Health-care incident—clinical service context, code N[N]

Identifying and definitional attributes

• Health, Standard 07/12/2011

Value domain attributes

Representational attributes

Source and reference attributes

Data element attributes

Collection and usage attributes

Only one code may be selected for this data element.

Where the incident occurred in a hospital, the name of the hospital department in which the incident occurred may provide the most appropriate description of the clinical service context. In many cases, the clinical service context will reflect the specialty of the main clinician treating the patient, but this will not always be the case. For example, where a patient is treated in the Emergency department by a gynaecologist, Code 1 ‘Emergency department’ should be recorded.

Where the ‘Primary incident or allegation type’ is ‘Anaesthetic’, the code chosen for this item should relate to the main procedure that was being carried out, in the context of which the anaesthetic was being administered. Note that complications arising from the anaesthetic administration should not be used as the basis for selecting a category, for example broken teeth as a complication should not be coded as ‘Dentistry’.

Where none of the other codes apply, select Code 88 'Other' and enter a brief description of the relevant clinical service area as described in the data element Health-care incident—clinical service context, text X[X(39)]. Code 88 supersedes Code 21 previously used in historical data.

CODE 2   Cardiology

'Cardiology' excludes cardio-thoracic surgery.

CODE 3   Dentistry

'Dentistry' excludes oral and maxillofacial surgery.

CODE 8   General surgery

'General surgery' is used for all operations performed by surgeons and procedural general practitioners. Circumcision should also be included in this category.

CODE 9   Gynaecology

'Gynaecology' should only be recorded when the patient is female.

CODE 11   Neurology

'Neurology' excludes neurosurgery.

CODE 12   Obstetrics

'Obstetrics' should only be recorded when the patient is a baby (less than 1 year old) or a female of childbearing age.

CODE 13   Oncology

'Oncology' includes radiotherapy or nuclear medicine and gynae–oncology.

CODE 15   Paediatrics

'Paediatrics' excludes neonatology.

CODE 16   Perinatology (including neonatology)

'Perinatology (including neonatology)' is only recorded where the health-care incident that is the basis for the medical indemnity claim occurred shortly before or shortly after the birth of the patient.

CODE 24   Community-based care

'Community-based care' includes community care, hospital in the home, district nursing, and care delivered in nursing homes.

CODE 29   Pathology

'Pathology' includes cytology and tissue retention disputes.

CODE 30   Public health

'Public health' includes vaccination and screening programs, for example, Breastscreen.

CODE 88   Other

'Other' should be selected when none of the more specific codes above apply.

CODE 97   Not applicable

'Not applicable' covers claims for health-care incidents which lack an identifiable clinical service context, for instance incidents in a hospital’s public access areas or complaints against disclosure of a patient’s medical records.

CODE 99   Not stated/inadequately described

'Not stated/inadequately described' should be used when the information is not currently available. Not stated/inadequately described should not be used when a medical indemnity claim is closed.

Source and reference attributes

Relational attributes