Diabetes Retinopathy Extension Dataset

Transcription

1 For reference only Do Not Use For more information contact: Diabetes Retinopathy Extension Dataset March 2006 National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: to: NCDDPsupportteam@isd.csa.scot.nhs.uk Website:

2 Contents 1. Patient Administration and Demographics...4 Patient Administration and Demographics Table Ethnic, Cultural and Diversity Details...5 Ethnic, Cultural and Diversity Details Table General Medical Practitioner Details...5 General Medical Practitioner Details Table Associated Professional Details...6 Associated Professional Details Table Class of Retinopathy Grader Diagnosis Details...7 Diagnosis Details Table Care Episode Administration Details...8 Care Episode Administration Details Table Review Date Appointment Type {Diabetes Retinopathy} Patient Status (Diabetic Retinopathy Screening) Date Temporarily Suspended Until (Diabetic Retinopathy Screening) Reason for Suspension (Diabetic Retinopathy Screening) Location Preferred (Diabetic Retinopathy Screening) Attendance Time Preferred (Diabetic Retinopathy Screening) Eye Clinic Attendance (Diabetic Retinopathy Screening) Quality Assurance Details...12 Quality Assurance Details Table Retinopathy Grading Referral Error (Quality Assurance) Date of Retinal Grading (Quality Assurance) Assessment and Management...13 Assessment and Management Table Image Capture Details...13 Image Capture Details Table Pupil Dilation Status Mydriatic Drug Batch Number Mydriatic Drug Expiry Date Retinal Screening Camera Number Retinal Image Status Image Interpretation Details...16 Image Interpretation Details Table Fundus Assessment Retinal Grading Date Diabetic Retinopathy Image Quality Diabetic Retinopathy Image Grading Status Microaneurysms Flame Haemorrhages Diabetes Retinopathy Extension Dataset 2

3 10.7 Cotton Wool Spots Blot Haemorrhages Venous Beading Intra-retinal Microvascular Abnormalities Vessels Elsewhere Vessels at Disc Vitreous Haemorrhages Retinal Detachment Exudates Blot Haemorrhages within 1 Disc Diameter Macular Oedema Cataract Details...24 Cataract Details Table Cataract Causing Disability Cataract Surgery Recommendation Cataract Surgery Decision Cataract Surgery Status Visual Acuity Details...26 Visual Acuity Details Table Visual Acuity Obtained Outcomes Details...27 Outcomes Details Table Retinopathy Grading Outcome Retinopathy Grading Outcome - Overwrite Non-diabetic Retinal Lesions Grader Referral Non-diabetic Retinal Lesions Final Grader Referral Ophthalmic Exam Details...29 Ophthalmic Exam Details Table Date Referred to Ophthalmologist Ophthalmology Outcome for Retinopathy Screening Programme Ophthalmic Exam Recommendation Ophthalmic Exam Recommendation Accepted Date...31 Date Table Appendix 1 - Membership of the Diabetes Retinopathy Dataset Clinical Working Group...32 Appendix 2 - Consultation Distribution List...33 Diabetes Retinopathy Extension Dataset 3

4 1. Patient Administration and Demographics Patient Administration and Demographics Table Data Item Definition Format & Field Length Structured Name 1 - Person Title - Person Family Name - Person Given Name - Person Preferred Forename - Previous Person Family Name An ordered sequence of person name elements such as title, forename(s) and family name. 35 characters (each) Person Full Name 1 (Unstructured) Person Current Gender Person Birth Date CHI Number Health Record Identifier Address (BS7666) 2 UK Postal Address 2 Postcode 2 UK Telephone Number This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned). The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. 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. A Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS. A collection of data describing the addressing of locations. Alternatively, address can be recorded in up to 5 lines of unstructured text (minimum 2 lines). The code allocated by the Post Office to identify a group of postal delivery points. A minimum standard is provided for holding a UK STD code. An extended set of component parts is provided for systems to hold more information. 70 characters 1 character 10 characters (CCYY- MM-DD) 10 characters 14 characters See Government Data Standards Website 5x35 characters 8 characters 35 characters Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary. 1 It is recommended that Structured Name should be used in all new IT systems. Person Full Name (Unstructured) should only be used in legacy systems, which should migrate to use of Structured Name in due course. 2 It is recommended that Address (BS7666), which is a structured address, should be used in all new IT systems. Unstructured UK Postal Address plus Postcode should only be used in legacy systems, which should migrate to use of Address (BS7666) in due course. Diabetes Retinopathy Extension Dataset 4

5 2. Ethnic, Cultural and Diversity Details Ethnic, Cultural and Diversity Details Table Data Item Description Format & Field Length Ethnic Group (Self-Assigned) A statement made by the service user 3 characters about their current ethnic group. Religion A statement made by the service user 6 (2+4) characters about their current religious affiliation / faith community. Preferred Language This data item is defined as the 6 characters person s language of preference and may differ from first language (as defined as the language spoken at home) and is required for effective communication with the person. Interpretation Assistance Indicator Indication of requirement for assistance to communicate in English. Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary. 3. General Medical Practitioner Details General Medical Practitioner Details Table Data Item Definition Format & Field Length Registered GP Practice Code Each GP practice in Scotland is 6 characters identified by a unique GP practice code. General Practice Registration Status of Patient The registration status of the patient with the general practice from which they are receiving care. 3 characters Note: All of the above data items have already been approved and are available in the Health & Social Care Data Dictionary. Diabetes Retinopathy Extension Dataset 5

6 4. Associated Professional Details Associated Professional Details Table Data Item Definition Format & Field Length Associated Professional Associated Professionals are Detailed in this table those individuals who are involved with the client/ patient in a professional capacity e.g. consultant, social worker, occupational therapist, etc. Structured Name - Title - Surname/ Family Name - First Forename An ordered sequence of person name elements such as title, forename(s) and family name. 35 characters Person Full Name (Unstructured) Associated Professional Identifier This alternative to recording structured name involves the whole name being recorded as a single character string with no separately identified elements. The unique identifier issued to all health and social care professionals by their professional regulatory body. 70 characters 8 characters Class of Retinopathy Grader For Consultation The above data items have already been approved and are available in the Health & Social Care Data Dictionary. 4.1 Class of Retinopathy Grader Definition: The level of grader grading the images, as defined by the national occupational standards for retinopathy screening. Explanatory Notes 00 Not Applicable 01 Level 1 Grader A level 1 grader, as defined by the national occupational standards for retinopathy screening, will grade images for image quality and the presence or absence of diabetic retinopathy. Images with any retinopathy (whatever level) will be passed on to the level 2 grader. The level 1 grader should have undergone a recognised and accredited training programme. Level 1 grading could, in some circumstances, be performed by camera operators who have received sufficient training. In due course it is hoped the level 1 grading role will be performed by automated grading systems. Diabetes Retinopathy Extension Dataset 6

7 02 Level 2 Grader A level 2 grader, as defined by the national occupational standards for retinopathy screening, will be presented with a list of images that have been referred by a level 1 grader. Level 2 graders will be required to undergo a more intensive training programme which has been recognised and accredited. Level 2 grading could, in some circumstances, be performed by camera operators who have received sufficient training The purpose of level 2 grading is to identify sight threatening retinopathy and other retinal problems that may be amenable to treatment. Such images will be passed on to the level 3 grader for final assessment. 03 Level 3 Grader A level 3 grader, as defined by the national occupational standards for retinopathy screening, will be presented with a list of images that have been referred by a level 2 grader. Level 3 graders (who usually but not necessarily will be ophthalmologists) confirm or refute the need for referral to ophthalmology. Related data items: See Associated Professional Details Table 5. Diagnosis Details Diagnosis Details Table Data Item Definition Format & Field Length Date of Diagnosis For Future Development 10 characters (CCYY- MM-DD) Diabetes Mellitus Type For Consultation see Diabetes Core Further information on this data item can be found in the Diabetes Core Data Standards. Diabetes Retinopathy Extension Dataset 7

8 6. Care Episode Administration Details Care Episode Administration Details Table Data Item Definition Format & Field Length Location Code A location is any building or set of 5 characters buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/ client s home. Clinic Code A code assigned locally to identify a 9 characters clinic session or group of clinic sessions. Date of Contact The date on which a contact took place between a patient/ client and an 10 characters (CCYY- MM-DD) individual care professional for the purpose of care. A contact can take place when the Health Care Professional (HCP) is on care premises or visiting the patient and may be in person, by telephone, e- mail, letter, text message or telemedicine. Contact Status A record of whether or not the patient/ client attended for their appointment or was present for a planned home visit. Eye Examination Method For Consultation see Diabetes Core Review Date For Consultation 10 characters (CCYY- MM-DD) Appointment Type For Consultation {Diabetes Retinopathy} Patient Status (Diabetic For Consultation Retinopathy Screening) Date Temporarily Suspended Until (Diabetic Retinopathy Screening) Reason for Suspension (Diabetic Retinopathy Screening) Location Preferred (Diabetic Retinopathy Screening) Attendance Time Preferred (Diabetic Retinopathy Screening) Eye Clinic Attendance (Diabetic Retinopathy Screening) Transport Access For Consultation For Consultation For Consultation For Consultation For Consultation The means of transport used by the patient in order to access care services. This includes aspects of the mode of transport and dependency upon another person. 10 characters (CCYY- MM-DD) 198 characters The above data items have already been approved and are available in the Health & Social Care Data Dictionary. Further information on this data item can be found in the Diabetes Core Data Standards. Diabetes Retinopathy Extension Dataset 8

9 6.1 Review Date Definition: The date of the next scheduled contact between the patient and the care professional, team or service. This is a date planned for the future and may not necessarily happen. (CCYY-MM-DD) Field length: 10 N/A 6.2 Appointment Type {Diabetes Retinopathy} Definition: Records the type of Diabetic Retinopathy Screening programme (DRSP) appointment made for the patient st Screening Appointment 02 6 Month Recall Month Recall 04 Recall for Slit-lamp Biomicroscopy 6 Month 05 Recall for Slit-lamp Biomicroscopy 12 Month 06 Ophthalmology 6.3 Patient Status (Diabetic Retinopathy Screening) Definition: Records the activity for the patient that is associated with delivering a result and outcome from the Diabetic Retinopathy Screening Programme (DRSP). 01 Ready for Screening 02 Invited 03 Booked 04 DNA 05 Examination Started 06 Awaiting Result Diabetes Retinopathy Extension Dataset 9

10 07 Temporarily Suspended 08 Permanently Suspended 6.4 Date Temporarily Suspended Until (Diabetic Retinopathy Screening) Definition: Records the date until when temporary suspension from the Diabetic retinopathy Screening Programme is valid. (CCYY-MM-DD) Field length: 10 N/A Related data item: Reason for Suspension (Diabetic Retinopathy Screening) 6.5 Reason for Suspension (Diabetic Retinopathy Screening) Definition: Records the reason for suspending the patient from the Diabetic Retinopathy Screening Programme. 01 Registered Blind 02 Deceased 03 Under Age 04 Unfit 05 Consent Not Given 06 Eye Clinic Patient 07 Lives Abroad 08 Lives Elsewhere 09 Unable to Cooperate 10 Not Diabetic 11 DNA X3 98 Other Related data item: Date Temporarily Suspended Until (Diabetic Retinopathy Screening) Recording guidance: Where 98 Other is recorded, systems may be configured to include a text box to allow specification of the Reason for Suspension. Diabetes Retinopathy Extension Dataset 10

11 6.6 Location Preferred (Diabetic Retinopathy Screening) Definition: Records the patient s preferred attendance location for a Diabetic Retinopathy Screening appointment. Field length: 198 N/A 6.7 Attendance Time Preferred (Diabetic Retinopathy Screening) Definition: Records the patient s preferred attendance time for a Diabetic Retinopathy Screening appointment. 01 Weekday 02 Evening 03 Saturday Morning 04 No Preference 6.8 Eye Clinic Attendance (Diabetic Retinopathy Screening) Definition: Records whether or not the patient is attending a diabetic retinopathy eye clinic. 01 No 02 Yes Diabetes Retinopathy Extension Dataset 11

12 7. Quality Assurance Details Quality Assurance Details Table Data Item Definition Format & Field Length Retinopathy Grading Referral For Consultation Error (Quality Assurance) Date of Retinal Grading (Quality Assurance) For Consultation 10 characters (CCYY- MM-DD) 7.1 Retinopathy Grading Referral Error (Quality Assurance) Definition: Records the type of error identified in the Retinopathy grading process as part of quality assurance. Explanatory Notes 00 No Error Noted in the Quality Assurance re-grader agrees with original grading. Referral Process 01 Level 1 Grader Failed to Notice Signs of No Quality Assurance re-grader identifies 'no retinopathy' [R0] which was not identified by level 1 grader. Retinopathy 02 Level 1 Grader Failed to Quality Assurance re-grader identifies retinopathy, which Notice Signs of Retinopathy 03 Level 1 Grader Failed to Refer for Slit Lamp Examination 04 Level 2 Grader Failed to Notice Signs of No Retinopathy 05 Level 2 Grader Failed to Notice Signs of Observable Retinopathy/ Maculopathy 06 Level 2 Grader Failed to Notice Signs of Referable Retinopathy 07 Level 2 Grader Failed to Refer for Slit Lamp Examination 08 Level 3 Grader Failed to Notice Signs of No Retinopathy was not identified by level 1 grader. Quality Assurance re-grader identifies poor image quality/technical failure, which should have been referred for slit-lamp examination by level 1 grader. Quality Assurance re-grader identifies 'no retinopathy' [R0] which was not identified by level 2 grader. Quality Assurance re-grader identifies mild retinopathy [R1], observable retinopathy [R2] or observable maculopathy [M1], which was not identified by level 2 grader. Quality Assurance re-grader identifies referable maculopathy [M2], referable retinopathy [R3], proliferative retinopathy [R4] or other referable condition, which was not identified by level 2 grader. Quality Assurance re-grader identifies poor image quality/technical failure, which should have been referred for slit-lamp examination by level 2 grader. Quality Assurance re-grader identifies 'no retinopathy' [R0] which was not identified by level 3 grader. Diabetes Retinopathy Extension Dataset 12

13 09 Level 3 Grader Failed to Notice Signs of Observable Retinopathy/ Maculopathy 10 Level 3 Grader Failed to Notice Signs of Referable Retinopathy 11 Level 3 Grader Failed to Identify Other Condition Requiring Action Quality Assurance re-grader identifies mild retinopathy [R1], observable retinopathy [R2] or observable maculopathy [M1], which was not identified by level 3 grader. Quality Assurance re-grader identifies referable maculopathy [M2], referable retinopathy [R3], proliferative retinopathy [R4] or other referable condition, which was not identified by level 3 grader. Quality Assurance re-grader identifies coincidental findings/non-diabetic retinopathy condition requiring action that level 3 grader failed to identify. 7.2 Date of Retinal Grading (Quality Assurance) Definition: Indicates the date when retinal grading is repeated as part of the quality assurance process of the screening programme. (CCYY-MM-DD) Field length: 10 N/A 8. Assessment and Management Assessment and Management Table Data Item Definition Format & Field Length Diabetes Care Type For Consultation see Diabetes Core Diabetes Management The type(s) of management of a patient's diabetes. The above data item has already been approved and is available in the Health & Social Care Data Dictionary. Further information on this data item can be found in the Diabetes Core Data Standards. 9. Image Capture Details Image Capture Details Table Data Item Definition Format & Field Length Pupil Dilation Status For Consultation Mydriatic Drug Batch For Consultation 4 characters Number Mydriatic Drug Expiry Date For Consultation 7 characters (CCYY- MM) Retinal Screening Camera Number For Consultation 4 characters Diabetes Retinopathy Extension Dataset 13

14 Retinal Image Status For Consultation 3 characters 9.1 Pupil Dilation Status Definition: Records whether or not a mydriatic drug was used during the Diabetic Retinopathy Screening and if so, which drug was used. Subcode Sub-value Explanatory notes 00 Pupils Undilated No Mydriatic drug used. 01 Pupils Dilated A 1% Tropicamide Note that this is the drug of choice for DRSP (0.5% Tropicamide is not recommended). B 1% Cyclopentolate Some people may be allergic to tropicamide and may be given cyclopentolate as an alternative. C 0.05% Proxymetacaine Related data items: Mydriatic Drug Batch Number Mydriatic Drug Expiry Date 9.2 Mydriatic Drug Batch Number Definition: The batch number of the Mydriatic drug used, as printed on the drug packaging. Field length: 4 N/A Related data items: Pupil Dilation Status Mydriatic Drug Expiry Date 9.3 Mydriatic Drug Expiry Date Definition: The expiry date of the Mydriatic drug used, as printed on the drug packaging. (CCYY-MM) Field length: 7 Diabetes Retinopathy Extension Dataset 14

15 N/A Related data items: Pupil Dilation Status Mydriatic Drug Batch Number 9.4 Retinal Screening Camera Number Definition: The reference number of the camera used in the retinal screening programme. Field length: 4 N/A Further Information: NHS board identifier 1 character plus 3 digits starting at Retinal Image Status Definition: Records whether or not a retinal image of the eye was captured and if not, the reason why not. Field length: 3 Subcode Sub-value Explanatory notes 00 No A Patient Factor Patient was not able to comply with photographic process. B Operator Error Photographer failed to follow correct procedure for obtaining digital image. C Equipment Failure Digital imaging equipment failed to perform. D Blind or Enucleated 01 Yes Diabetes Retinopathy Extension Dataset 15

16 10. Image Interpretation Details Image Interpretation Details Table Data Item Definition Format & Field Length Fundus Assessment For Consultation Retinal Grading Date For Consultation 10 characters (CCYY- MM-DD) Diabetic Retinopathy Image For Consultation Quality Diabetic Retinopathy Image For Consultation Grading Status Microaneurysms For Consultation Flame Haemorrhages For Consultation Cotton Wool Spots For Consultation Blot Haemorrhages For Consultation 3 characters Venous Beading For Consultation Intra-retinal Microvascular For Consultation Abnormalities Vessels Elsewhere For Consultation 3 characters Vessels at Disc For Consultation 3 characters Vitreous Haemorrhages For Consultation Retinal Detachment For Consultation Exudates For Consultation Blot Haemorrhages within 1 For Consultation Disc Diameter Macular Oedema For Consultation Non-diabetic Retinal For Consultation see Diabetes Lesions Core Laser Photocoagulation Scars (Grading Exam) For Consultation see Diabetes Core Further information on these data items can be found in the Diabetes Core Data Standards Fundus Assessment Definition: Records the result of the fundus assessment. 01 Fundus Gradable 02 Fundus Not Gradable 03 Unscreenable 04 Blind/ Enucleated Diabetes Retinopathy Extension Dataset 16

17 10.2 Retinal Grading Date Definition: Records the date on which the retinal grading was performed. (CCYY-MM-DD) Field length: 10 N/A 10.3 Diabetic Retinopathy Image Quality Definition: Records the quality of image. Explanatory notes 01 Image Quality Grade 1 Nerve fibre layer visible this is the best quality image. 02 Image Quality Grade 2 Nerve fibre layer not visible. 03 Image Quality Grade 3 Small vessels blurred. 04 Image Quality Grade 4 Major arcade vessels just blurred. 05 Image Quality Grade 5 Significant blurring of major arcade vessels in >1/3 of image in the absence of visible reference retinopathy. Patient is deemed a technical failure (patient factor) and has to be screened using slit-lamp biomicroscopy at a separate technical failure screening session. 06 Image Quality Grade 6 Enucleated eye. Patient is not classed as a technical failure despite only one eye's images being available for grading. Further information: The image quality grading is consistent with Facey et al (2002) Organisation of services for diabetic retinopathy screening Health Technology Assessment Report 1. Glasgow: Health Technology Board for Scotland. Diabetes Retinopathy Extension Dataset 17

18 10.4 Diabetic Retinopathy Image Grading Status Definition: The status of the grading process relating to digital images following Diabetic Retinopathy Screening. Explanatory notes 00 Not Yet Graded The digital image has not been graded. 01 Level 1 Graded, Referred for Level 2 Grading The digital image has been graded by a level 1 grader and referred for level 2 assessment. 02 Level 2 Graded, Referred for Level 3 Grading The digital image has been graded by a level 2 grader and referred for level 3 assessment. 03 Final Graded The digital image has been graded to final level. This may be reached by any level of grader as appropriate to the clinical findings. 04 Ungradable The digital image is not of gradable quality and the patient has been referred for slit lamp examination Microaneurysms Definition: Records whether or not there are microaneurysms in the eye. 00 No 01 Yes Diabetes Retinopathy Extension Dataset 18

19 10.6 Flame Haemorrhages Definition: Records whether or not there are flame haemorrhages in the eye. 00 No 01 Yes 10.7 Cotton Wool Spots Definition: Records whether or not there are cotton wool spots in the eye. 00 No 01 Yes 10.8 Blot Haemorrhages Definition: Records whether or not there are blot haemorrhages in the eye and if so, the quantity in each hemi-field. Field length: 3 Diabetes Retinopathy Extension Dataset 19

20 Subcode Sub-value Explanatory notes 00 No 01 Yes A < 4 in One Hemi-field Only In one hemi-field the fundal area covered by retinal haemorrhages < AH standard photograph 2a. B < 4 in Both Hemi-fields In both hemi-fields the fundal area covered by retinal haemorrhages < AH standard photograph 2a. C 4 in One Hemi-field Only In one hemi-field the fundal area covered by retinal haemorrhages AH standard photograph 2a. D 4 in Both Hemi-fields In both hemi-fields the fundal area covered by retinal haemorrhages AH standard photograph 2a Venous Beading Definition: Records whether or not there is venous beading in the eye. Explanatory notes 00 No 01 Yes Venous beading AH standard photograph 6a Intra-retinal Microvascular Abnormalities Definition: Records whether or not there are intra-retinal microvascular abnormalities (IRMA) in the eye. Diabetes Retinopathy Extension Dataset 20

21 Explanatory notes 00 No 01 Yes IRMA AH standard photograph 8a Vessels Elsewhere Definition: Records whether or not there are vessels elsewhere in the eye, other than at the disc and whether they are active or inactive. Field length: 3 Subcode 00 No 01 Yes A B Sub-value Active Inactive Vessels at Disc Definition: Records whether or not there are vessels at the disc in the eye and whether they are active or inactive. Field length: 3 Subcode 00 No 01 Yes A B Sub-value Active Inactive Diabetes Retinopathy Extension Dataset 21

22 10.13 Vitreous Haemorrhages Definition: Records whether or not there are vitreous haemorrhages in the eye. 00 No 01 Yes Retinal Detachment Definition: Records whether or not there is any retinal detachment in the eye. 00 No 01 Yes Exudates Definition: Records the occurrence of exudates in the eye. 01 > 1 but 2 Disc Diameters 02 Within a Radius of 1 Disc Diameter Diabetes Retinopathy Extension Dataset 22

23 10.16 Blot Haemorrhages within 1 Disc Diameter Definition: Records whether or not there are blot haemorrhages present within 1 disc diameter in the eye. 00 No 01 Yes Macular Oedema Definition: Records the occurrence of macular oedema in the eye. 01 > 1 but </= 2 Disc Diameters 02 Within a Radius of </= 1 Disc Diameter Diabetes Retinopathy Extension Dataset 23

24 11. Cataract Details Cataract Details Table Data Item Definition Format & Field Length Cataract Status For Consultation see Diabetes Core Cataract Causing Disability For Consultation Cataract Surgery For Consultation Recommendation Cataract Surgery Decision For Consultation Cataract Surgery Status For Consultation Further information on this data item can be found in the Diabetes Core Data Standards Cataract Causing Disability Definition: Records whether or not the cataract present causes visual function limitation. Explanatory notes 01 No Patient may have a cataract in left eye, but does not report consequent visual functional limitation. 02 Yes Patient has cataract in left eye and reports consequent visual functional limitation Cataract Surgery Recommendation Definition: Records whether or not cataract surgery is recommended for either or both eyes. Explanatory notes 01 Referral for Cataract Surgery Recommended Cataract surgery clinically indicated and recommended. 02 Referral for Cataract Surgery not Indicated Cataract not clinically indicated. Related data item: Diabetes Retinopathy Extension Dataset 24

25 Cataract Surgery Decision 11.3 Cataract Surgery Decision Definition: Records the decision of the patient regarding referral for cataract surgery. Explanatory notes 01 Agrees to Referral for Cataract Surgery Patient offered referral for cataract surgery and agrees. 02 Referral for Cataract Surgery Declined Patient offered referral for cataract surgery but declined. Related data item: Cataract Surgery Recommendation 11.4 Cataract Surgery Status Definition: Records whether or not the patient is listed for cataract surgery. 00 Patient not listed for surgery 01 Patient listed for surgery Diabetes Retinopathy Extension Dataset 25

26 12. Visual Acuity Details Visual Acuity Details Table Data Item Definition Format & Field Length Visual Acuity Obtained For Consultation Visual Acuity (Logmar) - For Consultation see Diabetes Corrected Core Visual Acuity (Snellen) - Corrected For Consultation see Diabetes Core Further information on these data items can be found in the Diabetes Core Data Standards Visual Acuity Obtained Definition: Records how the patient can obtain visual acuity. 01 Unaided 02 Spectacles 03 Contact Lens 04 Pin Hole 05 Acuity Unobtainable Diabetes Retinopathy Extension Dataset 26

27 13. Outcomes Details Outcomes Details Table Data Item Definition Format & Field Length Retinal Status {Diabetes} For Consultation see Diabetes Core Diabetic Maculopathy For Consultation see Diabetes Status Core Retinopathy Grading For Consultation Outcome Retinopathy Grading For Consultation Outcome Overwrite Non-diabetic Retinal Lesions For Consultation Grader Referral Non-diabetic Retinal Lesions Final Grader Referral For Consultation 3 characters Further information on these data items can be found in the Diabetes Core Data Standards Retinopathy Grading Outcome Definition: Records the overall grading outcome or recommendations as a result of the diabetic retinopathy screening. 01 Rescreen 12 Months 02 Rescreen 6 Months 03 Refer Ophthalmology 04 Technical Failure Related data item: Retinopathy Grading Outcome - Overwrite Further Information: Where each eye has a different grading outcome, the overall outcome recorded is that for the worse eye Retinopathy Grading Outcome - Overwrite Definition: The overwritten outcome or recommendations by the level 3 grader. Diabetes Retinopathy Extension Dataset 27

28 Subcode Sub-value 01 Fundus Photography A 6 Months Rescreen B 12 Months 02 Slit Lamp Rescreen A 6 Months B 12 Months 03 Refer for Ophthalmology for Diabetic Retinopathy 04 Fast Track Referral Related data item: Retinopathy Grading Outcome 13.3 Non-diabetic Retinal Lesions Grader Referral Definition: Records whether or not a level 1 or level 2 Grader refers to the next level of Grader for non-diabetic Retinopathy feature issues. 00 No 01 Yes 13.4 Non-diabetic Retinal Lesions Final Grader Referral Definition: Records whether or not the level 3 Grader refers the patient for non-diabetic retinopathy issues. Field length: 3 Subcode 00 No 01 Yes A B Sub-value Refer to Ophthalmology Refer to Elsewhere Diabetes Retinopathy Extension Dataset 28

29 14. Ophthalmic Exam Details Ophthalmic Exam Details Table Data Item Definition Format & Field Length Date Referred to Ophthalmologist For Consultation 10 characters (CCYY- MM-DD) Ophthalmology Outcome for For Consultation Retinopathy Screening Programme Ophthalmic Exam For Consultation Recommendation Ophthalmic Exam Recommendation Accepted For Consultation 14.1 Date Referred to Ophthalmologist Definition: Records the date on which a referral is made for the patient to attend an ophthalmologist. (CCYY-MM-DD) Field length: 10 N/A 14.2 Ophthalmology Outcome for Retinopathy Screening Programme Definition: The outcome following an examination by an ophthalmologist. Subcode Sub-value 01 Fundus Photography A 6 Months Rescreen B 12 Months 02 Slit Lamp Rescreen A 6 Months B 12 Months 03 Continued Ophthalmology Review Diabetes Retinopathy Extension Dataset 29

30 14.3 Ophthalmic Exam Recommendation Definition: Type of treatment recommended following ophthalmic exam. 01 Pan Retinal Photocoagulation (PRP) 02 Macular Grid 03 Macula Focal 04 VitreoRetinal (VR) Surgery 98 Other Related data item: Ophthalmic Exam Recommendation Accepted Recording guidance: Where 98 Other is recorded, systems may be configured to include a text box to allow specification of the Ophthalmic Exam Recommendation Ophthalmic Exam Recommendation Accepted Definition: Records whether or not the type of treatment recommended following an ophthalmic exam is accepted. 00 No 01 Yes Related data item: Ophthalmic Exam Recommendation Diabetes Retinopathy Extension Dataset 30

31 15. Date Date Table Data Item Definition Format & Field Length Date The day, month, year and century, or truncated combination of these elements, of an event. 10 characters (CCYY- MM-DD, CCYY-MM or CCYY) Note: The above data item has already been approved and is available in the Health & Social Care Data Dictionary. Diabetes Retinopathy Extension Dataset 31

32 Appendix 1 - Membership of the Diabetes Retinopathy Dataset Clinical Working Group Nicola O Keefe(chair) Angela Ellingford David Cromie Fiona Heggie Ginny Shapter Lorraine Cowie Michael Craig Ross Paterson Ruby Sloan Sam Philip Richmond Davies Dieter Arnold Gillian Cameron Hans-Dieter Schuell Diabetes Retinopathy Extension Dataset 32

33 Appendix 2 - Consultation Distribution List Diabetes Managed Clinical Networks (Scotland) NCDDP Stakeholders Centre for Change & Innovation (CCI) Clinical ehealth Leads Health & Social Care Information Centre, Datasets Development Programme (England) Improving Mental Health Information Programme Information Services Division, NSS Information Standards Group NHS Quality Improvement Scotland Royal College of General Practitioners (Scotland) Royal College of Nursing (Scotland) Royal College of Physicians Royal College of Physicians and Surgeons Glasgow Royal College of Physicians, London Royal College of Surgeons Scottish Care Information (SCI) Scottish Clinical Information Management Practice (SCIMP) Scottish Executive Data Standards Branch Scottish Intercollegiate Guidelines Network Scottish Executive Health Department NCDDP Diabetes Clinical Working Groups Diabetes Core Diabetes Secondary Care Extension Diabetes Paediatric Extension Diabetes Specialist Nursing Extension Diabetes Dietetics Extension Diabetes Retinopathy Extension Diabetes Foot Care Extension Diabetes Retinopathy Extension Dataset 33