SACT - Clinical Status

This section is required to record more information about the patient’s diagnosis.

May be up to one occurrence per submission (0..1)

Diagnosis Choice - Choice 1..2

Choice 1

End of Choice 1

Choice 2

End of Choice 2

End of Diagnosis Choice

Diagnosis Choice

* A combination of either ‘Primary Diagnosis (ICD-10)’ and/or ‘Morphology ICD-O’ are mandatory for the schema. The section is classified as [1..2], therefore both can be submitted, but a record cannot be submitted without at least one of these data items.

Notes:

• all patients will have a Primary Diagnosis (ICD), and this should always be included
• if both are available, then it is advised to submit both data items
  • this is important for Haematological, Sarcoma and CTYA diagnoses

Choice 1

Primary Diagnosis (ICD-10)

The ‘Primary Diagnosis (ICD-10)’ is normally agreed at the MDT meeting where the patient is discussed, and treatment agreed.

ICD-10 is the International Statistical Classification of Diseases and Related Health Problems (ICD) and is a comprehensive classification of causes of morbidity and mortality. The primary diagnosis is the main condition treated or investigated during the relevant episode of healthcare.

Notes:

• this data item name has been amended, previously ‘Primary Diagnosis’ and has a new description in v4
• use Appendix A and B for the full list of reportable codes
• all ICD codes must be provided using the full 4-digit code, to allow for accurate analysis and reporting
• where the ICD-10 code only has 3 characters, for example C01, please add “X” as a ‘packing digit’ to meet the validation rules (such as C01.X, C07.X, C73.X)
  • in addition, the reporting format excludes the decimal CXX.X or DXX.X, all csv reports must be recorded as CXXX or DXXX

Choice 2

Morphology ICD-O

The ‘Morphology ICD-O’ is the morphology code for the diagnosed cancer as defined by ICD-O-3. This data item must be completed for all Haematological, Sarcoma and CTYA diagnoses.

Notes:

• this data item has a new description in v4
• it is expected that for Haematology cases ICD-O should be used in preference to Primary Diagnosis ICD-10
• please refer to Appendix C for additional support and linkage

Diagnosis Code (SNOMED CT)

The ‘Diagnosis Code (SNOMED CT)’ is the SNOMED CT concept ID which is used to identify the clinical diagnosis given to the patient.

Notes:

• this data item has a new description and has changed to ‘Required’ in v4, previously ‘Optional’
• please refer to the ‘how to find a SNOMED CT diagnosis’ for support