Waiting Times Recording Manual - isdscotland.org · This recording manual is designed to cover the 18 weeks Referral to Treatment standard, the ‘New Ways’ Stage of Treatment standard,

Waiting Times Recording Manual

Waiting Times Recording Manual Version 5.1 published March 2016

Revision History: Version: Date: Summary of Changes:

V1.0 December 2007 No previous version

V4.0 November 2009 Notes and cross checks updated WT4 - New code added for Cataract (1-stop clinic)

V4.1 October 2010 (not released)

WT4 - New code added for Exceptional Aesthetic Procedures

V4.2 January 2012 WT4 – New code added for One-stop clinic (excluding cataracts) New Ways guidance section removed

V5.0 December 2014 TTG compliant update. Amended booking practice principles incorporated.

V5.1 March 2016 WT4 – new code added for local Health Board use.

Title: Waiting Times Recording Manual Date Published: March 2016 Version: V5.1 Document status: Final Author: Martin McCoy Owner: Service Access – Waiting Times, ISD Approver: Fiona MacKenzie

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Contents Waiting Times Recording Manual ................................................................................. 1

Introduction .......................................................................................................... 4 Purpose of this document ........................................................................................ 4 Data Items ........................................................................................................... 4

WT1 Referral Date.......................................................................................... 5 WT2 Referral Received Date ............................................................................ 6 WT3 Waiting List Date ..................................................................................... 7 WT4 Waiting Time Standard ............................................................................. 8 WT5 Urgency Category ................................................................................. 10 WT6 Offer Type ............................................................................................ 11 WT7 Offer Date ........................................................................................... 12 WT8 Appt/Admission Date ............................................................................. 13 WT9 Response Received Date ........................................................................ 14 WT10 Offer Outcome ..................................................................................... 15 WT11 Availability for admission/appointment at short notice .................................... 16 WT12 Minimum days notice required admission/appointment .................................. 17 WT13 Suitability of patient to be considered part of pooled list ................................. 18 WT14 Patient willing to change clinician .............................................................. 19 WT15 Patient willing to change Health Board ....................................................... 20 WT16 Non-attendance category ........................................................................ 21 WT17 Non-Attendance Date ............................................................................. 23 WT19 Non-attendance Outcome ....................................................................... 26 WT20 Unavailability Start Date.......................................................................... 27 WT21 Unavailability Type ................................................................................ 28 WT23 Planned Review Date ............................................................................. 31 WT24 Unavailability End Date........................................................................... 32 WT25 Review Date ........................................................................................ 33 WT26 Review Outcome ................................................................................... 34 WT27 Removal Date ...................................................................................... 35 WT28 Removal Reason .................................................................................. 36 WT29 Patient Status ....................................................................................... 37 WT30 Patient Type ........................................................................................ 38 WT31 Referrer Urgency Category ...................................................................... 39 GEN1 Surname ............................................................................................. 40 GEN2 Forename ........................................................................................... 41 GEN3 Date of Birth ........................................................................................ 42 GEN4 Gender ............................................................................................... 43 GEN5 CHI .................................................................................................... 44 GEN6 Case Reference Number ........................................................................ 45 GEN7 Postcode ............................................................................................. 46 GEN8 Ethnic Group ........................................................................................ 48

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GEN9 GP Practice Code ................................................................................. 49 GEN10 Location .............................................................................................. 50 GEN11 Specialty ............................................................................................. 51 GEN12 Consultant/HCP .................................................................................... 52 GEN13 Patient Category ................................................................................... 53 GEN14 Referral Source .................................................................................... 54 GEN15 Provider code ....................................................................................... 55 GEN16 Main Condition ..................................................................................... 56 GEN17 Other Condition .................................................................................... 57

Data Collection ................................................................................................... 59 Recording Rules ................................................................................................. 59

Offers of Appointments or Admission .................................................................... 59 Non-attendance ............................................................................................... 59 Unavailability ................................................................................................... 60 Unavailability and Patient Focused Booking ........................................................... 60

Calculation of Waiting Time ................................................................................... 60 National Data Submission ..................................................................................... 62

Data Extraction and Validation ............................................................................ 62 Coverage ....................................................................................................... 62 Types of Records ............................................................................................. 62 Access to Data ................................................................................................ 62 Quality Assurance of Waiting Times Data .............................................................. 62

Appendix A: List of Data Items ............................................................................... 64

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Introduction Waiting times are important to patients and are a measure of how the NHS is responding to demands for services. Measuring and regular reporting of waiting times highlights where there are delays in the system and enables monitoring of the effectiveness of NHSScotland’s performance. ISD Scotland continues to be committed to improving the information on waiting times along with our key stakeholders, the NHS Boards and Scottish Government. From 01 January 2008, the ‘New Ways’ of monitoring and measuring waiting times was implemented and subsequently updated in April 2010. More recently, the Patient Rights (Scotland) Act 2011 established a 12 week maximum Treatment Time Guarantee (TTG) for eligible patients who are due to receive planned inpatient or day case treatment. Eligible patients must start to receive that treatment within 12 weeks (84 days) of the treatment being agreed.

In addition Scottish Government and NHS Boards have agreed to manage outpatients under the same guidance. On the whole this does not affect outpatient reporting. However, it could affect the calculation of wait for outpatients i.e. NHS Boards previously applying a Could Not Attend (CNA)/Did Not Attend (DNA) to a patients record would have resulted in a patients clock being reset. Now there is an option to allow the flexibility, meaning a clock should only be reset if it is reasonable and clinically appropriate to do so. Purpose of this document This recording manual is designed to cover the 18 weeks Referral to Treatment standard, the ‘New Ways’ Stage of Treatment standard, and the Treatment Time Guarantee. It is intended for staff involved in collecting, extracting and submitting information to the national Data Warehouse for patients on stage of treatment pathways (outpatients, inpatients, day cases and return outpatients). This guidance provides recording information and rules around the waiting times and generic data items that are submitted to the national Data Warehouse. Supporting Documentation

Document Owner

NHS Scotland Waiting Time Guidance July 2012 SG

Waiting Time Validation Manual ISD

Waiting Time Calculation Manual ISD

Data Items

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http://www.legislation.gov.uk/asp/2011/5/pdfs/asp_20110005_en.pdf


WT1 Formal name: Referral Date Common Name(s): Date of referral, Date of patient referral Priority: S for new outpatients; M for Waiting Time Standard ‘080’ and ‘081’ Definition: A referral date is the date on which a referral is made to a healthcare service. Recording Rules: 1. A referral date should be recorded for all new outpatients. 2. Where a referral is made by letter, the date on the letter should be recorded as the referral date. 3. Where an electronic referral is made, the date the referral was made should be recorded as the referral date. 4. Where a referral has been made by telephone and then followed by written confirmation the date of the telephone referral takes precedence and should be recorded as the referral date. 5. The referral date (WT1) must be on or before the extract submission date. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. The referral date (WT1) may be the same date as the referral received date (WT2). Use of Information: 1. The referral date will be used to monitor the time taken between the referral date (WT1) and referral received date (WT2). 2. This item may be used in the future in conjunction with other waiting times data items to measure the patient journey. Cross Checks: 1. Referral date (WT1) to the service must be on or before the referral received date (WT2).

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WT2 Formal Name: Referral Received Date Common Name: Referral receipt date, Date of receipt of referral, Date referral received Priority: M for new outpatients Definition: Referral received date is the date on which a healthcare service receives a referral. Recording Rules: 1. The referral received date must be recorded for all new outpatients. 2. If a written referral has been made this is the date the referral letter was received/stamped and not the date it reaches the relevant department, service, team or person. 3. Where a referral has been made by telephone and then followed by written confirmation the date of the telephone referral takes precedence and should be recorded as the referral received date. 4. If the waiting times standard (WT4) is ART the definition of this field is the date tertiary care agree the patient should have treatment. 5. The referral received date must be on or before the extract submission date. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. The referral received date (WT2) can be the same date as the referral date (WT1). 2. New outpatient records cannot be submitted where the referral received date is before 01 April 2009. Use of Information: 1. The referral received date is used to calculate the waiting time for new outpatients. 2. The referral received date will be used to monitor the time taken between the referral date (WT1) and referral received date (WT2). 3. This item may be used in the future in conjunction with other waiting times data items to measure the patient journey. Cross Checks: 1. The referral received date (WT2) must be on or after the referral date (WT1) to the service. 2. Offer Date (WT7) must be on or after the referral received date for new outpatients. 3. Unavailability end date (WT24) must not fall before the referral received date for new outpatients. 4. Non-attendance date (WT17) must be on or after the referral received date for new outpatients.

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WT3 Formal Name: Waiting List Date Common Name: Date added to waiting list Priority: M for day cases, inpatients and outpatients for procedure Definition: Waiting List Date is the date that a decision is made, by the healthcare professional responsible for the patient’s care, to put the patient on a waiting list. Recording Rules: 1. Waiting list date must be recorded for inpatients, day cases and outpatients for procedure. 2. Waiting list date must be on or before the extract submission date. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. Waiting list date is not mandatory for new outpatients because referral received date (WT2) will be used to calculate waiting times information. Use of Information: 1. Waiting list date is used to measure the time a patient waits for admission for day cases, inpatients and return outpatients for procedure. 2. This item may be used in the future in conjunction with other waiting times data items to measure the patient journey. Cross Checks:1. Offer date (WT7) must be on or after the waiting list date for inpatients, day cases and return outpatients. 2. Non-attendance date (WT17) must be on or after the waiting list date for inpatients, day cases and return outpatients. 3. The unavailability end date (WT24) must not fall before the waiting list date for inpatients, day cases and return outpatients. 4. Removal date (WT27) must be on or after the waiting list date.

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WT4 Formal name: Waiting Time Standard Common name: Waiting Type, Waiting Times Standard Applied Priority: S Definition: The waiting time target or standard against which the waiting time will be measured. Recording Rules: 1. Waiting time standard should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Code 081 is for the ART HEAT target. Code 071 should be used for TTG exclusions. Format: Coded - 3 characters The following new Waiting Time Standard codes will be introduced to allow NHS Boards to identify patients who belong to treatment groups which will be excluded from the TTG. TARGET/GUARANTEE CODE General Outpatient 010 Outpatient Procedure 011 General Inpatient/Day Case 020 Cancer 040 Diagnostic Test 050 Diagnostics (Other key tests) 051 Other Diagnostics (excluding 050 and 051) 052 Exceptional Aesthetic Procedure 060 Assisted Reproduction 071 Obstetric Services 072 Organ, Tissue or Cell Transplantation 073 Surgical Intervention of Spinal Scoliosis 074 Spinal Treatment by Injection or Surgical Intervention 075 AHP MSK 080 ART 081 Non WT record (local use) 090

Points to Note: 1. If the patient is covered by two guarantees, the waiting times standard code used should be that which reflects the most specific (and shortest) target wait. 2. Current TTG exclusions are codes Codes 071,072 and 073. 3. Code 074 is only excluded for records with Initial Start Date < 01October 2014. 4. Code 075 is only excluded for records with an Initial Start Date < 01 April 2014. Use of Information: 1. The waiting time standard will allow specific waiting times targets/standards to be monitored. 2. This item may be used in the future in conjunction with other waiting times data items to measure the patient journey.

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Cross Checks: None

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WT5 Formal Name: Urgency Category Common Name: Urgency Priority: S Definition: The clinical decision on how quickly the patient needs to be seen/treated:

· URGENT: the patient requires an appointment at the earliest possible opportunity. · SOON: a patient requires an earlier appointment than he/she would receive if given

the next available routine appointment. · ROUTINE: a patient requires the next available routine appointment.

Recording Rules: 1. Urgency category should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Urgency category may be altered if the receiving healthcare professional considers the patient’s condition to have changed prior to the patient’s admission. Format: Coded - 2 characters CATEGORY CODE Urgent 01 Soon 02 Routine 03

Points to Note: 1. This variable differs from Referrer urgency category (WT31), which identifies the urgency category allocated by the referrer based on their clinical decision on how quickly the patient needs to be seen or treated. Use of Information: 1. The urgency category can be used for scheduling and prioritising patients. Cross Checks: None. Version 5.1 10


WT6 Formal Name: Offer Type Common Name: Type(s) of Offer(s) Priority: M (optional for AHP) Definition: Type of offer of appointment or admission made to the patient. Recording Rules: 1. Offer type must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Offer type must be recorded for all offers made. 3. Where a written offer has been made and is then followed by a verbal confirmation by the patient that they can attend, the written offer should be recorded as the offer type 4. For PFB invitations the offer type should be recorded as code 03 (Patient Focussed Booking letter of invitation). A new appointment record should be created when the patient contacts the service to arrange an appointment with the offer type as code 02 (Verbal offer). 5. PFB invitations can only be applied to non-TTG patients i.e. outpatients, diagnostic tests and AHP (MSK). Format: Coded - 2 characters OFFER TYPE CODE Written offer 01 Verbal offer 02 Patient Focussed Booking letter of invitation 03

Points to Note: 1. An appt/admission date (WT8) must be recorded for every written or verbal offer. 2. If a PFB letter of invitation (code 03) has been recorded with an offer date (WT7) there should be no associated appt/admission date (WT8) recorded. 3. A reminder / confirmation system should be in place to ensure patients are given a second notification of their appointment date and time Use of Information: 1. Offer type can be used in conjunction with other variables to monitor patient scheduling and the management of patient appointments. Cross Checks: 1. Offer type (WT6) must be present when an offer date of appointment or admission (WT7) is entered. 2. Where the offer type (WT6) is written (01) or verbal (02) the offer outcome (WT10) must not be responded to PFB invite (50, 60). 3. Where the offer type is PFB (03) the offer outcome (WT10) can only be responded to PFB invite (50, 60) or no response (70, 80, 90).

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WT7 Formal Name: Offer Date Common Name: Date(s) of offer(s) Priority: M Definition: The date any offer of appointment/admission is made to the patient or the date the PFB letter of invitation was sent. Recording Rules: 1. Offer date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Offer date (WT7) must be recorded when type of offer (WT6) is specified. 3. For written offers, the date the letter was sent should be recorded as the offer date. 4. For PFB invitations the date of the invitation letter should be recorded as the offer date. When the patient contacts the service to arrange an appointment a new appointment record should be created with the date of the contact as the offer date and the offer type (WT6) recorded as verbal (code 02). 5. The offer date must be on or before the extract submission date. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: Ten characters Points to Note: 1. Where the system generates a letter of appointment/admission/PFB invitation the date may be generated automatically. 2. Multiple offers can be recorded. At least the two most recent offer dates must be held on the system. 3. This is the date that a written offer, verbal offer or a PFB letter of invitation is sent to the patient and not the appt/admission date (WT8). 4. It is not appropriate to give 7 days notice when offering dates of appointment or admission if the patient has been recorded as needing treatment urgently (WT5). Use of Information: 1. Offer date can be used in conjunction with other variables to monitor patient scheduling and the management of patient appointments. 2. Offer date can be used to determine if the offer of appt/admission is a reasonable or a short notice offer. Cross Checks: 1. Offer date (WT7) must occur on or after the waiting list date (WT3) for day cases, inpatients and return outpatients for procedure. 2. Offer date (WT7) must occur on or after the referral received date (WT2) for new outpatients. 3. Appt/admission date (WT8) must be on or after the offer date (WT7). 4. Response received date (WT9) must be on or after the offer date (WT7).

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WT8 Formal Name: Appt/Admission Date Common Name: Date(s) of proposed appointment/admission Priority: M for written or verbal offers, excluding PFB invitation Definition: Date(s) of appointment or admission offered to the patient. Recording Rules: 1. The appt/admission date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The appt/admission date must be recorded for all written and verbal offers recorded in WT6. 3. The appt/admission date should not be recorded when the type of offer is PFB (see WT7 recording rule 4). 4. The appt/admission date cannot be within any defined periods of unavailability unless associated with a non-attendance category (WT16). 5. Where the waiting times standard code (WT4) is ART the date of proposed appointment/admission is the date of screening. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. A record may be completed for every appt/admission date offered. Under the ‘Reasonable Offer’ rule, under most circumstances, recording two refused dates prior to an acceptance will result in the waiting time clock being reset to the date when the patient refused the second appointment. Unless the urgency category (WT5) is classed as ‘Urgent’, where the next available appointment should be offered. 2. Short notice appointment dates (i.e. less than 7 days notice) can be offered. If the patient accepts such an offer, then it is deemed to be a reasonable offer of appointment. However, if the patient declines such a short notice offer, they must not be disadvantaged, and must be made a reasonable offer of a further two or more different dates of appointment within the waiting times standards and treatment time guarantee. 3. It is not appropriate to give 7 days notice when offering appt/admission dates if the patient has been recorded as needing treatment urgently (WT5). Use of Information: 1. Appt/admission date is used to monitor reasonable offers in conjunction with offer date (WT7). Cross Checks: 1. Appt/admission date (WT8) must be on or after the offer date of appointment or admission (WT7). 2. The response received date (WT9) must be on or before the appt/admission date (WT8).

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WT9 Formal Name: Response Received Date Common Name: Date(s) of receipt of response(s) Priority: M Definition: Date when the service receives a response from the patient to the proposed appointment/admission offer(s) or invitation to make contact (PFB). Recording Rules: 1. Response received date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Response received date should be recorded for all offers of appointment or admission. 3. If the response received date (WT9) is recorded the offer outcome (WT10) must be entered. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. Subsequent offers cannot be made before the response received date (WT9) of the current offer. Use of Information: 1. Response received date (WT9) can be used in conjunction with the offer date (WT7) to monitor the time taken to respond to an offer. Cross Checks: 1. The response received date (WT9) must be on or before the appt/admission date (WT8). 2. The response received date (WT9) must be on or before the removal date (WT27). 3. The response received date must be on or after the offer date (WT7).

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WT10 Formal Name: Offer Outcome Common Name: Outcome of offer Priority: M Definition: The patient’s response to the offer of an appointment or admission date or for outpatients only - PFB letter of invitation. Recording Rules: 1. Offer outcome must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Offer outcome code must be applied to each offer of an appointment or admission (WT7). 3. Only one code must be recorded for each date of proposed appointment or admission. 4. Offer outcome (WT10) can only be codes 70, 80 or 90 when the response received date (WT9) has not been entered. 5. Offer outcome (WT10) must be codes 10, 20, 30, 40, 50 or 60 when the response received date (WT9) has been entered. Format: Coded - 2 character OUTCOME CODE Accepted 10 Declined – New offer made/to be made 20 Declined – Removed from list 30 Declined – Awaiting decision 40 Responded to PFB invite – offer of appointment made/to be made 50 Responded to PFB invite – invitation declined/not wanting appointment 60 No response – Awaiting decision 70 No response – New offer made/to be made 80 No response – Removed from list 90

Points to Note: 1. If the patient has declined two offers and a further offer is made or to be made their waiting time clock will be reset to the date they declined the second offer (note: the date the PFB letter of invitation for outpatients was sent is not included in waiting times calculations as an offer). Unless the urgency category (WT5) is classed as ‘Urgent’, where the next available appointment should be offered. Use of Information: 1. Provides evidence of response/non response to offer(s) of appointment/admission. Cross Checks: 1. When offer type (WT6) is written (01) or verbal (02) the offer outcome (W10) must not be responded to PFB invite. 2. When offer type (WT6) is PFB (03) the offer outcome (WT10) can only be responded to PFB invite (50, 60) or no response (70, 80, 90). 3. Where the Removal Reason (WT28) is 10 (attended/admitted) then the offer outcome (WT10) of the most recent appointment date must be 10 (accepted). Version 5.1 15


WT11 Formal Name: Availability for admission/appointment at short notice Common Name: Short notice availability Priority: O Definition: To identify whether the patient can be available to be admitted or attend an appointment in less than the minimum 7 days notice required. Recording Rules: 1. Availability for admission or appointment at short notice can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Coded – 1 character AVAILABILITY CODE Available 1 Not available 2 Not known 9

Points to Note: 1. If the patient declines an offer given at short notice then this will not count against them, i.e. it will not affect their right to a reasonable offer. Use of Information: 1. WT11 can be used to identify if the patient is willing to attend an appointment at short notice. 2. The information can be used locally to assist in scheduling. Cross Checks: None.

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WT12 Formal Name: Minimum days notice required admission/appointment Common Name: Minimum notice required Priority: O Definition: The minimum number of day’s notice that the patient requires for date of appointment or admission. Recording Rules: 1. Minimum days notice should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The number of days is automatically calculated and populated by the system but the entry can be over written in cases where less than 7 days notice is accepted by the patient. 3. The default should be 7 days. Format: Number between 0 and 7. Points to Note: 1. For an offer to be considered as reasonable the date of appointment or admission offered must give at least 7 days notice from the date the offer is made (unless the patient is considered urgent or accepts a short notice appointment). 2. Appointments and admissions with less than 7 days notice can be offered and will be considered reasonable if the patient accepts. 3. If the patient declines an offer given at short notice then this will not count against them, i.e. it will not affect their right to a reasonable offer. Use of Information: 1. The information can be used locally to assist in scheduling. 2. The minimum days notice required (WT12) in conjunction with the availability for admission/appointment at short notice (WT11) can be used to identify patients who are willing to attend at short notice and if so the amount of notice they require. Cross Checks: None.

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WT13 Formal Name: Suitability of patient to be considered part of pooled list Common Name: Suitability for pooled list Priority: O Definition: Decision as to whether the patient could be seen as part of a generic list or clinically required to remain on the specific/original healthcare professional’s list. Recording Rules: 1. The suitability of the patient to be considered part of a pooled list should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The information should be recorded when a decision is made as to whether a patient can be considered part of a pooled list. Format: Coded – 1 character SUITABILITY CODE Suitable 1 Not suitable 2 Not known 9

Points to Note: 1. The response to this question impacts on the information recorded against Patient willing to change clinician (WT14), i.e. WT14 only becomes relevant if the patient is suitable to be considered part of a pooled list. Use of Information: 1. For local use to assist in scheduling. Cross Checks: None.

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WT14 Formal Name: Patient willing to change clinician Common Name: Willing to change clinician Priority: O Definition: To identify whether a patient is willing to be seen by another healthcare professional. Recording Rules: 1. Patient willing to change clinician should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Coded – 1 character WILLING TO CHANGE CODE Willing to change 1 Not willing to change 2 Not known 9

Points to Note: Use of Information: 1. For local use to assist in scheduling. Cross Checks: None.

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WT15 Formal Name: Patient willing to change Health Board Common Name: Willing to change HB Priority: O Definition: To identify whether a patient is willing to be seen at another Health Board, GJNH or private sector. Recording Rules: 1. Patient willing to change Health Board should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Coded – 1 character WILLING TO CHANGE CODE Willing to change 1 Not willing to change 2 Not known 9

Points to Note: 1. Where arrangements are in place for the patient to be seen at another provider, a list of available hospitals/clinics should be detailed in the local access policy. Use of Information: 1. The information can be used locally to assist in scheduling. Cross Checks: None.

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WT16 Formal Name: Non-attendance category Common Name: Priority: M Definition:

· DID NOT ATTEND: The patient may be categorised as did not attend (DNA) when he/she did not attend a previously accepted appointment and gave the hospital no prior warning of the non attendance.

· COULD NOT ATTEND: The patient may be categorised as could not attend (CNA) when the hospital is notified in advance that he/she will not attend a previously accepted appointment. Time limit on advanced notice should be detailed in the local access policy.

· CANCELLED BY SERVICE: Admission and appointment dates may be cancelled by the service for a variety of reasons, for example, if staff are not available to deliver the service or the location is unavailable. Patients may receive short notice of the cancellation.

Recording Rules: 1. Non-attendance category must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. One non-attendance category code must be recorded for each non-attendance. 3. All DNAs, CNAs and cancellations by service must be recorded. 4. Non-attendance category (WT16) should only be recorded when a non-attendance date (WT17) or the code denoting removed/remained on the list (WT19) has been supplied. 5. Non-attendance category (WT16) cannot be recorded where an offer has not been accepted. Format: Coded – 1 character CATEGORY CODE Could Not Attend 2 Did Not Attend 3 Cancelled by Service 5 Could Not Attend (wait unaffected) 6 Did Not Attend (wait unaffected) 7

Points to Note: 1. Further appointment/admission dates can be offered according to local and national guidance. 2. If the patient cancelled their appointment (CNA) their waiting time clock may be unaffected where it is reasonable and clinically appropriate to do so. 3. If the patient failed to attend (DNA) for their appointment their waiting time clock may be unaffected where it is reasonable and clinically appropriate to do so. 4. Admission or appointment arrangements cancelled by the hospital will not adversely affect the waiting period for the patient. The waiting time clock will not be reset. 5. The clock is only reset for a non-attendance which occurs when the adjusted wait to that point is 84 days or less.

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Use of Information: 1. Local use as part of patient’s attendance history. Cross Checks: None

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WT17 Formal Name: Non-Attendance Date Common Name: Non-attendance date(s) Priority: M Definition: The date the patient did not attend, date the patient cancelled their appointment or admission or the date the hospital cancelled the appointment or admission arrangements. Recording Rules: 1. Non-Attendance Date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. A Non-Attendance Date (WT17) must be recorded when a non-attendance category (WT16) code has been recorded. 3. Non-Attendance Date (WT17) cannot be recorded where an offer has not been accepted. 4. Non-attendance date must be on or before the removal date (WT27). 5. Non-attendance date must be on or after the referral received date (WT2) for new outpatients and the waiting list date (WT3) for inpatients, day cases and return outpatients. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. If the patient cancels their appointment (CNA) their waiting time clock will be reset to zero from the date they cancelled the appointment if it is reasonable and clinically appropriate to do so. 2. If the patient fails to attend (DNA) for their appointment their waiting time clock will be reset to zero from the date of the appointment if it is reasonable and clinically appropriate to do so. 3. Admission or appointment arrangements cancelled by the hospital will not adversely affect the waiting period for the patient. The waiting time clock will not be reset. 4. The clock is only reset after a non-attendance which occurs when the adjusted wait to that point is 84 days or less. Use of Information: 1. The date recorded will be used in the calculation of the patient’s waiting time. Cross Checks: 1. Non-attendance date (WT17) must be equal to the appt/admission date (WT8) for a non-attendance category (WT16) of Did Not Attend (code 3) or Did Not Attend (wait unaffected) (code 7). 2. Non-attendance date (WT17) must be on or before the appt/admission date (WT8) for a non-attendance category (WT16) of Cancelled by Service (code 5), Could Not Attend (code 2) or Could Not Attend- wait unaffected (code 6). 3. Non-Attendance Date must be on or after the Response Received Date where the Non-Attendance Category is Could Not Attend or Could Not Attend- wait unaffected.

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3. Non-attendance date must be on or before the extract submission date where the attendance category (WT16) is Did Not Attend (code 3).

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WT18 Formal Name: Explanatory text or code (for non-attendance) Common Name: Explanatory text or code Priority: O Definition: An explanation, if available, as to why the patient has not attended an appointment. Recording Rules: 1. An explanation of why the patient has not attended can be recorded for new outpatients, inpatients, day cases and return outpatients. 2. This item is for local use only and would only need to be recorded when a non-attendance date (WT17) has been recorded. Format: According to local instructions. Points to Note: 1. This information will not be loaded into the data warehouse and will therefore not be accessible using Business Objects or other reporting tools. Use of Information: 1. Local use only. Cross Checks: None.

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WT19 Formal Name: Non-attendance Outcome Common Name: Removed/retained on list Priority: M Definition: To identify whether a patient has been removed or has been retained on a waiting list after they cancelled or failed to attend their appointment or after the service cancelled the patient’s appointment. Recording Rules: 1. The non-attendance outcome must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The non-attendance outcome must be recorded when a non-attendance category (WT16) has been entered. 3. The non-attendance outcome cannot be recorded where an offer has not been accepted. Format: Coded – 2 characters OUTCOME CODE Removed 10 Remained 20 To be confirmed 90

Points to Note: 1. If the patient is retained on the list (code 20) after they cancelled their appointment (CNA) their waiting time clock will be reset to zero from the date they cancelled the appointment if it is reasonable and clinically appropriate to do so. 2. If the patient is retained on the list (code 20) after they failed to attend (DNA) their waiting time clock will be reset to zero from the date of the appointment if it is reasonable and clinically appropriate to do so. 3. The patient will be retained on the list (code 20) after the service cancels the patient’s appointment or admission arrangements. The patient’s waiting time clock will not be affected. 4. The clock will not be reset for any attendance type after a non-attendance where patients have waited over 84 days. Use of Information: 1. This item can be used to ensure that patients who do not attend are being managed. 2. Code 90 ‘To be confirmed’ can be used as a 'holding' code where the service is awaiting a clinical decision on whether to remove the patient from the list. The waiting time clock would be reset to zero from the date the patient cancelled their appointment or did not attend an appointment but would continue until a decision has been made. Cross Checks: None.

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WT20 Formal Name: Unavailability Start Date Common Name: Start of clock pause; Start Date(s) for period(s) of unavailability Priority: M Definition: Date the unavailability commences and clock pauses. Recording Rules: 1. Unavailability start date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Unavailability start date must be recorded when the patient becomes unavailable for medical , patient advised or patient requested reasons. 3. Unavailability start date must be recorded when the patient has not responded to a PFB letter within seven days for outpatients and diagnostics only. 4. Unavailability periods cannot overlap even if the unavailability is due to different reasons. One unavailability period must finish before another can be applied. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. There may be more than one period of unavailability. 2. Unavailability periods are inclusive of the start and end date. 3. All unavailability periods for medical, patient advised or patient requested reasons applied before the patient has waited 84 days will be deducted in the calculation of the patient’s waiting time. 4. Unavailability will not be deducted from a patients wait if it occurs when the patient has been on the list for over 84 days. 4. All unavailability periods resulting from a failure to respond to a PFB letter of invitation will be deducted irrespective of how many days have been recorded – for outpatients and diagnostics. This should be monitored locally and nationally in line with guidance on maximum unavailability period. 5. If consecutive periods of unavailability are recorded for the same reason the time recorded for the clock pauses will be aggregated and one period of unavailability will be recorded when analysing waiting times information. Use of Information: 1. The unavailability start date (WT20) will be used in conjunction with the unavailability end date (WT24) in the calculation of waiting times. Cross Checks: WT21 WT24 WT25

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WT21 Formal Name: Unavailability Type Common Name: Type(s) of unavailability Priority: M Definition: To identify the reason, for example whether the unavailability is due to medical, patient advised or patient requested reasons. Or for outpatients and diagnostics, a period of unavailability has resulted from a delay in responding to a PFB letter of invitation. Recording Rules: 1. Unavailability type must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The unavailability type must be recorded for every period of unavailability. 2. Unavailability type is recorded when it is known that the patient is unavailable for a known period of time or are indefinitely unavailable. 3. Only one unavailability type code must be recorded for each period of unavailability. Format: Code – 2 characters Unavailability Type Code

Unavailability Type Description

1A Patient Advised - on holiday 1B Patient Advised - personal commitment 1C Patient Advised - work commitment 1D Patient Advised - carer commitment 1E Patient Advised - academic commitment 1F Patient Advised - jury duty 1G Patient Requested - wishes named Consultant 1H Patient Requested - wishes to be treated within local Health

Board 1I Patient Advised - ‘Visiting Consultant Service’ – wishes to be seen

at next scheduled service within Health Board of residence 1J Patient Advised - following severe weather cancellation of Visiting

Consultant Service, wishes to be treated within local Health Board 1K Patient Advised - indefinitely unavailable 2A Medical - other medical condition 2B Medical - indefinitely unavailable 3A Suspension due to exceptional circumstances 3B Non-TTG – no response to PFB offer of appointment Points to Note: 1. All unavailability periods for medical, patient advised or patient requested reasons applied before the patient has waited 84 days will be deducted in the calculation of the patient’s wait. 2. Unavailability will not be deducted from a patients wait if it occurs when the patient has been on the list for over 84 days.

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3. All periods of unavailability resulting from a failure to respond to a PFB letter of invitation will be deducted irrespective of how many days have been recorded – for outpatients and diagnostics only. This should be monitored locally and nationally in line with guidance on maximum unavailability period. 4. If consecutive periods of unavailability are recorded for the same reason the time recorded for the period of unavailability will be aggregated and one derived period of unavailability will be deducted. 5. Following a period of indefinite unavailability the patients waiting time clock will be reset to the day after the unavailability end date (WT24) provided that the patients adjusted wait up to this point has not exceeded 84 days. Use of Information: 1. This item may be used in conjunction with other waiting times data items to facilitate patient management. Cross Checks: WT20, WT24

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WT22 Formal Name: Explanatory text or code for unavailability Common Name: Explanatory text or code Priority: O Definition: Explanation as to why the patient is unavailable. Recording Rules: 1. An explanation as to why the patient is unavailable can be recorded for new outpatients, inpatients, day cases and return outpatients. Format: According to local instructions. Points to Note: None Use of Information: 1. Allows the recording of specific reasons for periods of unavailability used by clinicians, to make judgements on what to do regarding the patient’s treatment. Cross Checks: None.

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WT23 Formal Name: Planned Review Date Common Name: Planned review of unavailability, Date of any planned review(s) Priority: O Definition: The date on which any planned review of unavailability should take place. Recording Rules: 1. The planned review date can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. This may not be the actual review date (WT25), but is the date that the review is planned to take place (WT23). Use of Information: 1. This item may be used in conjunction with other waiting times data items to facilitate patient management. Cross Checks: None

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WT24 Formal Name: Unavailability End Date Common Name: End date(s) of the period(s) of unavailability Priority: M Definition: The date on which the period of unavailability ends. Recording Rules: 1. The unavailability end date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The unavailability end date must be supplied for all periods of definite unavailability. 3. The unavailability end date must be supplied for all but the final period of indefinite unavailability. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. The patient is not available on the ‘unavailability end date’. 2. The unavailability period is inclusive of the start and end date. 3. All unavailability periods for medical, patient advised or patient requested reasons applied before the patient has waited 84 days will be deducted in the calculation of the patient’s waiting time. 4. For outpatients and diagnostics, all periods of unavailability resulting from a failure to respond to a PFB letter of invitation will be deducted irrespective of how many days have been recorded. This should be monitored locally and nationally in line with guidance on maximum unavailability period. 5. Unavailability will not be deducted from a patients wait if it occurs when the patient has been on the list for over 84 days. 6. If consecutive unavailability periods are recorded for the same reason, the time recorded will be aggregated and one derived clock pause will be used for analytical purposes. Use of Information: 1. Along with the unavailability start date (WT20) the date will be used in the calculation of waiting times. Cross Checks: 1. The unavailability end date (WT24) must be on or after the unavailability start date (WT20). 2. The unavailability end date (WT24) should not be before the referral received date (WT2) for new outpatients. 3. The unavailability end date (WT24) should not be before the waiting list date (WT3) for inpatients, day cases and return outpatients.

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WT25 Formal Name: Review Date Common Name: Date of review Priority: O Definition: The date when the actual review of the unavailability takes place. Recording Rules: 1. Review date can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: None. Use of Information: 1. This item may be used in conjunction with other waiting times data items to facilitate patient management. Cross Checks: None.

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WT26 Formal Name: Review Outcome Common Name: Outcome of review(s) Priority: M Definition: The outcome of the review of the patient’s period of unavailability. Recording Rules: 1. Review outcome can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure Format: Coded – 2 characters OUTCOME CODE Now available 10 New review planned 20 Removed from list 90

Points to Note: None. Use of Information: 1. This item may be used in conjunction with other waiting times data items to facilitate patient management. Cross Checks: None.

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WT27 Formal Name: Removal Date Common Name: Date of removal from list Priority: M Definition: The date a patient is removed from a waiting list. Recording Rules: 1. Removal date must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure 2. Removal date (WT27) must be entered when a removal reason (WT28) has been entered. 3. Where the waiting times standard code (WT4) is ART the date of removal from list is the date of screening. 4. Removal date must be on or before the extract submission date. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. Removal date must not be within a period of unavailability when the removal reason (WT28) is 10; 11; 12 or 13. Use of Information: 1. The information can be used to monitor the time the patient was on a waiting list. Cross Checks: 1. Removal date (WT27) must be on or after the referral received date (WT2) for new outpatients. 2. Removal date (WT27) must be on or after the waiting list date (WT3) for inpatients, day cases and return outpatients.

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WT28 Formal Name: Removal Reason Common Name: Reason for removal from list Priority: M Definition: Indicates why the patient has been removed from the waiting list. Recording Rules: 1. Removal reason must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure 2. All patients who are removed from the waiting list, i.e. have a removal date recorded (WT27), must have a removal reason code (WT28) recorded. Format: Coded – 2 characters REMOVAL REASON CODE Attended/admitted 10 Attended/admitted at GJNH 11 Attended/admitted at SRTC 12 Attended/admitted at private sector 13 Referred back to GP – Patient Advised unavailability 20 Referred back to GP – Medical unavailability 21 Referred back to GP – Could Not Attend 37 Referred back to GP – Did Not Attend 38 Referred back to GP – Refused ‘reasonable offer’ 40 Referred back to GP – No response to offer 41 Referred back to GP – Inappropriate referral 42 Inappropriate addition to list 43 Transferred same HB area, different specialty 50 Transferred within NHS Board area to another hospital 51 Transferred to another NHS Board area 59 Treatment no longer required 80 Died 90

Points to Note: 1. Currently only patients who attended or were admitted as planned (codes 10,11,12,13) will be used in routine waiting time calculations for completed waits. 2. Where the waiting times standard (WT4) is AHP MSK patients who attended or were admitted as planned (code 10) is the first clinical out-patient appointment (which could be by telephone, video-link or face to face). Use of Information: 1. The information can be used to monitor reasons for a patient’s removal from a waiting list and in the calculation of waiting times. Cross Checks: 1. Removal date (WT27) must not be within a period of unavailability when the removal reason is 10; 11; 12 or 13. 2. Where the removal reason is Attended/admitted (codes 10,11,12 or 13) the offer outcome (WT10) of the most recent offer must be accepted (code 10).

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WT29 Formal Name: Patient Status Common Name: Current Status of Patient Priority: M Definition: To identify the stage that the patient has reached in their current journey. Recording Rules: 1. The patient status must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Patients who have not or cannot be offered an appointment or admission have a code applied to denote status. 3. Patient status must be removed from list (code 40) where the removal date (WT27) has been entered. 4. Awaiting appointment/admission date (code 10) should be used when the patient is added to a waiting list and is waiting for an appointment or admission date. If the results of a diagnostic test or other specialty report are needed before an appointment date can be offered the appropriate code should be used to give a more specific indication of the reason the patient has not yet been offered an appointment. 5. When the patient has been offered an appointment (date of offer is completed) no code should be recorded. Format: Coded – 2 characters STATUS CODE Awaiting appointment/admission date 10 Awaiting diagnostic result(s) 20 Awaiting other specialty report(s) 30 Removed from list 40

Points to Note: 1. None. Use of Information: 1. For local use for patient and waiting list management. Cross Checks: None.

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WT30 Formal Name: Patient Type Common Name: Patient type Priority: M Definition: To identify the expected management of the patient, i.e. is the patient a new outpatient, inpatient, day case or return outpatient for procedure. Recording Rules: 1. Patient type must be recorded for all new outpatients, inpatients, day cases and return outpatients for procedure. 2. There is no requirement to record, measure and report 'general' return outpatients returning for a review appointment. There is a requirement, however, to record, measure and report patients waiting who return for procedures as outpatients in exactly the same way as treated as inpatients or day cases. Format: Coded – 2 characters PATIENT TYPE CODE Inpatient 01 Day case 11 New outpatient 21 Return outpatient 23

Points to Note: 1. Patient type will be used to identify how the patient wait should be analysed; referral date (WT1)/referral received date (WT2) will be used to measure a new outpatient wait and waiting list date (WT3) will be used for inpatients, day cases and return outpatients for procedure. Use of Information: 1. This item may be used in conjunction with other waiting times data items to facilitate patient management. Cross Checks: None.

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WT31 Formal Name: Referrer Urgency Category Common Name: Priority: S Definition: The referrer’s clinical assessment on how quickly the patient needs to be seen/treated.

· URGENT - For clinical reasons, the patient requires an appointment at the earliest possible opportunity.

· SOON - For clinical reasons, the patient requires an earlier appointment than he/she would receive if given the next available routine appointment.

· ROUTINE - The patient requires the next available routine appointment. Recording Rules: 1. The referrer urgency category should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Referrer urgency category may differ from Urgency Category (WT5) but must not be changed, i.e. the urgency recorded on the GP letter must be recorded. Format: Code – 2 characters CATEGORY CODE Urgent 01 Soon 02 Routine 03

Points to Note: 1. Referrer urgency category identifies the referrer’s classification of how urgently the patient needs to be seen and may differ from the code chosen by the healthcare professional to whom the patient has been referred. Use of Information: 1. Used to identify how quickly the patient requires an appointment or admission based on the referrer’s assessment. Cross Checks: None.

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GEN1 Formal Name: Surname Common Name: Priority: O Definition: The surname of the person represents the part of the name which indicates the family group of which the person is part. Recording Rules: 1. Surname can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Field length: 35 characters maximum Points to Note: 1. Although surname will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 2. Validation around surname has been turned off. Use of Information: Cross Checks: None.

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GEN2 Formal Name: Forename Common Name: First forename Priority: O Definition: The forename of the patient represents that part of the name of the patient which, after the Surname (GEN1), is the principal identifier of the person. Recording Rules: 1. Forename can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Field length: 35 characters maximum Points to Note: 1. Although forename will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 2. Validation around forename has been turned off. Use of Information: Cross Checks: None.

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GEN3 Formal Name: Date of Birth Common Name: DOB Priority: O Definition: The date on which a person was born or is officially deemed to have been born. Recording Rules: 1. Date of birth can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Day, month and year recorded as one item, to indicate when an event occurs. CCYY-MM-DD Field length: 10 characters Points to Note: 1. Although date of birth will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 2. Validation has around date of birth has been turned off. Use of Information: 1. Date of birth will be used to derive age. Cross Checks: None

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GEN4 Formal Name: Gender Common Name: Sex Priority: O Definition: Recording Rules: 1. Gender can be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Gender not known – the gender of the person cannot be determined for physical reasons, for example, a new-born baby. 3. Gender not specified – the gender of the person is not provided in the personal details, i.e. the data has not been supplied and gender cannot be ascertained from the data provided. Format: Coded - 1 character CATEGORY CODE Not Known 0 Male 1 Female 2 Not Specified 9

Points to Note: 1. Although gender will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 2. Validation around gender has been turned off. Use of Information: Cross Checks: None.

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GEN5 Formal Name: CHI Common Name: Community Health Index (CHI) Number Priority: S Definition: The Community Health Index (CHI) is a population register which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Recording Rules: 1. CHI should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The first digit of the CHI number will be 3 or less. 3. CHI number consists of the 6-digit Date of Birth (DDMMYY) followed by a 3-digit sequence number and a check digit. The ninth digit is always even for females and odd for males. Format: Field length: 10 characters Points to Note: 1. Where the patient’s CHI (GEN5) is used as the Case Reference Number (GEN6), the number should be recorded in both the CHI (GEN5) and Case Reference Number (GEN6) fields. 3. Validation around CHI number has been turned off. Use of Information: 1. CHI will be used to assist in the record linkage of data. 2. CHI will be used to populate the data warehouse with patient identifying information such as name, date of birth etc. Cross Checks: None.

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GEN6 Formal Name: Case Reference Number Common Name: Patient identifier, Health Record Identifier Priority: S Definition: A Case Reference Number is a code (set of characters) used to uniquely identify a patient within a health records system, e.g. PAS. Recording Rules: 1. Case Reference Number should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. Case Reference Number must be between 6 and 14 characters long. Format: Field length: 6 to 14 characters Points to Note: 1. Where the patient’s CHI (GEN5) is used as the Case Reference Number (GEN6), the number should be recorded in both the CHI (GEN5) and Case Reference Number (GEN6) fields. Use of Information: 1. To assist in patient identification. Cross Checks: None.

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GEN7 Formal Name: Postcode Common Name: Postcode Priority: S Definition: The postcode is a basic unit for identifying geographic locations. A postcode is associated with each address in the UK. A postcode has two component parts. Part one of the postcode is known as the outcode, and part two is known as the incode. Outcode: The outcode identifies the postal area and the postal district. The postal area is represented by 1 or 2 alpha characters and the postal district is represented by 1 or 2 digits. Therefore, part 1 contains 2, 3 or 4 characters. Incode: The incode is of length 3 characters. The postcode sector is represented by the outcode plus the first digit of the incode. The complete postcode represents the postman's walk Recording Rules: 1. Postcode should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The postcode should be recorded in full and valid on record closure, i.e. when removal date (WT27) has been recorded. 3. Although postcode will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 4. The postcode of the patient’s usual address should be entered wherever possible. 5. For residents of England, Wales or Northern Ireland the actual postcode for the patient’s address should be entered. 6. Refer to the SMR recording guidelines if the patient’s home is outside Scotland, England, Wales or Northern Ireland. 7. For patients who are with the armed forces and based in the United Kingdom, use postcode of their base. For British Forces Posted Overseas who return to Scotland and go direct to hospital for treatment, use the dummy postcode BF01 0AA. Format: Field length: 8 characters The postcode format is the same as that used in the Postal Address File. The following are all the valid formats. (A = alphabetic, N = numeric) Format example AN NAA G5 8BW ANN NAA M34 3AB AAN NAA EH5 3SQ AANN NAA EH12 6UP ANA NAA W1A 4WW AANA NAA EC1A 1HQ AAA NAA GIR 0AA (only one in UK)

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Note that the outcode is left justified and the outcode and the incode are always separated by one space. The field length is eight characters. See SMR Data Manual for data recording details. Points to Note: 1. The postcode must be a valid code on the POSTCODE reference file on record closure. Within the data warehouse records with invalid postcodes will not be initially rejected, but will be continually validated against a continuously refreshed postcode file. Use of Information: 1. Postcode will be used to derive NHS Board of Residence. Cross Checks: None.

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GEN8 Formal Name: Ethnic Group Common Name: Ethnicity Priority: S Definition: An ethnic group is a group of people having racial, religious, linguistic and/or other cultural traits in common. Recording Rules: 1. Ethnic group should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Coded - 2 characters. ETHNIC GROUP CODE Scottish 1A Other British 1B Irish 1C Gypsy/Traveller 1K Polish 1L Other White ethnic group 1Z Any mixed or multiple ethnic groups 2A Pakistani, Pakistani Scottish or Pakistani British 3F Indian, Indian Scottish or Indian British 3G Bangladeshi, Bangladeshi Scottish or Bangladeshi British 3H Chinese, Chinese Scottish or Chinese British 3J Other Asian, Asian Scottish or Asian British 3Z African, African Scottish or African British 4D Other African 4Y Caribbean, Caribbean Scottish or Caribbean British 5C Black, Black Scottish or Black British 5D Other Caribbean or Black 5Y Arab, Arab Scottish or Arab British 6A Other ethnic group 6Z Refused/not provided by patient 98 Not Known 99

Points to Note: 1. Ethnic group is the patient’s perception of his or own ethnic group. 2. Although ethnic group will be submitted as part of the extract to ISD the information that appears in the data warehouse will be taken from the CHI patient reference table. 3. Validation around ethnic group has been turned off. Use of Information: 1. Ethnic group is intended to assist the monitoring of equality of access to NHS services. Cross Checks: None.

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GEN9 Formal Name: GP Practice Code Common Name: GPPC Priority: S Definition: General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and single-handed practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each NHS Board. Recording Rules: 1. GP Practice code should be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. Format: Field length: 5 or 6 characters Points to Note: 1. If a patient changes GP practice between referral and attendance, the new GP Practice code should be recorded. 2. If the GP practice is Scottish (5 character code) then it must be an active record in the GP reference file (GPPRAC). The referral date (WT1) must be within the range specified by the date opened and date closed fields in the GPPRAC reference file. 3. If the GP practice code in not Scottish (6 character code) then it must be a valid UK Practice code (UKGPPRAC). 4. Validation around GP practice code has been turned off. Use of Information: Cross Checks: None.

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GEN10 Formal Name: Location of appointment/admission/treatment Common Name: Location code Priority: M Definition: A Location is any building or set of buildings where consultation/treatment is expected to take place. Locations include hospitals, health centres, GP surgeries, clinics, nursing homes and schools. Each location has a Location code. Recording Rules: 1. Location must be recorded for inpatients, day cases and return outpatients. 2. Location must be recorded on record closure for new outpatients, i.e. when removal date (WT27) has been recorded. 3. Location must be recorded as the expected location of consultation/treatment. Format: Field length: 5 characters Points to Note: 1. It is acknowledged that the precise location details may not be known when the patient is first added to the waiting list. Records should be updated when more detail is known or plans change in advance of admission/attendance. 2. Where location may not be known at the time of placing a new outpatient on a waiting list provider code will be used to derive NHS Board of treatment. 3. Cross checks will not be carried out for the waiting times dataset, but PAS data used for submission of SMR data requirements will be cross checked as reported in the SMR data manual. Use of Information: 1. Location code will be used to derive the NHS Board of treatment. Cross Checks: None.

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GEN11 Formal Name: Specialty or discipline Common Name: Specialty Priority: M Definition: Specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties. A Discipline is a non-medical profession related to healthcare, for which formal training leading to a recognised professional qualification is undertaken. Examples of disciplines are physiotherapy, nursing, pharmacology. Recording Rules: 1. Specialty must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. This field should be coded to the Specialty/Discipline of the healthcare professional who is in charge of the patient episode. If the healthcare professional is formally recognised and contracted to work in more than one specialty then the patient’s problem or condition should dictate the specialty. Format: Coded - 3 characters Points to Note: 1. Mental health services are not currently covered by national waiting time standards so the Scottish Government has not mandated the collection of waiting times data. For consistency in the measurement of waiting times NHS Boards may wish to utilise PAS systems to manage and monitor a wide range of 'non target' services and the waiting times data warehouse will support this. 2. Cross checks will not be carried out for the waiting times dataset, but PAS data used for submission of SMR data requirements will be cross checked as reported in the SMR data manual. Use of Information: Cross Checks: None.

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GEN12 Formal Name: Consultant/HCP Responsible for Care Common Name: Consultant/HCP Priority: M Definition: The consultant/healthcare professional (HCP) is the person who carries clinical responsibility for the patient’s healthcare during an episode. This is usually a consultant but may be another healthcare professional, for example a midwife or GP. Recording Rules: 1. Consultant/HCP must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The Consultant/HCP code must be in a valid format. 3. If the healthcare professional is not known when the patient is added to the waiting list a dummy code must be used to identify whether the HCP is a doctor (9999998), dentist (D999999), nurse (99X9999X) or allied health professional (XX999999). Only these dummy codes are valid. Format: Field length: 8 characters The consultant/HCP code must be 6, 7 or 8 characters in length and must agree with any of the following data formats: nnnnnn nnnnnnn Dnnnnnn nncnnnnc ccnnnnnn where n = any number (0-9), c = any letter (A-Z) & D = letter “D”. Points to Note: 1. A Specialist Registrar’s code number (if available to coding clerks) must not be used in lieu of the Consultant Code number. Use of Information: Identifies whether new outpatient is subject to Waiting Time standard. Cross Checks: None.

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GEN13 Formal Name: Patient Category Common Name: Patient Cat Priority: M Definition: Patient (administrative) category refers to a patient’s status regarding payment for NHS services. Recording Rules: 1. Patient category must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. If an overseas visitor has opted to become a private patient, code 2 should be used. 3. Code 2 should be used where the patient pays for all or part of their treatment. 4. Patients referred by a court for NHS psychiatric assessment where the court pays should be recorded as ‘NHS’ code 3 rather than ‘Paying’ code 2. Format: Coded – 1 character CATEGORY CODE Amenity 1 Paying 2 NHS 3 Overseas visitor – liable to pay for treatment 4 Overseas visitor – not liable to pay (reciprocal arrangements)

5

Special arrangements 7 Other (including Hospice) 8

Points to Note: None. Use of Information: Identifies whether patient is subject to Waiting Time standard or guarantee. Cross Checks:

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GEN14 Formal Name: Referral Source Common Name: Referral Source Priority: S for new outpatients Definition: A source of referral category is a broad category of organisation and/or professionals who may make a referral, for example consultant in another provider unit, self etc. Recording Rules: 1. Referral source should be recorded for new outpatients. 2. NHS24 (code N) should only be used if the waiting times standard (WT4) is AHP MSK. This code is for referrals through the Musculoskeletal (MSK) Advice and Triage Service (MATS). Format: Coded - 1 character REFERRAL SOURCE CODE Community health service (excludes Optometrist/Optician) 0 GP 1 Consultant at this provider unit 2 Consultant from another provider unit in this NHS Board 3 Consultant from a provider unit out with NHS Board 4 Self referral 5 Prison/penal establishments 6 Judicial 7 Local authority/ voluntary agency 8 Other (include Armed Forces) 9 A&E department A Optometrist/Optician B Dental practitioner D NHS24 N

Points to Note: 1. Self Referral (code 5) includes self, relations, friends and carers. 2. Community health service (code 0) should be recorded as the source of referral for cataract patients. Use of Information: Cross Checks: None.

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GEN15 Formal Name: Provider code Common Name: Provider Code Priority: M Definition: The Provider Code should be directly linked to the Location Code, i.e. the Provider Code should relate to the actual physical location where the treatment is expected to take place. Recording Rules: 1. Provider code must be recorded for new outpatients, inpatients, day cases and return outpatients for procedure. 2. The precise location details may not be known when the patient is first added to the waiting list, so this necessitates the recording of Provider Code on all records to indicate the expected NHS Board area where the appointment or admission will take place. Records should be updated when more detail is known or plans change in advance of admission or attendance. Format: Field length: 5 characters Points to Note: 1. This rule has implications when it is known that patients will definitely be treated out with their own NHS Board area in that a provider code other than the default home NHS Board code must be recorded. This situation will invariably occur for a range of specialist services, such as cardiac surgery, angioplasty and neurophysiology. 2. Information on funding or clinical input will be available via other data items, such as postcode and health care professional or other data sources, such as SMR01. Use of Information: 1. Provider code will be used to derive the NHS Board of treatment. Cross Checks: None.

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GEN16 Formal Name: Main Condition Common Name: Diagnosis 1 Priority: M for inpatients, day cases and return outpatients for procedure Definition: This item should describe the main medical (or social) condition managed or investigated during the patient’s stay. Recording Rules: 1. Main condition must be recorded for inpatients, day cases and return outpatients for procedure. 2. The main condition is the condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation. If there is more than one such condition, the one held responsible for the greatest use of resources should be selected. If no diagnosis was made, the main symptom, abnormal finding, or problem should be selected as the main condition. 3. Must be a valid code at 3 or 4 character level on the ICD10 reference table. Format: Coded – ICD10 code Points to Note: 1. If the main condition is an injury or other condition due to an external cause, the injury or condition should be entered as the main condition (GEN16) with the external cause coded second as other condition (GEN17). Use of Information: Cross Checks: None.

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GEN17 Formal Name: Other Condition Common Name: Diagnosis 2 Priority: M for inpatients, day cases and return outpatients for procedure Definition: In addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of healthcare. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient. Conditions related to an earlier episode that have no bearing on the current episode should not be recorded. Recording Rules: 1. Other condition must be recorded for inpatients, day cases and return outpatients for procedure. 2. Only one other condition can be recorded. 3. Must be a valid code at 3 or 4 character level on the ICD10 reference table. Format: Coded – ICD10 code Points to Note: None. Use of Information: Cross Checks: 1. A main condition (GEN16) must be recorded before the other condition (GEN17) field can be completed.

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GEN18 Formal Name: Procedure, Main Operation/Treatment/Investigative Procedure Common Name: Operation 1 Priority: M for inpatients, day cases and return outpatients for procedure Definition: The main operation should be specified in the appropriate place in the case notes by the clinician. Guidance should be sought from medical staff if there is difficulty in identifying the main operation. Recording Rules: 1. Main Operation must be recorded for inpatients, day cases and return outpatients for procedure. 2. Must be a valid code at 3 or 4 character level on the OPCS4 reference table. Format: Coded - OPCS code Points to Note: 1. It is important that the waiting record includes information about the procedure that the patient is waiting for. It is acknowledged that the precise details may not be known when the patient is first added to the waiting list, therefore 3 character OPCS4 codes will be acceptable in these circumstances. 2. Records should be updated when more detail is known or an operation is changed in advance of admission or attendance. There is no requirement to amend records if the detail changes after the patient has been removed from the waiting list and has attended or been admitted for treatment. Use of Information: Cross Checks: None.

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Data Collection Waiting records are created from when a patient is added to the Patient Administration System (PAS). Data is collected from the point of referral for all new outpatients, and from the date the decision is made to add the patient to the waiting list for inpatients, day cases and return outpatients for procedure. Separate waiting records are created for new outpatients and for inpatients, day cases and return outpatients. These records are built up as the patient progresses through their waiting journey, and end when the patient is removed from the waiting list. An update to a record should be submitted when a change has been made to any item in the dataset. Recording Rules Offers of Appointments or Admission Every offer of appointment or admission made to the patient should be recorded, and should include: § the type of offer (WT6), e.g. whether it is written, verbal or a PFB letter of invitation § the date the offer or invitation (WT7) was made § the date of the actual appointment (WT8) being offered § the location (GEN10) of the actual appointment offered

The response of each offer made and PFB letter of invitation must be recorded, including: § the date of receipt of the response (WT9) from the patient § the offer outcome (WT10), e.g. whether it was acceptable, not acceptable, or the

outcome of the PFB invitation, e.g. patient responded or did not respond Where no response is received to an offer, the offer outcome (WT10) would be either new offer given/to be given (code 80) or patient removed from list (code 90). Non-attendance If a patient contacts the hospital to reschedule their admission or appointment date, assuming a reasonable offer of appointment or admission has been accepted, the date of the CNA must always be recorded with additional explanatory text as required. If the patient does not report for treatment, with no prior discussion, the date of the DNA must be recorded with additional explanatory text as required. Where a patient is unable to or does not attend, or where the hospital cancels the appointment or admission, the information recorded against the appointment/offer will include: § non-attendance date (WT17), this is either the date the patient cancelled the

appointment or the date the patient did not attend, or the date of the appointment or admission that the hospital cancelled

§ non-attendance category (WT16) and additional information (WT18) can be added if required

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§ non-attendance outcome (WT19) to identify whether the patient was retained or removed from the list

Unavailability For all periods of unavailability the information recorded will include: § the start date of the period (WT20) § the end date of the period, where this is known (WT24) § the reason for unavailability (WT21)

Unavailability and Patient Focused Booking For outpatients and diagnostics, a period of unavailability can also be applied to Patient Focused Booking (PFB). Under PFB the patient should be allowed at least one week to respond to the initial invite to contact the hospital. If no contact has been made after this time, the waiting time clock can be paused by entering an unavailability start date. At this point a reminder letter should be sent to the patient. The waiting time clock restarts when the patient makes contact and an appointment date is arranged, when unavailability end date can be entered. PFB should only be applied twice at most and each PFB unavailability period must last for up to 7 days only. Calculation of Waiting Time The patient’s waiting time is calculated as the difference between the referral received date (WT2) for new outpatients or the waiting list date (WT3) for inpatients, day cases and return outpatients for procedure, and the removal date (WT27). The length of time the patient waits will be affected by any unavailability and/or clock resets. If these circumstances occur, the patient’s waiting time is adjusted to account for this. Adjustments to the patient’s waiting time are not made after the wait has exceeded 84 days. Further information on Calculation of Wait available on secure area of ISD website. Waiting Time - Declining an Offer of an Appointment If the patient declines a reasonable offer (i.e. 2 or more different dates of appointment where there is at least 7 days notice between the offer date (WT7) and the appointment/admission date (WT8)), their waiting time clock may be reset to zero, if it is reasonable and clinically appropriate to do so, from the date on which the last offer was declined, not the date of the offered appointment. Note that for a ‘reasonable offer’ to be declined, the patient needs to decline each date. Where the two or more dates of appointment or admission offers are made separately e.g. when one offer is made in writing and the patient is asked to phone in if they require a different date, the date the second offer was declined would be the date that the waiting time clock is reset to zero, where it is reasonable and clinically appropriate to do so. Declining a reasonable offer subsequent to an 84 day wait will not result in a clock reset.

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Waiting Time - Non-attendance Could Not Attend (CNA) When the patient cancels an agreed appointment the waiting time clock is reset to zero, if it is reasonable and clinically appropriate to do so, from the date of cancellation, not the date of the planned appointment or admission. Non Attendance subsequent to an 84 day wait will not result in a clock reset. Did Not Attend (DNA) In circumstances where the hospital clinician wishes the patient to be offered another appointment or admission date, the waiting time clock will be reset to zero, if it is reasonable and clinically appropriate to do so, from the original date of the appointment or admission and the patient should be made another ‘reasonable offer’. Non Attendance subsequent to an 84 day wait will not result in a clock reset. Cancelled by the Service The patient’s waiting time clock should not be affected in any way if the appointment is cancelled by the service.

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National Data Submission Data Extraction and Validation Data will be extracted from local Patient Administration System's (PAS), at a frequency agreed with each NHS Board, and validated centrally by ISD. The data will then 'sit' within the national Data Warehouse. This central approach has been adopted to minimise the burden of local extraction of data, and by validating centrally, the data extracted will be able to be managed in a more consistent way than was previously possible. Any errors identified at central validation will be reported back to the submitting NHS Board. Even though there is central validation NHS Boards should continue to carry out local validation using the validation rules provided, before submitting their waiting times data for upload. Partial episodes starting from when the patient is first added to a waiting list or date of receipt of referral for new outpatients, should be submitted. Coverage The following groups of patients, even if those patients only experience a short wait, must be entered on to the local PAS to enable monitoring of waiting times: § All new outpatient referrals § All elective day case and inpatients § All outpatients returning for a procedure

Data for other services (e.g. Allied Health Professionals (AHP's), nurse led clinics, mental health services) can also be extracted if details are entered on to systems and included in the extract that goes into the national data warehouse. Types of Records An extract should only include three types of records: § Insert – for new records, § Amend – for subsequent updates to a record, and § Delete - for records that are deleted from the PAS (note that this is not a closure of

this record but a physical deletion). Access to Data NHS Boards will have almost immediate access to any data that they submit using the Waiting Times Business Objects Universe. The Caldicott Guardian, or designated officer, is to be responsible for managing access levels for users within individual organisations. Quality Assurance of Waiting Times Data NHS Boards may find it necessary to view the extracted data for quality assurance purposes prior to inclusion in the analysis environment for national reporting. Scheduling of the data

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extract should therefore be timetabled to give the maximum time for any quality assurance deemed necessary. In addition to local quality assurance ISD will undertake a national quality assurance project to ensure that the processes outlined in this document are being adopted across Scotland.

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Appendix A: List of Data Items Key: WT Items that are specific to waiting times measurement GEN Items that are generic which are used to support waiting times measurement Reference Data Item WT1 Referral Date WT2 Referral Received Date WT3 Waiting List Date WT4 Waiting Time Standard WT5 Urgency Category WT6 Offer Type WT7 Offer Date WT8 Appt/Admission Date WT9 Response Received Date WT10 Offer Outcome WT11 Availability for Appt/Admission at Short Notice WT12 Minimum Days Notice Required Appt/Admission WT13 Suitability of Patient to Be Considered Part of Pooled List WT14 Patient Willing to Change Clinician WT15 Patient Willing to Change Health Board WT16 Non-Attendance Category WT17 Non-Attendance Date WT18 Explanatory Text or Code (for non-attendance) WT19 Non-Attendance Outcome WT20 Unavailability Start Date WT21 Unavailability Type WT22 Explanatory Text or Code (for Unavailability) WT23 Planned Review Date WT24 Unavailability End Date WT25 Review Date WT26 Review Outcome WT27 Removal Date WT28 Removal Reason WT29 Patient Status WT30 Patient Type WT31 Referrer Urgency Category GEN1 Surname GEN2 Forename GEN3 Date of Birth GEN4 Gender GEN5 CHI GEN6 Case Reference Number GEN7 Postcode GEN8 Ethnic Group GEN9 GP Practice Code GEN10 Location GEN11 Specialty GEN12 Consultant/HCP GEN13 Patient Category

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GEN14 Referral Source GEN15 Provider Code GEN16 Main Condition GEN17 Other Condition GEN18 Main Operation

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Documents

Waiting Times Recording Manual - isdscotland.org · This recording manual is designed to cover the 18 weeks Referral to Treatment standard, the ‘New Ways’ Stage of Treatment standard,