL = Activity of daily living TOT = Total The FIM tool has a cognitive and motor sub-scale used as an assignment variable when assigning to a rehabilitation or geriatric evaluation and management care type. For ADL type = FIM record 2 ADL subtypes MOT = Motor COG = Cognitive For ADL type = MBI, BAR and RUG record 1 ADL subtype Verification Rules: Related Data References: is used in conjunction with ADL (activity of daily living) tool type, QHLTH 040602 version 1

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ADL (activity of daily living) tool sub-type is used in conjunction with ADL score, QHLTH 040604 version 1 relates to the data element ADL (activity of daily living) date, QHLTH 040605 version 1 Source Document: Source Organisation: Comment:

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Admission

Data Element ID: 040381 Version number: 2 Type: DATA ELEMENT CONCEPT Status: CURRENT 01/07/2000 Definition: Admission is the process whereby the hospital accepts responsibility for the patient's care and/or treatment. Admission follows a clinical decision based upon specified criteria that a patient requires same-day or overnight care or treatment. An admission may be formal or statistical. Formal admission: The administrative process by which a hospital records the commencement of treatment and/or care and/or accommodation of a patient. Statistical admission: The administrative process by which a hospital records the commencement of a new episode of care, with a new care type, for a patient within one hospital stay. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element Admission date - episode, QHLTH 040008 version 1 relates to the data element Admitted patient, QHLTH 040380 version 1 supersedes previous data element Admission, QHLTH 040381 version Source Document: Source Organisation: Comment: PATIENTS IN ACCIDENT AND EMERGENCY AND OUTPATIENT DEPARTMENTS Patients attending these locations in a recognised hospital who come for a procedure that is classified as a day benefit procedure (in other words, they meet the criteria for admission) should be formally admitted. TIME AT HOSPITAL The length of time a patient spends in areas such as Outpatients or Accident and Emergency, is no indication of the need to admit the patient. Admission is allowed only on the basis that the medical practitioner wants the patient admitted and the patient meets one of the criteria listed in the policy. The concept of 'four hours' does not apply. The patient should be admitted at the time indicated by the medical practitioner, not at the time the patient arrived in Outpatients or Accident and Emergency.

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Admission date - episode

Data Element ID: 040008 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date on which an admitted patient commences an episode of care. Context: Institutional health care: used in systems/data collections that record by episodes of care. Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid dates Guide for Use: This may be a formal admission or a statistical admission. Verification Rules: Related Data References: is related but not equivalent to Admission date - formal, QHLTH 040131 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

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Admission date - formal

Data Element ID: 040131 Version Number: 1 Type: DATA ELEMENT Status: CURRENT

15/01/1998 Definition: Formal date of admission for the hospital stay. Context: Institutional health care: used in systems/data collections that record by hospital stay, rather than by episodes of care. Datatype: Numeric character Representational Form: DATE Representation Layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid dates Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Admission date - episode QHLTH 040008 version 1 Source Document: Source Organisation: Comment: Note the difference between this item and item 0009 "Admission date - episode", which relates to episodes of care. Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

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Admission time

Data Element ID: 040009 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Time at which a patient commences an episode of care. Context: Institutional health care Data type: Numeric character Representational form: TIME Representation layout: hhmm Minimum Size: 4 Maximum Size: 4 Data Domain: Valid times in 24 hour format, range 0000 to 2359 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Admission date - episode, QHLTH 040008 version 1 supersedes previous data element Admission time, QHLTH 040009 version 1 Source Document: Source Organisation: Comment:

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Admission weight - neonate

Data Element ID: 040011 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The weight of the neonate on the day of admission unless this is the day of birth, in which case the admission weight is taken as the birth weight. Context: Admission weight for neonates is required to generate Australian National Diagnosis Related Groups for neonates. Data type: Integer Representational form: QUANTITATIVE Representation layout: N(4) Minimum Size: 3 Maximum Size: 4 Data Domain: Integers in range 1 to 8999, weights in grams. Record missing / unknown weights as 9000. Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Birth weight, QHLTH 040001 version 2 supersedes previous data element Admission weight - neonate, QHLTH 040011 version 1 Source Document: Source Organisation: Comment: Recorded for neonates, and all infants less than 2500 grams at the time of admission.

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Apgar score (5 minutes)

Data Element ID: 040063 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Numerical score to evaluate the baby's condition at 5 minutes after birth. Context: Perinatal data collection: required to analyse pregnancy outcome, particularly after complications of pregnancy, labour and birth. The Apgar score is an indicator of the health of the baby. Data type: Numeric Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: Numeric codes in range 00 to 10. Not stated/missing values recorded as 99 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Apgar score (1 minute), QHLTH 040062 version 1 Source Document: Source Organisation: Comment: The score is based on the 5 characteristics of heart rate, respiratory condition, muscle tone, reflexes and colour of a live born baby. The maximum or best score at both 1 and 5 minutes is 10. This item is not applicable for still births.

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Australian South Sea Islander

Data Element ID: 040623 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/04/2003 Definition: Australian South Sea Islanders are the Australian-born descendants of predominantly Melanesian people who were brought to Queensland between 1863 and 1904 from eighty Pacific islands, but primarily Vanuatu and Solomon Islands. Context: Health Services: The accurate identification of Australian South Sea Islander patients/clients in Queensland Health data collections is crucial to getting information about their health status, their use of health services and the effectiveness of interventions. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No 9 Not stated/unknown Guide for Use: Australian South Sea Islanders will know who they are and will respond accordingly. However, there is a risk that some people could answer 'yes' when they should answer 'no' simply as a result of uncertainty about the term 'Australian South Sea Islander'. This may apply to people who have migrated to Australia from islands in the Pacific. The following information provides appropriate guidance if asked for clarification. Australian South Sea Islanders are almost invariably Australian-born. There may be a rare instance of the child of an Australian South Sea Islander being born overseas. Patients/clients born in Samoa, Tonga, or Fiji (sometimes referred to as Pacific Islanders) or their Australian born descendants are not Australian South Sea Islanders. Patients/clients born in countries such as Vanuatu or the Solomon Islands are not Australian South Sea Islanders (even though these are the major island groupings from which the original South Sea Islanders came). Only descendants of the original South Sea Islanders qualify for this term. If necessary reassure these people that we collect health information about their community by analysing birthplace data. We cannot do the same for Australian South Sea Islanders since they cannot be distinguished from other Australian-born people by this method. Verification Rules: Related Data References: supersedes previous data element Australian South Sea Islander, QHLTH 040623 version 1 Source Document: Source Organisation:

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Australian South Sea Islander Comment: The Queensland Government recognised Australian South Sea Islanders as a distinct cultural group in September 2000. As part of its Action Plan it says that Queensland Government agencies will "design forms and documents to enable people wishing to identify themselves as Australian South Sea Islanders to do so".

27

Australian State/Territory Identifier

Data Element ID: 040394 Version number: 2 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: An identifier of the Australian State or Territory. Context: This is a geographic indicator which is used for analysis of the distribution of clients or patients, agencies or establishments and services. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 New South Wales 2 Victoria 3 Queensland 4 South Australia 5 Western Australia 6 Tasmania 7 Northern Territory 8 Australian Capital Territory 9 Other territories (Cocos (Keeling) Islands, Christmas Island and Jervis Bay Territory Guide for Use: The order presented here is the standard for the ABS. Other organisations (including the AIHW) publish data in State order based on population (that is, WA before SA and ACT before NT). Irrespective of how the information is coded, conversion of the codes to the ABS standard must be possible. DSS - Health care client identification: When used specifically in the collection of address information for a client, the following local implementation rules may be applied: NULL may be used to signify an unknown address State; and Code 0 may be used to signify an overseas address. NHDD specific - Residential mental health care NMDS: This is the State or Territory of the establishment. NHDD specific - Admitted patient care NMDS: This data element applies to the location of the establishment and not to the patient's area of usual residence. Verification Rules: Related Data References: is a qualifier of Address line, QHLTH 040814 version 1 is composed of Establishment - organisation identifier (Australian), QHLTH 040925 version 1 supersedes previous data element State, QHLTH 040394 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare

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Australian State/Territory Identifier Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Other References: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia In AS4846 and AS5017 alternative codes are presented. Refer to the current standard for more details.

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Band

Data Element ID: 040059 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1994 Definition: Classification to categorise same day procedures into bands as defined in the Commonwealth Same Day Procedures Manual. Context: Institutional health care Data type: Character Representational form: CODE Representation layout: A(2) Minimum Size: 1 Maximum Size: 2 Data Domain: 1A Band 1A 1B Band 1B 2 Band 2 3 Band 3 4 Band 4 Guide for Use: Verification Rules: Related Data References: is used in the derivation of Account class, QHLTH 040165 version 1 relates to the data terminology item Same-day patient, QHLTH 040018 version 1 Source Document: Source Organisation: Comment: Mandatory only for private day benefit patients, however hospitals may supply bands for public patients.

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Behavioural issue potentially related to alcohol and/or other drug usage

Data Element ID: 040875 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: Client's behavioural issue that in the clinician's opinion is potentially related to the client's drug and/or alcohol use. Context: Queensland Health Minimum Data Set - Alcohol and Other Drug Treatment Services Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Unsafe sexual behaviour 02 Violent behaviour 03 Problem gambling 04 Perilous behaviour 05 Unlawful behaviour 98 Other 99 Not stated/inadequately described Guide for Use: Multiple domain items may be recorded as required. Code 01: refers to sexual behaviour that places the client at risk of unwanted pregnancy and/or transmissible diseases, including blood-borne viruses. Code 02: refers to the act of violence toward others that places the client and/or others at risk of injury. Code 03: refers to a client's reported preoccupation to gambling, to the extent that the client's life is affected. Code 04: refers to dangerous behaviour that leads to accidents and/or injuries. Code 05: refers to behaviour that has resulted in criminal proceedings Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Birth order

Data Element ID: 040024 Version number: 3 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The sequential order of each baby of a multiple birth. Context: Perinatal data collection Data type: Numeric character Representational form: CODE Representation layout: N (2) Minimum Size: 1 Maximum Size: 2 Data Domain: 1 Singleton or first of a multiple birth 2 Second of a multiple birth 3 Third of a multiple birth 4 Fourth of a multiple birth 5 Fifth of a multiple birth 6 Sixth of a multiple birth 8 Other 9 Not stated/inadequately described Guide for Use: CODE 2 Second of a multiple birth Stillborns are counted such that, if twins were born, the first stillborn and the second live-born, the second twin would be recorded as code 2 Second of a multiple birth (and not code 1 Singleton or first of a multiple birth). Verification Rules: Related Data References: is used in conjunction with Birth plurality, QHLTH 040025 version 2 supersedes previous data element Birth order, QHLTH 040024 version 2 Source Document: Source Organisation: Comment:

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Birth plurality

Data Element ID: 040025 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: Total number of births (live and stillbirths) resulting from this pregnancy. Context: Perinatal Data Collection: Multiple pregnancy increases the risk of complications during pregnancy, labour and delivery and is associated with higher risk of perinatal morbidity and mortality. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 2 Data Domain: 1 Singleton 2 Twins 3 Triplets 4 Quadruplets 5 Quintuplets 6 Sextuplets 8 Other 9 Not Stated/Unknown Guide for Use: Plurality of a pregnancy is determined by the number of live births or by the number of foetuses that remain in utero at 20 weeks gestation and that are subsequently born separately. In multiple pregnancies, or if gestational age is unknown, only live births of any birth weight or gestational age, or foetuses weighing 400g or more, are taken into account in determining plurality. Foetuses aborted before 20 completed weeks or foetuses compressed in the placenta at 20 or more weeks are excluded. Verification Rules: Related Data References: relates to the data terminology item Live birth, QHLTH 040055 version 1 supersedes previous data element Pregnancy plurality, QHLTH 040025 version 1 Source Document: Source Organisation: Comment:

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Birth weight

Data Element ID: 040001 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The first weight, in grams, of the live born or stillborn baby obtained after birth, or the weight of the neonate or infant on the date admitted if this is different from the date of birth. Context: Perinatal data collection Data type: Integer Representational form: QUANTITATIVE Representation layout: N (4) Minimum Size: 3 Maximum Size: 4 Data Domain: Weight in grams. If weight is not stated or unknown, record as 9999 Guide for Use: If birth weight is not available, record first available weight. Verification Rules: Related Data References: is related but not equivalent to Admission weight - neonate, QHLTH 040011 version 2 supersedes previous data element Birth weight, QHLTH 040001 version 1 Source Document: Source Organisation: Comment: If the baby was a stillbirth, the birth weight must be >=400 grams or the gestation at least 20 weeks to be within the scope of the collection. If a stillbirth was less than 20 weeks gestation and less than 400 grams, then the baby is not in scope for the perinatal database. All live births are within scope, regardless of weight or gestation.

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Birth-birth status

Data Element ID: 040982 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The status of the baby at birth. Context: Perinatal data collection Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Live birth 2 Stillbirth (fetal death) 9 Not stated/inadequately described Guide for Use: Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born (WHO, 1992 definition). Stillbirth is a fetal death prior to the complete expulsion or extraction from its mother of a product of conception of 20 or more completed weeks of gestation or of 400 g or more birth weight; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. (This is the same as the WHO definition of fetal death, except that there are no limits of gestational age or birth weight for the WHO definition.) Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Care type

Data Element ID: 040013 Version number: 6 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The overall nature of a clinical service provided to an admitted patient during an episode of care (admitted care), or the type of service provided by the hospital for boarders or posthumous organ procurement (other care). Context: Institutional health care: the identification of different care types is required in order to appropriately classify and count the care a person received whilst in hospital. The type of care received will determine the appropriate casemix classification that shall be employed to classify the episode of care. Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Acute 05 Newborn 06 Other care 07 Organ procurement 08 Boarder 09 Geriatric Evaluation and Management 10 Psychogeriatric 11 Maintenance 21 Rehabilitation - delivered in a designated unit 22 Rehabilitation - according to a designated program 23 Rehabilitation - principal clinical intent 31 Palliative - delivered in a designated unit 32 Palliative - according to a designated program 33 Palliative - principal clinical intent Guide for Use: An episode of care begins on the date the person meets the criteria defined above for a particular type of care; this may be the same as the date the person was admitted to hospital or a date during the hospital stay. An episode of care ends when the principal intent of the care changes or when the patient is formally separated from the hospital. There may be more than one care type within the one overnight stay period. Persons with mental illness may receive any one of the care types (except newborn and organ procurement). Classification depends on the principal clinical intent of the care received. Admitted care can be one of the following: CODE 01 Acute care Acute care is care in which the clinical intent or treatment goal is to: -manage labour (obstetric) -cure illness or provide definitive treatment of injury -perform surgery -relieve symptoms of illness or injury (excluding palliative care) -reduce severity of an illness or injury

36

Care type

-protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function -perform diagnostic or therapeutic procedures. CODE 21 Rehabilitation care delivered in a designated unit A designated rehabilitation care unit is a dedicated ward or unit (and can be a stand-alone unit) that receives identified funding for rehabilitation care and/or primarily delivers rehabilitation care. CODE 22 Rehabilitation care according to a designated program In a designated rehabilitation care program, care is delivered by a specialised team of staff who provide rehabilitation care to patients in beds that may or may not be dedicated to rehabilitation care. The program may, or may not be funded through identified rehabilitation care funding. Code 21 should be used instead of code 22 if care is being delivered in a designated rehabilitation care program and a designated rehabilitation care unit. CODE 23 Rehabilitation care is the principal clinical intent Rehabilitation as principal clinical intent occurs when the patient is primarily managed by a medical practitioner who is a specialist in rehabilitation care or when, in the opinion of the treating medical practitioner, the care provided is rehabilitation care even if the doctor is not a rehabilitation care specialist. The exception to this is when the medical practitioner is providing care within a designated unit or a designated program, in which case code 21 or 22 should be used, respectively. CODE 31 Palliative care delivered in a designated unit A designated palliative care unit is a dedicated ward or unit (and can be a stand-alone unit) that receives identified funding for palliative care and/or primarily delivers palliative care. CODE 32 Palliative care according to a designated program In a designated palliative care program, care is delivered by a specialised team of staff who provide palliative care to patients in beds that may or may not be dedicated to palliative care. The program may, or may not be funded through identified palliative care funding. Code 31 should be used instead of code 32 if care is being delivered in a designated palliative care program and a designated palliative care unit. CODE 33 Palliative care is the principal clinical intent Palliative care as principal clinical intent occurs when the patient is primarily managed by a medical practitioner who is a specialist in palliative care or when, in the opinion of the treating medical practitioner, the care provided is palliative care even if the doctor is not a palliative care specialist. The exception to this is when the medical practitioner is providing care within a designated unit or a designated program, in which case code 31 or 32 should be used, respectively. For example, code 33 would apply to a patient dying of cancer who was being treated in a geriatric ward without specialist input by palliative care staff. CODE 09 Geriatric evaluation and management Geriatric evaluation and management is care in which the clinical intent or treatment goal is to maximise health status and/or optimise the living arrangements for a patient with multi-dimensional medical conditions associated with disabilities and psychosocial problems, who is usually (but not always) an older patient. This may also include younger adults with clinical conditions generally associated with old age. This care is usually evidenced by multi-disciplinary management and regular assessments against a management plan that is working towards negotiated goals within

37

Care type

indicative time frames. Geriatric evaluation and management includes care provided: -in a geriatric evaluation and management unit; or -in a designated geriatric evaluation and management program; or -under the principal clinical management of a geriatric evaluation and management physician or, -in the opinion of the treating doctor, when the principal clinical intent of care is geriatric evaluation and management. CODE 10 Psychogeriatric care Psychogeriatric care is care in which the clinical intent or treatment goal is improvement in health, modification of symptoms and enhancement in function, behaviour and/or quality of life for a patient with an age-related organic brain impairment with significant behavioural or late onset psychiatric disturbance or a physical condition accompanied by severe psychiatric or behavioural disturbance. The care is usually evidenced by multi-disciplinary management and regular assessments against a management plan that is working towards negotiated goals within indicative time frames. It includes care provided: -in a psychogeriatic care unit; -in a designated psychogeriatic care program; or -under the principal clinical management of a psychogeriatic physician or, -in the opinion of the treating doctor, when the principal clinical intent of care is psychogeriatic care. CODE 11 Maintenance care Maintenance care is care in which the clinical intent or treatment goal is prevention of deterioration in the functional and current health status of a patient with a disability or severe level of functional impairment. Following assessment or treatment the patient does not require further complex assessment or stabilisation, and requires care over an indefinite period. This care includes that provided to a patient who would normally receive care in another setting eg at home, or in a residential aged care service, by a relative or carer, that is unavailable in the short term. CODE 05 Newborn care Newborn care is initiated when the patient is born in hospital or is nine days old or less at the time of admission. Newborn care continues until the care type changes or the patient is separated: -patients who turn 10 days of age and do not require clinical care are separated and, if they remain in the hospital, are designated as boarders -patients who turn 10 days of age and require clinical care continue in a newborn episode of care until separated -patients aged less than 10 days and not admitted at birth (eg transferred from another hospital) are admitted with newborn care type -patients aged greater than 9 days not previously admitted (eg transferred from another hospital) are either boarders or admitted with an acute care type -within a newborn episode of care, until the baby turns 10 days of age, each day is either a qualified or unqualified day -a newborn is qualified when it meets at least one of the criteria detailed in Newborn qualification status. Within a newborn episode of care, each day after the baby turns 10 days of age is counted as a qualified patient day. Newborn qualified days are equivalent to acute days and may be denoted as such. CODE 06 Other admitted patient care Other admitted patient care is care where the principal clinical intent does

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Care type

meet the criteria for any of the above. Other care can be one of the following: CODE 07 Organ procurement - posthumous (Other care)

Organ procurement - posthumous is the procurement of human tissue for the purpose of transplantation from a donor who has been declared brain dead. Diagnoses and procedures undertaken during this activity, including mechanical ventilation and tissue procurement, should be recorded in accordance with the relevant ICD-10-AM Australian Coding Standards. These patients are not admitted to the hospital but are registered by the hospital.

CODE 08 Hospital boarder (Other care) Hospital boarder is a person who is receiving food and/or accommodation but for whom the hospital does not accept responsibility for treatment and/or care. Hospital boarders are not admitted to the hospital. However, a hospital may register a boarder. Babies in hospital at age 9 days of less cannot be boarders. They are admitted patients with each day of stay deemed to be either qualified or unqualified. Verification Rules: Related Data References: supersedes previous data element Care type, QHLTH 040013 version 5 Source Document: Source Organisation: Comment:

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Census date

Data Element ID: 040352 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1998 Definition: Date on which the hospital takes a point in time count (census) and characterisation of patients currently on the waiting list. Context: Elective admission/Waiting list: this data element is necessary for the calculation of the waiting time until a census. Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date. Guide for Use: Census date is the first week day of each month (excluding public holidays). Verification Rules: Related Data References: is used in the calculation of Ready for care days since last category escalation - census, QHLTH 040369 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

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Chargeable status

Data Element ID: 040050 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1987 Definition: Accommodation chargeable status elected by a patient on admission. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Public 2 Private shared 3 Private single 9 Not stated/unknown Guide for Use: Verification Rules: Related Data References: is used in the derivation of Account class, QHLTH 040165 version 1 Source Document: Source Organisation: Comment: On admission to a public hospital, the patient must elect to be treated as either a public patient; a private patient in single accommodation; or a private patient in shared accommodation. This item is independent of patient's hospital insurance status.

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Compensable/eligibility status for non-admitted patients

Data Element ID: 040759 Version number: 1 Type: CROSS-CLASSIFICATORY Status: CURRENT 15/01/1998 Definition: Eligible patients are those patients who are deemed to be eligible for Medicare Services, under the Medicare Agreement. This includes: - Patients who reside in Australia and whose stay in Australia is not subject to any limitation as to time, imposed by law. - Patients who are visiting Australia but who are ordinarily a resident in the United Kingdom, New Zealand, Finland, Sweden, Malta, Italy or the Netherlands, as they are covered by reciprocal health care agreements. However, patients from Malta and Italy are covered for six months only. It does NOT include: - Foreign diplomats or their families, except if eligibility is expressly granted to them by the terms of a reciprocal health care agreement. C2.1 Eligible Third Party Eligible patients (under the Medicare Agreement) who: - are entitled to claim damages under Motor Vehicle Third Party Insurance (TPI); or - have, or may have, an entitlement to claim under some other form of third party insurance (eg, have injuries after a vehicle accident not covered under TPI, but compensation is possible under the Criminal Offence Victims Act 1995, or some form of public liability insurance, etc); C2.2 WCBQ Eligible Compensable Eligible patients (under the Medicare Agreement) who: - are entitled to claim damages under the Queensland Workers' Compensation Act or under another Workers' Compensation Act (eg, if they are an employee of the Commonwealth or employed interstate); C2.3 Other Eligible Compensable Eligible patients (under the Medicare Agreement) who: - are seeking compensation for injuries under the criminal code. C2.4 Eligible Public Eligible Public patients are eligible patients who, elect to be public patients and satisfy the necessary criteria. C2.5 Eligible Other Eligible Private patients are eligible patients who, upon admission to a recognised public hospital (or soon after) elect to: - be private patients treated by a medical practitioner of their own choice; or

42

Compensable/eligibility status for non-admitted patients

- occupy a bed in a single room and be responsible for paying the appropriate charges raised by the hospital and the treating medical or dental practitioner. C2.6 Ineligible

Ineligible patients are patients who are not deemed to be eligible for Medical Services under the Medicare Agreement.

Context: Reporting of activity data from health facilities Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: For the purposes of the Monthly Activity Report (PH1 form), Department of Veterans' Affairs (DVA) patients who are not compensable in the strict interpretation of the word, but are patients for whom another agency (the DVA) has accepted responsibility for the payment of any charges relating to their episode of care, should be classified as eligible compensable patients. Verification Rules: Related Data References: is used in conjunction with Ambulatory clinic types, QHLTH 040761 version 2 is used in conjunction with Type of non-admitted patient care, QHLTH 040760 version 1 Source Document: Source Organisation: Comment:

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Condition present on admission indicator

Data Element ID: 040946 Version number: 1 Type: DATA ELEMENT Status: CURRENT 18/10/2007 Definition: Indicates the presence of a condition (diagnosis) on admission to an episode of care. Context: Admitted Patient Care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes - Condition present on admission to the current episode of care 2 No - Condition arises during the current episode of care 9 Unknown/Uncertain Guide for Use: A relevant 'Condition present on admission indicator' shall be assigned to each ICD-10-AM code recorded for an episode of care that complies with the specific guidelines for correct assignment of 'Diagnostic code (ICD-10-AM)'. The guidelines are published in the current edition of ICD-10-AM Australian Coding Standards. 1 - (Yes) Condition present on admission to the current episode of care - a condition such as the presenting problem, a co morbidity, or chronic disease and in the case of neonates, the condition(s) present at birth - a previously existing condition not diagnosed until the current episode of care 2 - (No) Condition arises during the current episode of care - a condition which arises during the current episode of care and would not have been present on admission 9 - Unknown or uncertain - a condition where the documentation does not support assignment to 1 or 2 Verification Rules: A 'Condition present on admission indicator' must be associated with a Diagnostic code (ICD-10-AM). Related Data References: Source Document: NHDD Source Organisation: AIHW Comment: Relates to the data element 'Episode of admitted patient care - diagnosis onset type, code N' METeOR identifier: 270192

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Contact for feedback indicator

Data Element ID: 040757 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/01/2002 Definition: Contact for Feedback indicates whether the consumer consents to be contacted by Queensland Health, or its agent, to obtain his/her feedback on the services provided at the facility. Context: Health Services: Activities where consumer feedback on services provided is undertaken by Queensland Health, or its agent, including Patient Satisfaction Surveys. Data type: Numeric character Representational form: TEXT Representation layout: A Minimum Size: 1 Maximum Size: 1 Data Domain: N No U Unable to obtain Y Yes Guide for Use: Yes: indicates that the consumer consents to be contacted by Queensland Health, or its agent, to obtain his/her feedback on the services provided at the facility. No: indicates that the consumer does not consent to be contacted by Queensland Health, or its agent, to obtain his/her feedback on the services provided at the facility. Unable to obtain: indicates the consumer was not able to provide consent. For example: being unconscious, being under the influence of alcohol or drugs or requiring urgent trauma care that did not allow for registration data to be collected. This is not a default setting. If unable to obtain the consumer's consent, follow the hospital’s/service’s procedure for when registration information can not be collected. The domain of "Yes" and "No" matches the tick boxes on the 'Consumer Feedback Consent' form. The field "Unable to obtain" is to be used only in instances described above. Verification Rules: Related Data References: Source Document: Source Organisation: Queensland Health Comment: Providing consent gives Queensland Health the authority to access the patient's health care record at the facility and to contact the patient to ask him/her to participate in "feedback activities" for the purpose of reviewing and improving services. Providing consent gives Queensland Health the authority to supply information such as the patient's name, address, phone number, the name of the hospital that the patient attended and/or the ward that the patient was admitted to, to its agent, and consent for the agent to contact the patient.

45

46

Contract flag

Data Element ID: 040101 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: A flag which indicates that the procedure (or V code) was performed as a contracted service, and specifies whether it was performed on an admitted or non-admitted basis. It also records contracted services performed by private health organisations. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Contracted admitted procedure 2 Contracted non-admitted procedure or procedure performed by private health organisations Guide for Use: Hospitals that place a patient on contract leave to a private health organisation with no facility number, should record a dummy facility number of 99998. Code (2) of the contract flag has been extended to facilitate Verification Rules: Related Data References: is a qualifier of Diagnostic code (ICD-9-CM), QHLTH 040100 version 3 relates to the data terminology item Contract service, QHLTH 040130 version 1 Source Document: Source Organisation: Comment: Recorded by the contracting hospital. Flag procedure codes only, unless the procedure was not carried out, in which case flag the V code.

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Contract leave

Data Element ID: 040265 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Contract leave occurs when the patient leaves the hospital to receive a service under specific arrangement at another facility. Contract leave is reported by the hospital from which the patient is being contracted, whether the leave is same day or overnight. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element Contract flag, QHLTH 040101 version 1 relates to the data element Date returned from contract leave, QHLTH 040128 version 1 relates to the data element Date transferred for contract leave, QHLTH 040127 version 1 relates to the data terminology item Contract service, QHLTH 040130 version 1 Source Document: Source Organisation: Comment:

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Contract role

Data Element ID: 040806 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: Identifies whether the hospital is the purchaser of hospital care (contracting hospital) or the provider of an admitted or non-admitted service (contracted hospital). Context: Admitted patient care and public hospital establishments. Data type: Alphabetic Representational form: CODE Representation layout: A Minimum Size: 1 Maximum Size: 1 Data Domain: A Hospital A B Hospital B Guide for Use: Hospital A is the contracting hospital (purchaser). Hospital B is the contracted hospital (provider). Verification Rules: Related Data References: is used in conjunction with Contract type, QHLTH 040807 version 1 Source Document: Source Organisation: Comment:

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Contract service

Data Element ID: 040130 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Service that is provided to a patient under an agreement between a purchaser of hospital care (contractor) and a public or private hospital or day facility providing admitted or non-admitted services (service provider). These definitions do not apply to patients who are not admitted to either hospital and receive service only as a non-admitted patient. Contracted hospital service is provided to a patient under an agreement between a contractor and provider of hospital services. A contractor is a purchaser of hospital care from a service provider. Contractors can include health authorities, public or private hospitals. However, where the contractor is a health authority the service provider must be a private hospital or private day facility. Accurate recording of contract service is essential: * because the current Medicare Agreement requires separate reporting of patients and patient days for public contracted patients attending private hospitals; * to avoid duplication in the reporting of length of stay and patient days, diagnoses and procedures to allow analyses as required for funding, casemix, resource use and epidemiological purposes; and * because the introduction of casemix payments dictates that : i) the DRG assigned to a patient accurately reflects the total treatment provided, even when part of the treatment was provided under contract; and ii) potential double payments are identified and avoided. A patient can go on contract for services that are same day or overnight (or longer). If there is no agreement between the two facilities, then the patient must be discharged if he/she is to be admitted to the second facility. Note that procedures performed by Private Health Organisations with no facility number (eg x-rays) are not recognised as "true" contract services, however, these procedures should be included in the morbidity data at the hospital of admission.

Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References:

50

Contract service relates to the data element Contract flag, QHLTH 040101 version 1 Source Document: Source Organisation: Comment:

51

Contract type

Data Element ID: 040807 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: Contract Type describes the contract arrangement between the contractor and the contracted hospital. Contract types are distinguished by the physical movement of the patient between the contracting (where applicable) and contracted hospitals. Context: Admitted patient care and public hospital establishments. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 B 2 ABA 3 AB 4 (A)B 5 BA Guide for Use: The contracting hospital (purchaser) is termed Hospital A. The contracted hospital (provider) is termed Hospital B. 1 Contract Type B A health authority/other external purchaser contracts hospital B for admitted service which is funded outside the standard funding arrangements. 2 Contract Type ABA Patient admitted by Hospital A. Hospital A contracts Hospital B for admitted or non-admitted patient service. Patient returns to Hospital A on completion of service by Hospital B. For example, a patient has a hip replacement at Hospital A, then receives aftercare at Hospital B, under contract to Hospital A. Complications arise and the patient returns to Hospital A for the remainder of care. 3 Contract Type AB Patient admitted by Hospital A. Hospital A contracts Hospital B for admitted or non-admitted patient service. Patient does not return to Hospital A on completion of service by Hospital B. For example, a patient has a hip replacement at Hospital A and then receives aftercare at Hospital B, under contract to Hospital A. Patient is separated from Hospital B. 4 Contract Type (A)B This contract type occurs where a Hospital A contracts Hospital B for the

52

Contract type whole episode of care. The patient does not attend Hospital A. For example, a patient is admitted for endoscopy at Hospital B under contract to Hospital A. 5 Contract Type BA

Hospital A contract Hospital B for an admitted patient service following which the patient moves to Hospital A for remainder of care. For example, a patient is admitted to Hospital B for a gastric resection procedure under contract to Hospital A and Hospital A provide aftercare.

Verification Rules: Related Data References: relates to the data element Contract role, QHLTH 040806 version 1 Source Document: Source Organisation: Comment:

53

Country of birth

Data Element ID: 040161 Version number: 4 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: The country in which the person was born. Context: Country of birth is important in the study of access to services by different population sub-groups. Country of birth is the most easily collected and consistently reported of a range of possible data items that may indicate cultural or language diversity. Country of birth may be used in conjunction with other data elements such as Period of residence in Australia, etc., to derive more sophisticated measures of access to (or need for) services by different population sub-groups. Data type: Numeric Representational form: CODE Representation layout: NNNN Minimum Size: 4 Maximum Size: 4 Data Domain: Standard Australian Classification of Countries 1998 (SACC). Australian Bureau of Statistics Cat. no. 1269.0 Reference through http://www.abs.gov.au/Ausstats/abs@.nsf/StatsLibrary Select ABS classifications Guide for Use: The Standard Australian Classification of Countries 1998 (SACC) is a 4-digit, three-level hierarchical structure specifying major group, minor group and country. A country, even if it comprises other discrete political entities such as states, is treated as a single unit for all data domain purposes. Parts of a political entity are not included in different groups. Thus, Hawaii is included in Northern America (as part of the identified country United States of America), despite being geographically close to and having similar social and cultural characteristics as the units classified to Polynesia. Verification Rules: Related Data References: supersedes previous data element Country of birth, QHLTH 040161 version 3 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

54

Current accommodation type

Data Element ID: 040486 Version number: 3 Type: DATA ELEMENT Status: CURRENT 25/08/2006 Definition: The type of accommodation setting in which the consumer currently resides. Context: This item is considered to be an attribute of the consumer's current address. The setting in which a consumer currently resides can have a bearing upon the type of treatment and support required by the consumer and the outcome that results from their treatment. This item provides an indicator of service requirement to assist with planning for individual consumers. Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Private residence - owner occupied - of any type except caravan/boat 02 Private residence - owner occupied - caravan/boat 05 Private residence - rented by Department of Housing - any type of residence except caravan/boat 06 Private residence - rented by other than Department of Housing - of any type except caravan/boat 07 Private residence - rented - caravan/boat 11 Mental health extended treatment unit - campus based 12 Mental health extended treatment unit - non-campus based 15 Residential aged care facility (Type 1 and Type 2) 18 Specialised alcohol/other drug treatment residence 21 Domestic scale (home like) supported living facility 22 Boarding House/Hostel - Level 1 (accommodation only) 23 Boarding House/Hostel - Level 2 (accommodation and meals only) 24 Boarding House/Hostel - Level 3 (accommodation, meals, support) 25 Refuge/Shelter - excluding homeless shelters 31 Homeless - public place 32 Homeless - motor vehicle 33 Homeless - homeless shelter 34 Homeless - couch surfing 41 Correctional facility 51 Hotel/Motel 98 Other accommodation, not elsewhere classified 99 Not stated/inadequately described Guide for Use: This item describes the consumer's current accommodation. Current refers to what the patient identifies when address details are being updated. Users would be able to record Accommodation Type at the time of referral when the current address details are being taken as part of the registration process. However, the item would be mandatory if a service episode is commenced and would need to be actively reviewed every time the

55

Current accommodation type consumer changes current address or at least every 91 days. PRIVATE RESIDENCE Code 01: Private residence - owner occupied - of any type except caravan/boat A private residence, eg house, unit, flat, or independent unit in retirement village, owned or being purchased by the consumer or one of the people with whom the consumer resides. Code 02: Private residence - owner occupied - caravan/boat A private residence, caravan or boat owned or being purchased by the consumer or one of the people with whom the consumer resides Code 05: Private residence - rented by Department of Housing - of any type except caravan/boat A house, unit, flat, rented from the Department of Housing by the consumer or one of the people with whom the consumer resides. Code 06: Private residence - rented - of any type except caravan/boat A private residence, eg house, unit, flat, bed-sitter, independent unit in retirement village, rented by the consumer or one of the people with whom the consumer resides. Does not include private residences that are rented from Department of Housing. Code 07: Private residence - rented by other then Department of Housing - caravan/boat A caravan or boat rented by the consumer or one of the people with whom the consumer resides. TREATMENT/REHABILITATION FACILITY Code 11: Mental health extended treatment unit - campus based A specialised mental health extended care unit which provides ongoing assessment, longer-term treatment and rehabilitation on an inpatient basis, where a severe level of impairment exists. The expectation is for improvement over a longer period than in an acute setting. Campus based units include only those units located on a general hospital or psychiatric hospital campus. Code 12: Mental health extended treatment unit - non-campus based Specialised mental health community-based extended care unit which provides ongoing assessment, longer-term treatment and rehabilitation on a 24 hour live-in basis, where a severe level of impairment exists. Treatment is focused on prevention of deterioration and reduction in impairment. Non-campus based units include those units that are stand alone in the community or are co-located with nursing homes or other non-health institutions. Code 15: Residential aged care facility (Type 1 and Type 2) Includes Low level care (Type 1) focuses on personal care services (help with dressing, eating, toileting, bathing and moving around) and High level care (Type 2) which usually involves 24 hour care.

56

Current accommodation type

Does not include independent or semi-independent units in retirement villages, or extended treatment non-campus based services that are co- located with nursing homes. Code 18: Specialised alcohol/other drug treatment residence Includes residential alcohol/other drug treatment units in community with a focus towards longer stays. These longer-term residential programs are structured around the need to develop a disciplined work ethic and use peer support processes (eg., Alcoholics Anonymous and Narcotics Anonymous) as a means of attaining and maintaining recovery and to facilitate change in an individual's approach to life and to alter attitudes towards drinking and drug taking. SUPPORTED ACCOMMODATION Code 21: Domestic scale (home like) supported living facility Includes group homes for people with disabilities, cluster apartments where support workers live on site, community residential apartments (non-mental health), and congregate care arrangements. Support is provided by staff on either a live-in or rostered basis, and they may or may not have 24-hour supervision. Excludes: Mental Health Extended Treatment Units, Specialised alcohol/other drug treatment residence, Residential aged care services and supported hostels Code 22: Boarding House/Hostel - Level 1 (accommodation only) Code 23: Boarding House/Hostel - Level 2 (accommodation and meals only) Code 24: Boarding House/Hostel - Level 3 (accommodation, meals, support) Includes multi person accommodation catering to the needs of people with a mental illness, i.e. Level 3 supported accommodation registered with the Office of Fair Trading. Does not include aged person's hostels or boarding/rooming houses not specifically for persons with a mental illness. Code 25: Refuge/Shelter - excluding homeless shelters Accommodation specifically designed for short tem residence which is not a homeless person's shelter, eg. Short-term shelter for victims of domestic violence. PRIMARY HOMELESSNESS (People without conventional accommodation (e.g. sleeping rough or in improvised dwellings). Code 31: Homeless - public place A public place used by the consumer in absence of any other accommodation, eg park or other public place. Excludes those homeless persons living in cars. Code 32: Homeless - motor vehicle Where a motor vehicle is used by the person in the absence of any other accommodation.

57

Current accommodation type

SECONDARY HOMELESSNESS (People who frequently move from one temporary shelter to another e.g. emergency accommodation, youth refuges, friends' places). Code 33: Homeless - homeless shelter Accommodation specifically designed for homeless persons. Not intended for long tem residence. Code 34: Homeless - couch surfing Circumstances where a homeless person is transient and continually moving from house to house of friends, relatives and acquaintances. OTHER ACCOMMODATION Code 41: Correctional facility Includes prisons, youth detention centres and youth training centres Code 51: Hotel/Motel Code 98: Other accommodation, not elsewhere classified Any accommodation not covered by any other category. Code 99 Not stated/inadequately described Information on the consumer's current accommodation is not available. This

information should be updated as soon as current address details of the consumer become known.

Verification Rules: Related Data References: supersedes previous data element Type of current accommodation, QHLTH 040486 version 2 Source Document: Source Organisation: Comment: The Admitted Patient Mental Health Care NMDS, currently has two accommodation type data standards published in METeOR. These include; a) Person - accommodation type (prior to admission), code N (METeOR ID: 270079); and b) Person - accommodation type (usual), code N[N] (METeOR ID: 270088); Some variation exists between the states and territories in how accommodation type is collected. This has resulted in the need for two accommodation type items in the Admitted Patient Mental Health Care NMDS. Queensland is and will continue to report to Person - accommodation type (prior to admission), code N from QHAPDC as per NMDS requirements. This item is not suitable for the CESA's purposes as it is not the current accommodation of the consumer. Person - accommodation type (usual), code N[N] is also inadequate and does not allow for correct mapping to the items CESA require in a clinical information system. These issues has been raised nationally and in the meantime QLD will use this updated data item in the CESA and MHEIIS systems only. The CESA and MHEIIS do not report this item for the Admitted Patient Mental Health Care NMDS.

58

Date not ready for care

Data Element ID: 040354 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1998 Definition: The first date in the period that the patient will not be / is not ready for care. Context: Elective admission/Waiting list Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date. Guide for Use: Not ready for care patients are either: - staged patient whose medical condition will not require or be amenable to surgery until some future date. For example, a patient who has had internal fixation of a fractured bone and who will require removal of the fixation device after a suitable time: or - deferred patients who for personal reasons are not yet prepared to be admitted to hospital. For example, patients with work or other commitments which preclude their being admitted to hospital for a time. Not ready for care patients may also be termed staged or deferred waiting list patients. Staged or Deferred patients should not be confused with patients whose operation is postponed for reasons other than their own unavailability. For example, surgeon unavailable owing to emergency workload. These patients are still ready for care. Verification Rules: Related Data References: is used in the derivation of Total waiting time, QHLTH 040091 version 1 relates to the data element Last date not ready for care, QHLTH 040355 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

59

Date of birth

Data Element ID: 040163 Version number: 3 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: The date of birth of the person. Context: Required for a range of clinical and administrative purposes. Date of birth enables derivation of age for use in demographic analyses, assists in the unique identification of clients if other identifying information is missing or in question, and may be required for the derivation of other data elements (e.g. Diagnosis related group for admitted patients). Data type: Numeric Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: If date of birth is not known or cannot be obtained, provision should be made to collect or estimate age. Collected or estimated age would usually be in years for adults, and to the nearest three months (or less) for children aged less than two years. Additionally, an estimated date flag should be reported in conjunction with all estimated dates of birth. For data collections concerned with children's services, it is suggested that the estimated Date of birth of children aged under 2 years should be reported to the nearest 3 month period, i.e. 0101, 0104, 0107, 0110 of the estimated year of birth. For example, a child who is thought to be aged 18 months in October of one year would have his/her estimated Date of birth reported as 0104 of the previous year. Again, an estimated date flag should be reported in conjunction with all estimated dates of birth. Verification Rules: In data collections that also record Date of death for the same person, Date of birth must be less than or equal to Date of death. Related Data References: is qualified by Date accuracy indicator, QHLTH 040907 version 1 is used in conjunction with Date of confinement, QHLTH 040134 version 1 is used in conjunction with Time of birth, QHLTH 040160 version 1 relates to the data element Date of death, QHLTH 040102 version 2 supersedes previous data element Date of birth - client, QHLTH 040163 version 2 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Privacy issues need to be taken account in asking persons their date of birth.

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Date of birth Wherever possible and wherever appropriate, Date of birth should be used rather than Age because the actual date of birth allows more precise calculation of age. When Date of birth is estimated or default value, national health and community services collections typically use 0101 or 0107 or 3006 as the estimate or default for DDMM. It is suggested that different rules for reporting data may apply when estimating the Date of birth of children aged under 2 years because of the rapid growth and development of children within this age group which means that a child's development can vary considerably over the course of a year. Thus, more specific reporting of estimated age is suggested. NHDD specific: DSS Cardiovascular disease (clinical) Age is an important non-modifiable risk factor for cardiovascular conditions. The prevalence of cardiovascular conditions increases dramatically with age. For example, more than 60% of people aged 75 and over had a cardiovascular condition in 1995 compared with less than 9% of those aged under 35. Aboriginal and Torres Strait Islander peoples are more likely to have cardiovascular conditions than other Australians across almost all age groups. For example, in the 25-44 age group, 23% of Indigenous Australians reported cardiovascular conditions compared with 16% among other Australians (Heart, Stroke and Vascular Diseases: Australian Facts 2001, AIHW). Other References: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia

61

Date of confinement

Data Element ID: 040134 Version Number: 1 Type: DATA ELEMENT Status: CURRENT

15/01/1998 Definition: The date the mother delivered her baby and in the case of a multiple birth the date of delivery of the first baby. Context: Perinatal data collection Datatype: Numeric character Representational Form: DATE Representation Layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid dates Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Date of birth - client QHLTH 040163 version 2 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

62

Date of formal separation

Data Element ID: 040044 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date of formal separation of person (i.e., of discharge, transfer between facilities, or death). Context: Institutional health care: used in systems/data collections that record by hospital stay, rather than by episodes of care. Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid dates Guide for Use: Verification Rules: Related Data References: is used in conjunction with Discharge status – mother/baby, QHLTH 040043 version 1 Source Document: Source Organisation: Comment: This item does not refer to statistical separations (note the difference between this item and Separation date). Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems. This item is collected separately for both the mother and the baby.

63

Date of starting leave

Data Element ID: 040121 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date patient went on leave, to be recorded when a patient leaves hospital. Context: Institutional health care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date. Guide for Use: Verification Rules: Related Data References: is used in conjunction with Time of starting leave, QHLTH 040122 version 2 relates to the data terminology item Leave, QHLTH 040132 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

64

Date of transfer (ward)

Data Element ID: 040125 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date on which a patient is transferred between wards. Context: Institutional health care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date Guide for Use: Verification Rules: Related Data References: is used in conjunction with Time of transfer (ward), QHLTH 040126 version 1 Source Document: Source Organisation: Comment: A ward/unit transfer is recorded every time the patient moves from one ward or unit to another, within the same hospital. Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

65

Date returned from contract leave

Data Element ID: 040128 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date on which the patient returned from contract leave or from receiving a contract service. Context: Institutional health care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date. Guide for Use: Verification Rules: Related Data References: is used in conjunction with Date transferred for contract leave, QHLTH 040127 version 1 relates to the data terminology item Contract leave, QHLTH 040265 version 1 Source Document: Source Organisation: Comment: Only to be used when the patient is returning to the originating hospital after receiving contract care at another hospital. Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

66

Date returned from leave

Data Element ID: 040124 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Date patient returned from leave. Context: Institutional health care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date Guide for Use: If a patient who goes on leave fails to return within the 7 day limit, a separation code of 9 should be recorded, to take effect from the date the patient left the hospital to go on leave. Verification Rules: Related Data References: is used in conjunction with Time returned from leave, QHLTH 040123 version 2 relates to the data terminology item Leave, QHLTH 040132 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

67

Date transferred for contract leave

Data Element ID: 040127 Version Number: 1 Type: DATA ELEMENT Status: CURRENT

15/01/1998 Definition: Date on which the patient is sent for a contract service. Context: Institutional health care Datatype: Numeric character Representational Form: DATE Representation Layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date. Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Contract leave QHLTH 040265 version 1 is used in conjunction with Date returned from contract leave QHLTH 040128 version 1 relates to the data element Facility contracted to QHLTH 040129 version 1 Source Document: Source Organisation: Comment: Only to be used when the patient is to be returned to the originating hospital after receiving contract care at another hospital. Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

68

Delayed assessed separation event

Data Element ID: 040896 Version number: 2 Type: DATA ELEMENT CONCEPT Status: CURRENT 16/02/2006 Definition: The event in an episode of care when the patient who has been assessed by a treating clinician as ready to be separated from one stage of care to another stage, cannot be separated for one or more reasons. Context: Admitted patient Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event - waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event - waiting reason, QHLTH 040901 version 2 Source Document: Source Organisation: Comment: The patient is ready for another stage of care, but is unable to be separated (transferred or discharged) for one or more reasons. The separation may be within the same hospital (statistical separation), to another hospital, or to a non-hospital setting (includes residential aged care, community service, and community care arrangements). The concept includes transfers from acute to rehabilitation settings and separations from inpatient rehabilitation to community settings and excludes transfers within the acute care setting, for example, orthopaedic to medicine (where the care type does not change). Under this concept, a patient will be waiting for separation to a Proposed Hospital Setting or a Non- Hospital Setting. There can be multiple Waiting Periods within the one episode of care, however, there can only be one Waiting Period at any one time.

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Delayed assessed separation event Data definitions and processes for managing (episodes of) care type, although related, remain independent from the definitions for this concept and related data elements and must continue to be strictly followed. A change to the Proposed Setting or Service (for example, due to changes in the patient’s care needs), will require a new Delayed Assessed Separation Event. If separation is no longer required, the Delayed Assessed Separation Event should be end-dated.

70

Delayed assessed separation event - end date

Data Element ID: 040899 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The date that a patient is separated to another stage of care, or it is identified that the patient no longer requires a separation. Context: Admitted patient Data type: Numeric Representational form: CODE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: This is the date that the 'Delayed Assessed Separation Event - Waiting Period' finishes. If the patient no longer requires the care (for example, if a patient's care needs change), enter the date on which it is deemed that the separation is no longer required. If the proposed setting or service changes, a new 'Delayed Assessed Separation Event' will be required. An end date is required before a new 'Delayed Assessed Separation Event' commences. Verification Rules: Must be between 'Admission date - episode' and 'Separation date' (inclusive). Must be later than or equal to the 'Delayed assessed separation event - start Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element concept Delayed assessed separation event, QHLTH 040896 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event - waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event - waiting reason, QHLTH 040901 version 2 Source Document: Source Organisation: Comment:

71

Delayed assessed separation event - proposed service

Data Element ID: 040902 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The principal type of care/service that it is proposed that the patient will be separated to. Context: Admitted Patient Data type: Numeric character Representational form: CODE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: 001 No service is required 101 Community/home based - rehabilitation 102 Community/home based - palliative 103 Community/home based - geriatric evaluation and management 104 Community/home based - respite 105 Community/home based - psychogeriatric 106 Home and community care 107 Community aged care package, extended aged care in the home 108 Flexible care package 109 Transition care program (includes intermittent care service) 110 Outreach Service (was Community Outreach Service) 111 Community/home based - nursing / domiciliary 198 Community/home based - other (was Non-hospital based - other) 201 Hospital Based (admitted) - rehabilitation 202 Hospital Based (admitted) - maintenance / interim care 203 Hospital Based (admitted) - palliative 204 Hospital Based (admitted) - geriatric evaluation and management 205 Hospital Based (admitted) - respite 206 Hospital Based (admitted) - psychogeriatric 207 Hospital Based (admitted) - acute 208 Hospital Based - non-admitted services 298 Hospital Based - other 998 Other service 999 Not stated/unknown service Guide for Use: Only one service option can be selected. For example, if the patient is being separated to community rehabilitation and admitted day rehabilitation, the principal service should be selected. One service must be selected from the Community/Home Based options, Hospital Based options or No service required option. If the patient's care needs change and they are not separated, the proposed service should still be recorded. For example, if a patient is to receive Home and Community Care services, but they die, the proposed service should still be recorded as Home and Community Care services.

72

Delayed assessed separation event - proposed service

If care needs change and a different proposed setting or service is needed, a new Delayed Assessed Separation Event will be required. 001 - No service is required. Community/home based: excludes hospital in the home. 101 - Community/home based- rehabilitation; 201 - Hospital Based (admitted) - rehabilitation: "clinical intent or treatment goal is to improve the functional status of a patient with an impairment, disability or handicap". (QHAPDC) 102 - Community/home based - palliative; 203 - Hospital Based (admitted) - palliative: "clinical intent or treatment goal is primarily quality of life for a patient with an active, progressive disease with little or no prospect of cure". (QHAPDC) 103 - Community/home based - geriatric evaluation and management; 204 - Hospital Based (admitted) - geriatric evaluation and management: "clinical intent or treatment goal is to maximise the health status and/or optimise the living arrangements for a patient with multi-dimensional medical conditions associated with disabilities and psychosocial problems, who is usually (but not always) an older patient. This may also include younger adults with clinical conditions generally associated with old age". (QHAPDC) 104 - Community/home based - respite; 205 - Hospital Based (admitted) - respite: "The patient is receiving respite care. Respite care is care given as an alternative care arrangement with the primary purpose of giving the carer or a care patient a short term break from their usual arrangement. Note: Respite care should only be recorded when the primary purpose is to substitute for the usual care arrangement" (ACEMA, Final Report - Appendices, page E13). 105 - Community/home based - psychogeriatric; 206 - Hospital Based (admitted) - psychogeriatric: "clinical intent or treatment goal is improvement in health, modification of symptoms, enhancement in function, behaviour and/or quality of life for a patient with an age related organic brain impairment with significant behavioural or late onset psychiatric disturbance or a physical condition accompanied by severe psychiatric or behavioural disturbance" (QHAPDC). 106 - Home and community care: "A Commonwealth and State funded program to support frail older people to remain in their homes through the provision of a comprehensive range of high quality and cost effective care packages to them and their carers" (ACEMA, Final Report - Appendices, page E15). 107 - Community Aged Care Package, extended aged care in the home: A program that delivers community care as well as services to meet the needs of carers" (ACEMA, Final Report - Appendices, page E15).

73

Delayed assessed separation event - proposed service

108 - Flexible Care Package: "Flexible care is defined in the Aged Care Act 1997 (The Act) as "care provided in a residential or community setting through an aged care service that addresses the needs of care recipients in alternative ways to the care provided through residential care services and community care services. The Act currently provides for three forms of flexible care - Extended Aged Care at Home (EACH), Multi Purpose Services (including some regional Health Service Centres) and Innovative Care. Care is also provided outside The Act through “Flexible Services for Indigenous Australians" (ACEMA, Final Report - Appendices, page E15). 109 - Transition care program: "provides short-term support and active management for older people at the interface of the acute/sub-acute and residential aged care sectors." Transition care may offer: "nursing support, low intensity therapy or rehabilitation, personal care, medical support and case management" (COAWG). Intermittent care service: "provides short term interventions for older people with multiple complications and co- morbidities. The service interfaces between acute care, community and aged care and intends to decrease the need for both long term residential aged care and admission to hospital" (DSAC proposal, 12/10/04). 110 - Outreach Service: includes physical outreach by multidisciplinary teams or consultancy by telehealth (for example, rural stroke outreach teams. 111 - Nursing/domiciliary: includes only those domiciliary and community services provided by a registered or enrolled nurse, for example, health assessments and assistance with activities of daily living provided by non- government organisations such as Blue Care or St Luke's. Nursing services provided by the HACC program should be coded 106; nursing services provided through a Community aged care package should be coded 107. 198 - Community/home based - other (was Non-hospital based - other): other non-hospital based services. 202 - Hospital based (admitted) - Maintenance / Interim care: "clinical intent or treatment goal is prevention of deterioration in the functional and current health status of a patient with a disability or severe level of functional impairment". (QHAPDC). 207 - Hospital based (admitted) - Acute: "clinical intent or treatment goal is one or more of the following: manage labour, cure illness or provide definitive treatment of injury, perform surgery, relieve symptoms of illness or injury, protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function and/or perform diagnostic or therapeutic procedures." 208 - Hospital based - non-admitted services: includes outpatient appointments. 209 - Hospital based - other: other hospital based services, including multi- purpose health services.

74

Delayed assessed separation event - proposed service

998 - Other service: other service not stated above. 999 - Not stated/unknown: the service has not been specified or is unknown. Verification Rules: Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element concept Delayed assessed separation event, QHLTH 040896 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event - waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event - waiting reason, QHLTH 040901 version 2 supersedes previous data element Delayed assessed separation event - proposed service, QHLTH 040902 version 1 Source Document: Source Organisation: Comment:

75

Delayed assessed separation event - proposed setting

Data Element ID: 040903 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The principal care setting that it is proposed that the patient will be separated to. Context: Admitted Patient Data type: Numeric character Representational form: CODE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: 103 Residential aged care, unknown or unspecified level of care 104 Residential support institutions, hostels or group homes for people with a disability 105 Specialised residential mental health service 106 Other non-hospital health care residential facilities 107 Other non health-care supported accommodation 108 Private residence of a service provider 109 Private residence - other 110 Residential aged care, high level dementia specific care 111 Residential aged care, high level of care - other 112 Residential aged care, low level dementia specific care 113 Residential aged care, low level of care - other 198 Other non-hospital care setting 201 Admitted service, current treating hospital. 202 Admitted service, another hospital 203 Non-admitted service, current treating hospital. 204 Non-admitted service, another hospital 298 Other hospital care setting 999 Not Stated / Unknown setting Guide for Use: Only one setting can be selected. For example, if the patient is being separated to a `private residence / home' and also to hospital for admitted day rehabilitation, the principal setting only, should be selected. A selection needs to be made from the Non-hospital Setting options or the Hospital Setting options. If the patient's care needs change and they are not separated, the proposed setting should still be recorded. For example, if a patient is awaiting placement to a nursing home, but they die, the proposed setting should still be recorded as residential aged care facility (and the appropriate level of care).. If care needs change and a different proposed setting or service is needed, a new Delayed Assessed Separation Event will be required. 110,111,112, 113, 103, Note: if patient is returning to nursing home, use residential

aged care. Even if the patient is returning to a residential aged care facility, an assessment may still be required if the patient requires a higher level of care following hospitalisation.

103 - Residential aged care, unknown or unspecified level of care: includes nursing homes for the aged and aged care hostels where the level of care required is unknown or unspecified and requires assessment by an Aged Care Assessment Team unless the patient is returning to their usual residence in a residential aged care facility.

76

Delayed assessed separation event - proposed setting

104 - Residential support institutions, hostels or group homes for people with a disability: includes those facilities coded to the residential setting Supported accommodation facility (eg, hostels, supported residential services or facilities) in the Commonwealth State/Territory Disability Agreement National Minimum Data Set collection. Also includes those facilities coded to the residential setting Domestic-scale supported living facility (eg, group homes) in the Commonwealth State/Territory Disability Agreement National Minimum Data Set collection. 105 - Specialised residential mental health service: includes residential facilities where mental health trained staff are on-site 24 hours per day: see NHDD data element concept Residential mental health service. 106 - Other non-hospital health care residential facilities: includes non- hospital health care residential facilities other than specialised mental health care facilities, such as drug and alcohol residential centres, hospices, early parenting centres. Other non-hospital health care residential facilities excludes any form of hospital or part of any hospital, that is, to access the residential facility the patient must be separated (actually, not statistically) from the treating hospital and not undergo a hospital admission or readmission. 107 - Other non health-care supported accommodation: includes family group homes, cluster apartments where the support worker lives on site, non-health community residential care units, special purpose hostels for young people, emergency houses, shelters and refuges and secure welfare units for young people at risk of harm and care homes for the disabled eg Endeavour homes. 108 - Private residence of a service provider: includes foster care placements, family-based respite care, adolescent community placement, reception and permanent care. Formal care must be provided by the service provider. Private residences where informal care is provided, for example, by a person related to the patient, should be coded to 109 - private residence/home. 109 - Private residence / other: includes private residence or the patient's home, with or without formal care; informal care may be provided by relatives or family; excludes private residence of a service provider. 110 - Residential aged care, high-level dementia specific care - includes those aged care facilities as specified in 111 but also providing dementia specific care. 111- Residential aged care, high level of care - other: includes nursing homes for the aged and aged care hostels where a high level of care is required and requires assessment by an Aged Care Assessment Team unless the patient is returning to their usual residence in a residential aged care facility. A high care resident has a Resident Classification Scale level of 1-4.

77

Delayed assessed separation event - proposed setting The level of care required is similar to the previous system of nursing home care. (AIHW Residential Aged Care in Australia, 2002-03 - A Statistical Overview). 112 - Residential aged care, low level dementia specific care: includes those aged care facilities as specified in 113 but also providing dementia specific care. 113 - Residential aged care, low level of care - other: includes nursing homes for the aged and aged care hostels where a low level of care is required and requires assessment by an Aged Care Assessment Team unless the patient is returning to their usual residence in a residential aged care facility. A low care resident has a Resident Classification Scale level of 5-8. The level of care required is similar to the previous system of hostel care. (AIHW Residential Aged Care in Australia, 2002-03 - A Statistical Overview). 198 - Other non-hospital care setting: May also include any other non- private residence such as prisons, remand centres and other custodial settings, staff quarters, boarding schools, colleges, convents and monasteries, hotels (including private hotels). 201- Admitted service, in the current treating hospital (includes mental health extended treatment facilities (campus and non-campus based)). 202 - Admitted service, another hospital: admitted service in another hospital (public or private). 203 - Non-admitted service, in the current treating hospital, for example, outpatient appointments. 204 - Non-admitted service, another hospital: non-admitted service in another hospital, for example, outpatient appointments (public or private). 298 - Other hospital care setting: other hospital care setting. 999 - Not Stated / Unknown setting: the setting has not been specified or is unknown. Verification Rules: Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element concept Delayed assessed separation event, QHLTH 040896 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event – waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event – waiting reason, QHLTH 040901 version 2 supersedes previous data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 1 Source Document: Source Organisation: Comment:

78

Delayed assessed separation event - stage of care

Data Element ID: 040897 Version number: 2 Type: DATA ELEMENT CONCEPT Status: CURRENT 16/02/2006 Definition: The component of care within or outside the hospital in which a service appropriate to the type of care required by a patient is provided. Context: Delayed Assessed Separation Event Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element concept Delayed assessed separation event, QHLTH 040896 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event – waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event – waiting reason, QHLTH 040901 version 2 Source Document: Source Organisation: Comment: In the context of the Delayed Assessed Separation Event, the patient cannot be separated to the appropriate care setting for one or more reasons. For example: (i) a patient in a designated rehabilitation unit may be assessed as requiring discharge to a residential aged care facility, however, the patient's discharge is delayed due to waiting for a bed (awaiting placement) in the residential aged care facility (movement from rehabilitation to residential aged care); (ii) a patient in an acute episode of care is assessed as requiring rehabilitation in the hospital's designated unit, however, the patient's transfer/statistical separation is delayed due to waiting for a bed (awaiting placement) in the designated unit (movement from acute to rehabilitation).

79

Delayed assessed separation event - start date

Data Element ID: 040898 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The date that the treating clinician identifies that a patient is ready to be separated to another stage of care, but cannot be separated for one or more reasons. Context: Admitted patient Data type: Numeric Representational form: DATE Representation layout: DDMMYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid Date Guide for Use: This data element records the start date for the 'Delayed Assessed Separation Event - Waiting Period'. If the proposed setting or service changes, a new Delayed Assessed Separation Event will be required. Verification Rules: Must be between 'Admission date - episode' and 'Separation date' (inclusive). Must be earlier than or equal to the 'Delayed assessed separation event - end Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event – waiting period, QHLTH 040900 version 2 relates to the data element Delayed assessed separation event – waiting reason, QHLTH 040901 version 2 Source Document: Source Organisation: Comment:

80

Delayed assessed separation event - waiting period

Data Element ID: 040900 Version number: 2 Type: DERIVED DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The total number of days that the patient is in a Delayed assessed separation event. Context: Admitted patient Data type: Integer Representational form: QUANTITATIVE Representation layout: N4 Minimum Size: 1 Maximum Size: 4 Data Domain: Integers in the range 0 - 9999 Guide for Use: The 'Delayed assessed separation event - waiting period' is derived from the 'Delayed assessed separation event - start date' and the 'Delayed assessed separation event - end date', minus any leave days. There may be multiple waiting periods within one episode of care, however, there can only be one waiting period at any one time. The dates related to each 'Delayed assessed separation event' must not overlap. A 'Delayed assessed separation event - end date' is required before a new 'Delayed assessed separation event' commences. Verification Rules: Must be less than or equal to 'Patient days' Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event - waiting reason, QHLTH 040901 version 2 Source Document: Source Organisation: Comment:

81

Delayed assessed separation event - waiting reason

Data Element ID: 040901 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The reason/s for the delay to separate a patient. Context: Admitted Patient Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 13 Awaiting decision by patient, patient's family or patient's carer(s) 14 Awaiting decision by Guardianship and Administration Tribunal 15 Awaiting formal assessment, re-assessment or review - Clinical 16 Awaiting formal assessment, re-assessment or review - ACAT 23 Awaiting modifications to residence 24 Awaiting placement 25 Awaiting availability of hospital services or programs 26 Awaiting availability of community based services or programs 27 Awaiting equipment 31 Awaiting transport 32 Awaiting family / informal carer support 33 Awaiting a dwelling 98 Other reason 99 Not stated / unknown reason Guide for Use: At least one reason must be selected; up to three (3) reasons are permitted. This recognises that the delay in separation may be due to multiple reasons. The reason/s that contributed most to the delay, from a clinical perspective, should be selected (maximum of 3 reasons) Specifically: - Where multiple reasons have been identified as contributing to the delay and it is possible to prioritise the contribution of each reason, then the highest contributing reason should be specified as the first reason, followed by the second and third reasons. - If there are 3 reasons that equally contributed to the delay, then the reasons can be specified in any order. - If there are more than 3 reasons, the clinician should select the 3 reasons that they believe contributed most to the delay. - Specifying at least one reason is mandatory; specifying the second and third reason is optional. For example, initially, a patient may wait for formal clinical assessment and then for a community-based service or program as well as equipment to be organised and home modifications to be completed. Staff would need to determine the three (3) reasons that contributed most to the delay, for example, awaiting availability of community-based services or programs, followed by awaiting equipment and awaiting modifications to residence.

82

Delayed assessed separation event - waiting reason

A `comments' field will be available in HBCIS to allow users to record further details about the delay. Entry in the comments field is optional, but mandatory for the `98 - Other reason' option. This field will appear in hospital based HBCIS reports, but will not be extracted with other DASE details to the Data Collections Unit (via the HQI Extract). If required, '98 - Other reason' can be selected up to 3 times, to capture reasons that are not specified in the other options. Additionally, hospitals will have the option to utilise hospital defined waiting reasons, for example, hospital specific issues that are identified as potential reasons for delay such as awaiting transfer to another hospital for a specific procedure. These waiting reasons would appear in hospital-based HBCIS reports. They will be mapped to existing categories within the Principal Waiting Reasons element for reporting via the HQI Extract. 13 - Awaiting decision by patient, patient's family or patient's carer(s): The patient has been assessed as ready for separation by a treating clinician, but separation depends on one or more decisions being taken by the patient, the patient's family and/or the patient's carer(s), guardian or power of attorney - excluding Guardianship and Administration Tribunal decisions made on behalf of persons with impaired decision-making capacity. 14- Awaiting decision by Guardianship and Administration Tribunal: The patient has been assessed as ready for separation by a treating clinician. Separation depends on decisions by the Guardianship and Administration Tribunal. 15- Awaiting formal assessment, re-assessment or review - Clinical: The patient has been assessed as ready for separation by a treating clinician, but separation depends on a formal medical / clinical assessment or re- assessment by medical, allied health or nursing staff to determine the patient's care and/or setting needs. Also includes reviews. Excludes ACAT assessment/reassessment. 16 - Awaiting formal assessment, re-assessment or review - ACAT: The patient has been assessed as ready for separation by a treating clinician, but separation depends on ACAT assessment or re-assessment to determine the patient's care and/or setting needs. 24 - Awaiting placement: The patient has been assessed as ready for separation by a treating clinician, but separation depends on placement in a suitable non-hospital setting, for example, residential aged care facility, hostel. 25- Awaiting availability of hospital services or programs: The patient has been assessed as ready for separation by a treating clinician, but separation depends on the availability of appropriate hospital services or programs, for example, availability of a bed in a rehabilitation ward. 26 - Awaiting availability of community - based services or programs: The patient has been assessed as ready for separation by a treating clinician, but separation of the patient depends on the availability of appropriate community-based services or programs, for example, community support.

83

Delayed assessed separation event - waiting reason

23 - Awaiting modifications to residence - The patient has been assessed as ready for separation by a treating clinician, but the separation is dependent on physical modifications being made to the residence. 27- Awaiting equipment: The patient has been assessed as ready for separation by a treating clinician, but the separation is dependent on availability of equipment, for example, wheelchair, MASS aids / equipment. 31 - Awaiting transport: - The patient has been assessed as ready for separation by a treating clinician, but the separation is dependent on waiting for transport to the proposed setting. 32- Awaiting family/informal carer support: The patient has been assessed as ready for separation by a treating clinician, but the separation is dependent on availability of family or informal carer support, for example, awaiting patient's family or informal carers to return from holidays. 33 - Awaiting a dwelling: The patient has been assessed as ready for separation by a treating clinician, but the patient is unable to return to his/her pre-admission dwelling, for example private home is on the market. 98 - Other reason: The patient is waiting for another reason not specified above; includes internal hospital delays, eg, waiting for investigation results. It is mandatory to use the HBCIS `Comments' field to provide details of the reason. 99 – Not Stated/unknown: The reason the patient is waiting has not been specified. Verification Rules: Related Data References: relates to the data element concept Delayed assessed separation event - stage of care, QHLTH 040897 version 2 relates to the data element concept Delayed assessed separation event, QHLTH 040896 version 2 relates to the data element Delayed assessed separation event - end date, QHLTH 040899 version 2 relates to the data element Delayed assessed separation event - proposed service, QHLTH 040902 version 2 relates to the data element Delayed assessed separation event - proposed setting, QHLTH 040903 version 2 relates to the data element Delayed assessed separation event - start date, QHLTH 040898 version 2 relates to the data element Delayed assessed separation event – waiting period, QHLTH 040900 version 2 supersedes previous data element Delayed assessed separation event - principal waiting reason, QHLTH 040901 version 1 Source Document: Source Organisation: Comment:

84

Department of Veterans' Affairs card type

Data Element ID: 040626 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2001 Definition: The Department of Veterans' Affairs treatment entitlement card. Context: Data type: Numeric character Representational form: TEXT Representation layout: AAAAA Minimum Size: 5 Maximum Size: 5 Data Domain: 1 White 2 Gold Guide for Use: Gold card entitles a DVA patient to be treated for all medical conditions whether they are related to war service or not. Gold card holders have access to a range of health services in which there are arrangements with registered health care providers. White card entitles a DVA patient to be treated for service or specific war related conditions or malignant cancer, pulmonary tuberculosis and post traumatic stress disorder in health facilities where there is a DVA arrangement. Verification Rules: Related Data References: is used in conjunction with Department of Veterans' Affairs file number, QHLTH 040625 version 1 Source Document: Source Organisation: Comment:

85

Department of Veterans' Affairs file number

Data Element ID: 040625 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2001 Definition: The identification number of a Department of Veterans' Affairs card holder. Context: The Department of Veterans' Affairs identification number is recorded each time a patient presents for care. A Department of Veteran Affairs card holder is entitled to have their charges met by the Department. Data type: Alphanumeric Representational form: IDENTIFICATION Representation layout: AAAANNNNNN NUMBER Minimum Size: 10 Maximum Size: 10 Data Domain: Guide for Use: Verification Rules: The first digit is the state code The war/conflict code (0-3 digits) the Id number(1-6 digits) Dependant code (0-1 digit) Related Data References: is used in conjunction with Department of Veterans' Affairs card type, QHLTH 040626 version 1 is used in conjunction with Expected principal source of funds for the episode, QHLTH 040624 version 1 relates to the data element Compensable status, QHLTH 040051 version 3 Source Document: Source Organisation: Comment:

86

Diagnosis

Data Element ID: 040789 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 25/03/2002 Definition: A diagnosis is the decision reached, after assessment, of the nature and identity of the disease or condition of a patient/client. Context: Health services: Diagnostic information provides the basis for the analysis of health service usage, epidemiological studies and monitoring of specific disease entities. Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: National Health Data Committee (NHDC) Comment: Classification systems which enable the allocation of a code to the diagnostic information: International Statistical Classification of Diseases and Related Health Problems - Tenth Revision - Australian Modification (1998) (ICD-10-AM) British Paediatric Association Classification of Diseases (1979) North America Nursing Diagnosis Association (NANDA) International Classification of Primary Care International Classification of Impairments, Disabilities and Handicaps (1980) International Classification of Impairments, Disabilities and HandicapsBeta/1 draft revised classification (1997).

87

Diagnosis code type

Data Element ID: 040099 Version number: 3 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A qualifier for each ICD-10-AM code which indicates whether that particular code is for a principal or other diagnosis, procedure, external cause or morphology. Context: Used for epidemiological research, casemix studies; severity of illness analyses; resource utilisation and planning purposes. Data type: Character Representational form: CODE Representation layout: A(2) Minimum Size: 1 Maximum Size: 2 Data Domain: EX External cause M Morphology OD Other diagnosis PD Principal diagnosis PR Procedure Guide for Use: Only one diagnosis may be specified as the principal diagnosis. Verification Rules: Related Data References: is a qualifier of Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 relates to the data element External cause, QHLTH 040248 version 1 relates to the data element Principal diagnosis, QHLTH 040244 version 1 relates to the data terminology item Additional diagnoses, QHLTH 040245 version 3 relates to the data terminology item Procedure, QHLTH 040617 supersedes previous data element Diagnosis code identifier, QHLTH 040099 version 2 Source Document: Source Organisation: Comment:

88

Diagnosis related group (Facility calculated)

Data Element ID: 040097 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A code which signifies the patient's classification in the hospitals case mix, derived from the ICD-10-AM diagnostic codes for principal and secondary diagnoses, procedures performed, age, sex and discharge status. Context: Institutional health care: The development of Australian Refined DRGs has created a descriptive framework for studying hospitalisation. DRGs provide a summary of the varied reasons for hospitalisation and the complexity of cases a hospital treats. Moreover, as a framework for describing the products of a hospital (that is, patients receiving services), they allow meaningful comparisons of hospitals' efficiency and effectiveness under alternative systems of health care provision. Data type: Alphanumeric Representational form: CODE Representation layout: ANNA Minimum Size: 4 Maximum Size: 4 Data Domain: Valid DRG codes from the current version of the Australian Refined DRG Classification. ARDRG Definitions Manual Version 4.1 Volume I, II, and III Commonwealth Department of Health and Aged Care, 3M Health Information Systems. Guide for Use: DRGs are calculated using the related data items at the facility. Verification Rules: Related Data References: is derived from Admission date - episode, QHLTH 040008 version 1 is derived from Birth weight, QHLTH 040001 version 1 is derived from Diagnosis code type, QHLTH 040099 version 3 is derived from Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 is derived from Intended length of stay, QHLTH 040012 version 1 is derived from Mode of separation, QHLTH 040119 version 3 is derived from Separation date, QHLTH 040117 version 1 is derived from Sex - client, QHLTH 040000 version 2 is used in conjunction with Diagnosis related group (HSC calculated), QHLTH 040517 version 2 is used in conjunction with Major diagnostic category (Facility calculated), QHLTH 040098 version 1 supersedes previous data element Diagnosis related group (Facility calculated), QHLTH 040097 version 1 Source Document: Source Organisation: Comment:

89

Diagnosis related group (HSC calculated)

Data Element ID: 040517 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A code which signifies the patient's classification in the hospitals case mix, derived from the ICD-10-AM diagnostic codes for principal and secondary diagnoses, procedures performed, age, sex and discharge status. Context: Institutional health care: The development of Australian Refined DRGs has created a descriptive framework for studying hospitalisation. DRGs provide a summary of the varied reasons for hospitalisation and the complexity of cases a hospital treats. Moreover, as a framework for describing the products of a hospital (that is, patients receiving services), they allow meaningful comparisons of hospitals' efficiency and effectiveness under alternative systems of health care provision. Data type: Alphanumeric Representational form: CODE Representation layout: ANNA Minimum Size: 4 Maximum Size: 4 Data Domain: Valid DRG codes from the current version of the Australian Refined DRG Classification. ARDRG Definitions Manual Version 4.1 Volume I, II, and III. Commonwealth Department of Health and Aged Care, 3M Health Information Systems. Guide for Use: DRGs received from facilities are re-calculated from the related data items at the Data Collections Unit.. Verification Rules: Related Data References: is derived from Admission date - episode, QHLTH 040008 version 1 is derived from Birth weight, QHLTH 040001 version 1 is derived from Diagnosis code type, QHLTH 040099 version 3 is derived from Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 is derived from Intended length of stay, QHLTH 040012 version 1 is derived from Mode of separation, QHLTH 040119 version 3 is derived from Separation date, QHLTH 040117 version 1 is derived from Sex - client, QHLTH 040000 version 2 is used in conjunction with Diagnosis related group (Facility calculated), QHLTH 040097 version 2 is used in conjunction with Major diagnostic category (HSC calculated), QHLTH 040145 version 1 supersedes previous data element Diagnosis related group (HSC calculated), QHLTH 040144 version 1 Source Document: Source Organisation: Comment: The AR-DRGs are a patient classification scheme consisting of classes of patients who are similar clinically and in terms of their consumption of hospital resources.

90

Diagnostic code (ICD-10-AM)

Data Element ID: 040100 Version number: 3 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A code assigned after institutional health care to specify a disease, injury, morphology, procedure, external cause and/or other factor influencing health status that describes the reason for hospital stay. Context: Used for epidemiological research, casemix studies; severity of illness analyses; resource utilisation and planning purposes. Data type: Alphanumeric Representational form: CODE Representation layout: Minimum Size: 4 Maximum Size: 7 Data Domain: Valid codes from the current Australian version of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) Guide for Use: ICD-10-AM It is the current coding standard that disease, injury and morphology codes can NOT be duplicated within an episode; while procedure and external cause codes CAN be duplicated within an episode of care. Verification Rules: Related Data References: is qualified by Diagnosis code type, QHLTH 040099 version 3 is used in the calculation of Diagnosis related group (HSC calculated), QHLTH 040517 version 2 is used in the calculation of Diagnosis related group (Facility calculated), QHLTH 040097 version 2 is used in the calculation of Major diagnostic category (HSC calculated), QHLTH 040145 version 1 is used in the calculation of Major diagnostic category (Facility calculated), QHLTH 040098 version 1 Source Document: Source Organisation: Comment:

91

Discharge status - mother\baby

Data Element ID: 040043 Version Number: 2 Type: DATA ELEMENT Status: CURRENT

01/07/1999 Definition: Mode of formal separation of the mother\baby. (This item refers to formal separations, that is discharge, transfer to another facility, or death. It does not refer to statistical separations / episode of care type changes) Context: Perinatal data collection Datatype: Numeric character Representational Form: CODE Representation Layout: N Minimum Size: 1 Maximum Size: 1 Data Domain : 1 Discharged

2 Transferred 3 Died 4 Remaining in 9 Not stated/unknown

Guide for Use: Verification Rules: Related Data References: is used in conjunction with Date of formal separation QHLTH 040044 version 1 supersedes previous data element Discharge status - mother\baby QHLTH 040043 version 1 Source Document: Source Organisation: Comment: Note the difference between this item and item 0128 (Mode of separation) which relates to episodes of care. This item is collected separately for both the mother and the baby.

92

Elective care

Data Element ID: 040155 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Care that, in the opinion of the treating clinician, is necessary, and admission for which can be delayed for at least 24 hours. Context: Elective admission/Waiting list Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Elective surgery, QHLTH 040156 version 1 Source Document: Source Organisation: Comment:

93

Elective patient status

Data Element ID: 040291 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: Elective care is care that, in the opinion of the treating clinician, is necessary, and admission for which can be delayed for at least 24 hours. Emergency care is care that, in the opinion of the treating clinician, is necessary and admission for which cannot be delayed for more than 24 hours. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Emergency Admission 2 Elective admission 3 Not assigned Guide for Use: CODE 1 Emergency admission - The following guidelines may be used by health professionals, hospitals and health insurers in determining whether an emergency admission has occurred. These guidelines should not be considered definitive. An emergency admission occurs if one or more of the following clinical conditions are applicable such that the patient required admission within 24 hours. Such a patient would be: - at risk of serious morbidity or mortality and requiring urgent assessment and/or resuscitation; or - suffering from suspected acute organ or system failure; or - suffering from an illness or injury where the viability or function of a body part or organ is acutely threatened; or - suffering from a drug overdose, toxic substance or toxin effect; or - experiencing severe psychiatric disturbance whereby the health of the patient or other people is at immediate risk; or - suffering severe pain where the viability or function of a body part or organ is suspected to be acutely threatened; or - suffering acute significant haemorrhage and requiring urgent assessment and treatment; or - suffering gynaecological or obstetric complications; or - suffering an acute condition which represents a significant threat to the patient's physical or psychological wellbeing; or - suffering a condition which represents a significant threat to public health. If an admission meets the definition of emergency above, it is categorised as emergency, regardless of whether the admission occurred within 24 hours of such a categorisation being made, or after 24 hours or more. CODE 2 Elective admission -

94

Elective patient status

If an admission meets the definition of elective care, it is categorised as elective, regardless of whether the admission occurred after 24 hours or more, or it occurred within 24 hours. The distinguishing characteristic is that the admission could be delayed by at least 24 hours. Scheduled admissions: A patient who expects to have an elective admission will often have that admission scheduled in advance. Whether or not the admission has been scheduled does not affect the categorisation of the admission as emergency or elective, which depends only on whether it meets the definitions above. That is, patients both with and without a scheduled admission can be admitted on either an emergency or elective basis. CODE 3 Not assigned - Admissions for which an 'Elective patient status' is usually not assigned: - admissions for normal delivery (obstetric) - admissions which begin with the birth of the patient, or when it was intended that the birth occur in the hospital, commence shortly after the birth of the patient - statistical admissions - planned readmissions for the patient to receive limited care or treatment for a current condition, for example dialysis or chemotherapy. Verification Rules: Related Data References: relates to the data element Elective care, QHLTH 040155 version 1 supersedes previous data element Elective patient status, QHLTH 040291 version 1 Source Document: Source Organisation: Comment:

95

Elective surgery

Data Element ID: 040156 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Elective care where the procedure required by the patient is listed in the surgical operations section of the Medical Benefits Schedule book, with the exclusion of procedures frequently done by non-surgical specific clinicians. Context: Elective admission/Waiting list Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

96

Elective surgery specialty

Data Element ID: 040095 Version number: 2 Type: DERIVED DATA ELEMENT Status: CURRENT 27/02/2007 Definition: The area of clinical expertise held by the doctor who will perform the elective surgery. Context: Elective admission/Waiting list Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Cardiothoracic 02 Ear, Nose and Throat 03 General Surgery 04 Gynaecology 05 Neurology 06 Ophthalmology 07 Orthopaedic Surgery 08 Plastic and Reconstructive 09 Urology 10 Vascular Surgery 11 Other - surgical 90 Other - non-surgical Guide for Use: Verification Rules: Related Data References: is derived from Planned unit, QHLTH 040353 version 1 supersedes previous derived data element Elective surgery specialty, QHLTH 040095 version 1 Source Document: Source Organisation: Comment:

97

Elective surgery waiting list episode-waiting list removal date

Data Element ID: 040983 Version number: 1 Type: DATA ELEMENT Status: CURRENT 28/02/2007 Definition: Date on which a patient is removed from an elective surgery waiting list. Context: This metadata item is necessary for the calculation of the waiting time at removal from an elective surgery waiting list. Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: This date is recorded when a patient is removed from an elective surgery waiting list.

Removal date will be the same as admission date for patients in Reason for removal from elective surgery waiting list categories 1 and 2.

Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

98

Elective surgery waiting time (at census date)

Data Element ID: 040962 Version number: 1 Type: DERIVED DATA ELEMENT Status: CURRENT 28/02/2007 Definition: The time elapsed (in days) for a patient on the elective surgery waiting list from the date they were added to the waiting list to a designated census date. Context: Elective surgery Data type: Integer Representational form: QUANTITATIVE Representation layout: N (4) Minimum Size: 1 Maximum Size: 4 Data Domain: Positive integers in the range 0-9999 Guide for Use: The number of days is calculated by subtracting the Elective care waiting list episode-listing date for care, DDMMYYYY from the Hospital census (of elective surgery waitlist patients)-census date, DDMMYYYY, minus any days when the patient was 'not ready for care', and also minus any days the patient was waiting with a less urgent clinical urgency category than their clinical urgency category at the census date. Days when the patient was not ready for care is calculated by subtracting the date(s) the person was recorded as 'not ready for care' from the date(s) the person was subsequently recorded as again being 'ready for care'. When a patient is admitted from an elective surgery waiting list but the surgery is cancelled and the patient remains on or is placed back on the waiting list within the same hospital, the time waited on the list should continue. Therefore at the census date the patient's waiting time includes the number of days waited on an elective surgery waiting list, both before and after any cancelled surgery admission. The time waited before the cancelled surgery should be counted as part of the total time waited by the patient. Verification Rules: Related Data References: is calculated using Listing date on waiting list, QHLTH 040359 version 2 supersedes previous data element Total waiting time, QHLTH 040091 version 1 Source Document: Source Organisation: Comment:

99

Elective surgery waiting time (at removal date)

Data Element ID: 040963 Version number: 1 Type: DERIVED DATA ELEMENT Status: CURRENT 28/02/2007 Definition: The time elapsed (in days) for a patient on the elective surgery waiting list from the date they were added to the waiting list for the procedure to the date they were removed from the waiting list. Context: Elective surgery Data type: Integer Representational form: QUANTITATIVE Representation layout: N (4) Minimum Size: 1 Maximum Size: 4 Data Domain: Positive integers in the range 0-9999 Guide for Use: The number of days is calculated by subtracting the listing date for care from the removal date, minus any days when the patient was 'not ready for care', and also minus any days the patient was waiting with a less urgent clinical urgency category than their clinical urgency category at removal. Days when the patient was not ready for care is calculated by subtracting the date(s) the person was recorded as 'not ready for care' from the date(s) the person was subsequently recorded as again being 'ready for care'. If, at any time since being added to the waiting list for the elective surgical procedure, the patient has had a less urgent clinical urgency category than the category at removal, then the number of days waited at the less urgent clinical urgency category should be subtracted from the total number of days waited. In cases where there has been only one category reassignment (i.e. to the more urgent category attached to the patient at removal) the number of days at the less urgent clinical urgency category should be calculated by subtracting the listing date for care from the category reassignment date. If the patient's clinical urgency was reclassified more than once, days spent in each period of less urgent clinical urgency than the one applying at removal should be calculated by subtracting one category reassignment date from the subsequent category reassignment date, and then adding the days together. When a patient is removed from an elective surgery waiting list, for admission on an elective basis for the procedure they were awaiting, but the surgery is cancelled and the patient remains on or is placed back on the waiting list within the same hospital, the time waited on the list should continue. Therefore at the removal date, the patient's waiting time includes the number of days waited on an elective surgery waiting list, both before and after any cancelled surgery admission. The time waited before the cancelled surgery should be counted as part of the total time waited by the patient. Verification Rules: Related Data References:

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Elective surgery waiting time (at removal date) is calculated using Listing date on waiting list, QHLTH 040359 version 2 Source Document: Source Organisation: Comment:

101

Emergency department stay-physical departure date

Data Element ID: 040969 Version number: 1 Type: DATA ELEMENT Status: CURRENT 24/03/2006 Definition: The date on which a patient departs an emergency department after a stay. Context: Emergency department care. Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: Each emergency department stay should include a non-admitted patient emergency department service episode component. The value of the episode end status code should guide the selection of the value to be recorded in this field: If the patient is subsequently admitted then record the date the patient leaves the Emergency Department to go to the admitted patient facility. Physically moving the patient to a bed in an emergency department specialist care unit (including EMU, short stay ward, emergency care unit or observation unit) is defined as representing departure from the emergency department. If the service episode is completed without the patient being admitted, including referral to another hospital, record the date the patient leaves the Emergency Department. If the patient did not wait record the date the patient leaves the Emergency Department or was first noticed as having left. If the patient left at their own risk record the date the patient leaves the Emergency Department. If the patient died in the Emergency Department record the date of death. If the patient was dead on arrival then record the date of presentation at the Emergency Department. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: This data element has been developed for the purpose of State and Territory compliance with the Australian Health Care Agreement and the agreed national access performance indicator.

102

Emergency department stay-physical departure time

Data Element ID: 040970 Version number: 1 Type: DATA ELEMENT Status: CURRENT 24/03/2006 Definition: The time at which a patient departs an emergency department after a stay. Context: Emergency department care. Data type: Numeric character Representational form: TIME Representation layout: MMHH Minimum Size: 4 Maximum Size: 4 Data Domain: Valid time Guide for Use: Each emergency department stay should include a non-admitted patient emergency department service episode component. The value of the episode end status code should guide the selection of the value to be recorded in this field: If the patient is subsequently admitted then record the time the patient leaves the Emergency Department to go to the admitted patient facility. Physically moving the patient to a bed in an emergency department specialist care unit (including EMU, short stay ward, emergency care unit or observation unit) is defined as representing departure from the emergency department. If the service episode is completed without the patient being admitted, including referral to another hospital, record the time the patient leaves the Emergency Department. If the patient did not wait record the time the patient leaves the Emergency Department or was first noticed as having left. If the patient left at their own risk record the time the patient leaves the Emergency Department. If the patient died in the Emergency Department record the time of death. If the patient was dead on arrival then record the time of presentation at the Emergency Department. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: This data element has been developed for the purpose of State and Territory compliance with the Australian Health Care Agreement and the agreed national access performance indicator.

103

Employment - work hours per week

Data Element ID: 040862 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The employment status of the person taking into consideration the number of hours worked per week. Context: Alcohol and Other Drug Treatment Service Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Greater than or equal to 35 hours per week (Full Time) 2 20 hours to less than 35 hours per week (Part Time) 3 Less than 20 hours per week (Part Time) 9 Not stated/inadequately described Guide for Use: Only for those clients who have codes 2 or 3 chosen on the Employment Status (Patient) data element Verification Rules: Related Data References: relates to the data element Employment status (patient), QHLTH 040049 version 1 Source Document: Source Organisation: Comment:

104

Employment status (patient)

Data Element ID: 040049 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Self reported employment status of a person, immediately prior to admission to hospital. Context: Psychiatric hospitals and patients in designated psychiatric units of acute hospitals. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Child not at school 2 Student 3 Employed 4 Unemployed 5 Home Duties 6 Pensioner 8 Other 9 Not stated/unknown Guide for Use: Verification Rules: Related Data References: supersedes previous data element Employment status (patient), QHLTH 040049 version 1 Source Document: Source Organisation: Comment:

105

Episode number

Data Element ID: 040007 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The identifier assigned to each episode by an individual facility. Unique within each patient at a particular facility. Context: Institutional health care Data type: Character Representational form: TEXT Representation layout: A(12) Minimum Size: 12 Maximum Size: 12 Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Episode of care, QHLTH 040019 version 1 Source Document: Source Organisation: Comment:

106

Episode of care

Data Element ID: 040019 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: The period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type. Separation may be the result of death, discharge, transfer to another facility, or statistical separation to a different care type. An episode of care is a phase of treatment. There may be more than one episode of care within the one hospital stay. An episode of care ends when the principal clinical intent (and thus care type) changes or when the patient is formally separated from the facility.

Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: is used in conjunction with Care type, QHLTH 040013 version 6 relates to the data element concept Episode of care, QHLTH 040019 version 2 Source Document: Source Organisation: Comment:

107

Episode of Care - Contracting Hospital Identifier

Data Element ID: 041096 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2008 Definition: The identifier of the facility purchasing the contracted service. Context: Institutional Health Care Data type: Character Representational form: CODE Representation layout: NNNNN Minimum Size: 5 Maximum Size: 5 Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element concept Contract service, QHLTH 040130 version 1 relates to the data element Contract role, QHLTH 040806 version 1 relates to the data element Contract type, QHLTH 040807 version 1 relates to the data element Facility type, QHLTH 040263 version 5 Source Document: Source Organisation: Comment:

108

Episode of care-funding eligibility indicator (Department of Veterans Affairs)

Data Element ID: 040971 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Whether an eligible person's charges for this hospital admission are met by the Department of Veterans' Affairs (DVA). Context: Health services Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No Guide for Use: Refer to the Veterans' Entitlements Act 1986 for details of eligible DVA beneficiaries. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Eligible veterans and war widow/widowers can receive free treatment at any public hospital, former Repatriation Hospitals (RHs) or a Veteran Partnering (VP) contracted private hospital as a private patient in a shared ward, with the doctor of their choice. Admission to a public hospital does not require prior approval from the DVA. When treatment cannot be provided within a reasonable time in the public health system at a former RH or a private VP hospital, there is a system of contracted non-VP private hospitals which will provide care. Admission to a contracted private hospital requires prior financial authorisation from DVA. Approval may be given to attend a non-contracted private hospital when the service is not available at a public or contracted non-VP private hospital. In an emergency a Repatriation patient can be admitted to the nearest hospital, public or private, without reference to DVA. If an eligible veteran or war widow/widower chooses to be treated under Veterans' Affairs arrangements, which includes obtaining prior approval for non-VP private hospital care, DVA will meet the full cost of their treatment. To assist in analyses of utilisation and health care funding.

109

Episode of care-number of psychiatric care days

Data Element ID: 040981 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The sum of the number of days or part days of stay that the person received care as an admitted patient thin a designated psychiatric unit, minus the sum of leave days occurring during the stay within the designated unit. Context: Community mental health care: This metadata item is required to identify the characteristics of patients treated in specialist psychiatric 24-hour staffed community-based residential services and to analyse the activities of these units. The metadata item is necessary to describe and evaluate the progress of mainstreaming of mental health services. Data type: Integer Representational form: QUANTITATIVE Representation layout: N[NNNN] Minimum Size: 1 Maximum Size: 5 Data Domain: Integers in the range 0 - 9999 Guide for Use: Designated psychiatric units are staffed by health professionals with specialist mental health qualifications or training and have as their principal function the treatment and care of patients affected by mental disorder. The unit may or may not be recognised under relevant State and Territory legislation to treat patients on an involuntary basis. Patients are admitted patients in the acute and psychiatric hospitals and residents in community based residences. Public acute care hospitals: Designated psychiatric units in public acute care hospitals are normally recognised by the State/Territory health authority in the funding arrangements applying to those hospitals. Private acute care hospitals: Designated psychiatric units in private acute care hospitals normally require license or approval by the State/Territory health authority in order to receive benefits from health funds for the provision of psychiatric care. Psychiatric hospitals: Total psychiatric care days in stand-alone psychiatric hospitals are calculated by counting those days the patient received specialist psychiatric care. Leave days and days on which the patient was receiving other care (e.g. specialised intellectual ability or drug and alcohol care) should be excluded. Psychiatric hospitals are establishments devoted primarily to the treatment and care of admitted patients with psychiatric, mental or behavioural disorders. Private hospitals formerly approved by the Commonwealth Department of Health under the Health Insurance Act 1973

110

Episode of care-number of psychiatric care days (Commonwealth) (now licensed/approved by each State/Territory health authority), catering primarily for patients with psychiatric or behavioural disorders are included in this category. Community-based residential services: Designated psychiatric units refers to 24-hour staffed community-based residential units established in community settings that provide specialised treatment, rehabilitation or care for people affected by a mental illness or psychiatric disability. Special psychiatric units for the elderly are covered by this category, including psychogeriatric hostels or psychogeriatric nursing homes. Note that residences occupied by admitted patients located on hospital grounds, whether on the campus of a general or stand-alone psychiatric hospital, should be counted in the category of admitted patient services and not as community-based residential services. Counting of patient days and leave days in designated psychiatric units should follow the standard definitions applying to these items. For each period of care in a designated psychiatric unit, total days is calculated by subtracting the date on which care commenced within the unit from the date on which the specialist unit care was completed, less any leave days that occurred during the period. Total psychiatric care days in 24-hour community-based residential care are calculated by counting those days the patient received specialist psychiatric care. Leave days and days on which the patient was receiving other care (e.g. specialised intellectual ability or drug and alcohol care) should be excluded. Admitted patients in acute care:

Commencement of care within a designated psychiatric unit may be the same as the date the patient was admitted to the hospital, or occur subsequently, following transfer of the patient from another hospital ward. Where commencement of psychiatric care occurs by transfer from another ward, a new episode of care may be recorded, depending on whether the care type has changed (see metadata item Care type). Completion of care within a designated psychiatric unit may be the same as the date the patient was discharged from the hospital, or occur prior to this on transfer of the patient to another hospital ward. Where completion of psychiatric care is followed by transfer to another hospital ward, a new episode of care may be recorded, depending on whether the care type has changed (see metadata item Care type. Total psychiatric care days may cover one or more periods in a designated psychiatric unit within the overall hospital stay.

Verification Rules: Related Data References: Source Document: Source Organisation: Comment: This metadata item was originally designed to monitor trends in the delivery of psychiatric admitted patient care in acute care hospitals. It has been modified to enable collection of data in the community- based residential care sector. The metadata item is intended to improve understanding in this area and contribute to the ongoing evaluation of changes occurring in mental health services.

111

Episode of residential care end

Data Element ID: 040838 Version Number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT

14/11/2003 Definition: Episode of residential care end is the administrative process by which a residential care service either records: Formal episode of residential care end - The formal end of residential care and accommodation of a resident, - The end of residential care and accommodation of a resident who has commenced leave where t there is no intention that the resident returns to residential care within seven days, or Statistical episode of residential care end - The end of the reference period. Context: Specialised mental health services (Residential mental health care). Datatype: Representational Form: Representation Layout: Minimum Size: Maximum Size: Related Data References: is equivalent to Episode of residential care end NHIMG 000893 version 1 relates to the data element Episode of residential care end date QHLTH 040839 version 0 relates to the data element concept Episode of residential care start QHLTH 040840 version 1 relates to the data element concept Resident QHLTH 040843 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

112

Episode of residential care end date

Data Element ID: 040839 Version number: 0 Type: DATA ELEMENT Status: CURRENT 14/11/2003 Definition: Date on which a resident formally or statistically ends an episode of residential care. Context: Specialised mental health services (Residential mental health care). Data type: Numeric Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid dates Guide for Use: Verification Rules: Data in this field must: - be <= last day of reference period - be >= first day of reference period - be >= Episode of residential care start date Related Data References: relates to the data element concept Episode of residential care end, QHLTH 040838 version 1 relates to the data element concept Episode of residential care, QHLTH 040837 version 1 relates to the data element concept Resident, QHLTH 040843 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

113

Episode of residential care end mode

Data Element ID: 040835 Version number: 1 Type: DATA ELEMENT Status: CURRENT 14/11/2003 Definition: Reason for end of episode of residential care. Context: Specialised mental health services (Residential mental health care). Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Died 2 Left against clinical advice / at own risk 3 Commenced leave where there is no intention that the resident returns to overnight residential care within seven days 4 Other end of residential care at this establishment 5 End of reference period 9 Unknown / not stated / inadequately described Guide for Use: Codes 1-4 refer to the formal episode of residential care end, Code 5 refers to the statistical episode of residential care end, Code 9 refers to other. Verification Rules: Related Data References: is supplemented by the data element Referral from specialised mental health residential care, QHLTH 040836 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

114

Episode of residential care start date

Data Element ID: 040841 Version number: 0 Type: DATA ELEMENT Status: CURRENT 14/11/2003 Definition: Date on which the resident starts an episode of residential care either because of: Formal episode of residential care start - The start of treatment and/or care and accommodation of a resident, or Statistical episode of residential care start - The start of a reference period for a resident continuing their treatment and/or care and accommodation from the previous reference period. Context: Specialised mental health services (Residential mental health care). Data type: Numeric Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: Verification Rules: Right justified and zero filled. Episode of residential care start date <= episode of residential care end date. Episode of residential care start date >= date of birth. Related Data References: relates to the data element concept Episode of residential care start, QHLTH 040840 version 1 relates to the data element concept Episode of residential care, QHLTH 040837 version 1 relates to the data element concept Resident, QHLTH 040843 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

115

Episode of residential care start mode

Data Element ID: 040842 Version number: 0 Type: DATA ELEMENT Status: CURRENT 14/11/2003 Definition: Reason for start of episode of residential care. Context: Specialised mental health services (Residential mental health care). Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Unplanned return from leave where there had been no intention that the resident would return to overnight residential care at the establishment within seven days 2 Other (i.e. start of a new residential stay) 3 Start of a new reference period 9 Unknown / not stated / inadequately described Guide for Use: Codes 1-2 refer to the formal episode of residential care start, Code 3 refers to the statistical episode of residential care start, Code 9 refers to other. Verification Rules: Related Data References: Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

116

Episode of treatment for alcohol and other drugs-cessation reason

Data Element ID: 040949 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The reason for the client ceasing to receive a treatment episode from an alcohol and other drug treatment service Context: Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Treatment completed 02 Change in main treatment type 03 Change in the delivery setting 04 Change in the principal drug of concern 05 Transferred to another service provider 06 Ceased to participate against advice 07 Ceased to participate without notice 08 Ceased to participate involuntary (non-compliance) 09 Ceased to participate at expiation 10 Ceased to participate by mutual agreement 11 Drug court and /or sanctioned by court diversion service 12 Imprisoned, other than drug court sanctioned 13 Died 14 Ceased to participate-discharged YDC 20 12 month F/U completed (ADIS clients only) 21 Ceased employment (ADIS clients only) 22 Ineligible (ADIS clients only) 98 Other 99 Not stated/inadequately described Guide for Use: To be collected on cessation of a treatment episode. Codes 1 to 12 listed above are set out as follows to enable a clearer picture of which codes are to be used for what purpose: Treatment completed as planned: CODE 1 Treatment completed Client ceased to participate: CODE 6 Ceased to participate against advice CODE 7 Ceased to participate without notice CODE 8 Ceased to participate involuntary (non-compliance)

117

Episode of treatment for alcohol and other drugs-cessation reason CODE 9 Ceased to participate at expiation CODE 11 Drug court and /or sanctioned by court diversion service CODE 12 Imprisoned, other than drug court sanctioned CODE 14 Ceased to participate - discharged YDC Treatment not completed (other): CODE 2 Change in main treatment type CODE 3 Change in the delivery setting CODE 4 Change in the principal drug of concern CODE 5 Transferred to another service provider Treatment ceased by mutual agreement: CODE 10 Ceased to participate by mutual agreement ADIS clients only CODE 20 12 month F/U completed CODE 21 Ceased employment CODE 22 Ineligible CODE 1 Treatment completed This code is to be used when all of the immediate goals of the treatment have been completed as planned. Includes situations where the client, after completing this treatment, either does not commence any new treatment, commences a new treatment episode with a different main treatment or principal drug, or is referred to a different service provider for further treatment. CODE 2 Change in main treatment type A treatment episode will end if, prior to the completion of the existing treatment, there is a change in the main treatment type for alcohol and other drugs. See also Code 10. CODE 3 Change in the delivery setting A treatment episode may end if, prior to the completion of the existing treatment, there is a change in the treatment delivery setting for alcohol and other drugs. CODE 4 Change in the principal drug of concern

A treatment episode will end if, prior to the completion of the existing treatment, there is a change in the principal drug of concern. See also Code 10.

118

Episode of treatment for alcohol and other drugs-cessation reason

CODE 5 Transferred to another service provider

This code includes situations where the service provider is no longer the most appropriate and the client is transferred/referred to another service. For example, transfers could occur for clients between non-residential and residential services or between residential services and a hospital. Excludes situations where the original treatment was completed before the client transferred to a different provider for other treatment (use Code 1). CODE 6 Ceased to participate against advice This code refers to situations where the service provider is aware of the client's intention to stop participating in treatment, and the client ceases despite advice from staff that such action is against the client's best interest. CODE 7 Ceased to participate without notice This code refers to situations where the client ceased to receive treatment without notifying the service provider of their intention to no longer participate. CODE 8 Ceased to participate involuntary (non-compliance) This code refers to situations where the client's participation has been ceased by the service provider due to non-compliance with the rules or conditions of the program. CODE 9 Ceased to participate at expiation This code refers to situations where the client has fulfilled their obligation to satisfy expiation requirements (e.g. participate in a treatment program to avoid having a criminal conviction being recorded against them) as part of a police or court diversion scheme and chooses not to continue with further treatment. CODE 10 Ceased to participate by mutual agreement This code refers to situations where the client ceases participation by mutual agreement with the service provider even though the treatment plan has not been completed. This may include situations where the client has moved out of the area. Only to be used when Code 2, 3 or 4 is not applicable. CODE 11 Drug court and/or sanctioned by court diversion service This code applies to drug court and/or court diversion service clients who are sanctioned back into jail for non-compliance with the program.

CODE 12 Imprisoned, other than drug court sanctioned This code applies to clients who are imprisoned for reasons other than Code 11. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Given the levels of attrition within alcohol and other drug treatment programs, it is important to identify the range of different reasons for ceasing treatment with a service.

119

Episode of treatment for alcohol and other drugs-client type

Data Element ID: 040950 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The status of a person in terms of whether the treatment episode concerns their own alcohol and/or other drug use or that of another person. Context: Alcohol and other drug treatment services Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Own alcohol or other drug use 2 Other's alcohol or other drug use Guide for Use: CODE 1 Own alcohol or other drug use Use this code for a client who receives treatment or assistance concerning their own alcohol and/or other drug use. Use this code where a client is receiving treatment or assistance for both their own alcohol and/or other drug use and the alcohol and/or other drug use of another person. CODE 2 Other's alcohol or other drug use Use this code for a client who receives support and/or assistance in relation to the alcohol and/or other drug use of another person. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Required to differentiate between clients according to whether the treatment episode concerns their own alcohol and/or other drug use or that of another person to provide a basis for description of the people accessing alcohol and other drug treatment services.

120

Episode of treatment for alcohol and other drugs-treatment cessation date

Data Element ID: 040951 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The date on which a treatment episode for alcohol and other drugs ceases. Context: Alcohol and other drug treatment services Data type: Numeric Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: Refers to the date of the last service contact in a treatment episode between the client and staff of the treatment provider. In situations where the client has had no contact with the treatment provider for three months, nor is there a plan in place for further contact, the date of last service contact should be used. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Required to identify the cessation of a treatment episode by an alcohol and other drug treatment service.

121

Episode of treatment for alcohol and other drugs-treatment commencement date

Data Element ID: 040952 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The date on which the first service contact within the treatment episode when assessment and/or treatment occurs. Context: Alcohol and other drug treatment services Data type: Numeric Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: A client is identified as commencing a treatment episode if one or more of the following apply: they are a new client, they are a client recommencing treatment after they have had had no contact with the treatment provider for a period of three months or had any plan in place for further contact, their principal drug of concern for alcohol and other drugs has changed, their main treatment type for alcohol and other drugs has changed, their treatment delivery setting for alcohol and other drugs has changed. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Required to identify the commencement of a treatment episode by an alcohol and other drug treatment service.

122

Establishment - organisation identifier (Australian)

Data Element ID: 040925 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2003 Definition: Identifier for the establishment in which episode or event occurred. Each separately administered health care establishment to have a unique identifier at the national level. Context: Data type: Alphanumeric Representational form: IDENTIFICATION Representation layout: NNANNNNNN NUMBER Minimum Size: 9 Maximum Size: 9 Data Domain: Concatenation of: State/Territory identifier (character position 1) Establishment sector (character position 2) Region code (character positions 3-4) Establishment number (character positions 5-9) Guide for Use: Verification Rules: Related Data References: is composed of Establishment - organisational identifier (state/territory), QHLTH 040926 version 1 is composed of Establishment sector, QHLTH 040855 version 1 relates to the data element Person identifier type - health care, QHLTH 040924 version 1 relates to the data element Person identifier, QHLTH 040014 version 2 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: Establishment Identifier should be able to distinguish between all health care establishments nationally. NMDS - Admitted patient care: A residential establishment is considered to be separately administered if managed as an independent institution for which there are financial, budgetary and activity statistics. For example, if establishment-level data for components of an area health service are not available separately at a central authority, this is not grounds for treating such components as a single establishment unless such data are not available at any level in the health care system. This item is now being used to identify hospital contracted care. The use of this item will lead to reduced duplication in reporting patient activity and will enable linkage of services to one episode of care.

123

Establishment - organisational identifier (state/territory)

Data Element ID: 040926 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/01/2003 Definition: An identifier for an establishment, unique within the State or Territory. Context: All health services Data type: Numeric Representational form: IDENTIFICATION Representation layout: NNNNN NUMBER Minimum Size: 5 Maximum Size: 5 Data Domain: Valid establishment number Guide for Use: Verification Rules: Related Data References: is a composite part of Establishment - organisation identifier (Australian), QHLTH 040925 version 1 Source Document: Source Organisation: Comment: Establishment number should be a unique code for the health care establishment used in that State/Territory or uniquely at a national level.

124

Expected principal source of funds for the episode

Data Element ID: 040624 Version number: 2 Type: DATA ELEMENT Status: CURRENT 29/11/2006 Definition: Expected principal funding source for an admitted or non admitted patient care episode. Context: Admitted and non admitted patient care Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Australian Health Care Agreements 02 Private Health Insurance 03 Self-Funded 04 Worker's Compensation 05 Motor Vehicle Third Party Personal Claim 06 Other Compensation (e.g. public liability, common law, medical negligence) 07 Department of Veterans' Affairs 08 Department of Defence 09 Correctional Facility 10 Other Hospital or Public Authority (Contracted Care) 11 Reciprocal Health Care Arrangements (with other countries) 12 Other 13 No charge raised 99 Not stated/Unknown Guide for Use: The final payment class should be used 01 Australian Health Care Agreements Australian Health Care Agreements should be recorded as the funding source for Medicare eligible admitted patients who elect to be treated as public patients and Medicare eligible emergency department patients and Medicare eligible patients presenting at a public hospital outpatient department for whom there is not a third party arrangement. Excludes: Inter-hospital contracted patients and overseas visitors who are covered by Reciprocal health care agreements and elect to be treated as public admitted patients. 02 Private health insurance Excludes: overseas visitors for whom travel insurance is the major funding source. 03 Self funded includes, funded by the patient, patients family or friends or other beneficiaries. 10 Other hospital or public authority is used for contracted care. 11 Reciprocal health care agreements (with other countries).

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Expected principal source of funds for the episode Australia has Reciprocal Health Care Agreements with the United Kingdom, the Netherlands, Italy, Malta, Sweden, Finland, Norway, New Zealand and Ireland. The Agreements provide for free accommodation and treatment as public hospital services, but do not cover treatment as a private patient in any kind of hospital. The Agreements with Finland, Italy, Malta, the Netherlands, Norway, Sweden and the United Kingdom provide free care as a public patient in public hospitals, subsidised out-of-hospital medical treatment under Medicare, and subsidised medicines under the Pharmaceutical Benefits Scheme. The Agreements with New Zealand and Ireland provide free care as a public patient in public hospitals and subsidised medicines under the Pharmaceutical Benefits Scheme, but do not cover out-of-hospital medical treatment. Visitors from Italy and Malta are covered for a period of six months from the date of arrival in Australia only. Excludes: Overseas visitors who elect to be treated as private patients. 12 Other should be used for overseas visitors who have travel insurance as the major funding source. CODE 13 No charge Includes: Admitted patients who are Medicare ineligible and receive public hospital services free of charge at the discretion of the hospital or the state/territory. Also includes patients who receive private hospital services for whom no accommodation or facility charge is raised (for example, when the only charges are for medical services bulk-billed to Medicare), and patients for whom a charge is raised but is subsequently waived. Excludes: Admitted public patients (Medicare eligible) whose funding source should be recorded as Australian Health Care Agreements or Reciprocal Health Care Agreements. Also excludes Medicare eligible non-admitted patients, presenting to a public hospital emergency department and Medicare eligible patients (for whom there is not a third party payment arrangement) presenting at a public hospital outpatient department, whose funding source should be recorded as Australian Health Care Agreements. Also excludes patients presenting to an outpatient department who have chosen to be treated as a private patient and have been referred to a named medical specialist who is exercising a right of private practice. These patients are not considered to be patients of the hospital (see Guide for use). Verification Rules: Related Data References: relates to the data element Compensable status, QHLTH 040051 version 4 supersedes previous data element Expected principal source of funds for the episode, QHLTH 040624 version 1 Source Document: Source Organisation: Comment:

126

External cause

Data Element ID: 040248 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Event, circumstance or condition associated with the occurrence of injury, poisoning or violence. Context: Enables categorisation of injury and poisoning according to factors important for injury control. This information is necessary for defining and monitoring injury control targets, injury costing and identifying cases for in-depth research. It is also used as a quality of care indicator of adverse patient outcomes. Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element Diagnosis code type, QHLTH 040099 version 3 relates to the data terminology item Place of occurrence of external cause of injury, QHLTH 040249 version 1 Source Document: Source Organisation: Comment: Coded in ICD-10-CM. An external cause coded to ICD-10-CM should be sequenced following the related condition or injury code, or following the group of codes, if more than one injury or condition has resulted from this external cause. Provision must be made to record more than one external cause if appropriate. All external cause codes must be accompanied by a place of occurrence code.

127

Facility contracted to

Data Element ID: 040129 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The facility number for the hospital to which the patient is transferred for contract service. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N(5) Minimum Size: 5 Maximum Size: 5 Data Domain: Valid facility number Guide for Use: Hospitals that place a patient on contract leave who is sent off-site to a non- hospital private health organisation with no facility number, should record a dummy facility number of 99998. Code (2) of the contract flag has been extended to facilitate this. Verification Rules: Related Data References: relates to the data terminology item Contract service, QHLTH 040130 version 1 Source Document: Source Organisation: Comment: Private hospitals can also flag non-contracted procedures performed by private health organisations with no hospital facility number (eg., radiology, pathology).

128

Facility identifier

Data Element ID: 040006 Version number: 4 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Code which uniquely identifies a facility. Context: Data type: Numeric character Representational form: CODE Representation layout: N(5) Minimum Size: 3 Maximum Size: 5 Data Domain: The corporate standard facility code list is maintained by the Statistical Standards Unit. The Statistical Standards Unit, Health Statistics Centre should be contacted to obtain the most recent list of facilities. This list is also available on QHEPS from the HSC Infobank area. Guide for Use: Verification Rules: Related Data References: is used in conjunction with Facility contracted to, QHLTH 040129 version 1 is used in conjunction with Facility transferred from, QHLTH 040116 version 4 is used in conjunction with Facility transferred to, QHLTH 040120 version 4 Source Document: Source Organisation: Comment:

129

Facility transferred from

Data Element ID: 040116 Version number: 4 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The identifier for the facility from which the person is transferred. Context: Institutional health care. Data type: Numeric character Representational form: IDENTIFICATION Representation layout: N(5) NUMBER Minimum Size: 5 Maximum Size: 5 Data Domain: Valid facility identifier. Guide for Use: Verification Rules: Related Data References: is flagged by item Antenatal transfer (flag), QHLTH 040037 version 1 is used in conjunction with Facility identifier, QHLTH 040006 version 4 is used in conjunction with Source of referral, QHLTH 040010 version 2 Source Document: Source Organisation: Comment: This item is applicable for the Perinatal collection in the case of an antenatal transfer. It is applicable for QHAPDC if the patient is referred from another hospital (including contract) or correctional facility.

130

Facility transferred to

Data Element ID: 040120 Version number: 4 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The identifier for the facility to which the person is referred for admission. Context: Institutional health care. Data type: Numeric character Representational form: IDENTIFICATION Representation layout: N(5) NUMBER Minimum Size: 5 Maximum Size: 5 Data Domain: Valid facility identifier. Guide for Use: For QHAPDC, the facility transferred to may be a correctional facility. For the Perinatal collection, this item is collected separately for both mother and baby. Verification Rules: Related Data References: is used in conjunction with Facility identifier, QHLTH 040006 version 4 is used in conjunction with Mode of separation, QHLTH 040119 version 3 Source Document: Source Organisation: Comment:

131

Facility type

Data Element ID: 040263 Version Number: 5 Type: DATA ELEMENT Status: CURRENT

01/01/2004 Definition: Type of establishment (defined in terms of service provided, patients treated and/or legislative approval) for each separately administered establishment. Non-residential health services are classified in terms of separately administered organisations rather than in terms of the number of sites at which care is delivered. Thus, domiciliary nursing service would be counted in terms of the number of administered entities employing nursing staff rather than in terms of the number of clinic locations used by the staff. Establishments can cater for a number of activities and in some cases separate staff and financial details are not available for each activity. In these cases it is necessary to classify the establishment according to its predominant residential activity (measured by costs) and to allocate all the staff and finances to that activity. Where non-residential services only are provided at one establishment, that establishment is classified according to the predominant non-residential activity (in terms of costs). Residential establishments are considered to be separately administered if managed as an independent unit in terms of financial, budgetary and activity statistics. Context: Institutional Health Care Datatype: Numeric character Representational Form: CODE Representation Layout: N(2) Minimum Size: 1 Maximum Size: 2 Data Domain: 01 Licensed Private Freestanding Day Surgery Centre

02 Licensed Private Day Centre/Hospital 03 Licensed Private Hospital - Acute other

04 Unlicensed Private Acute Hospital 06 Private Psychiatric Residential Facility 07 Private Nursing Home For Aged - Non Profit 08 Private Nursing Home For Aged - Profit 09 Private Young Disabled Nursing Homes - Non-Profit 10 Private Young Disabled Nursing Homes - Profit 11 Private Alcohol & Drug Residential Facility 12 Private Hostel For Aged - Non Profit 13 Private Hostels (Excld For Aged) - Non Profit 14 Private Hospice 15 Private Community Health Centre - Non Profit

16 Private Domiciliary Nursing Services - Non Profit 17 Private Domiciliary Nursing Services - Profit 18 Private Pathology Laboratory 19 Private Birthing Centres 20 BOOT Hospital 30 Not recognised public hospitals 31 Public Freestanding Day Surgery Centre 32 Public Day Centre/Hospital 33 Recognised Public Hospital - Acute Outpost 34 Recognised Public Hospital - Acute other 35 Public Hospital - Dental 36 Public Psychiatric Residential Facility

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Facility type

37 Public Nursing Home For Aged 38 Public Young Disabled Nursing Homes 39 Public Alcohol & Drug Residential Facility 40 Public Community Health Facilities 41 Public Hostel For Aged - State Government 42 Public Hostel For Aged - Local Government 43 Public Hostel (Excld for Aged) - State Government 44 Public Hostel (Excld for Aged) - Local Government 45 Public Hospice 46 Public Domiciliary Nursing Services 47 Public Pathology Laboratory 48 Public Birthing Centres 49 Public Community Mental Health Facility 50 Public Child & Adolescent Mental Health - Community 51 Public Child & Adolescent Community Health 52 Public Aboriginal and Torres Strait Islander Health - Community 53 Public Alcohol and Drug - Community 54 Sexual Health Services - Community 55 Oral Health - Community 56 Transition/Intermittent Care Program 61 Central Office - Queensland Health 62 Public Community Health - Program Level 64 District Health Service 65 Public Trading Facility 66 Public Health Unit 67 Health Contact Centre 70 Adult - Community health centre dental clinic 71 School - fixed dental clinic 72 Adult - hospital dental clinic 73 Adult - community health centre dental clinic stand alone 74 Adult - mobile dental clinic 75 Adult - itinerant dental service 76 School - mobile dental clinic 77 School - itinerant dental service 80 Commonwealth Hospital - Veterans' Affairs 81 Commonwealth Hospital - Defence force 82 Other Commonwealth Hospital 92 Correctional Centres 93 Independent Living Unit 94 Flexible Residential Care Service 95 Residential Aged Care Facility 99 Other Health Services

Guide for Use: Acute Care Hospitals (corresponding facility types 33, 34, 35, 3, 80, 81, 82) Establishments which provide at least minimal medical, surgical or obstetric services for admitted patient treatment and/or care, and which provide round-the-clock comprehensive qualified nursing service as well as other necessary professional services. They must bel licensed by the State Health department, or controlled by government departments. Most oft the patients have acute conditions or temporary ailments and the average stay per admission is relatively short. Hospitals specialising in dental, ophthalmic aids and other specialised medical or surgical care are included in this category. Hospices (establishments providing palliative care to terminally ill patients) that are freestanding and do not provide any other form of acute care are classified to hospices.

133

Facility type

Psychiatric Hospitals (corresponding facility types 36, 6) Establishments devoted primarily to the treatment and care of in-patients with psychiatric, mental, or behavioural disorders. Private hospitals formerly approved by the Commonwealth Department of Health under the Health Insurance Act 1973 (Cwth) (now licensed/approved by each State health authority), catering primarily for patients with psychiatric or behavioural disorders are included in this category. Centres for the non-acute treatment of drug dependence, developmental and intellectual disability are not included here (see below). This code also excludes institutions mainly providing living quarters or day care. Nursing Homes (corresponding facility types 7, 8, 9, 10, 37, 38) Establishments which provide long-term care involving regular basic nursing care to chronically ill, frail, disabled or convalescent persons or senile in-patients. They must be approved by the Commonwealth Department of Health and Aged Care/ or licensed by the State, or controlled by government departments. Private profit nursing homes are operated by private profit making individuals or bodies. Private charitable nursing homes are participating nursing homes operated by religious and charitable organisations. Government nursing homes are nursing homes either operated by or on behalf of a State or Territory government. Alcohol and drug treatment centres (corresponding facility types 11, 39) Freestanding centres for the treatment of drug dependence on an admitted patient basis. Hostels and residential services (corresponding facility type 95 Residential Aged Care Facility) establishments run by public authorities or registered non-profit organisation to provide board, lodging or accommodation for the aged, distressed or disabled who cannot live independently but do not need nursing care in a hospital or nursing home. Only hostels subsidised by the Commonwealth are included. Separate dwellings are not included, even if subject to an individual rental rebate arrangement. Residents are generally responsible for their own provisions, but may be provided in some establishments with domestic assistance (meals, laundry, and personal care). Night shelters providing only casual accommodation are excluded. Hospices (corresponding facility types 14, 45) Establishments providing palliative care to terminally ill patients. Only freestanding hospices which do not provide any other form of acute care are included in this category. Same-day establishments (corresponding facility types 1, 2, 31, 32) Includes both the traditional day centre/hospital and also freestanding day surgery centres. Day centres/hospitals are establishments providing a course of acute treatment on a full-day or part-day non-residential attendance basis at specified intervals over a period of time. Sheltered workshops providing occupational or industrial training are excluded. Freestanding day surgery centres are hospital facilities providing investigation and treatment for acute conditions on a day-only basis and are approved by the Commonwealth for the purposes of basic table health insurance benefits.

134

Facility type

Non-residential health services (corresponding facility types 15, 16, 17, 40, 46) Services administered by public authorities or registered non-profit organisations which employ full-time equivalent medical or paramedical staff (nurses, nursing aides, physiotherapists, occupational therapists and psychologists, but not trade instructors or teachers). This definition distinguishes health services from welfare services (not within the scope of the National Minimum Data Project) and thereby excluded such services as sheltered workshops, special schools for the intellectually disabled, meals on wheels and baby clinics offering advisory services but no actual treatment. Non-residential health services should be enumerated in terms of services or organisations rather than in terms of the number of sites at which care is delivered.

Non-residential health services provided by a residential establishment (for example, domiciliary nursing service which is part of a public hospital) should not be separately enumerated.

Community Health Centres (corresponding facility types 15, 40)

Public or registered non-profit establishments which a range of non-residential health services is provided in an integrated and coordinated manner, or which provides for the coordination of health services elsewhere in the community.

Domiciliary nursing service (corresponding facility types 16, 17, 46)

Public or registered non-profit or profit making establishments providing nursing or other professional

Birthing Centre (corresponding facility types 19, 48) A birth centre is a facility where women are able to birth in an environment which:

(a) is freestanding or physically separate from a labour ward but has access to emergency medical facilities for both mother and child if required;

(b) has home-like atmosphere (c) focuses on a model of care (eg midwifery model) which ensures continuity of care/caregiver; a family-centred approach; and informed client participation in choices related to the management of care.

Note: Admission to the Birth Centre program is usually based on criteria which address risk factors. Transfer to a labour ward may occur according to criteria where deviation from the normal childbirth process requires medical intervention not accommodated by the birth centre.

("Physically separate" refers to a unit which has self-contained facilities and separate staffing arrangements from a labour ward within the same complex). BOOT Hospitals (20) - "Build, Own, Operate, Transfer" Hospitals

'Itinerant' dental services means a service provided across a variety of locations, but that is not provided full time (facility types 75 and 77).

Transition/Intermittent Care Program (56) are services that provide short-term support and active management for older people at the interface of the acute/sub-acute and residential aged care sectors. Transition care can be delivered in either a residential or community setting.

Flexible Residential Care Service (94) is an integrated service approach for residential, community and respite care for small rural communities who are isolated from main stream services.

135

Facility type

Health Contact Centre (67) provides a teletriage, referral and health information service, operating 24 hours, 7 days a week.

Verification Rules: Related Data References: supersedes previous data element Facility type QHLTH 040263 version 4 Source Document: Source Organisation: Comment:

136

Family name

Data Element ID: 040002 Version number: 2 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: That part of a name a person usually has in common with some other members of his/her family, as distinguished from his/her given names. Context: Administrative purposes and individual identification. Data type: Alphanumeric Representational form: TEXT Representation layout: AN (40) Minimum Size: 1 Maximum Size: 40 Data Domain: Text Guide for Use: The agency or establishment should record the client's full 'Family name' on their information systems. NCSDD specific: In instances where there is uncertainty about which name to record for a person living in a remote Aboriginal or Torres Strait Islander community, Centrelink follows the practice of recording the Indigenous person's name as it is first provided to Centrelink. In situations where proof of identity is required, the name recorded should appear on a majority of the higher point scoring documents that are produced as proof of identity. Verification Rules: Related Data References: relates to the data element concept Person name, QHLTH 040857 version 1 relates to the data element Given name, QHLTH 040003 version 1 relates to the data element Name conditional use flag, QHLTH 040853 version 1 relates to the data element Name suffix, QHLTH 040851 version 1 relates to the data element Name title, QHLTH 040850 version 1 relates to the data element Person name type, QHLTH 040858 version 1 relates to the data element Surname, QHLTH 040002 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Often people use a variety of names, including legal names, married/maiden names, nicknames, assumed names, traditional names, etc. Even small differences in recording - such as the difference between MacIntosh and McIntosh- can make record linkage impossible. To minimise discrepancies in the recording and reporting of name information, agencies or establishments should ask the person for their full (formal) 'Given name' and 'Family name'. These may be different from the name that the person may prefer the agency or establishment workers to use in personal dealings. Agencies or establishments may choose to separately record the preferred names that the person wishes to be used

137

Family name by agency or establishment workers. In some cultures it is traditional to state the family name first. To overcome discrepancies in recording/reporting that may arise as a result of this practice, agencies or establishments should always ask the person to specify their first given name and their family name or surname separately. These should then be recorded as 'Given name' and 'Family name' as appropriate, regardless of the order in which they may be traditionally given. NCSDD specific: Selected letters of the family name in combination with selected letters of the 'Given name',' Date of birth' and 'Sex', may be used for record linkage for statistical purposes only. Other References: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia

138

First admission for palliative care treatment

Data Element ID: 040620 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: The status of an episode in terms of whether it is a first or subsequent admission at any hospital for any condition, for palliative care treatment. Context: Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 No previous admission for palliative care treatment 2 Previous admission for palliative care treatment Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Previous specialised non-admitted palliative care treatment, QHLTH 040621 version 1 Source Document: Source Organisation: Comment:

139

First admission for psychiatric treatment

Data Element ID: 040057 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: Indicator of whether this is a first or subsequent admission, for any condition, for psychiatric treatment, whether in an acute or psychiatric hospital. Context: Admitted psychiatric care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 no previous admission for psychiatric treatment 2 previous admission for psychiatric treatment 9 not stated/unknown Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

140

Geographical Location of Service Delivery Outlet

Data Element ID: 041085 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: Geographical location of a site from which a health/community service is delivered, as represented by a code. Context: Alcohol and Other Drug Treatment Service. Data type: Numeric Representational form: CODE Representation layout: NNNNN Minimum Size: 5 Maximum Size: 5 Data Domain: Australian Standard Geographical Classification 2006 Guide for Use: The geographical location is reported using a five digit numerical code to indicate the Statistical Local Area (SLA) within the reporting state or territory, as defined in the Australian Standard Geographical Classification (ASGC). It is a composite of State identifier and SLA (first digit = State identifier, next four digits = SLA). The Australian Bureau of Statistics' National Localities Index (NLI) can be used to assign each locality or address in Australia to an SLA. The NLI is a comprehensive list of localities in Australia with their full code (including SLA) from the main structure of the ASGC. For the majority of localities, the locality name (suburb or town, for example) is sufficient to assign an SLA. However, some localities have the same name. For most of these, limited additional information such as the postcode or State can be used with the locality name to assign the SLA. In addition, other localities cross one or more SLA boundaries and are referred to as split localities. For these, the more detailed information of the number and street of the establishment is used with the Streets Sub- index of the NLI to assign the SLA. To enable the analysis of the accessibility of service provision in relation to demographic and other characteristics of the population of a geographic area. Verification Rules: Related Data References: Source Document: Australian Standard Geographical Classification (ABS Cat. No. 1216.0) Source Organisation: Intergovernmental Committee on Drugs National Minimum Data Set Working Group Comment:

141

Gestational age

Data Element ID: 040068 Version number: 4 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The estimated gestational age of the baby in completed weeks as determined by clinical assessment. Context: Perinatal data collection Data type: Integer Representational form: QUANTITATIVE Representation layout: N (2) Minimum Size: 2 Maximum Size: 2 Data Domain: Record not stated/unknown as 99 Guide for Use: The duration of gestation is measured from the first day of the last normal menstrual period. Gestational age is expressed in completed days or completed weeks (e.g. events occurring 280 to 286 completed days after the onset of the last normal menstrual period are considered to have occurred at 40 weeks of gestation). The World Health Organization identifies the following categories: - Pre-term: less than 37 completed weeks (less than 259 days) of gestation - Term: from 37 completed weeks to less than 42 completed weeks (259 to 293 days) of gestation - Post-term: 42 completed weeks or more (294 days or more) of gestation. Must be in completed weeks, for example, 40 weeks and 5 days is rounded down to 40 weeks. Verification Rules: Related Data References: supersedes previous data element Gestational age, QHLTH 040068 version 3 Source Document: Source Organisation: Comment:

142

Given name

Data Element ID: 040003 Version number: 1 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: The person's identifying name within the family group or by which the person is socially identified Context: Administrative purposes and individual identification Data type: Alphanumeric Representational form: TEXT Representation layout: AN(40) Minimum Size: 1 Maximum Size: 40 Data Domain: Text Guide for Use: A person may have more than one Given name. All given names should be recorded. NCSDD specific: In instances where there is uncertainty about which name to record for a person living in a remote Aboriginal or Torres Strait Islander community, Centrelink follows the practice of recording the Indigenous person's name as it is first provided to Centrelink. In situations where proof of identity is required, the name recorded should appear on a majority of the higher point scoring documents that are produced as proof of identity. NHDD specific: Health care provider identification DSS and Health care client identification DSS Each individual Given name should have a Given name sequence number associated with it. Health care establishments may record given names (first and other given names) in one field or several fields. This data element definition applies regardless of the format of data recording. A full history of names is to be retained. Verification Rules: Related Data References: is qualified by Given name sequence number, QHLTH 040911 version 1 relates to the data element concept Person name, QHLTH 040857 version 1 relates to the data element Family name, QHLTH 040002 version 2 relates to the data element First name, QHLTH 040003 version 1 relates to the data element Name conditional use flag, QHLTH 040853 version 1 relates to the data element Name suffix, QHLTH 040851 version 1 relates to the data element Name title, QHLTH 040850 version 1 relates to the data element Person name type, QHLTH 040858 version 1 Source Document: National Health Data Dictionary

143

Given name Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Often people use a variety of names, including legal names, married/maiden names, nicknames, assumed names, traditional names, etc. Even small differences in recording - such as the difference between Thomas and Tom - can make Record linkage impossible. To minimise discrepancies in the recording and reporting of name information, agencies or establishments should ask the person for their full (formal) Given name and Family name. These may be different from the name that the person may prefer the agency or establishment workers to use in personal dealings. Agencies or establishments may choose to separately record the preferred name that the person wishes to be used by agency or establishment workers. In some cultures it is traditional to state the family name first. To overcome discrepancies in recording/reporting that may arise as a result of this practice, agencies or establishments should always ask the person to specify their first given name and their family or surname separately. These should then be recorded as Given name and Family name as appropriate, regardless of the order in which they may be traditionally given. NCSDD specific: Selected letters of the Given name in combination with selected letters of the Family name, Date of birth and Sex may be used for Record linkage for statistical purposes only (see data concept Record linkage). NHDD specific: Health care provider identification DSS and Health care client identification DSS For the purpose of positive identification or contact, agencies or establishments that collect Given name should also collect Given name sequence number. Given name sequence number is also a metadata item in Australian Standard AS4846-2004 Health care provider identification and is proposed for inclusion in the review of Australian Standard AS5017-2002 Health care client identification. AS5017 and AS4846 use alternative alphabetic codes for Given name sequence number. Refer to the current standards for more details. Other References: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia

144

Health condition of concern - self reported

Data Element ID: 040873 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The client's current health condition of concern, as reported by the client. Context: Queensland Health Minimum Data Set - Alcohol and Other Drug Treatment Services Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Diabetes 02 Seizures/epilepsy 03 Allergies 04 Cardiovascular disease - Hypertension 05 Cardiovascular disease - Other 06 Asthma 07 Liver disease 08 Acquired brain injury 09 Cancer 10 Sexually transmitted disease 11 Pregnancy 12 Mental health condition - Suicidal thoughts 13 Mental health condition - Other 98 Other health condition 99 Not stated/inadequately described Guide for Use: Multiple domain items may be recorded as required. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

145

Health professional-area of clinical practice (principal)

Data Element ID: 040953 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Principal area of clinical practice is defined as either the field of principal professional clinical activity or the primary area of responsibility, depending on the profession. Context: Health labour force Data type: Character Representational form: CODE Representation layout: ANN Minimum Size: 3 Maximum Size: 3 Data Domain: A11 General Practitioner (GP)/primary medical care practitioner - general practice A12 GP/primary medical care practitioner - a special interest area (specified) A21 GP/primary medical care practitioner - vocationally registered A22 GP/primary medical care practitioner - holder of fellowship of Royal Australian College of General Practitioners (RACGP) A23 GP/primary medical care practitioner - RACGP trainee A24 GP/primary medical care practitioner - other B31 Non-specialist hospital (salaried) - Resident Medical Officer (RMO)/intern B32 Non-specialist hospital (salaried) - other hospital career B41 Non-specialist hospital (salaried) - holder of Certificate of Satisfactory Completion of Training B42 Non-specialist hospital (salaried) - RACGP trainee B44 Non-specialist hospital (salaried) - other B51 Non-specialist hospital (salaried) - specialist (includes private and hospital) B52 Non-specialist hospital (salaried) - specialist in training (e.g. registrar) B90 Non-specialist hospital (salaried) - not applicable C01 Nurse labour force - mixed medical/surgical nursing C02 Nurse labour force - medical nursing C03 Nurse labour force - surgical nursing C04 Nurse labour force - operating theatre nursing C05 Nurse labour force - intensive care nursing C06 Nurse labour force - paediatric nursing C07 Nurse labour force - maternity and obstetric nursing C08 Nurse labour force - psychiatric/mental health nursing C09 Nurse labour force - developmental disability nursing C10 Nurse labour force - gerontology/geriatric nursing C11 Nurse labour force - accident and emergency nursing C12 Nurse labour force - community health nursing C13 Nurse labour force - child health nursing C14 Nurse labour force - school nursing C15 Nurse labour force - district/domiciliary nursing C16 Nurse labour force - occupational health nursing

146

Health professional-area of clinical practice (principal) C17 Nurse labour force - private medical practice nursing C18 Nurse labour force - independent practice C19 Nurse labour force - independent midwifery practice C20 Nurse labour force - no one principal area of practice C98 Nurse labour force - other (specify) C99 Nurse labour force - unknown/inadequately described/not stated Guide for Use: Specifics will vary for each profession as appropriate and will be reflected in the classification/coding that is applied. Classification within the National Health Labour Force Collection is profession-specific. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: The nursing labour force-specific codes are subject to revision because of changes in the profession and should be read in the context of the comments below. It is strongly recommended that, in the case of the nurse labour force, further disaggregation be avoided as much as possible. The reason for this recommendation is that any expansion of the classification to include specific specialty areas (e.g. cardiology, otorhinolaryngology, gynaecology etc.) will only capture data from hospitals with dedicated wards or units; persons whose clinical practice includes a mix of cases within a single ward setting (as in the majority of country and minor metropolitan hospitals) will not be included in any single specialty count, leading to a risk of the data being misinterpreted. The data would show a far lower number of practitioners involved in providing services to patients with some of the listed specialty conditions than is the case.

147

Health professional-establishment type (employment), industry code

Data Element ID: 040954 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The sector of employment and main type of work/speciality area of the health professional. Context: Health labour force Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Private medical practitioner rooms/surgery (including 24-hour medical clinics) 02 Other public non-residential health care facility (e.g. Aboriginal health service, ambulatory centre, outpatient clinic, day surgery centre, medical centre, community health centre) 03 Other private non-residential health care (e.g. Aboriginal health service, ambulatory centre, outpatient clinic, day surgery centre, medical centre, community health 04 Hospital - acute care (including psychiatric or specialist hospital) hospital (public) 05 Hospital - acute care (including psychiatric or specialist hospital) hospital (private) 06 Residential health care (e.g. nursing home, hospice, physical disabilities residential centre) facility (public) 07 Residential health care (e.g. nursing home, hospice, physical disabilities residential centre) facility (private) 08 Tertiary education institution (public) 09 Tertiary education institution (private) 10 Defence forces 11 Government department or agency (e.g. laboratory, research organisation etc.) 12 Private industry/private enterprise (e.g. insurance, pathology, bank) 13 Other (specified) public 14 Other (specified) private 99 Unknown/inadequately described/not stated Guide for Use: Establishments are coded into self reporting groupings in the public and private sectors. This can be seen in the code list for medical practitioners. Minor variations in ordering of sequence and disaggregation of the principal categories will be profession-specific as appropriate; where a more detailed set of codes is used, the essential criterion is that there should not be an overlap of the detailed codes across the Australian and New Zealand Standard Industrial Classification category definitions. Note: Public psychiatric hospitals are non-acute care facilities, whereas private psychiatric hospitals are acute care facilities. To minimise the possibility of respondent confusion and mis-reporting, public psychiatric hospitals are included in the grouping for acute care public hospitals.

148

Health professional-establishment type (employment), industry code Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Day surgery centres, outpatient clinics and medical centres approved as hospitals under the Health Insurance Act 1973 (Commonwealth) have emerged as a new category for investigation. These will be included in a review of the National Health Labour Force Collection questions and coding frames.

149

Health professional-hours worked (in all jobs), total

Data Element ID: 040955 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Hours worked is the amount of time a person spends at work in a week in employment/self-employment. It may apply to hours actually worked in a week or hours usually worked per week, and the National Health Labour Force Collection collects hours usually worked. It includes all paid and unpaid overtime less any time off. It also: includes travel to home visits or calls out excludes other time travelling between work locations excludes unpaid professional and/or voluntary activities. Total hours worked is the amount of time spent at work in all jobs. As well as total hours worked, for some professions the National Health Labour Force Collection asks for hours worked in each of the main job, second job and third job. Hours worked for each of these is the amount of time spent at work in each job. Context: Health labour force Data type: Real Representational form: QUANTITATIVE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: Valid value 999 Not stated/inadequately described Guide for Use: Total hours expressed as 000, 001 etc. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: It is often argued that health professionals contribute a considerable amount of time to voluntary professional work and that this component needs to be identified. This should be considered as an additional item, and kept segregated from data on paid hours worked.

150

Health professional-labour force status

Data Element ID: 040956 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Employment status of a health professional in a particular profession at the time of registration. Context: Health labour force Data type: Numeric character Representational form: CODE Representation layout: N{.N} Minimum Size: 1 Maximum Size: 2 Data Domain: 1 Employed in the profession: working in/practising the reference profession - in reference State 2 Employed in the profession: working in/practising the reference profession - mainly in other State(s) but also in reference State 3 Employed in the profession: working in/practising the reference profession - mainly in reference State but also in other State(s) 4 Employed in the profession: working in/practising the reference profession - only in State(s) other than reference State 5.1 Employed elsewhere, looking for work in the profession: in paid work not in the field of profession but looking for paid work/practice in the profession - seeking either full-time or part-time work 5.2 Employed elsewhere, looking for work in the profession: in paid work not in the field of profession but looking for paid work/practice in the profession - seeking full-time work 5.3 Employed elsewhere, looking for work in the profession: in paid work not in the field of profession but looking for paid work/practice in the profession - seeking part-time work 5.9 Employed elsewhere, looking for work in the profession: in paid work not in the field of profession but looking for paid work/practice in the profession - seeking work (not stated) 6.1 Unemployed, looking for work in the profession: not in paid work but looking for work in the field of profession - seeking either full-time or part-time work 6.2 Unemployed, looking for work in the profession: not in paid work but looking for work in the field of profession - seeking full-time work 6.3 Unemployed, looking for work in the profession: not in paid work but looking for work in the field of profession - seeking part-time work 6.9 Unemployed, looking for work in the profession: not in paid work but looking for work in the field of profession - seeking work (not stated) 7 Not in the labour force for the profession: not in work/practice in the profession and not looking for work/practice in the profession 8 Not in the labour force for the profession: working overseas 9 Unknown/not stated Guide for Use: Employment in a particular health profession is defined by practice of that profession or work that is principally concerned with the discipline of the profession (for example, research in the field of the profession, administration of the profession, teaching of the profession or health

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Health professional-labour force status promotion through public dissemination of the professional knowledge of the profession). The term 'employed in the profession' equates to persons who have a job in Australia in the field of the reference profession. A person who is normally employed in the profession but is on leave at the time of the annual survey is defined as being employed. A health professional who is not employed but is eligible to work in, and is seeking employment in the profession, is defined as unemployed in the profession. A health professional looking for work in the profession, and not currently employed in the profession, may be either unemployed or employed in an occupation other than the profession. A registered health professional who is not employed in the profession, nor is looking for work in the profession, is defined as not in the labour force for the profession. Registered health professionals not in the labour force for the profession

may be either not employed and not looking for work, or employed in another occupation and not looking for work in the profession.

Verification Rules: Related Data References: Source Document: Source Organisation: Comment: The definitions of employed and unemployed in this metadata item differ from Australian Bureau of Statistics (ABS) definitions for these categories defined in LFA2 'Employed persons', LFA8 'Labour force status', LFA9 'Looking for full-time work', LFA10 'Looking for part-time work', LFA12 'Not in the labour force', LFA13 'Status in employment', and LFA14 'Unemployed persons'. The main differences are: The National Health Labour Force Collection includes persons other than clinicians working in the profession as persons employed in the profession. The ABS uses the Australian Standard Classification of Occupations where, in general, classes for health occupations do not cover non-clinicians. The main exception to this is nursing where, because of the size of the profession, there are classes for nursing administrators and educators. The labour force collection includes health professionals working in the Defence Forces; ABS does not, with the exception of the population census. ABS uses a tightly defined reference period for employment and unemployment; the labour force collection reference period is self-defined by the respondent as his/her usual status at the time of completion of the survey questionnaire. The labour force collection includes, among persons looking for work in the profession, those persons who are registered health professionals but employed in another occupation and looking for work in the profession; ABS does not. The labour force collection includes in the category not in the labour force health professionals registered in Australia ut working overseas; such persons are excluded from the scope of ABS bcensuses and surveys.

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Health professional-occupation

Data Element ID: 040957 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The position or job classification of a health professional. Context: Health labour force Data type: Character Representational form: CODE Representation layout: ANN Minimum Size: 3 Maximum Size: 3 Data Domain: A01 Medicine - General practitioner working mainly in general practice A02 Medicine - General practitioner working mainly in a special interest area A03 Medicine - Salaried non-specialist hospital practitioner: Resident medical officer or intern A04 Medicine - Salaried non-specialist hospital practitioner: other hospital career medical officer AO5 Medicine - Specialist AO6 Medicine - Specialist in training (e.g. registrar) B01 Dentistry (private practice only) - Solo practitioner B02 Dentistry (private practice only) - Solo principal with assistant(s) B03 Dentistry (private practice only) - Partnership B04 Dentistry (private practice only) - Associateship BO5 Dentistry (private practice only) - Assistant BO6 Dentistry (private practice only) - Locum C01 Nursing - Enrolled nurse C02 Nursing - Registered nurse C03 Nursing - Clinical nurse C04 Nursing - Clinical nurse consultant/supervisor C05 Nursing - Nurse manager C06 Nursing - Nurse educator C07 Nursing - Nurse researcher C08 Nursing - Assistant director of nursing C09 Nursing - Deputy director of nursing C10 Nursing - Director of nursing C11 Nursing - Tutor/lecturer/senior lecturer in nursing (tertiary institution) C12 Nursing - Associate professor/professor in nursing (tertiary institution) C98 Nursing - Other (specify) C99 Nursing - Unknown/inadequately described/not stated D01 Pharmacy (community pharmacist) - Sole proprietor D02 Pharmacy (community pharmacist) - Partner-proprietor D03 Pharmacy (community pharmacist) - Pharmacist-in-charge D04 Pharmacy (community pharmacist) - Permanent assistant D05 Pharmacy (community pharmacist) - Reliever, regular location

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Health professional-occupation D06 Pharmacy (community pharmacist) - Reliever, various locations E01 Pharmacy (Hospital/clinic pharmacist ) - Director/deputy director E02 Pharmacy (Hospital/clinic pharmacist ) - Grade III pharmacist E03 Pharmacy (Hospital/clinic pharmacist ) - Grade II pharmacist E04 Pharmacy (Hospital/clinic pharmacist ) - Grade I pharmacist E05 Pharmacy (Hospital/clinic pharmacist ) - Sole pharmacist F01 Podiatry - Own practice (or partnership) F02 Podiatry - Own practice and sessional appointments elsewhere F03 Podiatry - Own practice and fee-for-service elsewhere F04 Podiatry - Own practice, sessional and fee-for-service appointments elsewhere F05 Podiatry - Salaried podiatrist F06 Podiatry - Locum, regular location F07 Podiatry - Locum, various locations F08 Podiatry - Other (specify) G01 Physiotherapy - Own practice (or partnership) G02 Physiotherapy - Own practice and sessional appointments elsewhere G04 Physiotherapy - Own practice, sessional and fee-for-service appointments elsewhere G05 Physiotherapy - Salaried physiotherapist G06 Physiotherapy - Locum, regular location G07 Physiotherapy - Locum, various locations GO3 Physiotherapy - Own practice and fee-for-service elsewhere Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Position or job classifications are specific to each profession and may differ by state or territory. The classifications above are simplified so that comparable data presentation is possible and possible confounding effects of enterprise specific structures are avoided. For example, for medicine, the job classification collected in the national health labour force collection is very broad. State/territory health authorities have more detailed classifications for salaried medical practitioners in hospitals. These classifications separate interns, the resident medical officer levels, registrar levels, career medical officer positions, and supervisory positions including clinical and medical superintendents. Space restrictions do not at present permit these classes to be included in the National Health Labour Force Collection questionnaire.

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Health professional-principal role

Data Element ID: 040958 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The principal role in which the health professional usually works the most hours each week. Context: Health labour force Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Clinician 2 Administrator 3 Teacher/educator 4 Researcher 5 Public health/health promotion 6 Occupational health 7 Environmental health 9 Unknown/inadequately described/not stated Guide for Use: CODE 1 Clinician A clinician is a person mainly involved in the area of clinical practice, i.e. diagnosis, care and treatment, including recommended preventative action, to patients or clients. Clinical practice may involve direct client contact or may be practised indirectly through individual case material (as in radiology and laboratory medicine). CODE 2 Administrator An administrator in a health profession is a person whose main job is in an administrative capacity in the profession, e.g. directors of nursing, medical superintendents, medical advisors in government health authorities, health profession union administrators (e.g. Australian Medical Association, Australian Nurses Federation). CODE 3 Teacher/educator A teacher/educator in a health profession is a person whose main job is employment by tertiary institutions or health institutions to provide education and training in the profession. CODE 4 Researcher A researcher in a health profession is a person whose main job is to conduct research in the field of the profession, especially in the area of clinical activity. Researchers are employed by tertiary institutions, medical research bodies, health institutions, health authorities, drug companies and other bodies.

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Health professional-principal role CODES 5 - 7 CODE 5 Public health/health promotion CODE 6 Occupational health CODE 7 Environmental health Public health/health promotion, occupational health and environmental health are specialties in medicine, and fields of practice for some other health professions. They are public health rather than clinical practice, and hence are excluded from clinical practice. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

156

Hepatitis B infection indicator - self reported positivity indicator

Data Element ID: 040863 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: An indicator of the Hepatitis B infection status of the client, as reported by the client. Context: QMDS - AODTS Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No 9 Not stated/inadequately described Guide for Use: Code 1 refers to the client reporting a positive infection state for Hepatitis B. Code 2 refers to the client reporting a negative or unknown infection state for Hepatitis B.

Code 9 refers to the client not being questioned as to Hepatitis B status. This code includes where the client refuses to report on their Hepatitis B status.

Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Hepatitis C infection indicator - self reported positivity indicator

Data Element ID: 040864 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: An indicator of the Hepatitis C infection status of the client, as reported by the client. Context: QMDS - AODTS Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No 9 Not stated/inadequately described Guide for Use: Code 1 refers to the client reporting a positive infection state for Hepatitis C. Code 2 refers to the client reporting a negative or unknown infection state for Hepatitis C.

Code 9 refers to the client not being questioned as to Hepatitis C status. This code includes where the client refuses to report on their Hepatitis C status.

Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Hospital insurance (patient)

Data Element ID: 040020 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/1997 Definition: Type of hospital health insurance held by the patient. This is irrespective of whether the patient is admitted as a public or private patient and whether the patient intends to use the insurance for this admission. This data item is used to record whether patients have hospital level health insurance, irrespective of their chargeable status for this admission. That is, they may not choose to be admitted as private patients on this occasion, but the fact that they have hospital insurance at all should be recorded. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 7 Hospital insurance 8 No hospital insurance 9 Not stated/unknown Guide for Use: Verification Rules: Related Data References: supersedes previous data element Hospital insurance (patient), QHLTH 040020 version 1 Source Document: Source Organisation: Comment:

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Hospital unit

Data Element ID: 040170 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The unit that the patient was admitted or transferred to. Context: Institutional health care Data type: Character Representational form: CODE Representation layout: A(4) Minimum Size: 1 Maximum Size: 4 Data Domain: Site specific unit codes. Guide for Use: Verification Rules: Related Data References: is used in the derivation of Standard unit code, QHLTH 040166 version 1 Source Document: Source Organisation: Comment:

160

Hospital waiting list

Data Element ID: 040964 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 28/02/2007 Definition: A register which contains essential details about patients who have been assessed as needing elective hospital care. Context: Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Human Immunodeficiency Virus (HIV) infection indicator -self reported positivity

Data Element ID: 040865 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: An indicator of the HIV infection status of the client, as reported by the client. Context: QMDS - AODTS Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No 9 Not stated/inadequately described Guide for Use: Code 1 refers to the client reporting a positive infection state for HIV. Code 2 refers to the client reporting a negative or unknown infection state for HIV. Code 9 refers to the client not being questioned as to HIV status. This code includes where the client refuses to report on their HIV status. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Indicator procedure - national

Data Element ID: 040095 Version number: 2 Type: DERIVED DATA ELEMENT Status: CURRENT 28/02/2007 Definition: Indicator procedure for which an elective surgery patient is waiting. Context: Elective admission/Waiting list: Waiting list statistics for indicator procedures give a specific indication of performance in particular areas of elective care provision. It is not always possible to code all elective surgery procedures at the time of addition to the waiting list. Reasons for this include that the surgeon may be uncertain of the exact procedure to be performed, and that the large number of procedures possible and lack of consistent nomenclature would make coding errors likely. Furthermore, the increase in workload for clerical staff may not be acceptable. However, a relatively small number of procedures account for the bulk of the elective surgery workload. Therefore, a list of common procedures with a tendency to long waiting times is useful. Waiting time statistics by procedure are useful to patients and referring doctors. In addition, waiting time data by procedure assists in planning and resource allocation, audit and performance monitoring. Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Cataract extraction 02 Cholecystectomy 03 Coronary artery bypass graft 04 Cystoscopy 05 Haemorrhoidectomy 06 Hysterectomy 07 Inguinal herniorrhaphy 08 Myringoplasty 09 Myringotomy 10 Prostatectomy 11 Septoplasty 12 Tonsillectomy 13 Total hip replacement 14 Total knee replacement 15 Varicose veins stripping and ligation 16 Not applicable Guide for Use: The value of this data item may change whilst the patient is listed on the waiting list. Between 1/7/97 and 30/6/98, QHAPDC received only the last recorded value of this data item. From 1/7/98 all values, both the initial and any changed values are received by QHAPDC. The initial value of this item is supplied to QHAPDC linked to the data item "Listing Date on waiting list". If there is subsequent change/s to this item, the new value/s is submitted linked to the data item "Date of change of waiting list details". Verification Rules:

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Indicator procedure - national

Related Data References: is derived from Indicator procedure - site, QHLTH 040096 version 1 is used in conjunction with Listing date on waiting list, QHLTH 040359 version 2 supersedes previous data element Indicator procedure - national, QHLTH 040089 version 1 Source Document: Source Organisation: Comment: An indicator procedure is one which is of high volume, and is often associated with long waiting periods. The list of indicator procedures was developed by the National Waiting Times Working Group.

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Indicator procedure - site

Data Element ID: 040096 Version Number: 1 Type: DATA ELEMENT Status: LEGACY

15/01/1998 Definition: The planned procedure for a patient placed on the waiting list. Context: Elective admission/Waiting list Datatype: Character Representational Form: CODE Representation Layout: N(3) Minimum Size: 2 Maximum Size: 3 Data Domain: A valid procedure code from the 328 codes in the corporate reference file, available from the Surgical Access Team.

98 Other Guide for Use: The value of this data item may change whilst the patient is listed on the waiting list. Between 1/7/97 and 30/6/98, QHAPDC received only the last recorded value of this data item. From 1/7/98 all values, both the initial and any changed values are received by QHAPDC. The initial value of this item is supplied to QHAPDC linked to the data item "Listing Date on waiting list". If there are subsequent change/s to this item, the new value/s are submitted linked to the data item "Date of change of waiting list details". Verification Rules: Related Data References: is used in the derivation of Indicator procedure - national QHLTH 040089 version 1 Source Document: Source Organisation: Comment: This classification was developed by a Queensland Elective Surgery Coordinators Working Party and includes the most common procedures for elective surgery waiting list patients.

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Indigenous status

Data Element ID: 040290 Version number: 3 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: Indigenous status is a measure of whether a person identifies as being of Aboriginal or Torres Strait Islander origin. This is in accord with the first two of three components of the Commonwealth definition. See Comments for the Commonwealth definition. Context: Australia's Aboriginal and Torres Strait Islander peoples occupy a unique place in Australian society and culture. In the current climate of reconciliation, accurate and consistent statistics about Aboriginal and Torres Strait Islander peoples are needed in order to plan, promote and deliver essential services, to monitor changes in wellbeing and to account for government expenditure in this area. The purpose of this data element is to provide information about people who identify as being of Aboriginal or Torres Strait Islander origin. Agencies or establishments wishing to determine the eligibility of individuals for particular benefits, services or rights will need to make their own judgements about the suitability of the standard measure for these purposes, having regard to the specific eligibility criteria for the program concerned. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Aboriginal but not Torres Strait Islander origin 2 Torres Strait Islander but not Aboriginal origin 3 Both Aboriginal and Torres Strait Islander origin 4 Neither Aboriginal nor Torres Strait Islander origin 9 Not stated/inadequately described Guide for Use: This data element is based on the ABS Standard for Indigenous Status. For detailed advice on its use and application please refer to the ABS Website as indicated below under Source document. The classification for 'Indigenous Status' has a hierarchical structure comprising two levels. There are four categories at the detailed level of the classification which are grouped into two categories at the broad level. There is one supplementary category for 'not stated' responses. The classification is as follows: Indigenous: - Aboriginal but not Torres Strait Islander Origin - Torres Strait Islander but not Aboriginal Origin - Both Aboriginal and Torres Strait Islander Origin Non-indigenous: - Neither Aboriginal nor Torres Strait Islander Origin Not stated/ inadequately described: This category is not to be available as a valid answer to the questions but is intended for use: - primarily when importing data from other data collections that do not contain mappable data; - where an answer was refused; - where the question was not able to be asked prior to completion of

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Indigenous status assistance because the client was unable to communicate or a person who knows the client was not available. Only in the last two situations may the tick boxes on the questionnaire be left blank. Verification Rules: Related Data References: supersedes previous data element Indigenous status, QHLTH 040290 version 2 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

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Injecting drug status

Data Element ID: 041086 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The client's use of injection as a method of administering drugs, as represented by a code. Context: Alcohol and other drug treatment services: The data element is important for identifying patterns of drug use and harms associated with injecting drug use. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Last injected three months ago or less 2 Last injected more than three months ago but less than or equal to twelve months 3 Last injected more than twelve months ago 4 Never injected 9 Not stated/inadequately described Guide for Use: This metadata item has been developed for use in clinical settings. A code that refers to a three-month period to define 'current' injecting drug use is required as a clinically relevant period of time. The metadata item may also be used in population surveys that require a longer timeframe, for example to generate 12-month prevalence rates, by aggregating Codes 1 and 2. However, caution must be exercised when comparing clinical samples with population samples. This metadata item is important for identifying patterns of drug use and harms associated with injecting drug use. Verification Rules: Related Data References: Source Document: Source Organisation: Intergovernmental Committee on Drugs National Minimum Data Set Working Group Comment:

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Injecting drug use frequency within the last three months

Data Element ID: 040866 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The client's frequency of injection as a method of administering drugs, if injected within the last three months. Context: Alcohol and other drug treatment services: The data element is important for identifying patterns of drug use and harms associated with injecting drug use. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Injects daily 2 Injects at least weekly but not daily 3 Injects less frequently than weekly 9 Not stated/inadequately described Guide for Use: Refers to all forms of injecting and all types of licit and illicit drugs. Injecting drug use does not necessarily refer to the Principal Drug of Concern. Includes intravenous, intramuscular and subcutaneous forms of injection. Verification Rules: This data element is collected in conjunction with the data element `Injecting drug use status' only for code 1 (Last injected three months ago or less). Related Data References: relates to the data element Injecting drug status, QHLTH 041086 version 1 relates to the data element Method of use for principal drug of concern, QHLTH 040868 version 1 relates to the data element Other Drug of Concern, QHLTH 041087 version 0 relates to the data element Principal Drug of Concern, QHLTH 041084 version 0 Source Document: Source Organisation: Comment:

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Intended length of stay

Data Element ID: 040012 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The intention of the responsible clinician at the time of the patient's admission to hospital or at the time the patient is placed on an elective surgery waiting list, to discharge the patient either on the day of admission or a subsequent date. Context: Institutional health care Data type: Character Representational form: CODE Representation layout: A Minimum Size: 1 Maximum Size: 1 Data Domain: N No, intended to stay at least one night U Unknown Y Yes, intended to be separated from the hospital on the same day Guide for Use: This item also includes transfers between hospitals, eg patient admitted with intent to stabilise and transfer to another hospital. If patient in fact remains in the facility for longer than planned, the data remains as originally recorded. This item documents the intent. If the patient who has been recorded as "N" dies or is discharged unexpectedly on the day he/she is admitted, the code remains the same. Verification Rules: Related Data References: relates to the data terminology item Same-day patient, QHLTH 040018 version 1 Source Document: Source Organisation: Comment: This information will generally be obtained from a booking form or other details available from the treating doctor.

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Inter-hospital contracted patient status

Data Element ID: 041092 Version number: 0 Type: DATA ELEMENT Status: CURRENT 02/11/2007 Definition: An episode of care for an admitted patient whose treatment and/or care is provided under an arrangement between a hospital purchaser of hospital care (contracting hospital) and a provider of an admitted service (contracted hospital), and for which the activity is recorded by both hospitals, as represented by a code. Context: Admitted patient care: To identify patients receiving services that have been contracted between hospitals. This metadata item is used to eliminate potential double-counting of hospital activity in the analysis of patterns of health care delivery and funding and epidemiological studies. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Inter-hospital contracted patient from public sector hospital 2 Inter-hospital contracted patient from private sector hospital 3 Not an inter-hospital contract 9 Not reported/unknown Guide for Use: A specific arrangement should apply (either written or verbal) whereby one hospital contracts with another hospital for the provision of specific services. This data element item is derived as follows. If Contract role = B (Hospital B, that is, the provider of the hospital service; contracted hospital), and Contract type = 2, 3, 4 or 5 (that is, a hospital (Hospital A) purchases the activity, rather than a health authority or other external purchaser, and admits the patient for all or part of the episode of care, and/or records the contracted activity within the patient's record for the episode of care); then record a value of 1, if Hospital A is a public hospital, or record a value of 2, if Hospital A is a private hospital.

Otherwise if the Contract role is not B, and/or the Contract type is not 2, 3, 4 or 5, record a value of 3

Verification Rules: Related Data References: is derived from Contract role, QHLTH 040806 version 1 is derived from Contract type, QHLTH 040807 version 1 Source Document: Source Organisation: Comment:

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Interpreter service required

Data Element ID: 040799 Version number: 2 Type: DATA ELEMENT Status: CURRENT 02/11/2006 Definition: Whether an interpreter service is required by or for the person. Context: To assist in planning for provision of interpreter services. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No Guide for Use: Includes verbal language, non verbal language and languages other than English. CODE 1 - Yes (Use this code where interpreter services are required) CODE 2 - No (Use this code where interpreter services are not required) Persons requiring interpreter services for any form of sign language should be coded as 1 - Interpreter required. Verification Rules: Related Data References: is used in conjunction with Preferred language, QHLTH 040798 version 1 supersedes previous data element Interpreter required, QHLTH 040799 version 1 Source Document: Australian Standard Classification of Languages (1267.0) Source Organisation: Australian Bureau of Statistics Comment:

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Labour onset type

Data Element ID: 040045 Version number: 3 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The manner in which labour started in a birth event. Context: Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Spontaneous 2 Induced 3 No labour (Caesarean section) 9 Not stated/inadequately described Guide for Use: Labour commences at the onset of regular uterine contractions, which act to produce progressive cervical dilatation, and is distinct from spurious labour or pre-labour rupture of membranes. If prostaglandins were given to induce labour and there is no resulting labour until after 24 hours, then code the onset of labour as spontaneous. CODE 3 No labour can only be associated with a caesarean section. Verification Rules: Related Data References: supersedes previous data element Labour onset type, QHLTH 040045 version 2 Source Document: Source Organisation: Comment:

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Leave

Data Element ID: 040132 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Leave occurs when the patient leaves the hospital during a period of treatment or care for not more than seven days, and intends on return to the hospital to continue the current course of treatment. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Contract leave, QHLTH 040265 version 1 Source Document: Source Organisation: Comment:

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Listing date on waiting list

Data Element ID: 040359 Version number: 2 Type: DATA ELEMENT Status: CURRENT 28/02/2007 Definition: The date on which a hospital or a community health service accepts notification that a patient requires admission for elective hospital care and is placed on the elective surgery waiting list. Context: Elective admission/Waiting list Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date Guide for Use: For elective surgery, the listing date is the date on which the patient is added to an elective surgery waiting list. The acceptance of the notification by the hospital or community health service is conditional upon the provision of adequate information about the patient and the appropriateness of the patient referral. Verification Rules: Related Data References: is used in conjunction with Ready for care days since last category escalation - census, QHLTH 040369 version 1 is used in the calculation of Total waiting time, QHLTH 040091 version 1 supersedes previous data element Listing date on waiting list, QHLTH 040359 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

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Main treatment type for alcohol and other drugs

Data Element ID: 040867 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The main activity determined at assessment by the treatment provider to treat the client's alcohol and/or drug problem for the `Principal drug of concern’. Context: Alcohol and other drug treatment services Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Withdrawal management (detoxification) 03 Rehabilitation 04 Pharmacotherapy 05 Support and Case Management only 06 Information and education only 07 Assessment only 08 Other 11 Counselling - Individual 12 Counselling - Group Guide for Use: The main treatment type is the principal activity, as judged by the treatment provider that is necessary for the completion of the treatment plan for the principal drug of concern. The Main treatment type for alcohol and other drugs is the principal focus of a single treatment episode. Consequently, each treatment episode will only have one main treatment type. For brief interventions, the main treatment type may apply to as few as one contact between the client and agency staff. Code 1: refers to any form of withdrawal management, including medicated and non-medicated, in any delivery setting. Code 3: refers to an intensive treatment program that integrates a range of services and therapeutic activities that may include behavioural treatment approaches, recreational activities, social and community living skills, group work and relapse prevention. Rehabilitation treatment can provide a high level of support (i.e. up to 24 hours a day) and tends towards a medium to longer- term duration. Rehabilitation activities can occur in residential or non-residential settings. Code 4: refers to pharmacotherapies that include those used as maintenance therapies (eg. Naltrexone, buprenorphine, and specialist methadone treatment). Use code 1 (withdrawal management) where a pharmacotherapy is used solely for withdrawal. Code 5: refers to support and case management offered to clients (eg treatment provided through youth alcohol and drug outreach services). This choice only applies where support and case management treatment is

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Main treatment type for alcohol and other drugs recorded as individual client data and the treatment activity is not included in any other category. Code 6: refers to when there is no treatment provided to the client other than information and education. It is noted that, in general, service contacts would include a component of information and education. Code 7: refers to when there is no treatment provided to the client other than assessment. It is noted that, in general, service contacts would include an assessment component. Code 11: refers to any method of individual counselling (a single client) directed towards identified problems with alcohol and/or other drug use or dependency. This code includes cases where an individual is counselled in the presence of persons in a client support role (eg. Family, spouse/partner, friends) and excludes counselling activity that is part of a rehabilitation program as defined in code 3. Code 12: refers to any method of group counselling (therapy involving a number of clients in the same session) directed towards identified problems with alcohol and/or other drug use or dependency. This code excludes counselling activity that is part of a rehabilitation program as defined in code 3. Verification Rules: Related Data References: relates to the data element Other treatment type for alcohol and other drugs, QHLTH 040869 version 1 Source Document: Source Organisation: Comment:

177

Major diagnostic category (Facility calculated)

Data Element ID: 040098 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: One of twenty-three mutually exclusive principal diagnostic categories, that correspond to a single organ system or aetiology. In general these are associated with a particular medical specialty. An additional two categories address exceptions (pre-MDCs) and errors. They are derived from the DRG code. Context: Institutional health care: The development of Australian Refined DRGs has created a descriptive framework for studying hospitalisation. DRGs provide a summary of the varied reasons for hospitalisation and the complexity of cases a hospital treats. Moreover, as a framework for describing the products of a hospital (that is, patients receiving services), they allow meaningful comparisons of hospitals' efficiency and effectiveness under alternative systems of health care provision. Data type: Character Representational form: CODE Representation layout: N(3) Minimum Size: 1 Maximum Size: 3 Data Domain: Valid MDC codes from the current version of AR-DRGs (ARDRG Definitions Manual Version 4.1 Volume I, II and III Commonwealth Department of Health and Aged Care, 3M Health Information Systems.). Guide for Use: Verification Rules: Related Data References: is derived from Birth weight, QHLTH 040001 version 1 is derived from Diagnosis code type, QHLTH 040099 version 3 is derived from Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 is used in conjunction with Diagnosis related group (Facility calculated), QHLTH 040097 version 2 is used in conjunction with Major diagnostic category (HSC calculated), QHLTH 040145 version 1 Source Document: Source Organisation:

Comment:

178

Major diagnostic category (HSC calculated)

Data Element ID: 040145 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: One of twenty-three mutually exclusive principal diagnostic categories, that correspond to a single organ system or aetiology. In general these are associated with a particular medical specialty. An additional two categories address exceptions (pre-MDCs) and errors. They are derived from the DRG code. Context: Institutional health care: The development of Australian Refined DRGs has created a descriptive framework for studying hospitalisation. DRGs provide a summary of the varied reasons for hospitalisation and the complexity of cases a hospital treats. Moreover, as a framework for describing the products of a hospital (that is, patients receiving services), they allow meaningful comparisons of hospitals' efficiency and effectiveness under alternative systems of health care provision. Data type: Character Representational form: CODE Representation layout: N(3) Minimum Size: 1 Maximum Size: 3 Data Domain: Valid MDC codes from the current version of AR-DRGs (ARDRG Definitions Manual Version 4.1 Volume I, II and III Commonwealth Department of Health and Aged Care, 3M Health Information Systems). Guide for Use: Verification Rules: Related Data References: is derived from Birth weight, QHLTH 040001 version 1 is derived from Diagnosis code type, QHLTH 040099 version 3 is derived from Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 is used in conjunction with Diagnosis related group (HSC calculated), QHLTH 040517 version 2 is used in conjunction with Major diagnostic category (Facility calculated), QHLTH 040098 version 1 Source Document: Source Organisation: Comment:

179

Marital status

Data Element ID: 040005 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/1998 Definition: Marital status of the person. Context: Marital status is a core data element in a wide range of social, labour and demographic statistics. Its main purpose is to establish the living arrangements of individuals, to facilitate analysis of the association of marital status with the need for and use of services and for epidemiological analysis. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 never married 2 married/de facto 3 widowed 4 divorced 5 separated 9 not stated/unknown Guide for Use: Separated includes legally and/or socially separated persons, but not people temporarily living apart. The category Married (registered and de facto) should be generally accepted as applicable to all de facto couples, including of the same sex. Verification Rules: Related Data References: supersedes previous data element Marital status, QHLTH 040005 version 1 Source Document: Source Organisation: Comment:

180

Medical practitioner-hours on-call, total

Data Element ID: 040959 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The number of hours in a week that a medical practitioner is required to be available to provide advice, respond to any emergencies etc. Context: Health labour force Data type: Real Representational form: QUANTITATIVE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: Valid value 999 Not stated/inadequately described Guide for Use: Total hours expressed as 000, 001, etc. This metadata item relates to each position (job) held by a medical practitioner. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

181

Medical practitioner-hours worked (in direct patient care), total

Data Element ID: 040960 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The number of hours worked in a week by a medical practitioner on service provision to patients including direct contact with patients, providing care, instructions and counselling, and providing other related services such as writing referrals, prescriptions and phone calls. Context: Health labour force Data type: Real Representational form: QUANTITATIVE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: Valid value 999 Not stated/inadequately described Guide for Use: Total hours expressed as 000, 001 etc. This metadata item relates to each position (job) held by a medical practitioner, not the aggregate of hours worked for all jobs. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: It is often argued that health professionals contribute a considerable amount of time to voluntary professional work and that this component needs to be identified. This should be considered as an additional item, and kept segregated from data on paid hours worked.

182

Medical practitioner-hours worked, total

Data Element ID: 040961 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The total hours worked in a week in a job by a medical practitioner, including any on-call hours actually worked (includes patient care and administration) Context: Health labour force Data type: Real Representational form: QUANTITATIVE Representation layout: NNN Minimum Size: 3 Maximum Size: 3 Data Domain: Valid value 999 Not stated/inadequately described Guide for Use: This metadata item relates to each position (job) held by a medical practitioner, not the aggregate of hours worked in all. Verification Rules: Related Data References: Source Document: Source Organisation: Comment: It is often argued that health professionals contribute a considerable amount of time to voluntary professional work and that this component needs to be identified. This should be considered as an additional item, and kept segregated from data on paid hours worked.

183

Medicare eligibility

Data Element ID: 040058 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: An indicator of a person's eligibility for Medicare services as specified under the Commonwealth Health Insurance Act 1973. Context: Institutional health care: to facilitate analyses of hospital utilisation and policy relating to health care financing. Data type: Numeric character Representational form: CODE Representation layout: Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Eligible 2 Not eligible 9 Not stated/unknown Guide for Use: An eligible person includes a person who resides in Australia and is one of the following: - an Australian citizen - a permanent resident - a New Zealand citizen - a temporary resident who has applied for permanent residency and who has either an authority to work in Australia or an immediate family member who is an Australian citizen or permanent resident - a person, or class of persons, who has been declared eligible for Medicare for the purposes of the Health Insurance Act 1973. Other persons, as temporary residents, who are fully eligible for Medicare include: - a person who is a head or member of a diplomatic mission or consular post or is a member of such a person's family, where there is a Reciprocal Health Care Agreement (RHCA) in place between Australia and the country they represent (currently United Kingdom, Republic of Ireland, the Netherlands, Malta, Italy, Sweden and Finland) - with the exception of New Zealand diplomats. Other persons, as visitors or temporary residents, who are eligible for Medicare, in certain circumstances, include: - persons who are visiting Australia and are eligible persons because there is a RHCA in place between Australia and their usual country of residence (currently United Kingdom, Republic of Ireland, the Netherlands, Malta (eligibility limited to 6 months), Italy (eligibility limited to 6 months), Sweden, Finland and New Zealand - it should be noted that the RHCA with New Zealand and the Republic of Ireland limits the access to medical services for their residents to that of public patients in public hospitals) - with the exception of New Zealand diplomats. With respect to hospital services, persons covered by an RHCA (except RHCA diplomats as they have full Medicare eligibility) are eligible only as public patients in a public hospital and are ineligible persons if they are admitted as a private patient in either a public or private hospital;

184

Medicare eligibility

It should also be noted that some patients can be both an 'eligible person' and either personally or a third party liable for the payment of charges for hospital services received; for example: - prisoners - patients with Defence Force personnel entitlements - compensable patients - Department of Veterans' Affairs beneficiaries - Nursing Home Type Patients. A newborn will usually take the Medicare eligibility status of the mother. However, the eligibility status of the father will be applied to the newborn if the baby is not eligible solely by virtue of the eligibility status of the mother.

Verification Rules: Related Data References: is used in conjunction with Medicare number, QHLTH 040164 version 1 Source Document: Source Organisation: Comment: An eligible person means: - a person who resides in Australia and whose stay in Australia is not subject to any limitation as to time imposed by law; but - does not include a foreign diplomat or family (except where eligibility is expressly granted to such persons by the terms of a reciprocal health care agreement); or - persons visiting Australia who are ordinarily resident in the United Kingdom, New Zealand, Sweden, Malta, Italy and the Netherlands are covered by reciprocal health care agreements. However, persons from Malta or Italy are covered for 6 months only.

185

Medicare number

Data Element ID: 040164 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/04/2003 Definition: Medicare number of patient. Personal identifier allocated by the Health Insurance Commission to eligible persons under the Medicare scheme. Context: Medicare utilisation statistics and institutional health care. Data type: Numeric character Representational form: IDENTIFICATION Representation layout: N(11) NUMBER Minimum Size: 11 Maximum Size: 11 Data Domain: The 11 digit Medicare Number comprises: 8 digits a check digit (1 digit) an issue number (1 digit) a person number (1 digit) Guide for Use: Alignment with this standard is not mandatory for legacy systems. However, for any new system where the collection of Medicare number is required, the collection of 11 digits is mandatory. Verification Rules: Related Data References: supersedes previous data element Medicare number, QHLTH 040164 version 1 Source Document: Source Organisation: Comment: Some legacy systems that do not fully comply with this standard may still exist (eg. Those collecting 10 digits only). Under Medicare, each eligible family in the population is assigned a unique identifying number. This number, together with age and sex, provides an essentially unique identifier.

186

Mental health legal status indicator

Data Element ID: 040077 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Indicates that a person was treated on an involuntary basis under the relevant state or territory mental health legislation, at some point during a hospital stay. Involuntary patients are persons who are detained under mental health legislation for the purpose of assessment or provision of appropriate treatment or care. Context: Psychiatric hospitals and patients in designated psychiatric units of acute hospitals. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 involuntary patient for any part of episode 2 voluntary patient for all of episode Guide for Use: Collected at separation. Verification Rules: Related Data References: is related but not equivalent to Mental health legal status, QHLTH 040532 version 1 Source Document: Source Organisation: Comment:

187

Method of birth

Data Element ID: 040071 Version number: 5 Type: DATA ELEMENT Status: CURRENT 13/04/2006 Definition: The method of complete expulsion or extraction from its mother, a product of conception. Context: Perinatal Statistics: the method of delivery may affect the health status of the mother and the baby at birth and during the postpartum period. Data type: Numeric Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 02 Forceps 03 Vacuum 04 Lower Segment Caesarean Section (LSCS) 05 Classical Caesarean section 08 Other methods 10 Vaginal (non-instrumental) 99 Not stated Guide for Use: In a vaginal breech with forceps to the after coming head, code as forceps. In a vaginal breech that has been manually rotated, code as vaginal (non- instrumental). Where forceps/vacuum extraction are used to assist the extraction of the baby at caesarean section, code as caesarean section. Code 08 Other methods includes hysterotomy. Verification Rules: Related Data References: supersedes previous data element Method of birth, QHLTH 040071 version 4 Source Document: Source Organisation: Comment:

188

Method of use for principal drug of concern

Data Element ID: 040868 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The client's usual method of administering their Principal drug of concern as stated by the client. Context: Alcohol and other drug treatment services: Identification of drug use methods is important for minimising specific harms associated with drug use, and is consequently of value for informing treatment approaches. Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 11 Ingests - swallowing 12 Ingests - sublingual 21 Smokes 31 Injects - intravenous 32 Injects - intramuscular 33 Injects - subcutaneous 38 Injects - other 41 Sniffs powder 51 Inhales - vapour 61 Absorption - rectal 62 Absorption - dermal 98 Other 99 Not stated/inadequately described Guide for Use: In the event that multiple routes of administration are used, the method the client uses most frequently to administer their principal drug should be recorded. Code 11: Refers to eating, drinking or swallowing as the primary method of administration. Code 12: Refers to dissolving beneath the tongue. Code 38: Refers to other injecting methods not already described. Code 61: Refers to the use of suppositories. Code 62: Refers to the use of skin patches. Code 98: Refers to other methods of use excluding injection. Verification Rules: Related Data References: relates to the data element Injecting drug status, QHLTH 041086 version 1

189

Method of use for principal drug of concern relates to the data element Principal Drug of Concern, QHLTH 041084 version 0 Source Document: Source Organisation: Comment:

190

Mode of separation

Data Element ID: 040119 Version number: 6 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Status at separation of person (discharge/transfer/death) and place to which person is released. Context: Institutional health care Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Home/usual residence 04 Other health care establishment 05 Died in hospital 06 Episode change 07 Discharged at own risk 09 Non return from leave 12 Correctional facility 13 Organ Procurement 14 Boarder 15 Residential Aged Care Service 16 Transfer to another hospital 19 Other 99 Unknown Guide for Use: Verification Rules: Related Data References: is used in conjunction with Facility contracted to, QHLTH 040129 version 1 is used in conjunction with Facility transferred to, QHLTH 040120 version 4 relates to the data element concept Contract leave, QHLTH 040265 version 1 relates to the data element concept Contract service, QHLTH 040130 version 1 relates to the data element Date transferred for contract leave, QHLTH 040127 version 1 supersedes previous data element Mode of separation, QHLTH 040119 version 5 Source Document: Source Organisation: Comment:

191

Multidisciplinary care plan date

Data Element ID: 041041 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2007 Definition: The date that a multidisciplinary care plan has been established. Context: Admitted SNAP patients - admission type 21 or 09 Health Care Services Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: - Valid Date Guide for Use: The date for the Multidisciplinary Care Plan should be within 7 working days of separation. Verification Rules: Mandatory if Y entered in Multidisciplinary Care Plan Flag Field. Related Data References: is related but not equivalent to Multidisciplinary care plan indicator, QHLTH 041040 version 1 Source Document: Source Organisation: Comment:

192

Multidisciplinary care plan indicator

Data Element ID: 041040 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2007 Definition: An indicator of whether there is documented evidence that a multidisciplinary care plan has been established. Context: Health Care Services Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Yes 2 No 9 Unknown Guide for Use: Multidisciplinary care plan refers to a series of documented and agreed initiatives/treatment (specifying program goals, actions and time frames) which has been established through multidisciplinary consultation (including the patient/carers where appropriate). - Multidisciplinary consultation refers to a consultation with a multidisciplinary team. - Multidisciplinary team refers to a team of no less that 3 health professionals from different health professions, e.g. nursing, medical, allied health. Coverage: All admitted patients, including residents of other States/Territories and overseas residents who receive rehabilitation or GEM care delivered in designated Sub and Non-acute Patient (SNAP) Units of a peer group A and B public hospitals. The Multidisciplinary Care Plan should be established within 7 working days of separation. Saturday, Sunday and public holidays are excluded. A Multidisciplinary Care Plan indicator is not collected for patients with a

rehabilitation or GEM care type that are separated with a length of stay of less than 7 working days or died during the rehabilitation or GEM program.

Verification Rules: Mandatory if admission type is 21 or 09 Related Data References: is related but not equivalent to Multidisciplinary care plan date, QHLTH 041041 version 1 Source Document: Source Organisation: Comment:

193

Non-admitted patient care - outpatient clinic type code

Data Element ID: 040761 Version number: 2 Type: DATA ELEMENT Status: CURRENT 16/02/2006 Definition: The nature of service provided by an organisational unit or organisational arrangement through which a hospital provides outpatient clinic services represented by a codeset. Context: Reporting of activity data from health facilities. Data type: Numeric Representational form: CODE Representation layout: N(6) Minimum Size: 6 Maximum Size: 6 Data Domain: 010100 Nutrition 010200 Occupational Therapy 010300 Physiotherapy 010400 Podiatry 010500 Prosthetics 010600 Psychology 010700 Other Allied Health 010800 Speech Pathology/Audiology 010900 Social Work 020000 Dental 030000 Imaging 040100 Aged Care 040101 Geriatric 040102 Gerontology 040201 Allergy 040301 Cardiology 040400 Clinical haematology 040500 Clinical measurement 040600 Dementia 040701 Diabetes 040702 Endocrinology 040801 Dermatology 040900 Falls 041000 Gastroenterology 041100 Internal Medicine 041200 Neurology 041300 Pain Clinic 041400 Primary Care 041500 Rehabilitation 041600 Rheumatology 041700 Transplants

194

Non-admitted patient care - outpatient clinic type code 041800 Wound Management 041900 Dialysis 042001 Infectious Disease 042101 Renal Medicine 042201 Thoracic Medicine 042301 Chemotherapy 042302 Oncology 042400 Drug and Alcohol 042500 Endoscopy and related procedures 050101 Gynaecology 050201 Maternity 060101 General Paediatrics 060102 Paediatric Surgery 070000 Pathology 080000 Pharmacy 090000 Psychiatry 100100 Ear, Nose and Throat Surgery 100200 General Surgery 100300 Neurosurgery 100400 Ophthalmology 100500 Orthopaedic Surgery 100600 Plastic and Reconstructive Surgery 100700 Pre-admission 100800 Urology 100900 Vascular Surgery Guide for Use: 010100 - Outpatient services provided by a dietician or nutritionist who is Registered with the Queensland Board of Nutrition and Dietetics. Services may also be provided by diet aides or monitors under instruction from a nutritionist. 010200 - Outpatient services provided by an occupational therapist that is registered with the Occupational Therapists Board of Queensland. Services include those provided to burns patients presenting at this clinic. 010300 - Outpatient services provided by a physiotherapist who is Registered with the Physiotherapists Board of Queensland. 010400 - Outpatient services provided by a podiatrist who is Registered with the Podiatrists Board of Queensland. 010500 - Outpatient services provided by a prosthetist or orthotist who is eligible for membership with the Australian Orthotics and Prosthetics Association. 010600 - Outpatient services provided by a psychologist who is Registered with the Psychologists Board of Queensland. 010700 - Outpatient services provided by allied health professionals not elsewhere classified, including services provided by recreation officers or by medical illustrators and photographers.

195

Non-admitted patient care - outpatient clinic type code

010800 - Outpatient services provided by a speech pathologist who is registered with the Speech Pathologists' Board or by a qualified audiologist who is eligible for membership with the Australian Audiological Society Incorporated. 010900 - Outpatient services provided by a social worker that is eligible for the Australian Association of Social Workers or a social work associate who is under the direction of a Social Worker. 020000 - Outpatient services provided by a dentist recognised by the Dental Board of Queensland. Oral surgery occasions of service map to facial/maxillary and thus to Plastic Surgery. 040100 - Services related to the assessment, management and treatment of older people; may or may not be provided by a geriatrician/rehabilitation specialist. Services may be targeted to those 65 years and over and those 45 years and over (Indigenous), however, in clinical practice, frailty, co- morbidities and degenerative, disabling and age-associated conditions are the relevant indicators for services. Includes services for older people with complex health care needs, often with more than one condition; includes both chronic and acute conditions. This category should be used for services that are not included in the other more specific categories of geriatric, dementia, falls and rehabilitation. 040101 - Services provided by a geriatrician, including assessment, treatment, rehabilitation and clinical advice and liaison for older people with physical, cognitive/dementia, mental health and/or functional support needs. Services may be provided in conjunction with multi-disciplinary teams of professionals who may have specific qualifications and/or expertise in disease processes and injury in older people and in assessment and rehabilitation for older people. Services may be targeted to those 65 years and over and those 45 years and over (Indigenous), however, in clinical practice, frailty, co-morbidities and degenerative, disabling and age- associated conditions are the relevant indicators for services. If the clinic is a dementia clinic, code to '040600 - Dementia'; if the clinic is a falls clinic, code to 040900 - Falls. 040102 - Services related to the processes and the phenomena of ageing. 040201- Outpatient services provided by an immunologist or allergist recognised by the Royal Australasian College of Physicians, or provided by junior medical staff or registrars rostered to a recognised immunologist or allergist. Examples of services provided include diagnostic skin testing and blood testing for specific immune responses. 040301 - Outpatient services provided by a cardiologist recognised by the Royal Australasian College of Physicians; or outpatient services provided by a cardiac surgeon recognised by the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised cardiologist or cardiac surgeon. Services provided by the clinic include echocardiography for diagnostic purposes and cardiac rehabilitation.

196

Non-admitted patient care - outpatient clinic type code 040400 - (Formerly Haematology) Outpatient services provided by a haematologist or an autologist who is recognised as a specialist by the Roy l a Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised haematologist or autologist. The clinic also includes the collection of blood by health professionals from donors at a number of remote hospital facilities which use their own supply as Red Cross Blood Bank supplies are not available. 040500 - Outpatient services which a range of staff may provide, (nursing, applied scientists and technicians). This clinic must have a minimum capability to provide ECGs, and typically also provides EEGs and EMGs. Respiratory function-type clinics map to this clinic type. 040600 - Services provided by a geriatrician for early identification and support of patients with cognitive deficits or memory loss; provide diagnostic evaluation, assessment of the impact of impairment within the home or other environment, education, information and referral to other services. Services may be targeted to those 65 years and over and those 45 years and over (Indigenous), however, in clinical practice, frailty, co- morbidities and degenerative, disabling and age-associated conditions are the relevant indicators for services. 040701 - Outpatient services which may be provided by a range of staff such as nurse educators, podiatrists, dieticians, endocrinologists, and general physicians to patients with diabetes or suspected diabetes. 040702 - Outpatient services provided by an endocrinologist recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised endocrinologist. Where clinics are set up to provide follow-up to diabetes patients only, then occasions of service should be recorded under the Diabetes Clinic type. 040801 - Outpatient services provided by a dermatologist recognised by the Australian College of Dermatologists; or provided by junior medical staff or registrars rostered to a recognised dermatologist. 040900 - Services provided by a geriatrician which focus on the assessment and management of patients with falls, mobility and balance problems; provide time limited, specialist intervention to the patient and advice and referral to mainstream services for ongoing management and education and training; may be provided in conjunction with multidisciplinary services. Treatment may be targeted to those 65 years and over and those 45 years and over (Indigenous), however, in clinical practice, frailty, co-morbidities and degenerative, disabling and age-associated conditions are the relevant indicators for services. 041000 - Outpatient services provided by a gastroenterologist specialist who is recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised gastroenterologist.

197

Non-admitted patient care - outpatient clinic type code 041100 - (Formerly Internal General Medicine) Outpatient services provided by a specialist medical physician or provided by junior medical staff or registrars rostered to a recognised specialist medical physician. Some very specialised services are likely to map to this clinic type. 041200 - Outpatient services provided by a neurologist who is recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised neurologist. 041300 - Outpatient services provided by neurosurgeons, psychiatrists, psychologists, general medical staff or anaesthetists to patients experiencing chronic pain. 041400 - GP/ dispensary type services provided by a medical doctor. 041500 - Services provided by a specialist in rehabilitation medicine or a geriatrician with skills in rehabilitation providing diagnosis, evaluation and treatment of people with limited function as a consequence of disease, injury, impairment and/or disorder; services may be provided in conjunction with multi-disciplinary teams. Services may be targeted to those 65 years and over and those 45 years and over (Indigenous), however, in clinical practice, frailty, co-morbidities and degenerative, disabling and age- associated conditions are the relevant indicators for services. 041600 - Outpatient services provided by a rheumatologist recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised rheumatologist. 041700 - Outpatient services delivered by multi-disciplinary teams to patients who have had lung, liver, heart or kidney transplants. 041800 - Outpatient services involving the treatment of breaches of the skin including treatment for burns through the use of pressure garments. However, outpatient services provided to burns patients by plastic surgeons or junior medical staff rostered to plastic surgeons should be recorded as plastic surgery occasions of service. Similarly, occasions of services relating to burns patients presenting to occupational therapy clinics should be recorded as occupational therapy occasions of service. 041900 - Includes all patients receiving dialysis within the facility who do not undergo the facility's formal admission process and are treated as non- admitted patients for this service. 042001 - Outpatient services provided by a specialist in infectious diseases who is recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised specialist in infectious diseases. 042101 - (Formerly Nephrology) Outpatient services provided by a nephrologist who is recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised nephrologist.

198

Non-admitted patient care - outpatient clinic type code 042201 - (Formerly pulmonary) Outpatient services provided by a pulmonary/ respiratory specialist recognised by the Royal Australasian College of Physicians; or provided by junior medical staff or registrars rostered to a recognised pulmonary/respiratory specialist. 042301 - Outpatient services provided by oncologists and other clinical staff for chemotherapy. Services may also be provided by junior medical staff or registrars rostered to a recognised oncologist. 042302 - Outpatient services provided by oncologists and other clinical staff including radiotherapy, palliative care and haematology. Services may also be provided by junior medical staff or registrars rostered to a recognised oncologist. 042400 - This is an area of outpatient activity, which is being de- institutionalised with most service provision now occurring in the community. Outpatient services recorded under this clinic type are provided typically by either by a specialist medical physician recognised by the Royal Australasian College of Physicians or by a psychiatrist recognised by the Royal Australian and New Zealand College of Psychiatrists; but also include services provided by junior medical staff or registrars rostered to a recognised specialist medical physician or psychiatrist. 042500 - Includes all occasions of service to non-admitted patients for endoscopy including cystoscopy, gastroscopy, oesophagoscopy, duodenoscopy, colonoscopy, bronchoscopy, laryngoscopy and sigmoidoscopy procedures. 050101 - Outpatient services provided by a gynaecologist who is recognised as a specialist by the Royal Australian College of Obstetricians and Gynaecologists; or provided by junior medical staff or registrars rostered to a recognised gynaecologist. 050201 - (Formerly Obstetrics) Outpatient services provided by obstetricians recognised by the Royal Australian College of Obstetricians and Gynaecologists, or midwives registered with the Queensland Nurses Registration Board, or general practitioners recognised by the Royal Australian College of General Practitioners; or provided by junior medical staff or registrars rostered to a recognised obstetrician. Services include antenatal care and ultrasonography. 060101 - Outpatient services provided by a specialist medical physician who is recognised by the Royal Australasian College of Physicians with credentials in paediatrics; or provided by junior medical staff or registrars rostered to a recognised paediatric surgeon. 060102 - Outpatient services provided by a paediatric surgeon recognised by the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised paediatric surgeon. 090000 - Outpatient services provided by a psychiatrist recognised by the Royal Australian and New Zealand College of Psychiatrists; or provided by

199

Non-admitted patient care - outpatient clinic type code junior medical staff or registrars rostered to a recognised psychiatrist. 100100 - (Formerly Ear, Nose and Throat) Outpatient services provided by an ear, nose and throat specialist who is recognised by the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised ENT specialist. 100200 - Outpatient services provided by a doctor who is recognised as a surgeon from the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised surgeon. 100300 - Outpatient services provided by a neurosurgeon who is recognised by the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised neurosurgeon.

100400 - Outpatient services provided by an ophthalmologist who is recognised by the Royal Australian College of Ophthalmologists. Services may also be provided by junior medical staff or registrars rostered to a recognised ophthalmologist. Note that means testing of patients should not be counted as an occasion of service. Provision of optometric aids, should not be recorded as occasions of service. 100500 - (Formerly Orthopaedics) Outpatient services provided by an orthopaedic surgeon who is recognised by the Australian Orthopaedic Association (AOA); or provided by junior medical staff or registrars rostered to a recognised orthopaedic surgeon. 100600 - (Formerly Plastic Surgery) Outpatient services provided by a plastic surgeon or oral surgeon recognised by the Royal Australasian College of Surgeons; or provided by junior medical staff or registrars rostered to a recognised plastic surgeon or oral surgeon. 100700 - Outpatient services which may be provided by a range of clinicians such as surgeons, anaesthetists, GPs, non-specialist hospital medical staff, and advanced practice nursing staff. Services include pre-surgical work-ups and assessment, the ordering of tests, patient education, counselling, follow- up and discharge planning. 100800 - Outpatient services provided by an urologist recognised by the Royal Australasian College of Surgeons or by an advanced urological trainee who is enrolled with the Royal Australasian College of Surgeons. 100900 - Outpatient services provided by a vascular surgeon recognised by the Royal Australasian College of Surgeons, including pre-operative and post-operative follow-up. Services may also be provided by junior medical staff or registrars rostered to a recognised vascular surgeon. Verification Rules: Related Data References: is used in conjunction with Compensable/eligibility status for non-admitted patients, QHLTH 040759 version 1

200

Non-admitted patient care - outpatient clinic type code supersedes previous data element Ambulatory clinic types, QHLTH 040761 version 1 Source Document: Source Organisation: Comment: The following information contains a mapping of potential clinic names to the required reporting categories and can be used to determine how to report hospital specific clinics. Its use is recommended to provide guidance for hospitals to report activity. Possible service name (outpatient or community) = MAC service name - Options include: aged care, geriatric, gerontology, rehabilitation, dementia and falls Dementia = Dementia Memory disorder = Dementia Continence (geriatric) = Geriatric Falls & mobility = Falls Movement disorders (geriatric) = Geriatric Pain Management (geriatric) = Geriatric Parkinsons = Geriatric Aged care = Aged Care Domiciliary (home and residential aged care) = Home: geriatric; Residential aged care: Aged care Gerontology = Geriatric Rehabilitation = Rehabilitation Osteoporosis (geriatric) = Geriatric Health Living (older people) = Geriatric General Geriatric = Geriatric Community based rehabilitation (day therapy) = Rehabilitation

201

Non-admitted patient ED service episode-episode end date

Data Element ID: 040973 Version number: 1 Type: DATA ELEMENT Status: CURRENT 24/03/2006 Definition: The date on which the non-admitted patient emergency department service episode ends. Context: Emergency department care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Guide for Use: A non-admitted patient emergency department service episode ends when either the patient is admitted or, if the patient is not to be admitted, when the patient is recorded as ready to leave the emergency department or when they are recorded as having left at their own risk. For patients who subsequently undergo a formal admission an admitted patient episode of care should be recorded. The end of the non-admitted patient emergency department service episode should indicate the commencement of the admitted episode of care. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

202

Non-admitted patient ED service episode-episode end status

Data Element ID: 040974 Version number: 1 Type: DATA ELEMENT Status: CURRENT 24/03/2006 Definition: The status of the patient at the end of the non-admitted patient emergency department service episode. Context: Non-admitted patient emergency department care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Admitted to this hospital (including to units or beds within the emergency department) 2 Non-admitted patient emergency department service episode completed - departed without being admitted or referred to another hospital 3 Non-admitted patient emergency department service episode completed - referred to another hospital for admission 4 Did not wait to be attended by a health care professional 5 Left at own risk after being attended by a health care professional but before the non-admitted patient emergency department service episode was completed 6 Died in emergency department as a non-admitted patient 7 Dead on arrival, not treated in emergency department Guide for Use: CODE 2 Non-admitted patient emergency department service episode completed - departed without being admitted or referred to another hospital This code includes patients who departed under their own care, under police custody, under the care of a residential aged care facility or other

carer. Code 2 excludes those who died in the emergency department, which should be coded to Code 6

Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

203

Non-admitted patient ED service episode-episode end time

Data Element ID: 040975 Version number: 1 Type: DATA ELEMENT Status: CURRENT 24/03/2006 Definition: The time at which the non-admitted patient emergency department service episode ends. Context: Emergency department care Data type: Numeric character Representational form: TIME Representation layout: HHMM Minimum Size: 4 Maximum Size: 4 Data Domain: Valid time Guide for Use: A Non-admitted patient emergency department service episode ends when either the patient is admitted or, if the patient is not to be admitted, when the patient is recorded as ready to leave the emergency department or when they are recorded as having left at their own risk. For patients who subsequently undergo a formal admission an admitted patient episode of care should be recorded. The end of the non-admitted patient emergency department service episode should indicate the commencement of the admitted episode of care. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

204

Non-admitted patient ED service episode - service commencement date

Data Element ID: 040965 Version number: 1 Type: DATA ELEMENT Status: CURRENT 07/12/2005 Definition: The date on which a non-admitted patient emergency department service event commences. Context: Emergency Department care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: In an Emergency Department the service event commences when the medical officer (or, if no medical officer is on duty in the Emergency Department, a treating nurse) provides treatment or diagnostic service. The date of triage is recorded separately. The commencement of a service event does not include contact associated with triage. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

205

Non-admitted patient ED service episode - service commencement time

Data Element ID: 040966 Version number: 1 Type: DATA ELEMENT Status: CURRENT 07/12/2005 Definition: The time at which a non-admitted patient emergency department service event commences. Context: Emergency Department care Data type: Numeric character Representational form: TIME Representation layout: HHMM Minimum Size: 4 Maximum Size: 4 Data Domain: Valid time Guide for Use: In an Emergency Department the service event commences when the medical officer (or, if no medical officer is on duty in the Emergency Department, a treating nurse) provides treatment or diagnostic service. The time of triage is recorded separately. The commencement of a service event does not include contact associated with triage. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

206

Non-admitted patient ED service episode-service episode length

Data Element ID: 040976 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The amount of time, measured in minutes, between when a patient presents at an emergency department for an emergency department service episode, and when the non-admitted component of the emergency department service episode has concluded. Context: Emergency department care. Data type: Numeric character Representational form: QUANTITATIVE Representation layout: N(5) Minimum Size: 1 Maximum Size: 5 Data Domain: Minutes Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

207

Non-admitted patient ED service episode-transport mode (arrival)

Data Element ID: 040977 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The mode of transport by which the person arrives at the emergency department. Context: Emergency department care. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Ambulance (Road) 2 Ambulance (helicopter) 3 Ambulance (fixed wings) 4 Community Services 5 Police or Prison Vehicle 6 Walked In / Public or Private Transport 8 Other Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

208

Non-admitted patient ED service episode-triage category

Data Element ID: 040978 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The urgency of the patient's need for medical and nursing care. Context: Emergency department care: Required to provide data for analysis of emergency department processes. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Resuscitation: immediate (within seconds) 2 Emergency: within 10 minutes 3 Urgent: within 30 minutes 4 Semi-urgent: within 60 minutes 5 Non-urgent: within 120 minutes Guide for Use: This triage classification is to be used in the emergency departments of hospitals. Patients will be triaged into one of five categories on the National Triage Scale according to the triageur's response to the question: 'This patient should wait for medical care no longer than ...?'. The triage category is allocated by an experienced registered nurse or medical practitioner. If the triage category changes, record the more urgent category. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

209

Non-admitted patient ED service episode-triage date

Data Element ID: 040967 Version number: 1 Type: DATA ELEMENT Status: CURRENT 07/12/2005 Definition: The date on which the patient is triaged. Context: Emergency Department care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Valid date Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

210

Non-admitted patient ED service episode-triage time

Data Element ID: 040968 Version number: 1 Type: DATA ELEMENT Status: CURRENT 07/12/2005 Definition: The time at which the patient is triaged. Context: Emergency Department care. Data type: Numeric character Representational form: TIME Representation layout: HHMM Minimum Size: 4 Maximum Size: 4 Data Domain: Valid time Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

211

Non-admitted patient ED service episode-type of visit

Data Element ID: 040979 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The reason the patient presents to an emergency department. Context: Hospital non-admitted patient care Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Emergency presentation: attendance for an actual or suspected condition which is sufficiently serious to require acute unscheduled care. 2 Return visit, planned: presentation is planned and is a result of a previous emergency department presentation or return visit. 3 Pre-arranged admission: a patient who presents at the emergency department for either clerical, nursing or medical processes to be undertaken, and admission has been pre-arranged by the referring medical officer and a bed allocated. 4 Patient in transit: the emergency department is responsible for care and treatment of a patient awaiting transport to another facility. 5 Dead on arrival: a patient who is dead on arrival at the emergency department. Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Required for analysis of emergency department services.

212

Not ready for care

Data Element ID: 040377 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 01/07/1997 Definition: Not ready for care patients are either: - staged patient whose medical condition will not require or be amenable to surgery until some future date. For example, a patient who has had internal fixation of a fractured bone and who will require removal of the fixation device after a suitable time; or - deferred patients who for personal reasons are not yet prepared to be admitted to hospital. For example, patients with work or other commitments which preclude their being admitted to hospital for a time. Not ready for care patients may also be termed staged or deferred waiting list patients. Staged or Deferred patients should not be confused with patients whose operation is postponed for reasons other than their own unavailability. For example, surgeon unavailable owing to emergency workload. These patients are still ready for care. Context: Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

213

Number of acute (qualified)/unqualified days for newborns

Data Element ID: 040375 Version number: 1 Type: DERIVED DATA ELEMENT Status: CURRENT 12/11/1998 Definition: The number of acute (qualified) and unqualified newborn days occurring within a newborn episode of care. Context: Institutional health care Data type: Numeric Representational form: QUANTITATIVE Representation layout: N(3) Minimum Size: 3 Maximum Size: 3 Data Domain: Number of days Guide for Use: The rules for calculating the number of acute (qualified) and unqualified newborn days are outlined below: - the number of acute (qualified) and unqualified days are calculated from the date of admission, date of separation and any date(s) of change to qualification status. - the date of admission is counted as a day against the initial qualification status. - the day on which a change in qualification status occurs is counted against the new qualification status. - if more than one change of qualification status occurs on a single day, the day is counted against the final qualification status for that day. - the date of separation is not counted as either an acute (qualified) or unqualified day. - normal rules which apply to calculation of patient days apply, e.g. same day, leave. - the newborn's length of stay is equal to the sum of the acute (qualified) and unqualified days. Verification Rules: Related Data References: is used in the calculation of Patient days, QHLTH 040015 version 2 Source Document: Source Organisation: Comment:

214

Number of days of hospital-in-the-home care

Data Element ID: 040980 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The number of hospital-in-the-home days occurring within an episode of care for an admitted patient. Context: Admitted patient care Data type: Numeric character Representational form: QUANTITATIVE Representation layout: N Minimum Size: 1 Maximum Size: 3 Data Domain: Guide for Use: The rules for calculating the number of hospital-in-the-home days are outlined below: The number of hospital-in-the-home days is calculated with reference to the date of admission, date of separation, leave days and any date(s) of change between hospital and home accommodation; The date of admission is counted if the patient was at home at the end of the day; The date of change between hospital and home accommodation is counted if the patient was at home at the end of the day; The date of separation is not counted, even if the patient was at home at the end of the day; The normal rules for calculation of patient days apply, for example in relation to leave and same day patients. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

215

Number of leave days

Data Element ID: 040984 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Sum of the length of leave (date returned from leave minus date went on leave) for all periods within the hospital stay. Context: Recording of leave days allows for exclusion of these from the calculation of patient days. This is important for analysis of costs per patient and for planning. The maximum limit allowed for leave affects admission and separation rates, particularly for long-stay patients who may have several leave periods. Data type: Integer Representational form: QUANTITATIVE Representation layout: N[NN] Minimum Size: 1 Maximum Size: 3 Data Domain: Guide for Use: A day is measured from midnight to midnight. The following rules apply in the calculation of leave days for both overnight and same-day patients: The day the patient goes on leave is counted as a leave day. The day the patient is on leave is counted as a leave day. The day the patient returns from leave is counted as a patient day. If the patient is admitted and goes on leave on the same day, this is counted as a patient day, not a leave day. If the patient returns from leave and then goes on leave again on the same day, this is counted as a leave day. If the patient returns from leave and is separated on the same day, the day should not be counted as either a patient day or a leave day. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

216

Other Drug of Concern

Data Element ID: 041087 Version Number: 0 Type: DATA ELEMENT Status: DRAFT

01/07/2007 Definition: A drug apart from the principal drug of concern which the client states as being a concern, as represented by a code. Context: Alcohol and Other Drug Treatment Service. Datatype: Numeric character Representational Form: CODE Representation Layout: NNNN Minimum Size: 4 Maximum Size: 4 Data Domain: The Australian Standard Classification of Drugs of Concern (ASCDC) 2000 extended

Supplementary Values

0005 - Opioid analgesics not further defined 0006 - Psychostimulants not further defined

Guide for Use: Record each additional drug of concern (according to the client) relevant to the treatment episode. The other drug of concern does not need to be linked to a specific treatment type. More than one drug may be selected. There should be no duplication with the principal drug of concern. The Australian Standard Classification of Drugs of Concern (ASCDC) provides a number of supplementary codes that have specific uses and these are detailed within the ASCDC e.g. 0000 = inadequately described. Other supplementary codes that are not already specified in the ASCDC may be used in National Minimum Data Sets (NMDS) when required. In the Alcohol and other drug treatment service NMDS, two additional supplementary codes have been created which enable a finer level of detail to be captured: CODE 0005 Opioid analgesics not further defined This code is to be used when it is known that the client's principal drug of concern is an opioid but the specific opioid used is not known. The existing code 1000 combines opioid analgesics and non-opioid analgesics together into Analgesics nfd and the finer level of detail, although known, is lost. CODE 0006 Psychostimulants not further defined This code is to be used when it is known that the client's principal drug of concern is a psychostimulant but not which type. The existing code 3000 combines stimulants and hallucinogens together into Stimulants and hallucinogens nfd and the finer level of detail, although known, is lost. Psychostimulants refer to the types of drugs that would normally be coded to 3100-3199, 3300- 3399 and 3400-3499 categories plus 3903 and 3905. This item complements principal drug of concern. The existence of other drugs of concern may have a role in determining the types of treatment required and may also influence treatment outcomes. Verification Rules: Related Data References: Source Document: Source Organisation: Intergovernmental Committee on Drugs National Minimum Data Set Working Group Comment:

217

Other treatment type for alcohol and other drugs

Data Element ID: 040869 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: All other forms of treatment provided to the client in addition to the data element `Main treatment type for alcohol and other drugs'. Context: Alcohol and other drug treatment services: Information about treatment provided is of fundamental importance to service delivery and planning. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Withdrawal management (detoxification) 2 Counselling - Individual 3 Rehabilitation 4 Pharmacotherapy 5 Counselling - Group 8 Other Guide for Use: Only report treatment that is in addition to, and not a component of, the Main treatment type for alcohol and other drugs. Treatment activity reported here is not necessarily for Principal drug of concern in that it may be treatment for Other drugs of concern. Code 1 refers to any form of withdrawal management, including medicated and non-medicated, in any delivery setting. Code 2 refers to any method of individual counselling (a single client) directed towards identified problems with alcohol and/or other drug use or dependency. This code includes cases where an individual is counselled in the presence of persons in a client support role (eg. family, spouse/partner, friends) and excludes counselling activity that is part of a rehabilitation program as defined in code 3. Code 3 refers to an intensive treatment program that integrates a range of services and therapeutic activities that may include behavioural treatment approaches, recreational activities, social and community living skills, group work and relapse prevention. Rehabilitation treatment can provide a high level of support (i.e. up to 24 hours a day) and tends towards a medium to longer- term duration. Rehabilitation activities can occur in residential or non-residential settings. Code 4 refers to pharmacotherapies that include those used as maintenance therapies (eg. Naltrexone, buprenorphine, and specialist methadone treatment). Use code 1 (withdrawal management) where a pharmacotherapy is used solely for withdrawal. Code 5 refers to any method of group counselling (therapy involving a number of clients in the same session) directed towards identified problems with alcohol and/or other drug use or dependency. This code excludes

218

Other treatment type for alcohol and other drugs counselling activity that is part of a rehabilitation program as defined in code 3. Verification Rules: Codes 1, 2, 3, 4, 5, 8 not to be used for those clients that have codes 5 (Support and Case Management Only), 6 (Information and eduction only), or 7 (Assessment only) chosen on the Main Treatment Type data element for the principal drug of concern. Related Data References: relates to the data element Main treatment type for alcohol and other drugs, QHLTH 040867 version 1 Source Document: Source Organisation: Comment:

219

Overnight-stay patients

Data Element ID: 040257 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Patients who are admitted to, and separated from, the hospital on different dates (i.e., are not same day patients). This type of patient: - has been registered as a patient at the hospital; - meets the minimum criteria for admission; - has undergone a formal admission process; - remains in the hospital at midnight on the day of admission. Boarders are excluded from this definition. An overnight stay patient in one hospital cannot be concurrently an admitted patient in another hospital, unless they are on contract leave. If not on contract leave, a patient must be discharged from one hospital and admitted to the other hospital on each occasion of transfer. Treatment provided to an intended same day patient who is subsequently classified as an overnight stay patient shall be regarded as part of the overnight episode of care. A non-admitted service (i.e., an emergency or outpatient service) provided to a patient who is subsequently classified as an admitted patient shall be regarded as part of the admitted episode of care. That is, any occasion of service should be reported and identified as part of the admitted patient episode of care. The definition of an overnight stay patient excludes patients who, on the first day of their stay in hospital: - leave of their own accord; - die; or - are transferred, as such patients should be classified as same day patients. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Same-day patient, QHLTH 040018 version 1 Source Document: Source Organisation: Comment:

220

Palliative phase type

Data Element ID: 040606 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: A code that describes the distinct period or stage of illness for a palliative care phase. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Currently sub and non- acute patient (SNAP) details are collected only for those patients in designated SNAP units. The scope of this collection includes all admitted patient episodes where the patient's episode type is not acute, newborn, boarder, organ procurement or other care, and the ward (either at admission to the episode or through a ward transfer during the episode) is assigned to a designated SNAP unit. A new item, standard ward code, is to be assigned a value of 'SNAP' for those wards which are assigned to a designated SNAP unit. Patients should have SNAP details reported for each sub and non-acute care type (SNAP episode) within an episode of care. Data type: Numeric Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Stable 02 Unstable 03 Deteriorating 04 Terminal care 05 Bereaved Guide for Use: Stable Phase All clients not classified as unstable, deteriorating, or terminal. The person's symptoms are adequately controlled by establishing management. Further interventions to maintain symptom control and quality of life have been planned. The situation of the family/carers is relatively stable and no new issues are apparent. Any needs are met by the established plan of care. Unstable Phase The person experiences the development of a new problem or a rapid increase in the severity of existing problems, either of which require an urgent change in management or emergency treatment. The family/carers experience a sudden change in their situation requiring urgent intervention by members of the multidisciplinary team. Deteriorating Phase The person experiences a gradual worsening of existing symptoms or the

221

Palliative phase type development of new but expected problems. This requires the application of specific plans of care and regular review but not urgent or emergency treatment. The family/carers experience gradually worsening distress and other difficulties, including social and practical difficulties, as a result of the illness of the person. This requires a planned support program and counselling as necessary. Terminal Care Phase Death is likely in a matter of days and no acute intervention is planned or required. The typical features of a person in this phase may include the following: profoundly weak, essentially bed bound, drowsy for extended periods, disoriented for a time and has a severely limited attention span, increasing disinterest in food and drink, finding it difficult to swallow medication. This requires the use of frequent usually daily interventions aimed at physical, emotional and spiritual issues. The family/carers recognise that death is imminent and care is focused on emotional and spiritual issues as a prelude to bereavement. Bereaved Phase Death of the patient has occurred and the carers are grieving. A planned bereavement support program is available including counselling as necessary. Verification Rules: Related Data References: relates to the data element SNAP care type, QHLTH 040599 version 1 Source Document: Source Organisation: Comment:

222

Patient - presentation time

Data Element ID: 040972 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The time at which the patient/client presents to a hospital or community health service facility for the delivery of a service. Context: Admitted patient care. Community health care. Hospital non-admitted patient care: Required to identify commencement of a visit and for calculation of waiting times. Data type: Numeric character Representational form: TIME Representation layout: HHMM Minimum Size: 4 Maximum Size: 4 Data Domain: Guide for Use: For community health care, outreach services and services provided via telephone or telehealth, this may be the date on which the service provider presents to the patient/client or the telephone/telehealth session commences. The time of patient/client presentation at the Emergency Department is the earliest occasion of being registered clerically or triaged. The date that the patient/client presents is not necessarily: - the listing date for care (see Listing date for care data element concept), nor - the date on which care is scheduled to be provided, nor

- the date on which commencement of care actually occurs (for admitted patients see Admission date, for hospital non-admitted patient care and community health care see Date of commencement of service event).

Verification Rules: Related Data References: Source Document: Source Organisation: National Institution Based Ambulatory Model Reference Group National Health Data Committee Comment: This data element is required to identify commencement of a visit and for calculation of waiting times. It supports the provision of client record and/or summary level data by State and Territory health authorities as part of the NMDS - Emergency department waiting times.

223

Patient days

Data Element ID: 040015 Version Number: 2 Type: DERIVED DATA ELEMENT Status: CURRENT

15/01/1998 Definition: The total number of days or part days of stay for all patients who were admitted for an episode of care and who underwent separation during the reference period. Same day patients are counted as having a stay of one day. Periods of leave are excluded where the patient was absent at midnight. If a patient is on contract leave to another hospital the day(s) on contract are counted as patient days for the calculation of length of stay. The day of admission is included in the count but not the day of separation. Context: Institutional health care Datatype: Integer Representational Form: QUANTITATIVE VALUE Representation Layout: N(5) Minimum Size: 1 Maximum Size: 5 Data Domain: Non-negative integer Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Accrued patient days QHLTH 040016 version 2 is calculated using Admission date - episode QHLTH 040008 version 1 relates to the data terminology item Contract leave QHLTH 040265 version 1 relates to the data terminology item Leave QHLTH 040132 version 1 is equivalent to Patient days NHIMG 000206 version 3 is calculated using Separation date QHLTH 040117 version 1 Source Document: Source Organisation: Comment:

224

Pension status

Data Element ID: 040048 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Whether or not a patient is in receipt of a pension at the time of admission and the nature of that pension. Context: Psychiatric hospitals and patients in designated psychiatric units of acute hospitals. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Aged pension 2 Repatriation pension 3 Invalid pension 4 Unemployment benefit 5 Sickness benefit 7 Other 8 No pension/benefit 9 Not stated/unknown Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Note that this does not mean the pension is necessarily the recipient's main source of income.

225

Person identifier

Data Element ID: 040014 Version number: 2 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: Person identifier unique within an establishment or agency. Context: This item could be used for editing at the agency, establishment or collection authority level and, potentially, for episode linkage. There is no intention that this item would be available beyond collection authority level. Data type: Alphanumeric Representational form: IDENTIFICATION Representation layout: AN(20) NUMBER Minimum Size: 6 Maximum Size: 20 Data Domain: Valid person identification number Guide for Use: Individual agencies, establishments or collection authorities may use their own alphabetic, numeric or alphanumeric coding systems. Verification Rules: Field cannot be blank. Related Data References: supersedes previous data element Patient identifier, QHLTH 040014 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Other References: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia

226

Person-sex

Data Element ID: 040000 Version number: 3 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: Sex is the biological distinction between male and female. Where there is an inconsistency between anatomical and chromosomal characteristics, sex is based on anatomical characteristics. Context: Sex is a core data element in a wide range of social, labour and demographic statistics. Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Male 2 Female 3 Intersex or indeterminate 9 Not stated/inadequately described Guide for Use: Code 3 Intersex or indeterminate, refers to a person, who because of a genetic condition, was born with reproductive organs or sex chromosomes that are not exclusively male or female or whose sex has not yet been determined for whatever reason. Verification Rules: Code 3 Intersex or indeterminate, should be confirmed if reported for people aged 90 days or greater. Diagnosis and procedure codes should be checked against the national ICD- 10-AM sex edits, unless the person is undergoing, or has undergone a sex change as detailed in Collection methods or has a genetic condition resulting in a conflict between sex and ICD-10-AM code. Related Data References: is used in the calculation of Diagnosis related group (HSC calculated), QHLTH 040517 version 2 is used in the calculation of Diagnosis related group (Facility calculated), QHLTH 040097 version 2 supersedes previous data element Sex - client, QHLTH 040000 version 2 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. The definition for Intersex in Guide for use is sourced from the ACT Legislation (Gay, Lesbian and Transgender) Amendment Act 2003. NHDD specific: DSS - Diabetes (clinical): Referring to the National Diabetes Register Statistical profile (December 2000), the sex ratio varied with age. For ages less than 25 years, numbers of males and females were similar. At ages 25-44 years, females strongly outnumbered males, reflecting the effect of gestational diabetes in women from this

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Person-sex group. For older age groups (45-74 years), males strongly outnumber females and in the group of 75 and over, the ratio of males to females was reversed, with a substantially lower proportion of males in the population in this age group due to the higher female life expectancy. (AIHW National Mortality Database 1997/98; National Diabetes Register; Statistical Profile, December 2000). Other References: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia In AS4846 and AS5017 alternative codes are presented. Refer to the current standard for more details.

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Place of occurrence of external cause of injury

Data Element ID: 040249 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: The place where the external cause of injury, poisoning or violence occurred. Context: Admitted patients: enables categorisation of injury and poisoning according to factors important for injury control. Necessary for defining and monitoring injury control targets, injury costing and identifying cases for in-depth research. Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item External cause, QHLTH 040248 version 1 Source Document: Source Organisation: Comment: ICD-10-AM is the preferred classification for this data item. A place of occurrence code must accompany each related external cause code.

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Planned accommodation status

Data Element ID: 040385 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/1998 Definition: Planned type of accommodation of a patient on the elective waiting list. Context: Elective admission/Waiting list Data type: Character Representational form: CODE Representation layout: A Minimum Size: 1 Maximum Size: 1 Data Domain: P Public R Private single S Private shared Guide for Use: This value may change whilst the patient is listed on the waiting list. Between 1/7/97 and 30/6/98, QHAPDC received only the most recent value of this data item. From 1/7/98 all values, both the initial and any changed values are received by QHAPDC. The initial value of this item is supplied to QHAPDC linked to the data item "Listing Date on waiting list". If there are subsequent change/s to this item, the new value/s are submitted linked to the data item "Date of change of waiting list details". Verification Rules: Related Data References: relates to the data element Chargeable status, QHLTH 040050 version 1 relates to the data element Planned accommodation status - throughput, QHLTH 040370 version 1 supersedes previous data element Intended accommodation status, QHLTH 040086 version 1 Source Document: Source Organisation: Comment:

230

Postcode - Australian

Data Element ID: 040395 Version number: 2 Type: DATA ELEMENT Status: CURRENT 02/09/2003 Definition: The numeric descriptor for a postal delivery area, aligned with locality, suburb or place for the address of a party (person or organisation), as defined by Australia Post. Context: Postcode is an important part of a person's or organisation's postal address and facilitates written communication. It is one of a number of geographic identifiers that can be used to determine a geographic location. Postcode may assist with uniquely identifying a person or organisation. Data type: Numeric Representational form: CODE Representation layout: NNNN Minimum Size: 4 Maximum Size: 4 Data Domain: Valid Australian postal code Guide for Use: The postcode book is updated more than once annually as postcodes are a dynamic entity and are constantly changing. Verification Rules: Related Data References: relates to the data element Australian State/Territory Identifier, QHLTH 040394 version 2 relates to the data element Labour force status, QHLTH 040828 version 1 relates to the data element Postal delivery point identifier, QHLTH 040823 version 1 relates to the data element Postcode, QHLTH 040395 version 1 relates to the data element Suburb/town/locality name, QHLTH 040859 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment: This metadata item is common to both the National Community Services Data Dictionary and the National Health Data Dictionary. Postcode-Australian may be used in the analysis of data on a geographical basis, which involves a conversion from postcodes to the ABS postal areas. This conversion results in some inaccuracy of information. However, in some data sets postcode is the only geographic identifier, therefore the use of other more accurate indicators (e.g. Statistical Local Area) is not always possible. When dealing with aggregate data, postal areas, converted from postcodes, can be mapped to ASGC codes using an ABS concordance, for example to determine SLAs. It should be noted that such concordances should not be used to determine the SLA of any individual's postcode. Where individual street addresses are available, these can be mapped to ASGC codes (eg SLAs) using the ABS National Localities Index (NLI). Refer to ABS Catalogue No. 1252.0 for full details of the NLI.

231

Postcode - Australian NHDD specific: DSS Cardiovascular disease (clinical): Postcode-Australian can also be used in association with the Australian Bureau of Statistics Socio- Economic Indexes for Areas (SEIFA) index (Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA), Australia - CD-ROM Latest Issue: Aug 1996 was released on 30/10/1998) to derive socio-economic disadvantage, which is associated with cardiovascular risk. People from lower socio-economic groups are more likely to die from cardiovascular disease than those from higher socio-economic groups. In 1997, people aged 25 - 64 living in the most disadvantaged group of the population died from cardiovascular disease at around twice the rate of those living in the least disadvantaged group (Australian Institute of Health and Welfare (AIHW) 2001. Heart, stroke and vascular diseases- Australian facts 2001.). This difference in death rates has existed since at least the 1970s. Other references: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia

232

Postcode of usual residence

Data Element ID: 040081 Version number: 4 Type: DATA ELEMENT Status: CURRENT 01/07/2002 Definition: Australian postcode corresponding to usual residential address. Context: Data type: Numeric character Representational form: CODE Representation layout: N(4) Minimum Size: 4 Maximum Size: 4 Data Domain: Valid postcodes for Australia, and the following supplementary codes: 0989 not stated/unknown 9301 Papua New Guinea 9302 New Zealand 9399 overseas - other (not PNG or NZ) 9799 at sea 9989 no fixed address Guide for Use: Allocate Australian External Territories their actual postcode, not an overseas default postcode. Australian External Territories include the following : Christmas Island (Australia), Cocos (Keeling) Islands, Norfolk Island. Verification Rules: Related Data References: is used in conjunction with State of usual residence, QHLTH 040078 version 2 is used in conjunction with Statistical Local Area (SLA), QHLTH 040082 version 6 is used in conjunction with Suburb/town/locality of usual residence, QHLTH 040080 version 2 supersedes previous data element Postcode of usual residence, QHLTH 040081 version 3 Source Document: Source Organisation: Comment: The Statistical Standards Unit maintains a corporately standardised file of suburbs, postcodes, states and associated Statistical Local Areas. The content of this locality data set is derived from two main sources, the ABS and Australia Post, with supplementary data supplied by Queensland Health. The Australian Bureau of Statistics provides annual releases on 1 July each year of the NLI, Street Sub- Index and ASGC data. Quarterly updates are now also received and loaded into CRDS. Australia Post data is downloaded from their website at the same time as the ABS updates are received for synchronisation of data. Ad hoc additions are made to the locality data set as advised by the source organisations. The most up-to-date locality file and associated documentation are available from the Corporate Reference Data System (CRDS). The file can be browsed at: http://qheps.health.qld.gov.au/masters/crds.htm or can be downloaded by contacting the CRDS Project Officers, Statistical Standards Unit, on: Ph: (07) 3239 9451 or via email: crds@health.qld.gov.au.

233

Pre-admission clinic

Data Element ID: 040143 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: Pre-admission clinics are conducted at the hospital for patients who are booked for admission. Such clinics are usually required for patients seeking elective surgery, and sometimes for patients needing non-invasive tests or medical management. The pre-admission clinic determines the patient's fitness for the procedure, and ensures adequate arrangements are made in preparation for his or her hospitalisation. The patient's visit to the pre-admission clinic is undertaken prior to hospital admission, i.e. before the patient is admitted to hospital. Context: Elective admission/Waiting list Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Source: "A Guide for Service Delivery - Pre-Admission" (Draft national guideline). Note that this publication refers to "Pre-admission Assessment", but for the purposes of the QHAPDC the above definition refers specifically to "Pre-Admission Clinics".

234

Preferred language

Data Element ID: 040798 Version number: 1 Type: DATA ELEMENT Status: CURRENT 16/07/2002 Definition: The language (including sign language) most preferred by the person for communication. Context: Health and welfare services: An important indicator of ethnicity, especially for persons born in non-English-speaking countries. Its collection will assist in the planning and provision of multilingual services and facilitate program and service delivery for migrants and other non-English speakers. Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: The classification used is a 2-digit level modified version of the of the "Australian Standard Classification of Languages" (1267.0) Guide for Use: This may be a language other than English even where the person can speak fluent English. All non-verbal means of communication, including sign languages, are to be coded to 97. Code 96 should be used where some information, but insufficient, is provided. Code 98 is to be used when no information is provided. All Australian Indigenous languages not shown separately on the code list Verification Rules: Related Data References: Source Document: "Australian Standard Classification of Languages" (1267.0) Source Organisation: Australian Bureau of Statistics Comment: This data element was recommended by the Information Steering Committee through the Data Standards Advisory Committee. It was approved as the QH standard by the Deputy Director-General (Policy & Outcomes).

235

Presentation of baby

Data Element ID: 040046 Version number: 3 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: That part of the foetus which lies in the lower pole of the uterus at birth. Context: Perinatal data collection Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Vertex 2 Breech 3 Cephalic 4 Face 5 Brow 7 Transverse/shoulder 8 Other (eg. oblique/hand etc) 9 Not stated/unknown Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

236

Previous specialised non-admitted palliative care treatment

Data Element ID: 040621 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/2000 Definition: The status of the episode in terms of whether the patient has had a previous non-admitted service contact for palliative care treatment. Context: Data type: Numeric Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Patient has no previous non-admitted service contact(s) for Palliative care treatment 2 Patient has previous non-admitted service contact(s) for Palliative care treatment Guide for Use: Verification Rules: Related Data References: is related but not equivalent to First admission for palliative care treatment, QHLTH 040620 version 1 Source Document: Source Organisation: Comment:

237

Previous specialised non-admitted treatment

Data Element ID: 040596 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: Whether the patient has had previous non-admitted service contact(s) for psychiatric treatment. Context: Institutional health care Data type: Numeric Representational form: CODE Representation layout: N(1) Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Patient has no previous non-admitted service contact(s) for psychiatric treatment 2 Patient has previous non-admitted service contact(s) for psychiatric treatment 9 Not stated/unknown Guide for Use: Includes patients who have been seen at any time in the past for psychiatric treatment, regardless of whether it was part of the current episode or a previous service contact many years in the past. Use the codes regardless of whether the previous treatment was provided within the service in which the person is now being treated, or another equivalent specialised service (either institutional or community-based). Verification Rules: Related Data References: is related but not equivalent to First admission for psychiatric treatment, QHLTH 040057 version 1 Source Document: Source Organisation: Comment:

238

Primary reason for induction

Data Element ID: 040114 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Primary reason for the need to induce labour. Context: Perinatal data collection Data type: Alphanumeric Representational form: CODE Representation layout: ANNNN Minimum Size: 4 Maximum Size: 5 Data Domain: A valid ICD-10-AM code. Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

239

Principal diagnosis

Data Element ID: 040244 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: The diagnosis established after study to be chiefly responsible for occasioning the patient's episode of care in hospital (or attendance at the health care facility). Context: Health services: used for epidemiological research, casemix studies and planning purposes. Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data element Diagnosis code type, QHLTH 040099 version 3 relates to the data terminology item Additional diagnoses, QHLTH 040245 version 3 Source Document: Source Organisation: Comment: This field must: - start with a digit or a Z - be reported as per coding guidelines For the provision of Diagnosis Related Groups, some ICD diagnosis codes cannot be used as a Principal diagnosis, and will result in a fatal error in the grouping process. Diagnosis codes starting with a V or Y, describing the circumstances that cause an injury, rather than the nature of an injury, cannot be used as a Principal diagnosis. Diagnosis codes starting with an M are morphology codes, and cannot be used as a Principal diagnosis and will result in a fatal error. A Principal diagnosis should be recorded for each episode of patient care. Where the principal diagnosis is recorded prior to discharge (as in annual census of public psychiatric hospital inpatients), it is the current provisional principal diagnosis. Only use the admission diagnosis when no other diagnostic information is available. The current provisional diagnosis may be the same as the admission diagnosis.

240

Principal Drug of Concern

Data Element ID: 041084 Version Number: 0 Type: DATA ELEMENT Status: DRAFT

01/07/07 Definition: The main drug, as stated by the client, that has led a person to seek treatment from the service, as represented by a code. Context: Alcohol and Other Drug Treatment Service. Datatype: Numeric character Representational Form: CODE Representation Layout: NNNN Minimum Size: 4 Maximum Size: 4 Data Domain: The Australian Standard Classification of Drugs of Concern (ASCDC) 2000 extended

Supplementary Values

0005 - Opioid analgesics not further defined 0006 - Psychostimulants not further defined

Guide for Use: The principal drug of concern should be the main drug of concern to the client and is the focus of the client's treatment episode. If the client has been referred into treatment and does not nominate a drug of concern, then the drug involved in the client's referral should be chosen. The Australian Standard Classification of Drugs of Concern (ASCDC) provides a number of supplementary codes that have specific uses and these are detailed within the ASCDC e.g. 0000 = inadequately described. Other supplementary codes that are not already specified in the ASCDC may be used in National Minimum Data Sets (NMDS) when required. In the Alcohol and other drug treatment service NMDS, two additional supplementary codes have been created which enable a finer level of detail to be captured: CODE 0005 Opioid analgesics not further defined This code is to be used when it is known that the client's principal drug of concern is an opioid but the specific opioid used is not known. The existing code 1000 combines opioid analgesics and non-opioid analgesics together into Analgesics nfd and the finer level of detail, although known, is lost. CODE 0006 Psychostimulants not further defined This code is to be used when it is known that the client's principal drug of concern is a psychostimulant but not which type. The existing code 3000 combines stimulants and hallucinogens together into Stimulants and hallucinogens nfd and the finer level of detail, although known, is lost. Psychostimulants refer to the types of drugs that would normally be coded to 3100-3199, 3300- 3399 and 3400-3499 categories plus 3903 and 3905. Verification Rules: Related Data References: Source Document: Source Organisation: Intergovernmental Committee on Drugs National Minimum Data Set Working Group Comment:

241

Procedure

Data Element ID: 040617 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 01/07/1999 Definition: A clinical intervention that: - is surgical in nature; and/or - carries a procedural risk; and/or - carries an anaesthetic risk; and/or - requires specialised training; and/or - requires special facilities or equipment only available in an acute care setting. Context: Institutional health care: this item gives an indication of the extent to which specialised resources, for example, human resources, theatres and equipment, are used. It also provides an estimate of the numbers of surgical operations performed and the extent to which particular procedures are used to resolve medical problems. It is used for classification of episodes of acute care for admitted patients into Australian Refined Diagnosis Related Groups. Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Admitted patients: record all procedures undertaken during an episode of care in accordance with the ICD-10-AM Australian Coding Standards. The order of codes should be determined using the following hierarchy: - procedure performed for treatment of the principal diagnosis - procedure performed for the treatment of an additional diagnosis - diagnostic/exploratory procedure related to the principal diagnosis; or - diagnostic/exploratory procedure related to an additional diagnosis for the episode of care. Verification Rules: As a minimum requirement procedure codes must be valid codes from ICD- 10-AM procedure codes and validated against the nationally agreed age and sex edits. Related Data References: relates to the data element Diagnosis code type, QHLTH 040099 version 3 relates to the data element Diagnostic code (ICD-10-AM), QHLTH 040100 version 3 supersedes previous data element Additional procedures, QHLTH 040247 version 1 supersedes previous data element Principal procedure, QHLTH 040246 version 1 Source Document: International Statistical Classification of Diseases and Related Health Problems - Tenth Revision - Australian Modification (1998); National Centre for Classification in Health, Sydney.

242

Procedure Source Organisation: National Centre for Classification in Health, National Health Data Committee Comment: The National Centre for Classification in Health advises the National Health Data Committee of relevant changes to the ICD-10-AM.

243

Qualification status

Data Element ID: 040376 Version number: 1 Type: DATA ELEMENT Status: CURRENT 12/11/1998 Definition: Qualification status indicates whether the newborn day of stay is either acute (qualified) or unqualified (for all or part of a newborn episode of care). Context: Institutional health care: To provide accurate information on care to babies to enable analysis to exclude normal babies. Data type: Alphanumeric Representational form: CODE Representation layout: A Minimum Size: 1 Maximum Size: 1 Data Domain: A Acute U Unqualified Guide for Use: All babies 9 days old or less should be admitted as a newborn episode of care. On admission the newborn will have a qualification status of either acute (qualified) or unqualified depending on meeting certain criteria. A newborn is qualified if it meets at least one of the following criteria: - is the second or subsequent live born infant of a multiple birth, whose mother is currently an admitted patient; - is admitted to an intensive care facility in a hospital, being a facility approved by the Commonwealth Minister for the purpose of the provision of special care; - is admitted to, or remains in hospital without its mother. A newborn is unqualified if it does not meet any of the above criteria. Verification Rules: Related Data References: is used in conjunction with Care type, QHLTH 040013 version 6 is used in the calculation of Number of acute (qualified)/unqualified days for newborns, QHLTH 040375 version 1 Source Document: Source Organisation: Comment:

244

Queensland Ambulance Service patient event identifier

Data Element ID: 040948 Version number: 1 Type: DATA ELEMENT Status: CURRENT 22/12/2006 Definition: A unique event identifier that is allocated to a patient when transported by the Queensland Ambulance Service (QAS) to a hospital. Context: This item will be used to improve the monitoring of costs and outcomes in QAS patients overall and for specific investigations of other subgroups of patients. Data type: Alphanumeric Representational form: IDENTIFICATION Representation layout: XXXXXX[X(14)] NUMBER Minimum Size: 20 Maximum Size: 6 Data Domain: Valid patient event identification number Guide for Use: The QAS patient event identifier can be used to uniquely link patient episodes in the admitted and non-admitted emergency patient record to patient events in extracts of QAS clinical data. If more than one patient is delivered to the hospital at one time, each patient will have their own EARF number. See comments below for more details about how an EARF number is allocated by QAS. Verification Rules: Field cannot be blank if the patient’s mode of transport is recorded as ambulance. Related Data References: Source Document: Source Organisation: Comment: The EARF number is a unique identifier for patient events attended by the Queensland Ambulance Service (QAS). Each QAS team has a portable tablet PC that they use to record clinical details about each patient attended. Each tablet PC is allocated a unique set of EARF numbers and when a new patient template is opened on the PC an EARF number is automatically allocated to the patient. It should be noted that the number is only unique to a patient event NOT a person. That is, a person receives a new EARF number each time they are attended to/transported by QAS. If more than one QAS team attend a patient, all clinical details are transferred to the PC of the team who transports the patient so each patient is allocated only one EARF number per patient event. The EARF number is included on the form that the QAS transporting team print out and leave at the hospital when they deliver a patient. The number will be manually entered into Queensland Health data systems (HBCIS and EDIS) at each hospital until such a time as electronic transfer of this information is possible.

245

Ready for care days since last category escalation - census

Data Element ID: 040369 Version Number: 1 Type: Data Element Status: Legacy

01/07/1998 Definition: The number of days the patient was ready for care, from last category escalation date or listing date to the census date or from waiting list date if there was no category escalation. Context: Elective admission/Waiting list: this is the critical waiting times data element. This data element is used to examine the distribution of waiting time, for example, measures of central tendency. Information based on this data item will have many uses including to assist doctors and patients in making decisions about hospital referral, to assist in the planning and management of hospitals and in health care related research. Datatype: Integer Representational Form: QUANTITATIVE VALUE Representation Layout: N(4) Minimum Size: 1 Maximum Size: 4 Data Domain: Positive integers in range 0-9999. Guide for Use: Verification Rules: Related Data References: is calculated using Census date QHLTH 040352 version 1 is calculated using Listing date on waiting list QHLTH 040359 version 1 relates to the data element Not ready for care QHLTH 040377 version 1 relates to the data element Ready for care days since last category escalation QHLTH 040093 version 1 Source Document: Source Organisation: Comment:

246

Reason for removal from waiting list (admitted patient)

Data Element ID: 040373 Version number: 4 Type: DATA ELEMENT Status: CURRENT 28/02/2007 Definition: The reason why a patient is removed from the elective surgery waiting list. Context: Elective admission/Waiting list. Used for patients who have been admitted to hospital for the elective procedure Data type: Numeric character Representational form: CODE Representation layout: N (2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Admitted and treated as elective patient for awaited procedure in this hospital 02 Admitted and treated as an emergency patient for awaited procedure 03 Could not be contacted (includes patients who have died while waiting whether or not the cause of death was related to the condition requiring treatment) 04 Treated elsewhere for awaited procedure 05 Surgery not required or declined 06 Transferred to other hospital's waiting list 09 Not stated/inadequately described Guide for Use: 01 Identifies patients undergoing the awaited procedure whilst admitted for another reason 02 Identifies patients who are admitted because the condition requiring treatment deteriorated whilst waiting. Admission as an emergency patient could also be due to other causes such as inappropriate urgency rating, delays in the system or unpredicted biological variation Codes 03 to 05 identify patients who have been removed following a clerical audit of the waiting list. Either the patient could not be contacted (03), or after the patient was contacted, the patient was removed from the list because they had received their procedure at another facility (04) or had decided to no longer have the procedure (05). 06 Identifies patients who are transferred to another hospital's waiting list. Verification Rules: Related Data References: is used in the derivation of Booking status, QHLTH 040372 version 2 Source Document: Source Organisation: Comment:

247

Referral from specialised mental health residential care

Data Element ID: 040836 Version Number: 1 Type: Data Element Status: Current

14/11/2003 Definition: The type of specialised mental health care service the resident is referred to by the residential care service for further care at the end of residential stay. Context: Specialised mental health services (Residential mental health care). Datatype: Numeric Representational Form: CODE Representation Layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Specialised mental health admitted patient care

2 Specialised mental health residential care 3 Specialised mental health ambulatory care 4 Private psychiatrist care 5 General practitioner care 6 Other care 7 Not referred 8 Not applicable (i.e. end of reference period) 9 Unknown / not stated / inadequately described

Guide for Use: Where the resident is referred to two or more types of health care, the type of health care provided by the service primarily responsible for the care of the resident is to be reported. Verification Rules: Related Data References: is equivalent to Referral from specialised mental health residential care NHIMG 001003 version 1 Source Document: National Health Data Dictionary Source Organisation: Australian Institute of Health and Welfare Comment:

248

Referral to further care (psychiatric)

Data Element ID: 040083 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: The type of further health service care to which a person is referred from mental health. Context: Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Not referred 02 Private psychiatrist 03 Other private medical practitioner 04 Mental health/alcohol and drug facility - admitted patient 05 Mental health/alcohol and drug facility - non-admitted patient 06 Acute hospital - admitted patient 07 Acute hospital - non-admitted patient 08 Community health program 29 Other Guide for Use: Verification Rules: Related Data References: supersedes previous data element Referral to further care (psychiatric), QHLTH 040083 version 1 Source Document: Source Organisation: Comment:

249

Same-day patient

Data Element ID: 040018 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: A same-day patient is a person who is admitted and separates on the same date. This patient: * has been registered as a patient at the hospital; * meets the minimum criteria for admission; * has undergone a formal admission process; * is separated prior to midnight on the day of admission. Boarders are excluded from this definition. Note: * Same day patients may be either intended to be discharged on the same day, or intended overnight stay patients who were discharged, died or were transferred on their first day in hospital. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: relates to the data terminology item Overnight-stay patients, QHLTH 040257 version 1 Source Document: Source Organisation: Comment: Same day patients may either be intended to be discharged on the same day, or intended overnight stay patients who were discharged, died, or were transferred on their day in the hospital. Treatment provided to an intended same day patient, who is subsequently classified as an overnight stay patient, should be regarded as part of the overnight episode of care. A non-admitted service (an emergency or outpatient service) provided to a patient, who is subsequently classified as an admitted patient, shall be regarded as part of the admitted episode of care. That is, any occasion of service should be reported and identified as part of the admitted patient episode of care. Data on same day patients are derived by a review of admission and separation dates. The data excludes patients who were to be discharged on the same day but were subsequently required to stay in hospital for one night or more.

250

Second name

Data Element ID: 040004 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Second name of person Context: Institutional health care Data type: Character Representational form: TEXT Representation layout: A(50) Minimum Size: 1 Maximum Size: 50 Data Domain: Left justified character string Guide for Use: If no given name then leave blank. Verification Rules: Related Data References: is used in conjunction with First name, QHLTH 040003 version 1 is used in conjunction with Surname, QHLTH 040002 version 1 Source Document: Source Organisation: Comment:

251

Separation

Data Element ID: 040017 Version number: 1 Type: DATA ELEMENT CONCEPT Status: CURRENT 15/01/1998 Definition: A separation is the process by which an admitted patient completes an episode of care. A separation may be formal or statistical. Formal separation is the administrative process by which a hospital records the completion of treatment and/or care and accommodation of an admitted patient. This generally occurs when a patient is discharged, is transferred to another institution, absconds, or dies whilst in care. Statistical separation on type change is the administrative process by which a hospital records the completion of each episode of care occurring within a single hospital stay. Context: Institutional health care Data type: Representational form: Representation layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: Non-return from leave is used when a patient goes on leave and does not return to the hospital within seven days. Note that the patient is to be discharged from the date that he/she left the hospital.

252

Separation date

Data Element ID: 040117 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/03/2005 Definition: Date on which an admitted patient completes an episode of care. Context: Institutional health care Data type: Numeric character Representational form: DATE Representation layout: DDMMYYYY Minimum Size: 8 Maximum Size: 8 Data Domain: Must be a valid date Guide for Use: Verification Rules: Related Data References: is used in conjunction with Mode of separation, QHLTH 040119 version 5 is used in conjunction with Separation time, QHLTH 040118 version 2 relates to the data element concept Separation, QHLTH 040017 version 1 supersedes previous data element Separation date, QHLTH 040117 version 1 Source Document: Source Organisation: Comment: Some Queensland Health information systems restrict date storage to CCYYMMDD format e.g. Oracle systems.

253

Separation time

Data Element ID: 040118 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Time at which a patient finishes an episode of care. Context: Institutional health care Data type: Numeric character Representational form: TIME Representation layout: HHMM Minimum Size: 4 Maximum Size: 4 Data Domain: Valid times in 24 hour format, range 0000 to 2359 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Separation date, QHLTH 040117 version 1 Source Document: Source Organisation: Comment:

254

Service delivery mode

Data Element ID: 040780 Version number: 2 Type: DATA ELEMENT Status: CURRENT 13/12/2005 Definition: The mode of delivery by which the service was provided. Context: Allows analysis of service mode patterns. Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 11 In person 21 Telephone 22 Videoconference 23 Electronic mail 81 Postal/courier service 98 Other Guide for Use: In Person: Code 11: The service provider delivers the service in the physical presence of the target individual (i.e., in the same room). Code 11 and Code 22 provide a measure of 'Face-To-Face' service delivery. Telehealth: The word 'tele' originally meant 'at a distance'. However, in recent times it has taken on a more specific meaning of 'communication over a distance by electrical means'. Therefore this broad category represents health services that are provided over a distance by electrical means. Telehealth can assist people in rural and remote areas receive follow-up care and other specialist health care. Code 21: The service provider delivers the service using a telephone. This includes teleconference. Code 22: The service provider delivers the service using videoconference equipment. Code 11 and Code 22 provides a measure of 'Face-To-Face' service delivery. Code 23: The service provider delivers the service via electronic mail. Code 81: The service provider delivers the service via postal (including courier) services. Code 98: Other:. Verification Rules: AODTS Rules that apply for this data element when collected in conjunction with `Treatment delivery setting for alcohol and other drugs'.

255

Service delivery mode For the domain values 21, 22, 23, 81 and 98 the `Treatment delivery setting for alcohol and other drugs' domain value must be 8 - `Other Setting'.

Related Data References: relates to the data element Main treatment type for alcohol and other drugs, QHLTH 040867 version 1 relates to the data element Sexual health service contact, QHLTH 040772 version 3 relates to the data element Treatment delivery setting for alcohol and other drugs, QHLTH 040871 version 1 supersedes previous data element Service activity delivery mode, QHLTH 040780 version 1 Source Document: Source Organisation: Comment:

256

SNAP care type

Data Element ID: 040599 Version Number: 1 Type: Data Element Status: Provisional

22/09/05 Definition: Classification of a patient's care type based on characteristics of the person, the primary treatment goal and evidence. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Currently sub and non-acute patient (SNAP) details are collected only for those patients in designated SNAP units. The scope of this collection includes all admitted patient episodes where the patient's episode type is not acute, newborn, boarder, organ procurement or other care, and the ward (either at admission to the episode or through a ward transfer during the episode) is assigned to a designated SNAP unit. A new item, standard ward code, is to be assigned a value of 'SNAP' for those wards which are assigned to a designated SNAP unit. Patients should have SNAP details reported for each sub and non-acute care type (SNAP episode) within an episode of care. Datatype: Character Representational Form: CODE ` Representation Layout: NNN Minimum Size: 3 Maximum Size: 6 Data Domain: GAO Geriatric Evaluation and management - assessment only

GEM Geriatric evaluation and management GSD Geriatric evaluation and management - planned same day MCO Maintenance - convalescent care MNH Maintenance - nursing home type MOT Maintenance - other MRE Maintenance - respite PAL Palliative care PAO Psychogeriatric - assessment only PSG Psychogeriatric RAL Rehabilitation - amputation of limb RAO Rehabilitation - assessment only RAR Rehabilitation - arthritis RBD Rehabilitation - brain dysfunction RBU Rehabilitation - burns RCA Rehabilitation - cardiac RCD Rehabilitation - congenital deformities RDD Rehabilitation - developmental disabilities RDE Rehabilitation - debility RMT Rehabilitation - major multiple trauma RNE Rehabilitation - neurological ROC Rehabilitation - orthopaedic conditions ROI Rehabilitation - other disabling impairments RPS Rehabilitation - pain syndromes RPU Rehabilitation - pulmonary RSC Rehabilitation - spinal cord dysfunction RST Rehabilitation - stroke

Guide for Use: GERIATRIC EVALUATION AND MANAGEMENT Geriatric Evaluation and Management is provided for a person with complex multi- dimensional medical problems associated with disabilities and psychosocial problems, usually (but not always) an older person.

257

SNAP care type

GAO - Geriatric Evaluation and Management - Assessment only GEM - Geriatric Evaluation and Management GSD - Geriatric Evaluation and Management - Planned Same Day

GAO/GEM/GSD includes evaluation and management of younger adults with clinical problems generally associated with old age. MAINTENANCE Maintenance is provided for a person with a disability who, following assessment or treatment, does not require further complex assessment or stabilisation. MCO - Maintenance Care (Convalescent) CLASS A patient who is admitted post acutely for the purpose of maintaining functional ability to aid self caring prior to returning to the home environment. MNH - Maintenance - Nursing Home Type includes: -Care and support of a person in an inpatient setting whilst the patient is awaiting transfer to residential care or alternate support services or where there are factors in the home environment (physical, social, psychological) which make discharge to home inappropriate for the person in the short term. -Ongoing care and support of a person in a residential setting. -Patients in receipt of care where the sole reason for admitting the person to hospital is that the care that is usually provided in another environment e.g. at home, in a nursing home, by a relative or with a guardian, is unavailable in the short-term. -Care and support of a person with a functional impairment for whom there is no multidisciplinary program aimed at improvement of functional capacity. -Patients classified as Nursing Home Type Patients i.e. when a patient has been in hospital for a continuous period exceeding 35 days and does not have a current acute care certificate. MOT - Maintenance Care (Other Maintenance) CLASS A patient who has not qualified as NHT or would normally not require hospital treatment but where there are factors in the home environment (physical, social, psychological) which make it inappropriate for the person to be discharged in the short term. Also includes patients treated in a psychiatric unit, who have a stable but severe level of functional impairment, and inability to function independently without extensive care and support, and for whom the principal function is provision of care over an indefinite period. MRE - Maintenance Care (Respite) CLASS A patient who has not qualified as NHT but is in receipt of respite care where the sole reason for admitting the person to hospital is that the care that is usually provided in another environment, e.g. at home, in a nursing home, by a relative or with a guardian, is unavailable in the short term. PALLIATIVE CARE Palliative care is provided for a person with an active, progressive, far advanced disease with little or no prospect of cure. PAL - Palliative care Palliative care includes grief and bereavement support services for the family and carers during the life of the person and continuing after death.

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SNAP care type

PSYCHOGERIATRIC Psychogeriatric care is provided for an elderly person with either an age-related organic brain impairment with significant behavioural disturbance or late onset psychiatric disturbance or a physical condition accompanied by severe psychiatric or behavioural disturbance. PAO - Psychogeriatric - Assessment only PSG - Psychogeriatric PAO and PSG includes psychogeriatric care of younger adults with clinical conditions generally associated with old age as well as care of people with long term psychiatric disturbance and/or substance abuse. REHABILITATION Rehabilitation care is provided for a person with an impairment, disability or handicap. RAL - Amputation of Limb Single Upper Extremity Above the Elbow, Single Upper Extremity Below the Elbow, Single Lower Extremity Above the Knee, Single Lower Extremity Below the Knee, Double Lower Extremity Above the Knee, Double Lower Extremity Above/below the Knee, Double Lower Extremity Below the Knee, Other Amputation. RAO - Assessment only The person is seen on one occasion only for assessment and/or treatment and no further intervention by this service/team are planned. RAR - Arthritis Rheumatoid Arthritis, Osteoarthritis, Other Arthritis. RBD - Brain Dysfunction Non-Traumatic, Traumatic unspecified, Open Injury, Closed Injury, Other Brain. RBU - Burns Burns. RCA - Cardiac Cardiac. RCD - Congenital deformities Spina Bifida, Other Congenital. RDD - Developmental Disabilities Developmental Disabilities. RDE - Debility Debility, unspecified include only patients who are debilitated for reasons other than cardiac or pulmonary conditions. RMT - Major Multiple Trauma (MMT) Brain + Spinal Cord Injury, Brain + Multiple Fracture/ Amputation, Spinal + Multiple Fracture/ Amputation, Other Multiple Trauma. RNE - Neurological Multiple Sclerosis, Parkinsonism, Polyneuropathy, Guillian-Barre, Cerebral Palsy, Other Neurologic.

259

SNAP care type

ROC - Orthopaedic Conditions Status Post Hip Fracture, Status Post Femur (shaft) Fracture, Status Post Pelvis Fracture, Status Post Major Multiple Fracture, Status Post Hip Replacement, Other Orthopaedic. ROI - Other Disabling Impairments Other Disabling Impairments - cases that cannot be classified into a specific group. RPS - Pain Syndromes Neck Pain, Back Pain, Extremity Pain, Other Pain. RPU - Pulmonary Chronic Obstructive Pulmonary Disease, Other Pulmonary. RSC - Spinal Cord Dysfunction Non-Traumatic Spinal Cord Dysfunction, Unspecified Paraplegia, Incomplete Paraplegia, Complete Paraplegia, Unspecified Quadriplegia, Incomplete C1-4 Quadriplegia, Incomplete C5-8 Quadriplegia, Complete C1-4 Quadriplegia, Complete C5-8 Quadriplegia, Other non- traumatic Spinal Cord Injury, Traumatic Spinal Cord Dysfunction, Unspecified Paraplegia, Incomplete Paraplegia, Complete Paraplegia, Unspecified Quadriplegia, Incomplete C1-4 Quadriplegia, Incomplete C5-8 Quadriplegia, Complete C1-4 Quadriplegia, Complete C5-8 Quadriplegia, Other non-traumatic Spinal Cord Injury. RST - Stroke Left Body Involvement - No paresis, Right Body Involvement - Other Stroke, Bilateral Involvement. Verification Rules: The codes for each SNAP type are validated against valid HBCIS sub and non-acute episodes types. Related Data References: relates to the data element SNAP episode number QHLTH 040598 version 1 relates to the data element SNAP group classification QHLTH 040753 version 1 Source Document: Source Organisation: Comment:

260

SNAP end date

Data Element ID: 040601 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: The end date of each SNAP episode in a designated SNAP (Sub and Non- Acute Patient) unit. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Currently sub and non- acute patient (SNAP) details are collected only for those patients in designated SNAP units. The scope of this collection includes all admitted patient episodes where the patient's episode type is not acute, newborn, boarder, organ procurement or other care, and the ward (either at admission to the episode or through a ward transfer during the episode) is assigned to a designated SNAP unit. A new item, standard ward code, is to be assigned a value of 'SNAP' for those wards which are assigned to a designated SNAP unit. Patients should have SNAP details reported for each sub and non-acute care type (SNAP episode) within an episode of care. Data type: Character Representational form: DATE Representation layout: CTYYMMDD Minimum Size: 8 Maximum Size: 8 Data Domain: Guide for Use: Each SNAP episode must meet the criteria for sub and non-acute admitted patient care, as identified by the SNAP types. Verification Rules: Related Data References: relates to the data element SNAP care type, QHLTH 040599 version 1 relates to the data element SNAP episode number, QHLTH 040598 version 1 Source Document: Source Organisation: Comment:

261

SNAP episode number

Data Element ID: 040598 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: The unique SNAP (Sub and Non-Acute Patient) episode number assigned to a SNAP episode within an episode of care. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Currently sub and non- acute patient (SNAP) details are collected only for those patients in designated SNAP units. The scope of this collection includes all admitted patient episodes where the patient's episode type is not acute, newborn, boarder, organ procurement or other care, and the ward (either at admission to the episode or through a ward transfer during the episode) is assigned to a designated SNAP unit. A new item, standard ward code, is to be assigned a value of 'SNAP' for those wards which are assigned to a designated SNAP unit. Patients should have SNAP details reported for each sub and non-acute care type (SNAP episode) within an episode of care. Data type: Numeric Representational form: TEXT Representation layout: N(3) Minimum Size: 3 Maximum Size: 3 Data Domain: Guide for Use: Each set of SNAP details will be assigned a unique SNAP episode number by HBCIS. This number will form part of each record's unique identifier when the SNAP details are forwarded to the Data Collections Unit. Verification Rules: Related Data References: is related but not equivalent to Episode number, QHLTH 040007 version 1 Source Document: Source Organisation: Comment:

262

SNAP group classification

Data Element ID: 040753 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: The SNAP group classification provides a summary of the various SNAP care types allocated to patients, by grouping together homogenous SNAP care types. This then provides a means of relating the number and types of patients treated in a designated SNAP unit to the resources required by the unit. It also allows meaningful comparisons to be made of SNAP units' effectiveness and efficiency. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Currently sub and non- acute patient (SNAP) details are collected only for those patients in designated SNAP units. The scope of this collection includes all admitted patient episodes where the patient's episode type is not acute, newborn, boarder, organ procurement or other care, and the ward (either at admission to the episode or through a ward transfer during the episode) is assigned to a designated SNAP unit. A new item, standard ward code, is to be assigned a value of 'SNAP' for those wards which are assigned to a designated SNAP unit. Patients should have SNAP details reported for each sub and non-acute care type (SNAP episode) within an episode of care. Data type: Numeric character Representational form: CODE Representation layout: N(3) Minimum Size: 3 Maximum Size: 3 Data Domain: 101 Stable, RUG 4 102 Stable, RUG 5-17 103 Stable, RUG 18 104 Unstable, RUG 4-17 105 Unstable, RUG 18 106 Deteriorating, RUG 4-17 107 Deteriorating, RUG 18, age <=71 108 Deteriorating, RUG 18, age >=72 109 Terminal, RUG 4-16 110 Terminal, RUG 17-18 111 Bereavement 201 Admit for assessment only 202 Brain, Neuro, Spine and MMT, FIM 13 203 All other impairments, FIM 13 204 Stroke and Burns, motor 63-91, cognition 20-35 205 Stroke and Burns, motor 63-91, cognition 5-19 206 Stroke and Burns, motor 47-62

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SNAP group classification 207 Stroke and Burns, motor 14-46, age >=75 208 Stroke and Burns, motor 14-46, age <=74 209 Brain Dysfunction, motor 71-91 210 Brain Dysfunction, motor 29-70, age >=55 211 Brain Dysfunction, motor 29-70, age <=54 212 Brain Dysfunction, motor 14-28 213 Neurological, motor 74-91 214 Neurological, motor 41-73 215 Neurological, motor 14-40 216 Spinal Cord Dysfunction, motor 81-91 217 Spinal Cord Dysfunction, motor 47-80 218 Spinal Cord Dysfunction, motor 14-46 219 Amputation of limb, motor 66-91 220 Amputation of limb, motor 47-65 221 Amputation of limb, motor 14-46 222 Pain Syndromes 223 Orthopaedic conditions, motor 74-91 224 Orthopaedic conditions, motor 58-73 225 Orthopaedic conditions, motor 52-57 226 Orthopaedic conditions, motor 14-51 227 Cardiac 228 Major Multiple Trauma 229 All other impairments, motor 67-91 230 All other impairments, motor 53-66 231 All other impairments, motor 25-52 232 All other impairments, motor 14-24 251 Brain, MMT & Pulmonary 252 Burns, Cardiac, Pain, Spine, & Neuro 253 All other impairments 301 HoNOS Overactive behaviour 4, 5 302 HoNOS Overactive behaviour 2, 3, ADL 5 303 HoNOS Overactive behaviour 2, 3, ADL 1-4 304 HoNOS Overactive behaviour 1, HoNOS total >=30 305 HoNOS Overactive behaviour 1, HoNOS total <=29 306 Long term care 401 Cognition <=15, motor 13-43 402 Cognition <=15, motor 44-91, age >=84 403 Cognition <=15, motor 44-91, age <=83 404 Cognition 16-35, motor 13-50 405 Cognition, 16-35, motor 51-77 406 Cognition 16-35, motor 78-91 451 Assessment only 454 All Someday 501 Respite, RUG 15-18 502 Respite, RUG 5-14

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SNAP group classification 503 Respite, RUG 4 504 Nursing Home Type, RUG 11-18 505 Nursing Home Type, RUG 4-10 506 Convalescent care 507 Other Maintenance, RUG 14-18 508 Other Maintenance, RUG 4-13 509 Long term care, RUG 17-18 510 Long term care, RUG 10-16 511 Long term care, RUG 4-9 Guide for Use: Verification Rules: Related Data References: is used in conjunction with SNAP care type, QHLTH 040599 version 1 Source Document: Source Organisation: Comment:

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Social issue potentially related to alcohol and/or other drug usage

Data Element ID: 040876 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: Social issue of significance that in the clinician's opinion is potentially related to and/or influenced by alcohol and/or drug use. Context: QMDS - AODTS Data type: Numeric character Representational form: CODE Representation layout: NN Minimum Size: 2 Maximum Size: 2 Data Domain: 01 Relationship issues 02 Legal issues - Child protection 03 Legal issues - Other 04 Employment issues 05 Financial issues 06 Accommodation issues - Homelessness 07 Accommodation issues - Other 98 Other 99 Not stated / Inadequately described Guide for Use: Multiple domain items may be recorded as required. Code 01 refers to relationship and interpersonal problems currently being experienced by a client in their social interactions with others, for example, a spouse, partner, parents, colleagues or peers. Code 02 refers to clients who present with child protection issues. Code 03 refers to any current forensic or legal problems, excluding child protection issues. Code 04 refers to work-related difficulties including workplace accidents, absenteeism and difficulties finding or maintaining employment. Code 05 refers to financial difficulties being experienced. Code 06 refers to clients who are currently without sheltered accommodation, for example, those who live on the street or in a park. Code 07 refers to difficulties with accommodation excluding homelessness. Examples of accommodation problems include temporarily boarding or staying with others, being unable to pay rent on time, etc. If the client is currently without sheltered accommodation, then code 9 `homelessness' should be recorded as well. Verification Rules: Related Data References: Source Document: Source Organisation: Comment:

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Source of referral

Data Element ID: 040010 Version number: 5 Type: DATA ELEMENT Status: CURRENT 01/07/2003 Definition: Source of referral / transfer for the statistical or formal admission. The referral point of the patient immediately before admission. Context: Institutional health care. Data type: Numeric character Representational form: CODE Representation layout: N(2) Minimum Size: 2 Maximum Size: 2 Data Domain: 01 private medical practitioner (not psychiatrist) 02 emergency department - this hospital 03 outpatient department - this hospital 06 episode change 09 born in facility 14 other health care establishment 15 private psychiatrist 16 correctional facility 17 law enforcement agency 18 community service 19 routine readmission not requiring referral 20 organ procurement 21 boarder 23 residential aged care service 24 Admitted patient transferred from another hospital 25 Non-Admitted patient referred from another hospital 29 other Guide for Use: Verification Rules: Related Data References: is used in conjunction with Facility transferred from, QHLTH 040116 version 4 supersedes previous data element Source of referral, QHLTH 040010 version 4 Source Document: Source Organisation: Comment:

267

Standard unit code

Data Element ID: 040166 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Standard unit code to describe the treating doctor specialty/unit. Context: Institutional health care Data type: Character Representational form: CODE Representation layout: A(4) Minimum Size: 4 Maximum Size: 4 Data Domain: Corporate reference file as listed in Appendix K of the current QHAPDC Manual. Guide for Use: Standard unit codes in the range PYAA to PYZZ can only be used by facilities with designated psychiatric units. Verification Rules: Related Data References: is derived from Hospital unit, QHLTH 040170 version 1 Source Document: Source Organisation: Comment:

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Standard ward code

Data Element ID: 040608 Version number: 1 Type: DATA ELEMENT Status: CURRENT 01/07/1999 Definition: Denotes whether the ward the patient was admitted to is assigned as a Designated SNAP (Sub and Non-Acute Patient) Unit. Context: The Australian National Sub and Non-Acute Patient (AN-SNAP) Classification System is being implemented in Queensland public hospitals to better inform service planning, purchasing, and clinical management. Data type: Character Representational form: CODE Representation layout: A(4) Minimum Size: 4 Maximum Size: 4 Data Domain: SNAP Designated SNAP Unit Guide for Use: Verification Rules: Related Data References: is mapped from Ward, QHLTH 040169 version 1 Source Document: Source Organisation: Comment:

269

State of usual residence

Data Element ID: 040078 Version number: 2 Type: DATA ELEMENT Status: CURRENT 01/07/2002 Definition: State of usual residence Context: Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 0 Overseas 1 New South Wales 2 Victoria 3 Queensland 4 South Australia 5 Western Australia 6 Tasmania 7 Northern Territory 8 Australian Capital Territory 9 not stated / unknown / no fixed address / at sea Guide for Use: Allocate Australian External Territories their actual state code, not an overseas state code. Australian External Territories include the following: Christmas Island (Australia), Cocos (Keeling) Islands, Norfolk Island. Verification Rules: Related Data References: is used in conjunction with Postcode of usual residence, QHLTH 040081 version 4 Source Document: Source Organisation: Comment: Must be used with other items to distinguish between categories such as "overseas" and "at sea". Do not rely on the postcode as there are some Queensland postcodes for patients who live over the border in other States such as New South Wales. The Statistical Standards Unit maintains a corporately standardised file of suburbs, postcodes, states and associated Statistical Local Areas. The content of this locality data set is derived from two main sources, the ABS and Australia Post, with supplementary data supplied by Queensland Health. The Australian Bureau of Statistics provides annual releases on 1 July each year of the NLI, Street Sub- Index and ASGC data. Quarterly updates are now also received and loaded into CRDS. Australia Post data is downloaded from their website at the same time as the ABS updates are received for synchronisation of data. Ad hoc additions are made to the locality data set as advised by the source organisations. The most up-to-date locality file and associated documentation are available from the Corporate

270

State of usual residence Reference Data System (CRDS). The file can be browsed at: http://qheps.health.qld.gov.au/masters/crds.htm or can be downloaded by contacting the CRDS Project Officers, Statistical Standards Unit, on: Ph: (07) 3235 9451 or via email: crds@health.qld.gov.au.

271

Statistical Local Area (SLA)

Data Element ID: 040082 Version number: 6 Type: DERIVED DATA ELEMENT Status: CURRENT 01/07/1998 Definition: Statistical local area of usual residence. Context: Used with other elements to determine the Statistical Local Area (SLA) of usual residence. This enables: - comparison of the use of services by persons residing in different geographical areas, - characterisation of catchment areas and populations for facilities for planning purposes, and - documentation of the provision of services to residents of States or Territories other than Queensland. Data type: Numeric character Representational form: CODE Representation layout: N(4) Minimum Size: 4 Maximum Size: 4 Data Domain: Valid SLA codes for Queensland as defined by the Australian Bureau of Statistics plus the supplementary codes as described below. Guide for Use: Verification Rules: Related Data References: is used in conjunction with Address of usual residence, QHLTH 040079 version 1 is used in conjunction with Postcode of usual residence, QHLTH 040081 version 4 is used in conjunction with State of usual residence, QHLTH 040078 version 2 is used in conjunction with Suburb/town/locality of usual residence, QHLTH 040080 version 2 supersedes previous data element Statistical Local Area (SLA), QHLTH 040082 version 5 Source Document: Source Organisation: Comment: The Statistical Standards Unit maintains a corporately standardised file of suburbs, postcodes, states and associated Statistical Local Areas. The content of this locality data set is derived from two main sources, the ABS and Australia Post, with supplementary data supplied by Queensland Health. The Australian Bureau of Statistics provides annual releases on 1 July each year of the NLI, Street Sub- Index and ASGC data. Quarterly updates are now also received and loaded into CRDS. Australia Post data is downloaded from their website at the same time as the ABS updates are received for synchronisation of data. Ad hoc additions are made to the locality data set as advised by the source organisations. The most up-to-date locality file and associated documentation are available from the Corporate Reference Data System (CRDS). The file can be browsed at: http://qheps.health.qld.gov.au/masters/crds.htm or can be downloaded by contacting the CRDS Project Officers, Statistical Standards Unit, on: Ph: (07) 3235 9451 or via email: crds@health.qld.gov.au.

272

Suburb/town/locality of usual residence

Data Element ID: 040080 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Name of suburb/town/locality of usual residence. Context: Used with other elements to determine the Statistical Local Area (SLA) of usual residence. This enables: - comparison of the use of services by persons residing in different geographical areas, - characterisation of catchment areas and populations for facilities for planning purposes, and - documentation of the provision of services to residents of States or Territories other than Queensland. Data type: Character Representational form: TEXT Representation layout: A(50) Minimum Size: 1 Maximum Size: 50 Data Domain: Guide for Use: The usual residential address is the place where the patient lives. For example, it is not the address where the patient might be staying temporarily before or after the period of hospitalisation. Verification Rules: Related Data References: is used in conjunction with Address of usual residence, QHLTH 040079 version 1 is used in conjunction with Postcode of usual residence, QHLTH 040081 version 4 is used in conjunction with State of usual residence, QHLTH 040078 version 2 is used in conjunction with Statistical Local Area (SLA), QHLTH 040082 version 6 Source Document: Source Organisation: Comment: The Statistical Standards Unit maintains a corporately standardised file of suburbs, postcodes, states and associated Statistical Local Areas. The content of this locality data set is derived from two main sources, the ABS and Australia Post, with supplementary data supplied by Queensland Health. The Australian Bureau of Statistics provides annual releases on 1 July each year of the NLI, Street Sub- Index and ASGC data. Quarterly updates are now also received and loaded into CRDS. Australia Post data is downloaded from their website at the same time as the ABS updates are received for synchronisation of data. Ad hoc additions are made to the locality data set as advised by the source organisations. The most up-to-date locality file and associated documentation are available from the Corporate Reference Data System (CRDS). The file can be browsed at: http://qheps.health.qld.gov.au/masters/crds.htm or can be downloaded by contacting the CRDS Project Officers, Statistical Standards Unit, on: Ph: (07) 3235 9451 or via email: crds@health.qld.gov.au.

273

Surname

Data Element ID: 040002 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Surname of person. Context: Institutional health care Data type: Character Representational form: TEXT Representation layout: A(50) Minimum Size: 1 Maximum Size: 50 Data Domain: Left justified character string Guide for Use: Verification Rules: Related Data References: is used in conjunction with First name, QHLTH 040003 version 1 is used in conjunction with Second name, QHLTH 040004 version 1 relates to the data element Family name, QHLTH 040002 version 2 Source Document: Source Organisation: Comment:

274

Time of starting leave

Data Element ID: 040122 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Time the patient went on leave. Context: Institutional health care Data type: Numeric character Representational form: TIME Representation layout: hhmm Minimum Size: 4 Maximum Size: 4 Data Domain: Valid times in 24 hour format, range 0000 to 2359 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Date of starting leave, QHLTH 040121 version 1 relates to the data terminology item Leave, QHLTH 040132 version 1 Source Document: Source Organisation: Comment:

275

Time of transfer (ward)

Data Element ID: 040126 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Time at which a patient is transferred. Context: Institutional health care Data type: Numeric character Representational form: TIME Representation layout: hhmm Minimum Size: 4 Maximum Size: 4 Data Domain: Valid times in 24 hour format, range 0000 to 2359 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Date of transfer (ward), QHLTH 040125 version 1 Source Document: Source Organisation: Comment: A ward/unit transfer is recorded every time the patient moves from one ward or unit to another, within the same hospital.

276

Time returned from leave

Data Element ID: 040123 Version number: 2 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Time the patient returned from leave. Context: Institutional health care Data type: Numeric character Representational form: TIME Representation layout: hhmm Minimum Size: 4 Maximum Size: 4 Data Domain: Valid times in 24 hour format, range 0000 to 2359 Guide for Use: Verification Rules: Related Data References: is used in conjunction with Date returned from leave, QHLTH 040124 version 1 relates to the data terminology item Leave, QHLTH 040132 version 1 Source Document: Source Organisation: Comment:

277

Total waiting time

Data Element ID: QHLTH 040091 Version Number: 1 Type: DERIVED DATA ELEMENT Status: LEGACY SUPERSEDED

15/01/1998 27/02/2007 Definition: Total days on waiting list, excluding days not ready for care. Calculated from actual admission date minus date placed on list minus days not ready for care. Context: Elective admission/Waiting list Datatype: Integer Representational Form: QUANTITATIVE VALUE Representation Layout: N(4) Minimum Size: 1 Maximum Size: 4 Data Domain: Positive integers in range 0 - 9999 Guide for Use: Verification Rules: Related Data References: is calculated using Admission date - episode QHLTH 040008 version 1 has been superseded by Elective surgery waiting time (at census date) QHLTH 040962 version 1 is calculated using Listing date on waiting list QHLTH 040359 version 1 Source Document: Source Organisation: Comment: Between 1/7/97 and 30/6/98 this item was supplied by HBCIS. From 1/7/98 this item is derived in QHAPDC.

278

Treatment delivery setting for alcohol and other drugs

Data Element ID: 040871 Version number: 1 Type: DATA ELEMENT Status: CURRENT 20/12/2007 Definition: The setting in which the main treatment is provided. Context: Alcohol and other drug treatment services. Required to identify the settings in which treatment is occurring, allowing for trends in treatment patterns to be monitored. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 Non-residential alcohol and other drugs treatment facility 2 Residential alcohol and other drugs treatment facility 3 Home 4 Outreach - correctional setting 5 Outreach - hospital setting 6 Outreach - watch-house setting 7 Outreach - Other setting 8 Other setting Guide for Use: Observe verification rules For settings identified by the codes ranging from 1 to 7 the delivered treatment provided must be in person. Code 1 refers to any non-residential centre that provides alcohol and other drug treatment services, including hospital outpatient services and community health centres. Code 2 refers to community-based settings in which clients reside either temporarily or long-term in a facility that is not their home or usual place of residence to receive alcohol and other drug treatment. This does not include ambulatory situations but includes therapeutic community settings. Code 3 refers to the client's own home or usual place of residence. This includes residential aged care facility/nursing home and hostel. Code 4 refers to an outreach episode where treatment is provided to a client in a correctional facility. Code 5 refers to an outreach episode where treatment is provided to a client in a hospital setting. Code 6 refers to an outreach episode where treatment is provided to a client in a watch-house setting. Code 7 refers to an outreach episode where treatment is provided to a client in an Other Outreach setting.

279

Treatment delivery setting for alcohol and other drugs Code 8 refers to a treatment provided not in person.

Verification Rules: For settings identified by the domain value codes ranging from 1 to 7 the ` Service activity delivery mode' domain value must be 1 - `In Person'. For settings identified by the domain value code 8 `Other setting', the data element `Service activity delivery mode' domain value must be 2, 3 or 4. Related Data References: relates to the data element Main treatment type for alcohol and other drugs, QHLTH 040867 version 1 Source Document: Source Organisation: Comment:

280

Type of non-admitted patient care

Data Element ID: 040760 Version Number: 1 Type: CROSS-CLASSIFICATORY Status: CURRENT SUPERSEDED

15/01/1998 30/06/2000 Definition: This classification identifies types of services provided to non-admitted patients in different institutional ways in different systems. Definitions for each category are as follows: Emergency departments and emergency services C3.1 emergency services Services to patients who are not admitted and who receive treatment that was either unplanned or carried out in designated emergency departments within a hospital. Unplanned patients are patients who have not been booked into the hospital before receiving treatment. In general it would be expected that most patients would receive surgical or medical treatment. However, where patients receive other types of treatment that are provided in emergency departments these are to be included. The exceptions are for dialysis and endoscopy and related procedures which have been recommended for separate counting. Used to describe what happens to patients after leaving the emergency department, under the broad categories of admitted/transferred, died, and discharged. Admitted patients that are those admitted to the hospital directly from the emergency department, including those admitted as same day patients. Transferred patients are those sent from the emergency department to any other acute facility. Died. The patient was dead on arrival at the emergency department, or died whilst still considered to be under the care of the emergency department. Discharged patients are those discharged from the emergency department to home, or to another facility or residence, other than an acute facility. The triage grading of 1 to 5 is based on the national triage scale, where: 1 = resuscitation (immediate); 2 = emergency (within 10 minutes); 3 = urgent (half an hour); 4 = semi-urgent (one hour); 5 = non-urgent (two hours). For the purposes of activity reporting smaller hospitals need to only provide a count of emergency services. Outpatient services C3.2 dialysis

This represents all non-admitted patients receiving dialysis within the facility. Where a non-admitted patient receives dialysis treatment in a ward or clinic classified elsewhere, for example accident and emergency, those patients are to be counted as dialysis patients and excluded from the other category. All forms of dialysis which are undertaken as a treatment necessary for renal failure are to be included. Note, however that facilities would usually admit these patients, as they meet

281

Type of non-admitted patient care

the minimum criteria for admission. If a patient has been admitted for dialysis treatment, they are not in the scope of this service.

C3.3 pathology This includes all occasions of service to non-admitted patients from designated pathology laboratories. Each diagnostic test, or set of diagnostic tests, for the one patient referred to a pathology laboratory constitutes one occasion of service. C3.4 radiology and organ imaging This includes all occasions of service to non-admitted undertaken in radiology (x-ray) departments, as well as in specialised organ imaging clinics carrying out ultrasound, computerised tomography (CT) and magnetic resonance imaging. Each diagnostic test, or simultaneous set of related of diagnostic tests, for the one patient to a radiology department constitutes one occasion of service. C3.5 endoscopy and related procedures Includes all services non-admitted patients for endoscopy including cytoscopy, gastroscopy, oesophagoscopy, duodenoscopy, colonoscopy, bronchoscopy and laryngoscopy. Where one of these procedures is carried out in a ward or clinic classified elsewhere, for example in Accident and Emergency, the occasion is to be reported under Endoscopy related procedures and be excluded from the other category. Note that facilities would usually admit patients for endoscopy and related procedures, as they meet the minimum criteria. If patients have been admitted they should not be categorised under this data item. C3.6 other medical/surgical/diagnostic Any occasion of service to a non-admitted patient given at a designated unit primarily responsible for the provision of medical/surgical or diagnostic services which have not been reported under dialysis, pathology, radiology and organ imaging or endoscopy and related procedures. Includes ECG, obstetrics, nuclear medicine, general medicine, general surgery, fertility and so on. C3.7 mental health All occasions of service to non-admitted patients attending designated psychiatric or mental health units within hospitals that are operated and managed by the hospital. C3.8 drug and alcohol All occasions of service to non-admitted patients attending designated drug and alcohol units within the facility. C3.9 dental All occasions of service to non-admitted patients attending designated dental units within the facility, that are operated and managed by the facility. C3.10 pharmacy All occasions of service to non-admitted patients from pharmacy departments. Drugs dispensed/administered in other departments such as Accident and Emergency or Outpatient departments, are to be recorded as occasions of service by the respective departments. C3.11 allied health procedures All occasions of service to non-admitted patients where services are provided at units or clinics providing treatment or counselling to the patients. These include units primarily concerned with physiotherapy, speech therapy, family planning, dietary advice, optometry, occupational therapy and so on.

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Type of non-admitted patient care Other non-admitted services C3.12 community health services Occasions of service to non-admitted patients/clients provided by designated community health units funded from the facility's operating expenditure, that are operated and managed by the facility. Community health units include baby clinics, immunisation units and aged care assessment teams. It is intended that all community health services funded through the facility be reported, regardless of where the services are provided. C3.13 district nursing services Occasions of service to non-admitted patients which: - are for medical/surgical/psychiatric care - are provided by a nurse, paramedic or medical officer - involve travel by the service provider - are not provided by staff from a defined community health service.

Travel does not include movement within a facility, movement between sites in a multiple-campus facility, or between facilities. Such cases should be classified under the appropriate non-admitted patient category.

C3.14 other outreach services

Occasions of service to non-admitted patients/clients which involve travel by the service provider, and are not classified as community health services or allied health services. Travel does not include movement within a facility, movement between sites in a multicampus facility, or between facilities.

It is intended that the Other Outreach Services classification exclude medical, surgical, or psychiatric services. These should be reported under District Nursing Services. Other Outreach Services include activities such as home cleaning, meals on wheels and home maintenance.

Context: Reporting of activity data from health facilities. Required to describe the broad types of services provided to non-admitted patients, community patients and outreach clients. Datatype: Representational Form: Representation Layout: Minimum Size: Maximum Size: Data Domain: Guide for Use: Verification Rules: Related Data References: is used in conjunction with Compensable/eligibility status for non-admitted patients QHLTH 040759 version 1 has been superseded by Type of non-admitted patient care QHLTH 040094 version 2 Source Document: Source Organisation: Comment:

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Type of non-admitted patient care

Data Element ID: 040094 Version Number: 2 Type: CROSS-CLASSIFICATORY Status: CURRENT

01/07/2000 Definition: This classification identifies types of services provided to non-admitted patients in different institutional ways in different systems. Definitions for each category are as follows: Emergency departments and emergency services C3.1 emergency services Services to patients who are not admitted and who receive treatment that was either unplanned or carried out in designated emergency departments within a hospital. Unplanned patients are patients who have not been booked into the hospital before receiving treatment. In general it would be expected that most patients would receive surgical or medical treatment. However, where patients receive other types of treatment that are provided in emergency departments these are to be included. The exceptions are for dialysis and endoscopy and related procedures which have been recommended for separate counting. Used to describe what happens to patients after leaving the emergency department, under the broad categories of admitted/transferred, died, and discharged. Admitted patients that are those admitted to the hospital directly from the emergency department, including those admitted as same day patients. Transferred patients are those sent from the emergency department to any other acute facility. Died. The patient was dead on arrival at the emergency department, or died whilst still considered to be under the care of the emergency department. Discharged patients are those discharged from the emergency department to home, or to another facility or residence, other than an acute facility. The triage grading of 1 to 5 is based on the national triage scale, where: 1 = resuscitation (immediate); 2 = emergency (within 10 minutes); 3 = urgent (half an hour); 4 = semi-urgent (one hour); 5 = non-urgent (two hours). For the purposes of activity reporting smaller hospitals need to only provide a count of emergency services. Outpatient services C3.2 dialysis Refers to all non-admitted patients receiving dialysis related treatment (but not actual dialysis) within the facility. Non-admitted occasions of service include all patients who present for injections, dressings, treatment of infections, or blood and other biochemical checks. When presenting for dialysis treatment, patients should be admitted as a day procedure.

284

Type of non-admitted patient care

C3.3 pathology This includes all occasions of service to non-admitted patients from designated pathology laboratories. Each diagnostic test, or set of diagnostic tests, for the one patient referred to a pathology laboratory constitutes one occasion of service. For example, if two blood samples and a urine sample are taken from a single patient so that two separate sets of blood tests can be done (a set on each blood sample) and a single set of urine testes can be done, this should be counted as 3 occasions of service rather than one.

C3.4 radiology and organ imaging This includes all occasions of service to non-admitted undertaken in radiology (x-ray) departments, as well as in specialised organ imaging clinics carrying out ultrasound, computerised tomography (CT) and magnetic resonance imaging. Each diagnostic test, or simultaneous set of related of diagnostic tests, for the one patient to a radiology department constitutes one occasion of service. C3.5 endoscopy and related procedures Includes all services non-admitted patients for endoscopy including cytoscopy, gastroscopy, oesophagoscopy, duodenoscopy, colonoscopy, bronchoscopy and laryngoscopy. Where one of these procedures is carried out in a ward or clinic classified elsewhere, for example in Accident and Emergency, the occasion is to be reported under Endoscopy related procedures and be excluded from the other category. Note that facilities would usually admit patients for endoscopy and related procedures, as they meet the minimum criteria. If patients have been admitted they should not be categorised under this data item. C3.6 other medical/surgical/diagnostic Any occasion of service to a non-admitted patient given at a designated unit primarily responsible for the provision of medical/surgical or diagnostic services which have not been reported under dialysis, pathology, radiology and organ imaging or endoscopy and related procedures. Includes ECG, obstetrics, nuclear medicine, general medicine, general surgery, fertility and so on. C3.7 mental health All occasions of service to non-admitted patients attending designated psychiatric or mental health units within hospitals that are operated and managed by the hospital. C3.8 drug and alcohol All occasions of service to non-admitted patients attending designated drug and alcohol units within the facility. C3.9 dental All occasions of service to non-admitted patients attending designated dental units within the facility, that are operated and managed by the facility. C3.10 pharmacy All occasions of service to non-admitted patients from pharmacy departments. Drugs dispensed/administered in other departments such as Accident and Emergency or Outpatient departments, are to be recorded as occasions of service by the respective departments. C3.11 allied health procedures All occasions of service to non-admitted patients where services are provided at units or clinics providing treatment or counselling to the patients. These include units primarily concerned with physiotherapy, speech therapy, family planning, dietary advice, optometry, occupational therapy and so on.

285

Type of non-admitted patient care Other non-admitted services C3.12 community health services Occasions of service to non-admitted patients/clients provided by designated community health units funded from the facility's operating expenditure, that are operated and managed by the facility. Community health units include baby clinics, immunisation units and aged care assessment teams. It is intended that all community health services funded through the facility be reported, regardless of where the services are provided. C3.13 district nursing services Occasions of service to non-admitted patients which: - are for medical/surgical/psychiatric care - are provided by a nurse, paramedic or medical officer - involve travel by the service provider - are not provided by staff from a defined community health service.

Travel does not include movement within a facility, movement between sites in a multiple-campus facility, or between facilities. Such cases should be classified under the appropriate non-admitted patient category.

C3.14 other outreach services

Occasions of service to non-admitted patients/clients which involve travel by the service provider, and are not classified as community health services or allied health services. Travel does not include movement within a facility, movement between sites in a multicampus facility, or between facilities.

It is intended that the Other Outreach Services classification exclude medical, surgical, or psychiatric services. These should be reported under District Nursing Services. Other Outreach Services include activities such as home cleaning, meals on wheels and home maintenance. C3.15 Home dialysis patients Home dialysis patients refers to the non-admitted patients who perform their own dialysis at home. This item is not reported as occasions of service, but as a count of patients. It is a count of patients for whom the facility pays the costs associated with the dialysis fluid, nursing products and ancillaries which are delivered directly to the patients' homes to enable home dialysis. Four categories of dialysis are collected separately: - home haemodialysis - Home CAPD/Automated Peritoneal Dialysis - Home intermittent Peritoneal Dialysis - Self-care haemodialysis Not all facilities incur these expenditures. For those facilities that do, that most frequently used modalities for dialysis at home are haemodialysis and Continuous Ambulatory Peritoneal Dialysis (CAPD). Care should be taken to ensure correct recording of this information against the appropriate dialysis modality. A self-care haemodialysis unit provides a venue for medically stable haemodialysis patients, who with the support of a trained dialysis carer, are independent in the dialysis procedure.

Context: Reporting of activity data from health facilities. Required to describe the broad types of services provided to non-admitted patients, community patients and outreach clients. Datatype: Representational Form: Representation Layout: Minimum Size: Maximum Size: Data Domain: Guide for Use:

286

Type of non-admitted patient care Verification Rules: Related Data References: is used in conjunction with Compensable/eligibility status for non-admitted patients QHLTH 040759 version 1 is equivalent to Type of non-admitted patient care NHIMG 000231 version 1 supersedes previous data element Type of non-admitted patient care QHLTH 040760 version 1 Source Document: Source Organisation: Comment:

287

Type of usual accommodation

Data Element ID: 040027 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: The type of physical accommodation the patient lived in prior to admission. Context: Psychiatric hospitals and patients in designated psychiatric units of acute hospitals. Data type: Numeric character Representational form: CODE Representation layout: N Minimum Size: 1 Maximum Size: 1 Data Domain: 1 house or flat 2 independent unit as part of retirement village or similar 3 hostel or hostel type accommodation 4 psychiatric hospital 5 acute hospital 7 other accommodation 8 no usual residence 9 not stated/unknown Guide for Use: Verification Rules: Related Data References: Source Document: Source Organisation: Comment: The patients view/beliefs, not based on any amount of time spent in that accommodation.

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Ward

Data Element ID: 040169 Version number: 1 Type: DATA ELEMENT Status: CURRENT 15/01/1998 Definition: Ward that patient was admitted or transferred to. Context: Institutional health care Data type: Character Representational form: CODE Representation layout: A(6) Minimum Size: 1 Maximum Size: 6 Data Domain: Site specific codes Guide for Use: Verification Rules: Related Data References: is related but not equivalent to Standard ward code, QHLTH 040608 version 1 Source Document: Source Organisation: Comment: