Information Requirements from 1st June 2023 Onwards

Information Requirements from 1^st June 2023 Onwards

Note: The purpose of mandating the dataset is not to direct sexual history taking but to record activity in the clinic. Sexual history taking is down to the discretion of the clinician in line with existing clinical practice guidance.

The Reference IDs in the previous table have been removed as these were not used as part of the Standard or implementation.

The code UNK – Unknown is the least detailed of all the ‘null’ values and simply means that the information is not known or wasn’t recorded. The reason a piece of information is not recorded, or provided, is beneficial to understanding information collection, consequently it is important to select one of the more detailed ‘null’ values where possible e.g. ASKX – Asked but declined should be used where the patient was asked for the information but declined to answer, ASKU – Asked but unknown should be used where the patient was asked for the information but was unsure how to respond or didn’t know, NASK - Not Asked should be used where the patient was not asked for the information.

For Activity Code, please refer to the Data Standards Wales – Sexual Health list at https://nhswales365.sharepoint.com/sites/DHC_WRD/SitePages/Content-Request-Forms.aspx. If the Activity Code is not listed, contact Public Health Wales (PHW) at PHW.sexualhealthsurveillance@wales.nhs.uk to request an addition. If approved, Public Health Wales will then contact Digital Health and Care Wales (DHCW) Welsh Reference Data and Terminology Service (WRTS) to update the Activity Code list.

Data Item	Definition	Business Rule	Type	Format	Status	Code List (Code)	Code List (Text)
Service Details
Service Name	Unique service name in Wales (i.e. WEL Codes)	N/A	String	an6	M	N/A	N/A
Patient Details
Patient ID	Service's unique patient code	N/A	String	an30	M	N/A	N/A
NHS Number	The NHS Number for the patient	N/A	String	n10	O	N/A	N/A
Gender Identity	Gender identity of patient as stated by the patient. Male includes trans man Female includes trans woman Non-binary denotes the gender of a person who does not identify as Male or Female	N/A	Code List	a1	M	M F N O* Z	Male Female Non-binary In another way Not disclosed or unknown
Gender Identity Same at Birth	The person's gender identity is the same as their gender assigned at birth	N/A	Code List	an4	M	Y N ASKX UNK	Yes No Asked but declined Unknown
Country of Birth	Patient’s country of birth as stated by the patient ISO 3166-1 3 character. 2-character codes MUST NOT be used	N/A	Code List	an4	M	ASKU ASKX NASK UNK	Asked but unknown Asked but declined Not asked Unknown
Ethnicity	Ethnicity as stated by the patient	N/A	Code List	an2	M	Q* U* B V* W* D E F G H J K R L M N P T S Z 99	English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Roma Any other White background White and Black Caribbean White and Black African White and Asian Any other mixed background/multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background Caribbean African Any other Black background Arab Any other ethnic group Not stated Not known
Date of Birth	The patient’s date of birth	Enables the generation of the patient’s age at the Date of Interaction.	Date	max an10 ISO8601 date and time format	M	N/A	N/A
Interaction Details
Date of Interaction	Date the patient attends their appointment with the service or the date they attended on, in their home or other location.	N/A	Date	max an10 ISO8601 date and time format	M	N/A	N/A
Initial Contact	Indicates whether this is the patient’s first ever contact with the service.	Any subsequent visits (regardless of time gap) should be coded as No.	Code List	an4	M	Y N UNK	Yes No Unknown
Postcode of Residence	Postcode of patient residence. The postcode of service should not be entered where a patient’s postcode is not known. These should be 8-digit alphanumeric codes. The specific code format as specified by the Office of National statistics (ONS) is: • 2, 3 or 4-character outward code (i.e., first half of the postcode, before the space) – left aligned; • 3-character inward code (i.e., second half of the postcode after the space(s)) – right aligned; • 5th character always blank and • 3rd and 4th characters may be blank (Δ) This allows a space to be inserted to differentiate between the inward and outward segments of the code, enabling full use to be made of the Royal Mail postcode functionality. There are occasions when the use of a 'pseudo code' is necessary, particularly when dealing with an overseas address. Full details of pseudo country codes and other codes may be obtained from the Office of National Statistics website. Some of the more common pseudo codes are: ZZ99 3VZ No fixed abode ZZ99 3CZ England/UK not otherwise specified ZZ99 3GZ Wales not otherwise specified ZZ99 1WZ Scotland not otherwise specified ZZ99 2WZ Northern Ireland not otherwise specified UK Postcodes are available via the Welsh Reference Data Service (WRDS): http://wrds.wales.nhs.uk/ (NHS Wales Users Only)	This will be used to derive Lower layer Super Output area (LSOA), Middle layer Super Output Area (MSOA), Local Authority, and Local Health Board of residence.	String	an8	M	ZZ99 3VZ ZZ99 3CZ ZZ99 3GZ ZZ99 1WZ ZZ99 2WZ	No fixed abode England/UK not otherwise specified Wales not otherwise specified Scotland not otherwise specified Northern Ireland not otherwise specified
GP Practice Code	Code of the GP Practice the patient is registered with. This is the code issued by the Department of Health for practising GPs in Wales and England. Where the GP Practice is not known, record one of the following: V81997 No Registered GP Practice (a patient presents, who is not currently registered at a GP Practice, but is eligible to be registered should they wish to) V81998 Practice Not applicable (where a patient should not have a registered GP Practice, due for instance to them having only recently entered the country) (e.g.: MOD or prison practice, overseas patient) V81999 Practice Code is Unknown (where it is not possible to determine a patient’s registered GP Practice code, but it is known that they should have one, or where it is impossible to determine whether they should or shouldn't have a registered practice (for instance the patient cannot communicate and is unidentifiable).	This data item is system generated from the patient’s GP details recorded at registration.	String	an7	M	V81997 V81998 V81999	No Registered GP Practice Practice Not applicable Practice Code is Unknown
Interaction Sexuality	Patient's sexuality at the time of the interaction. The default should be set as Not known/not recorded but it is important to record specific and accurate information whenever possible. Sexual orientation should be collected for both males and females (see BASHH National Guidelines for Sexual History Taking at http://www.bashh.org/documents/Sexual History Taking guideline 2013.pdf) Note: Users are expected to replace the Not Known/not recorded default with a specific value.	N/A	Code List	an4	M	1 2 3 OTH ASKU ASKX UNK	Heterosexual Gay/Lesbian Bisexual Other (sexual orientation not listed) Asked but unknown Asked but declined Unknown
Number of Sexual Partners (last 3 months)	Number of sexual partners in the last 3 months (including oral sex). Record the actual number or one of the codes listed where the information is not known	N/A	String & Code List	an4	M	ASKU ASKX	Asked but unknown Asked but declined
Use of Condoms (last 3 months)	Use of condoms in the last 3 months.	N/A	Code List	an4	M	1 2 3 0 ASKX NASK UNK	Always Most times Sometimes Never Asked but declined Not asked Unknown
Sex Abroad (last 3 months)	Whether patient had sex abroad, with casual non-British partner encountered abroad, in the last 3 months	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
IDU (last 3 months)	Has patient injected drugs in the last 3 months	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
App/Internet Use to Meet Partners (last 3 months)	App/Internet use to meet sexual partners in the last 3 months	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
Chem Sex (last 3 months)	Use of recreational drugs before/during sex in the last 3 months	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
Contact with Sex Worker (last 3 months)	Sexual contact with sex worker in the last 3 months (including oral sex).	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
Prisoner	Currently in prison	N/A	Code List	an4	M	Y N NASK UNK	Yes No Not asked Unknown
Sex worker	Currently a sex worker	N/A	Code List	an4	M	Y N ASKX NASK UNK	Yes No Asked but declined Not asked Unknown
Victim of Domestic Violence	Current concern of domestic violence (or abuse)	N/A	Code List	an4	M	Y N NASK UNK	Yes No Not asked Unknown
Sexual Exploitation - Adult	For patients 18 years or over at date of Interaction. Sexual exploitation detected/disclosed	N/A	Code List	an4	M	Y N NASK UNK	Yes No Not asked Unknown
Sexual Exploitation - Child	For patients under 18 years of age at date of Interaction. Sexual exploitation detected/disclosed	N/A	Code List	an4	M	Y N NASK UNK	Yes No Not asked Unknown
Vulnerability	Vulnerability factors detected/disclosed (defined nationally – see https://www.gov.uk/government/publications/vulnerabilities-applying-all-our-health/vulnerabilities-applying-all-our-health)	N/A	Code List	an4	M	Y N NASK UNK	Yes No Not asked Unknown
Patient Management Details
Consultation Medium Used	Identifies the communication mechanism used to relay information between the care professional and the patient. Telephone or online consultation should directly support diagnosis and care planning, must replace a face to face attendance, and be recorded in the patient's records.	Telephone contacts solely for informing patients of results are excluded.	Code List	n1	M	1 2 3	Face to Face Appointment Virtual Clinical Appointment (Patient Contact) – Video Virtual Clinical Appointment (Patient Contact) – Phone
Location Type	The type of location where the patient is seen by the service	N/A	Code List	n2	M	01 02 03 04 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39	Clients or patients home Health Centre Other GMP Premises Ward or NHS Hospital Site Hospice Other Voluntary or Private Hospital or Nursing Home Group Home managed by the NHS Group Home managed by Local Authority Group Home managed by Voluntary or Private Agents Other Residential Care Homes managed by Local Authority Other Residential Care Homes managed by Voluntary or Private Agents NHS Day Care Facility on NHS Hospital Sites NHS Day Care Facility on Other sites Day Centre managed by Local Authority Day Centre managed by Voluntary or Private Agents NHS Consultant Clinic Premises on a NHS Hospital Site NHS Consultant Clinic Premises off a NHS Hospital Site Health Clinic managed by the NHS Health Clinic managed by Voluntary or Private Agents Resource Centre on NHS Hospital Site Resource Centre managed by the NHS off NHS Hospital Site Resource Centre managed by Local Authority Resource Centre managed by Voluntary or Private Agents Professional Staff Group Department on NHS Hospital Site Professional Staff Group Department managed by the NHS off NHS Hospital Site Professional Staff Group Department managed by Local Authority Professional Staff Group Department managed by Voluntary or Private Agents School Premises managed by Local Authority or Grant Maintained School Premises managed by Voluntary or Private Agents Other Health or Local Authority Facility on NHS Hospital Site Other Health or Local Authority Site managed by the NHS off NHS Hospital Site Other Health or Local Authority Site managed by Local Authority Other Health or Local Authority Site managed by Voluntary or Private Agents Prison Department Establishments Public Place or Street, or Police Station Other locations not classified elsewhere NHS Nursing Home Other Residential Care Homes managed by the NHS
Location Type		N/A	Code List	n2	M
Appointment or Drop In	Whether patient made an appointment or attended via a drop-in clinic	Only required where Consultation Medium = 1 (i.e. Face to Face Appointment)	Code List	an4	D	1 2 UNK	Drop in Appointment Unknown
Contact Date	Date and time that patient contacted the service	N/A	Date and Time	max an25 ISO8601 date and time format	M	N/A	N/A
Date of Appointment Offered	Date of the appointment offered to the patient	N/A	Date	max an10 ISO8601 date and time format	M	N/A	N/A
Staff Performing Consultation	The member of staff conducting the consultation	N/A	Code List	an4	M	1 2 3 4 5 OTH UNK	Clinic Doctor Consultant Nurse Health Advisor Pharmacist Other Unknown
Activity Details
Activity Code	Diagnosis and service codes Please refer to the Data Standards Wales – Sexual Health list at https://nhswales365.sharepoint.com/sites/DHC_WRD/SitePages/Content-Request-Forms.aspx If the Activity Code is not listed, contact Public Health Wales (PHW) at PHW.sexualhealthsurveillance@wales.nhs.uk to request an addition. If approved, Public Health Wales will then contact Digital Health and Care Wales (DHCW) Welsh Reference Data and Terminology Service (WRTS) to update the Activity Code list.	N/A	Code List	an20	M	Please refer to the Data Standards Wales – Sexual Health list at https://nhswales365.sharepoint.com/sites/DHC_WRD/SitePages/Content-Request-Forms.aspx
Activity Code - SNOMED CT Concept ID	The equivalent SNOMED CT Concept ID, if known, for the Activity Code	N/A	String	an18	O	N/A	N/A
Activity Code - SNOMED CT Concept Term	The text description for the Activity Code - SNOMED CT Concept ID	N/A	String	an255	O	N/A	N/A
Contraceptive Method (Type)	Denotes whether the contraception method that the patient receives during their attendance to the service is the main or supporting method of contraception, or whether emergency contraception was provided.	Only required where a contraception method has been collected (see Activity Code).	Code List	an4	D	1 2 3 UNK	Main Other Post-coital Unknown
Contraception Method Status	Denotes whether the service issues the patient, at the point of contact, with either a new or changed method, where the current method is maintained, or where an initial consultation/advice on contraception is given prior to receiving the contraception. New (patient not currently using a main method and receives a method following the consultation for the first time or receives a method for the first time after a time lapse >=1 month) Changed (The patient changes from one contraception method to another, regardless of where the main method currently in use was obtained, e.g., GP or another SRH service. Only the new method is recorded in the “Contraception Main Method” field. This is where the actual method changes and not merely where a device is changed) Maintain (The patient receives care with respect to their current main method of contraception (e.g., a repeat supply of pills or adjustment of a long-acting contraception method) regardless, of where the current method was first obtained, e.g., GP or another SRH service. Pre-contraception consultation/contraception advice (no regular contraception is issued; emergency contraception permitted).	Only required where Contraceptive Method (Type) is 1 (Main)	Code List	an4	D	1 2 3 4 UNK	New Changed Maintain Pre-contraception consultation / contraception advice Unknown

* These codes are not currently part of the Core Reference Data Standards. As Core Reference Data is a standard that all systems should comply with, Digital Health Care and Wales (DHCW) will submit a change request for that standard to be updated. If it is the case that the Core Reference Data Standards changes do not get approved, this would result in those specific codes in the National Data Set for Sexual Health Services in Wales to be mapped to achieve future interoperability.