Core – Diagnostic procedures

These data allow for all diagnostic procedures to be correctly recorded within the data set. The organisation code and date are mandatory, however either OPCS or SNOMED CT can be used to record the diagnostic procedure, but if selected are mandatory.

There will be linked ‘child groups’ throughout the data set to ‘CORE - Diagnostic Procedures’, this is to allow greater depth of data collection whilst maintaining accuracy and ensuring that both the organisation and date are recorded.

May be multiple occurrences per record (0..*)

Diagnostic Procedures Choice - Choice 1..2

Diagnostic Procedures - Choice 1

Start of Repeating Item - Diagnostic Procedure (OPCS)

End of Repeating Item - Diagnostic Procedure (OPCS)

End of Diagnostic Procedures - Choice 1

Diagnostic Procedures - Choice 2
Start of Repeating Item - Diagnostic Procedure (SNOMED CT)

End of Repeating Item - Diagnostic Procedure (SNOMED CT)
End Of Diagnostic Procedures - Choice 2

End Of Diagnostic Procedures Choice

Organisation Site Identifier (Diagnostic Procedure)

This is the ‘Organisation Identifier’ of the organisation site where the diagnostic procedure took place.

Diagnostic Procedure Date

Record the date the diagnostic procedure was carried out.

Note:

• the next 2 data items form a choice menu and at least one of the following must be provided per submission (1..2)

Choice 1:

Diagnostic Procedure (OPCS)

Record the diagnostic procedure(s) carried out during the diagnostic event using OPCS. There may be more than one available, where multiple procedures are classified as a single event.

Choice 2:

Diagnostic Procedure (SNOMED CT)

Record the diagnostic procedure(s) carried out during the diagnostic event using SNOMED CT. There may be more than one available, where multiple procedures are classified as a single event.

This is a child of ‘CORE – Diagnostic Procedures’ group.

Must be at least one of the following choices per ‘CORE – Diagnostic Procedures’ (0..1)

Sentinel Node Biopsy Outcome

Record the outcome of the ‘Sentinel Node Biopsy’.

Notes:

• by adding the diagnostic procedures section both sentinel node biopsy (OPCS code T91.1) and Lymph node dissection (T85) can be easily recorded
• the SNOMED CT procedure code for ‘Sentinel Node Biopsy’ is: 396487001
• these codes are for guidance only
  • it is possible that these codes change over time
  • it is the responsibility of the reporting Trust to ensure correct codes are used