The Maternity Inpatient and Day Case dataset (SMR02) collects episode level data every time a mother goes in for an obstetric event (this can be an antenatal, delivery or postnatal episode).

MDW Discover  > Maternity Inpatient and Day Case - Scottish Morbidity Record (SMR02) @ 81

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https://publichealthscotland.scot/services/data-research-and-innovation-services/electronic-data-research-and-innovation-service-edris/overview/what-is-edris/

https://www.researchdata.scot/media/cbtlmdox/maternity-inpatient-and-day-case-scottish-morbidity-record-smr02-variables.pdf

Scottish Morbidity Record 02 (SMR02) is submitted by maternity hospitals to ISD, who have collected this information since 1975.

A wide range of information is collected on the SMR02 - for example:

Mother - age, height, smoking history, previous obstetric history.
Birth - induction, analgesia, method of delivery, outcome.
Baby - apgar score, sex, gestation, weight.

HDR UK

Definition

Priority (as below)

A contract identifier is a code which identifies each health care contract. It is a three part code:

Provider code
Purchaser code
Contract number which uniquely identifies the contract between the contracting parties


Provider Code (5 characters) - Priority Mandatory

This is a UK national code which uniquely identifies a Health Board/Health Care Provider which is an organisation acting as a direct provider of health care services. It is a legal entity, or a subset thereof, which may contract for the provision of health care, and it may operate in one or more locations within and outside hospitals.

Points to Note

When completing the provider code on ISD returns, the code of the Health Board/Health Care Provider which actually provides clinical services must be recorded.
Example
If a consultant from Health Board/Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care on outreach basis (i.e. continues to be employed by Health Board/Health Care Provider A), recorded provider should be Health Board/Health Care Provider A.

If a consultant from Health Board/ Health Care Provider A visits the premises of Health Board/Health Care Provider B to provide care and Health Board/Health Care Provider B pays for this work either directly to the consultant or to Health Board/Health Care Provider A, the consultant is thought of as temporarily employed by Health Board/Health Care Provider B and the recorded provider should be Health Board/Health Care Provider B.

Cross Checks

Must be valid provider code.

Purchaser Code (5 characters) - Priority Optional

This is a UK national code which uniquely identifies a health care organisation that commissions health care services on behalf of its residents or patients, e.g. a Health Board which is responsible for commissioning comprehensive healthcare services for its residents.

Points to Note

This field may be blank.
Cross Checks

If Purchaser Code is present, then it must be a valid code and will be validated against the organisation reference file.

Contract Number (6 characters) - Priority Local

This is an alphanumeric code which uniquely identifies the contract between the contracting parties.

Points to Note

This field may be blank.
Contract Identifier
Contract Identifier (which consists of 16 characters) should be entered thus:

Provider (first 5 digits), Purchaser (next five digits), Contract Number (final six digits).

Contract Identifier

Development Data

This section is reserved to be used for the collection of data items which are being piloted and evaluated, for specific epidemiological/ clinical research projects, and for short term surveys.

This may be used for local purposes, and for agreed national projects.

Development Data Section

Definition

Priority Optional (up to four allowed, two on forms)

Some interest was shown during the consultative process in the USA developments of disease staging, originally developed to classify oncology patients and now extended to all diseases typically seen in hospital inpatient and outpatient care. It allows the noting of increased severity based on the spread of the disease and the presence of complications. The Disease Category codes (3 characters) and Disease Stage codes (3 characters) area relate currently to ICD9-CM and DRG codes. They can be related to "resource" measures and "outcome" measures.

They are indicative of the possible use of the SMR Dataset for experimental and developmental purposes, and space has been allowed for these, or other, codes such as Read codes. Up to 4 codes have been included, each of up to 6 characters.

Severity Measures

Definition

Priority Local

These fields together uniquely identify the invoice and the line within that invoice into which the charge for this patient has been aggregated.

Invoice Number and Invoice Line

Definition

Priority Optional (up to four allowed, two on forms)

Interest was shown during the consultative process in the use of dependency measures particularly in the areas of Geriatric Long Stay (SMR Record Type 50) and Mental Health (SMR Record Type 04). Optional provision has therefore been made in the SMR Dataset for the future, or extended, use of such dependency measures as used with the Scottish Health Resource Utilisation Groups (SHRUGS), which involve the collection of data on patient characteristics at defined intervals during the period of care.

For example, with Geriatric Long Stay (SHRUGS), patient characteristics are collected from care staff who know the patient well, defined in terms of need for special care, clinically complex conditions or treatments, behavioural difficulties, and personal dependency. An algorithm is used to determine a resource use group for each patient on the basis of these characteristics.

With Mental Health (using the Dependency and Needs Information System, DANIS), similar data is collected, including major sustained training needs, complex nursing care needed, clinically complex treatments or conditions, and behavioural difficulties.

Provision has been made in the SMR Dataset for the developmental use of these measures. Up to four measures have been included, each with up to six characters, to allow for a variety of codes that may be used.

Dependency Measures

Definition

Priority Optional

Patient care events occur at different points in time; some are discrete, and some may need to be associated with others, for example, for budgeting or contracting for 'care packages' across inpatient and outpatient episodes, and for the evaluation and monitoring of the efficiency of care.

It is proposed that a separate code be included for the overall clinical problem associated with an episode, a group of episodes, or a 'care package'. For example, a diabetes condition may result in episodes associated with vascular and ophthalmological disease.

Up to six characters have been included, so as to allow for Read or ICD10 codes. The ways in which this data item may be used for 'care packages' will depend upon the definition and characteristics of such packages as agreed by Providers and Purchasers for different Specialties.

Clinical Problem Identifier for Spell/Care Package

Definition

Priority Optional (up to four allowed, two on forms)

The consultative process indicated that Optional provision should be allowed for the future recording of lifestyle factors of interest to particular Specialties.

These are those factors inherent in a patient's way of living that may have a significant effect on their propensity to ill health or the likely success of treatment. These may include the degree of smoking, alcohol, or drug abuse, diet, exercise, and other factors indicated in the ICD10 Z chapter, or relevant Read codes.

Up to four such factors have been included, with up to six characters per factor, to allow for the use of ICD10 or Read codes.

Lifestyle Factors

Definition

Priority Local

This field allows further mapping of the contracted service within a contract for invoice verification, where the database in use uses this construct. It should be left blank where there is only one contracted service under the contract.

Contract Service Number

Definition

Priority Local

A patient is chronically sick or disabled if he/she is blind, deaf or dumb, or is substantially and permanently handicapped by illness, injury, or congenital deformity.

This is recorded at the time of admission and it is used under the Chronically Sick and Disabled Persons Act 1970 to record the number of such people who are accommodated inappropriately, e.g. admitted to or resident in wards intended for elderly people.

This data item may be of value for specific clinical or contracting purposes within certain Specialties.

Chronic Sick/Disabled

Definition

Priority Optional (up to four allowed, two on forms)

During the consultative process it was noted that there was a strong interest from Purchasers and Providers in developing the use of outcome measures related to the individual patient episode. It was also noted that these had not yet been sufficiently developed, and could include the following:

"general" outcome measures, such as mortality within specific periods after discharge, readmission rates (to the same or other hospitals), discharges to home or other institution, and reoperation rates, etc. (These are best able to be analysed at present using the ISD SMR Record Linked database, and will be significantly extended by the SMR Dataset.)
"medium term" outcome measures, related to specific Specialties, that could only be followed up after a specified period after discharge, through follow-up appointments or by communication with the GP.
"on discharge" outcome measures, which relate the assessment on admission of the patient with the result of the treatment or operation during the period of care that the patient was under the responsibility of a particular Consultant, Department, or Hospital. This would include infection rates.
The Clinical Outcomes Working Group of CRAG (Clinical Resource and Audit Group) are proposing national guidelines and a continuing development programme for specific clinical outcome measures.

Optional provision has been made in the SMR Dataset for up to four measures to be recorded for each episode, each of up to six characters, to allow for a variety of codes, including Read codes.

Outcome Measures

Definition

Priority Local

This is the charge applicable to this patient episode.

The last five fields indicated above (Contract Service Number to Contract Charge) are optional. The way in which they are used will be dependent upon local arrangements between Providers and Commissioners as part of their contract management reporting arrangements.

Contract Charge

Definition

Priority Local

Diagnostic Related Groups (DRG) or Health Resource Groups (HRG) may not necessarily be part of the information available following local processing of the SMR data. If the DRG/HRG is required in the contract assignments process, then arrangements have to be made locally for grouping software to be run against the ICD10 and OPCS4 coding to produce the DRG/HRG.

Iso-resource Group

Field Length
20

Priority
Mandatory

Definition
The surname of a person represents that part of the name of a person which indicates the family group of which the person is part.

It should be noted that in Western culture this is normally the latter part of the name of a person. However, this is not necessarily true of all cultures. This will, of course, give rise to some problems in the representation of the name. This is resolved by including with the name a preferred name format indicating amongst other things the order of various parts of the name.

Recording Rules

Surname should be entered in the character spaces provided. CAPITAL LETTERS should be used and the item left justified.
Hyphens or apostrophes occurring within a name should be entered as a separate character (but not as a first character).
Double-barrelled surnames should be entered with a hyphen between the two parts of the surname, whether or not the patient normally uses a hyphen.
In the very rare circumstances when the surname is not known, the first two character spaces should be filled with "X".

Examples
S	M	I	T	H															
D	U	R	H	A	M	-	J	O	N	E	S								
O	-	H	A	R	A														
X	X																		
Points to Note

A surname must have at least one alphabetic character.
Space for up to 20 characters is provided; it is recommended that the full 20 characters be allowed in use for future systems development.
Where a patient requires to remain anonymous, a pseudo-name, such as A N Other, should be used.

Based on UK Government Data Standards Catalogue: BSEN 7372:1993
Cross Checks
None.

SMR Validation - Surname

Surname

Patient Identification and Demographic Information

ormat
Characters

Field Length
4

Priority
Local

Definition
A health records system identifier is a code which identifies a health records system.

Cross Checks
None.

SMR Validation - Health Records System Identifier


Related items:

Health Records System
Tags:
code  SMR00  SMR01  SMR02  SMR04

Health Records System Identifier

Format
Characters

Field Length
13

Priority
Optional

Definition
A unique identifier allocated to new referrals to a consultant led service, to enable identification of patient pathways.

Points to Note

The UCPN was initiated by the 18 Weeks RTT team and was first used by SCI Gateway Referrals in September 2009.
A UCPN should be generated for all source referrals made to a Consultant led service.
Where referrals are not received via SCI Gateway, local systems should generate a UCPN.
The format of the UCPN was defined by the SCI Gateway as SSS999999999C.
“SSS” is a 3 character alphanumeric System Source Identifiers (SSI), assigned by ISD.
“999999999” is a 9 digit sequential number.
“C” is a check digit/character calculated on the preceding 12 characters.
ISD maintains a National Reference File of System Source Identifiers (SSIs) and provides Health Boards with these codes on request.
When one referral is received with more than one referring complaint then the primary referring complaint should keep the UCPN received from SCI Gateway. This should be managed as one pathway. Further referring complaints should each have a UCPN generated by the local system. These should be managed as separate pathways, i.e. that patient has two (or more) concurrent 18 Week RTT pathways.
One UCPN may be recorded on a single SMR return.
The UCPN will be used to link SMR00 and SMR01 datasets and will enable the tracking of patients as they move between consultants, specialties, hospital settings (outpatient to inpatient) and Health Boards and will not be used by ISD for the purpose of measuring 18wRTT.
See the following site for further information: Unique Care Pathway Number (UCPN) - FAQs
E-Health
Cross Checks
None.

SMR Validation - UCPN

Tags:
identifier  referrals  consultant.  patient  pathway  led  service  system  source  SCI  gateway  ssi  National  Reference  File  SMR00  SMR01  SMR02  SMR04

Unique Care Pathway Number (UCPN)

Format
Characters

Field Length
10

Priority
Mandatory

Common Name(s)
Patient Identifier, Case Reference Number, CRN, Hospital Number

Main Source of Standard
Scottish Executive Health Department

Definition
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

Recording Rules
Note: If more than 10 characters are required for the Health Record Identifier, ISD should be contacted for advice.

A Health Record Identifier should be recorded on every record - advice should be sought from your Medical Records Manager if no Health Record Identifier is available.

Example 1: 6 digits or less - The first 6 character spaces should be used. Enter preceding zeros to make the number up to 6 digits e.g. 1234 = 001234

Example 2: 7 digits or more - The number should be entered starting from the left and leaving no spaces between digits. Unused character spaces should be left blank, e.g. PT123432 = PT123432
Points to Note

Where the CHI is used as the HRI, please continue to record this number in both the HRI and CHI fields.
Cross Checks
None.

SMR Validation - Patient Health Record Identifier

Tags:
patient  health  number  unique  register  SMR00  SMR01  SMR02  SMR04

Health Record Identifier

Format
Characters

Field Length
20

Priority
Optional

Definition
A second and/or middle name that some people have between their first name and surname.

Recording Rules

If the patient does not have a second forename, leave this item blank. Otherwise complete exactly as specified for first forename.
Points to Note

Made up of Second Initial and Second Forename (remainder).
Cross Checks
None

SMR Validation - Second Forename

Tags:
name  middle  surname  patient  identifier  SMR00  SMR01  SMR02  SMR04

Second Forename

Format
Date (ddmmccyy)

Field Length
8

Priority
Mandatory

Definition
The date on which a person was born or is officially deemed to have been born as recorded on their birth certificate.

Recording Rules
Date of birth should be entered thus:

9th February 1942
0	9	0	2	1	9	4	2
All dates must consist of eight digits by entering preceding zeros for single digits in day, month or year.

Patients age only is available
- year of birth should be calculated and day and month infilled with zero, thus:

Age 25 (in 1999): therefore year of birth = (1999-25) = 1974

0	0	0	0	1	9	7	4
Age not known
- if all avenues have been explored and neither date of birth nor age is available then the clinicians or nursing staffs estimate of age should be used to calculate year of birth. If this is not possible, refer to your Medical Records Manager

Estimated Age 27 (in 1999): therefore estimated year of birth = (1999-27) = 1972

0	0	0	0	1	9	7	2
Points to Note

The Date of Birth is allocated 8 digits to record the full year of birth.
Cross checks

Age (and consequently the Date of Birth) is an important data item and is used in a number of cross-checks, e.g.
Specialty
Diagnoses
Admission /Transfer From
Discharge/ Transfer To
Referral Received Date (SMR00 Only)
Date of Birth is also checked to be in sequence with the other dates recorded. To view sequence of dates checks please refer to Date Sequences
Date of Birth must be less than date of admission for all record types (except SMR01, where Date of Birth can equal date of admission when Significant Facility is 11 or 16).
Date of Birth may equal date of clinic or date of referral for SMR00.
SMR01 and 04, and age on admission is greater than 100 years, the record will be queried
If record is SMR02, and age on admission is less than 10 or greater than 50, the record will be queried.
If record is SMR04, and age on admission is less than 1 year, the record will be queried.
For SMR01 where specialty is AB (Geriatrics), and age on admission is less than 49 and Significant Facility is not 18, the record will be queried.
If record type is SMR01 and Specialty is AF (Paediatrics), CA (Paediatric Surgery) or D8 (Paediatric Dentistry), and age on admission is 18 or over, the record will be queried
Age is also checked with diagnoses, e.g
Senile Dementia - The current check will generate a query if the patient is less than 55 years of age.
Similarly childhood diagnoses will generate a query if the patient is greater than 16 years of age.
SMR Validation - Date of Birth

Tags:

Date of Birth

Format
Characters (right justified)

Field Length
6

Priority
Mandatory

Common names
Registered GP Practice

Definition
Registered 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 Health Board.
(Scottish Morbidity Record - NHS Information Services)

Recording Rules

A standard 5 digit numerical code has been developed for the whole of Scotland. It comprises a 4 digit identifying code, which is within an agreed range for each Health Board, and a check digit.
It is the Practice Code of the patients registered GP which is recorded in this field
It should be noted that the GP Practice code in England is 6 characters long.
The General Practice code should be right justified, with the first character a space, unless it is a valid GP Practice Code from outwith Scotland.
Points to Note

Practice code will be used to provide information to GMPs on referral activity.
The Practice Code on the patients referral or attendance should be record. If a patient changes GP practice between referral and attendance, the new Practice Code should be recorded.
Dummy practice codes are held in the reference files and are hard coded for validation. These codes are:
99942 - Patients registered with a private practice only
99957 - Patients not registered with a GP in the UK
99961 - Patients where practice code is unknown and who are not covered by codes 99942, 99957, 99976, 99981, 99995 and 99961
99976 - British armed forces patients not registered with a GP in the UK
99981 - Foreign visitors not registered with a GP in Scotland
99995 - Patients registered with a GP in England, Wales or Northern Ireland (excluding patients included under code 99942)
GPPC is not validated for SMR00 or SMR01 records from Dental Hospitals (G106H, S206H, T113H).
Cross Checks

If it is a Scottish GPPC it must be a valid practice code which is open on the clinic date (SMR00), date of arrival (SMR30) or admission date (all other record types).
If it is a practice outwith Scotland it must be a valid code on the "Rest of UK" practice reference file.
Further Information
It should be noted that patients are no longer registered with an individual GP, but with a practice.

In NHS Scotland, the practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board. ISD maintains a GP Practice code reference file which contains up to date details of address, postcode, telephone number for each GP Practice in Scotland.

In England and Wales, the field is 6 digits therefore to accommodate cross border patient flows, this should be taken into account.

SMR Validation - General Practitioner Practice Code
Tags:
general  medical  practitioner  services  registered  GMP  SMR00  SMR01  SMR02  SMR04

General Practitioner Practice Code (GPPC)

Format
Characters

Field Length
8

Priority
Mandatory

Definition
The postcode is a basic unit for identifying geographic locations. A postcode is associated with each address in the UK..

Postcode Format
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 postmans walk.

Points to Note
Postcodes for Scotland

The instructions for determining a postcode given at the front of the Postcode Directories should be followed and the Postcodes entered in the spaces provided, and left justified. There should be no embedded blanks.
Postcodes as written have two parts. The first part, consisting of one or two letters and one or two numbers identifies the Post Town and Postal district. The second part, consisting of one number and two letters, identifies the Postcode Sector and postmans walk.
The postcode of the patients usual address should be entered wherever possible. If only a temporary address is known, then this should be coded.
If a postcode cannot be found using the Postcode Directory, the appropriate Postcode Enquiry office should be contacted.
Address not known. Where a patients address is not known (but the patient is not of "no fixed abode"), and all reasonable means of attempting to trace the address have been exhausted, the dummy postcode "NK01 0AA" should be used. The use of this postcode will always be queried.
The querying of postcodes valid to sector level was discontinued on 1st April 1998. The whole postcode must be valid to be accepted; if not an error will be produced.
Local Government District Dummy Postcodes can no longer be entered.
The postcode must be recorded in full
A list of all valid postcodes in Scotland, together with the permitted dummy postcodes, is held on the computer files at ISD.
If the full Postcode is not on the reference file, the record will be flagged with an error message and the postcode must be corrected.
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.
Cross Checks (applicable to SMR only)

If postcode is OS14AA, OS16AA, OS17AA, OS18AA, then Category of Patient should be 4 or 5 (i.e. overseas visitors). If not, the record will be queried.
From 1st April 2000 if postcode is BF01 0AA and the category of patient is not 3 (NHS), the record will be queried.
SMR Validation - Postcode

Tags:
geographic  locations  address  outcode  incode  postal  area  district  SMR00  SMR01  SMR02  SMR04

Postcode

Format
Characters

Field Length
10

Priority
Optional (SMR only)
Mandatory (A&E only)
Main Source of Standard
Scottish Government.

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.

Points to Note

Where the CHI is used as the Health Record Identifier (Case Reference Number), please continue to record this number in both the HRI and CHI fields.
Cross Checks
None.

Further Information

The Community Health Index is a register of all patients in NHS Scotland. CHI Index contains details of all Scottish residents and exists to ensure that patients can be correctly identified, and that relevant information pertaining to a patients health is available to providers of care.

The CHI number is a unique is a 10-character numeric identifier, allocated to each patient on first registration with the system.

The CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records.

Although there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications.

Non-Scottish patients and other temporary residents can have a CHI number allocated if required.

Should it be required patients can contact their GP Surgery in the first instance for their individual CHI Number.

See also - Baby CHI – Babies 1 to 3

SMR Validation - Community Health Index

Tags:
community  health  index  population  register  identifier  patient  allocation  status  SMR00  SMR01  SMR02  SMR04  scotland  records  individual  hospital

Marital Status

Format
Characters

Field Length
10

Priority
Local

Definition
An alternative patient identifier used locally e.g. Local case note reference for merged case notes..

Recording Rules
This is a local item. Local guidance will be given concerning the completion of this field. Examples of use may be in departmental indexing of records.

Points to Note

This field may have been used in the past to record a patients CHI number. In the SMR Dataset a separate field is now available to record CHI.
This field should NOT be used to record CHI numbers
Cross Checks
None.

SMR Validation - No Validation.

Tags:
local  guidance  field  indexing  CHI  patient  identifier  SMR00  SMR01  SMR02  SMR04

Alternative Case Reference Number

Format
Characters

Field Length
20

Priority
Mandatory

Definition
The first forename of a person represents that part of the name of a person which after the surname, is the principal identifier of a person

Recording Rules

Where only the initial letter of the first forename is available this should be entered in the first character space.
In the very rare circumstances where the first forename is not known "X" should be entered in the first character space.
Where the full forename is available the remainder of the forename should be entered in the character spaces provided, using CAPITAL LETTERS.
Hyphens occurring within a forename should be given a separate character space
Notes
Based on UK Government Data Standards Catalogue: BSEN 7372:1993

Cross Checks
None

SMR Validation - First-Forename

Related items:

Person Name
Previous Name
Previous Surname
Surname
Tags:
name  surname  principal  identifier  patient  SMR00  SMR01  SMR02  SMR04

First Forename

Format
Characters

Field Length
4

Priority
Local

Definition
A health records system identifier is a code which identifies a health records system.

Cross Checks
None.

SMR Validation - Health Records System Identifier


Related items:

Health Records System
Tags:
code  SMR00  SMR01  SMR02  SMR04

NHS Number

Format
Characters

Field Length
2

Priority
Optional

Definition
Ethnic group classifies the person according to their own perceived ethnic group and cultural background. (Scotland Census)

Points to Note

This is included as an Optional item, but may be made Mandatory at a later date in order to conform to UK-wide requirements.
This is the patients perception of his or her own ethnic group, and is intended to assist the monitoring of equality of access to NHS services..
For the A&E datamart, please ensure this data item is as complete as possible
Cross Checks
None.

Notes
The following list is the current ethnicity classification (2011 Census categories). This should be used by NHS Scotland organisations for local and SMR return purposes. Local systems may record more detailed codes as required but these must map to the categories for SMR return purposes.

The letters that appear in the group headings in the codes and value list refer to positions in the census list and are not valid SMR codes. Please only use the codes in the code list (1A, 1B etc.).

Codes and Values: Ethnic Group (Code order)

Group A - White
1A Scottish
1B Other British
1C Irish
1K Gypsy/ Traveller
1L Polish
1Z Other white ethnic group

Group B - Mixed or multiple ethnic groups
2A Any mixed or multiple ethnic groups

Group C - Asian, Asian Scottish or Asian British
3F Pakistani, Pakistani Scottish or Pakistani British
3G Indian, Indian Scottish or Indian British
3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British
3J Chinese, Chinese Scottish or Chinese British
3Z Other Asian, Asian Scottish or Asian British

Group D - African
4D African, African Scottish or African British
4Y Other African

Group E - Caribbean or Black
5C Caribbean, Caribbean Scottish or Caribbean British
5D Black, Black Scottish or Black British
5Y Other Caribbean or Black

Group F - Other ethnic group
6A Arab, Arab Scottish or Arab British
6Z Other ethnic group

Group G - Refused/Not provided by patient
98 Refused/Not provided by patient

Group H - Not Known
99 Not Known

SMR Validation - Ethnic Group

Tags:
ethnicity  classification  census  person  perceived  cultural  background  categories  SMR00  SMR01  SMR02  SMR04

Ethnic Group

Format
Characters

Field Length
20

Priority
Optional

Definition
This is any surname by which a person was previously known.

Recording Rules

It may be used for Maiden Surname for married females including those widowed, divorced or separated; or for Birth Name and Alternative name, where these are required. Where several surnames are known for a patient, it is recommended that Birth Surname should be entered as previous surname. This item also applies to any person, including males, who have changed their surname (e.g. by deed poll).
This data item has been retained primarily for maternity and record linkage purposes until a unique identifier is available.
Points to Note

This information is required to assist in the matching of an individual patients records
This item must not be used to record the birth surnames of adopted children.
For SMR02 (Maternity) this field should be used to record Maiden Surname.
Cross Checks
None.

SMR Validation - Previous Surname

Tags:
previously  known  maiden  surname  birth  alternative  deed  poll  maternity  patient  identifier  SMR00  SMR01  SMR02  SMR04

Previous Surname

Format
Characters

Field Length
10

Priority
Local

Definition
The NHS number is the identifier allocated to an individual to enable unique identification within the UK for NHS health care purposes.

Recording Rules

This field should be left blank for Scottish Residents until further instructions are issued.
This is the new NHS Number which was implemented by the NHS in England and Wales in April 1997 and will be required to be held by Scottish health care systems for English or Welsh patients.
The CHI number will eventually be the NHS Number for Scottish patients.
The first digit of the NHS Number in England and Wales will be 4 or greater.
Points to Note
None.

Cross Checks
None.

SMR Validation - NHS Number

Tags:
identifier  allocated  individual  unique  health  care  UK  england  wales  SMR00  SMR01  SMR02  SMR04

Community Health Index (CHI) Number

Format
Characters (right justified)

Field Length
8

Priority
Local

Definition
The GMC (General Medical Council) number is the personal identification number issued to each doctor in the UK by the General Medical Council.

Recording Rules

If this item is to be completed, it is the General Medical Council registration number (GMC number) of the referring Doctor or Dentist which should be used.
The GMC number can consist of 7 numeric or L + 6 numeric. The L format is used for limited registrations, usually overseas doctors, and in time this number could be changed to a permanent number, usually 7 numeric.
The General Dental Council (GDC) Number consists of D + 6 numeric.
The 8 digit personal identification number (PIN) allocated to Nurses and other Allied Healthcare Professionals (AHP) is used as the Nurse/AHP code. In the case of a nurse the PIN consists of an 8 character alpha/numeric code, although this format may differ for other AHPs (e.g. Podiatrists).
The GMC/GDC/PIN number should be right justified in the eight character spaces provided.
From April 2020 this data item was no longer required for national collection on SMR00.
Points to Note

The referring Doctor may not belong to the patients registered GP Practice.
Cross Checks
None.

SMR Validation - GMC Number

Tags:
general  medical  council  personal  identification  doctor  AHP  registered  bodies  number  dentist  nurse  SMR00  SMR01  SMR02  SMR04

GMC No of Referring Doctor/Dentist/Nurse/Allied Healthcare Professional

Format
Characters

Field Length
1

Priority
Optional

Definition
An indicator to identify the legal marital or civil status of a person.

Points to Note

Code Y - OTHER should be used for cohabiting or stable relationships.
Code Z - NOT KNOWN should be reserved for rare occasions such as:-
* the patient refuses to divulge it
* the patient has left the hospital before it could be recorded.
Cross Checks
None.

Codes and Values: (code order)

A Never married nor registered civil partnership
B Married
C Registered civil partnership
D Separated, but still married
E Separated, but still in civil partnership
F Divorced
G Dissolved civil partnership
H Widowed
J Surviving civil partner
Y Other
Z Not known
SMR Validation - Marital Status

Tags:
legal  person  patient  identifier  married  divorced  civil  partnership  widowed  SMR00  SMR01  SMR02  SMR04

Field Length
6

Priority
Conditional

Definition
The date on which the baby is delivered.

Recording Rules
The Date of Delivery should be entered thus:

10 November 2004

1	0	1	1	0	4
Points to Note

For multiple births, the date of the first delivery should be entered.
Cross Checks

All dates on SMR02 are checked to ensure that they are in the correct sequence. In this case, the Date of Delivery must be the same or before the Date of Discharge.
Date of Delivery is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).
SMR Validation - Delivery Date


Related items:

Condition on Discharge
Tags:
birth  baby  SMR02

Date of Delivery

An SMR02 is generated for patients receiving care in the Obstetrics Specialties/ Health Professions listed when the following events occur:

Inpatients and Day Cases are admitted to NHS hospitals from locations external to the NHS.
Inpatients and Day Cases are admitted to contracted NHS beds in non-NHS institutions.
Inpatients and Day Cases change specialty/health profession (with or without a change of consultant).
Transfers between Midwifery and Obstetrics specialties are excluded.

An inpatient transfers to become an Inpatient in Obstetrics or Midwifery in the same hospital.
Inpatient becomes a Day Case in Obstetrics or Midwifery during the inpatient stay.
A Day Case transfers to become an Inpatient in Obstetrics or Midwifery (except when the Day Case episode is during an Obstetric or Midwifery inpatient stay and the patient is transferring back to the original consultant/midwife).
A Day Case transfers back to resume an Obstetric or Midwifery Inpatient stay but does NOT transfer back to the original consultant/midwife for medical reasons.
Inpatients and Day Cases transfer from another NHS hospital (including contracted NHS beds in non-NHS institutions).
Inpatients and Day Cases change consultant/midwife for medical reasons within the same specialty.
An inpatient transfers as an Inpatient to the care of a different consultant/ midwife for medical reasons in the same specialty in the same hospital.
An inpatient becomes a Day Case in the same specialty under a different consultant/midwife for medical reasons during the inpatient stay.
A Day Case transfers to become an Inpatient under the care of a different consultant in the same specialty for medical reasons (except when the Day Case episode is during an Obstetric or Midwifery inpatient stay and the patient is transferring back to the original consultant/midwife).
A Day Case transfers back to resume an Inpatient stay in the same specialty but does NOT transfer back to the original consultant/midwife for medical reasons.
Inpatients return to hospital having been on pass for more than 5 days.
Inpatients move into and/or out of one of the valid significant facilities.
Inpatients and Day Cases are admitted to hospital for a postnatal episode, following a planned or unplanned home delivery.
Please note
Home births (planned and unplanned) should be recorded on SMR02.

Note: Items in bold denote the patient type of the further SMR record generated by the transfers described in these categories.

Maternity Inpatient and Day Case

Field Length
1

Priority
Conditional

Definition
This denotes the type of location to which the patient is re-designated for delivery following a change of type of location in her DELIVERY PLAN.

Points to Note

Emergencies causing:
· a transfer from the original hospital to another during labour
· emergency admissions because of premature labour to another hospital

do not fall into the category of a Booking Change and Code 8 should be recorded for these cases.
Cross Checks

Booking Change - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).
Booking Change - Place is cross-checked with all other Proposals for Delivery fields.
Codes and Values: Location Code - SMR02 (Code order)
0 Home Birth
1 Consultant Unit
2 GP Unit
3 Midwife Unit
7 No change
8 Not booked/Other
9 Not known

SMR Validation - Booking Change - Place


Related items:

Condition on Discharge
Delivery Plan - Place
Original Booking
Tags:
location  type  patient  transfer  hospital  labour  delivery  plan  SMR02  consultant  GP  midwife  unit

Booking change - Place

Field Length
2

Priority
Mandatory

Definition
Number of units of alcohol consumed in the course of a typical week. One unit is defined as half a pint of normal beer or one pub measure of spirits or one small glass of wine or one glass of sherry.

Recording Rules
Enter the number of units as follows:

00	None
01-97	Actual number of units consumed
98	98 or more units consumed
99	Not known

The number of units should be recorded as a two-digit number, right-justified, with leading zeroes as appropriate. For example:

5 units recorded as	05
9 units recorded as	09
15 units recorded as	15
102 units recorded as	98

Points to Note

Alcohol consumption by the mother during pregnancy may have adverse effects on the baby.
Midwives undertaking the antenatal booking appointment are asked to record in the Scottish Woman Held Maternity Record (SWHMR) the number of units of alcohol that the woman states she has drunk "in an average week". Concern has been raised that simply considering the week prior to the booking appointment will not capture whether a woman was drinking very early in pregnancy, possibly before confirmation of pregnancy.

The revised current advice for midwives in Scotland from April 2013 is to ask women about their average weekly consumption of alcohol over the three months prior to booking. Midwives are asked to record the womans answer in the SWHMR maternity information system so it can be reported on SMR02. If the woman says she has not drunk any alcohol at all over the last three months, number of units should be recorded as 0. If the woman states that she has consumed an average of 0 to 1 unit per week over the three months code as 1. Otherwise code as nearest number averaged over the three months.
Cross Checks
None.

SMR Validation - Typical Weekly Alcohol Consumption

Tags:
number  units  consumed  during  pregnancy  scottish  woman  held  maternity  record  SWHMR  SMR02

Typical Weekly Alcohol Consumption

An SMR02 is raised for each Inpatient and Day Case admission for care in the Obstetrics specialties listed below (including non-delivery admissions), and completed at the end of the Inpatient or Day Case episode. An Inpatient or Day Case admission marks the start of an Inpatient or Day Case episode. Inpatient and Day Case admissions include Inpatient and Day Case Transfers-In.

Note: An SMR02 is NOT raised for a change of ward only.

 

Codes and Values:
For specific Significant Facility Codes valid for SMR02 - see the SMR02 CRIB Sheet

Generic Definition
Significant Facility

Significant Facilities for SMR02

Field Length
1

Priority
Conditional

Definition
Whether or not a midwife was present at the delivery.

Points to Note

A midwife will always be present at a delivery - except for circumstances such as a birth in the ambulance on the way to hospital (Born Before Arrival - BBA) or other unattended or emergency delivery. The only likely circumstance in which a doctor (but not a midwife) is present at a delivery is one that takes place in an Accident and Emergency Department.
Cross Checks

This field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).
Codes and Values: Midwife present (Code order)
0 No
1 Yes
9 Not Known

SMR Validation - Midwife Present at Delivery


Related items:

Condition on Discharge
Tags:
birth  ambulance  hospital  emergency  born  before  arrival  SMR02

Midwife Present at Delivery

Field Length
1

Priority
Conditional

Definition
The treatment given to a woman who has an abortion.

Recording Rules
This field must be completed if Type of Abortion has been coded, otherwise it should be blank.

Points to Note

If an attempt at therapeutic abortion has completely failed and the patient is still pregnant when another, successful method is used, the successful method must be coded.
If a therapeutic abortion, using prostaglandins is partially successful, but some retained products remain, being subsequently removed by D & C, the appropriate code is 4 (not A).
Antiprogestagens (e.g. RU486) are a relatively new method of termination of pregnancy. RU486 is normally administered as an outpatient (SMR00) and a planned day case is arranged for 48 hours later for the administration of prostaglandins. It is at this stage that a SMR02 should be completed and the Management of Abortion should be coded as 4.
Cross Checks

Management of Abortion MUST be completed when Condition on Discharge = 2.
Management of Abortion is cross-checked with Type of Abortion e.g. if management is code 3 (Hysterotomy) then Type of Abortion must be coded to 4 (Therapeutic Abortion) or 9 (Unspecified).
See table below.
The use of codes 8 and 9 will always be queried.

Management of Abortion	Type of Abortion
0	Conservative/Expectant	1,5 or 9
A	Dilation & Cureltage(D&C) or Vacuum Aspiration	1-5,8 or 9
3	Hystertomy	4 or 9
4	Medical	1-4, 8 or 9
B-E	Ectopic Laparoscopy / Laparotomy	6
8 or 9	Use of these codes will be queried	

Codes and Values: Abortion (Code order)
0 Conservative/expectant management
3 Hysterotomy
4 Medical (includes Misoprostol and Prostaglandin)
8 Other (incl. Methotrexate)
9 Management not stated
A Dilatation and Curettage (D & C) or vacuum aspiration
B Ectopic Laparoscopic Salpingectomy
C Ectopic Laparoscopic Salpingostomy
D Ectopic Laparotomy & Salpingectomy
E Ectopic Laparotomy & Salpingostomy

SMR Validation - Management of Abortion


Related items:

Condition on Discharge
Type of Abortion
Tags:
woman  type  treatment  coded  therapeutic  antiprogestagens  outpatient  termination  recording  laparotomy  laparoscopic  salpingectomy  salpingostomy  hysterotomy    SMR02

Management of Abortion

Field Length
1

Priority
Conditional

Definition
Presentation at delivery is the part of the fetus which is lowest in relation to the position within the maternal pelvis.

Points to Note

Where the position is changed by operative intervention (e.g. rotation of the head by forceps) the presentation to be entered should be the presentation before the operation began.
Various initials may summarise the presentation, e.g. OP may also be POP, persistent occipito-posterior; LOL or ROL, left or right Occipito-Lateral. Face to pubis should be coded to 2 Occipito-Posterior.
Occipito-transverse (OT) should be coded to Occipito-lateral (OL). Occipito-sacral (OS) should be coded to Occipito-posterior (OP).
Provision is made for the coding of presentation in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank.
The fourth and subsequent babies in quadruplet and high order pregnancies should not be coded.
When midwives complete the presentation field on SWHMR, if the presentation (at delivery) is recorded as ‘cephalic’ or ‘cephalic vertex’ what the person completing the SMR02 actually needs to know is the fetal head position.
The quality of the data recorded for this SMR02 data item could be vastly improved if midwives could also record the position of the fetal head at the time of delivery where the presentation was cephalic vertex, e.g. Cephalic vertex OA. If the fetal head position is not noted in a cephalic vertex delivery, it can be assumed to be OA.
Cross Checks

Presentation is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
Presentation at Delivery is cross-checked against Mode of Delivery.
See checks under Outcome of Pregnancy.
Codes and Values: Presentation at delivery (Code order)
1 Occipito-Anterior (OA)
2 Occipito-Posterior (OP)
3 Occipito-Lateral (OL)
4 Breech
5 Face/brow
6 Shoulder
7 Cord
8 Other
9 Not Known

SMR Validation - Presentation at Delivery


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Outcome of Pregnancy - Babies 1 to 3
Tags:
part  fetus  lowest  maternal  pelvis  operative  breech  intervention  occipito-anterior  occipito-posterior  occipito-lateral  midwives  SMR02

Presentation at delivery (or at start of operative delivery) - Babies 1 to 3

Field Length
2

Priority
Mandatory

Definition
The number of previous INPATIENT or DAY CASE ADMISSIONS to any specialty in any hospital during the current pregnancy, but excluding the current EPISODE of CARE.

Recording Rules
The actual number of events should be entered as follows:

00-97 = none to 97 actual events
98 = 98 or more events
99 = Not Known

If there are less than 10 previous admissions, preceding zeros should be entered.
Points to Note

The previous admissions should include inpatient episodes and day cases in any specialty in any hospital.
Normal deliveries can be coded (O80.0) even if there have been previous INPATIENT or DAY CASE ADMISSIONS to any specialty in any hospital during the current pregnancy.
Cross Checks
None.

SMR Validation - Previous Admissions this Pregnancy

Tags:
inpatient  day  case  specialty  current  SMR02

Previous Admissions to Hospital This Pregnancy

Field Length
1

Priority
Conditional

Definition
Mother’s status of diabetes.

Points to Note

In addition to the completion of this field the appropriate ICD10 code should be recorded.
See coding guidelines under Other Conditions in the Diagnostic Section.
Cross Checks
None.

Codes and Values: Diabetes (Code order)
1 Yes, pre-existing diabetes (diagnosed before pregnancy)
2 Yes, Gestational diabetes (diagnosed during pregnancy)
3 Yes, time of diagnosis unknown
4 No (no diabetes during this pregnancy)
9 Not Known

SMR Validation - Diabetes

Tags:
ICD10  code  recorded  guidelines  conditions  diagnostic  mother  pre-existing  gestational  SMR02

Diabetes

Field Length
1

Priority
Conditional

Definition
The state of being male or female in a new born baby.

Points to Note

Provision is made for coding the sex of three babies. In singleton pregnancies only the first field should be completed.
‘0’ - Sex not known - The sex of the person cannot be determined for physical reasons, e.g. a new born baby.
‘9’ - Sex not specified - The sex of the person is not provided in the personal details i.e. the data has not been supplied and sex cannot be ascertained from the data provided
‘Intersex’ should be recorded under code ‘0’ – not known
Cross Checks

Sex is cross-checked with Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).
See checks under Outcome of Pregnancy.
Points to Note
0 Not Known (i.e. indeterminate sex, includes ‘Intersex’)
1 Male
2 Female
9 Not Specified (includes not stated by patient, or not recorded)

SMR Validation - Sex


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
personal  details  outcome  pregnancy  codes  male  female  new  born  baby  intersex  SMR02

Sex (Gender) - Babies 1 to 3

Field Length
2

Priority
Optional

Definition
The length of the baby from its head to its heels when the legs are fully extended.

Recording Rules
Enter the measurement in centimetres.

Points to Note

In some units, the crown-rump measurement is recorded (length of the baby from head to base of spine). This measurement MUST NOT BE USED in the Crown-heel field.
Cross Checks

Crown Heel is cross-checked with Condition on Discharge, and MAY ONLY be present if Condition on Discharge = 3.
See checks under Outcome of Pregnancy.
For stillbirths this field should be left blank
The record will be queried if Crown-heel length for Birthweight falls outwith the following ranges (unless Crown-heel = 99 and/or Birthweight = 9999).

Crown-heel (cm)	Birthweight (g)
26-42	<1000
30-48	1000-1499
34-50	1500-1999
38-52	2000-2499
41-54	2500-2999
44-56	3000-3499
44-58	3500-3999
46-60	4000-4499
46-62	4500-9998

SMR Validation - Crown - Heel


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
length  baby  head  heel  measurement  centimetres  birthweight  SMR02

Crown-Heel - Babies 1 to 3

Field Length
10

Priority
Optional

Definition
The Community Health Index (CHI) is a population register which is used for health care purposes. The CHI number uniquely identifies a person on the index.

Points to Note

Most babies now have their CHI number allocated at birth. For a minority of cases there is a short lag (usually no more than 3 months) between birth and the baby CHI number being fed through into the national CHI database. An example would be a home birth or a birth in a remote community. Often there is no immediate CHI-allocation/registration facility available in such circumstances.
Once the CHI number becomes available on the Master Patient Record it is important that these numbers should be added to all SMR returns. The CHI is critical for record linkage, linking this record to the infant SBR or SMR01, and for data-sharing.

Provision is made for coding Baby CHI number for three babies if required. In the commonest circumstances (singleton pregnancies) only the first field should be completed.
Cross Checks

See checks under Outcome of Pregnancy.
Further Information
See - CHI Number


SMR Validation - Baby CHI Number


Related items:

Outcome of Pregnancy - Babies 1 to 3
Tags:
community  health  index  population  register  identification  confidentiality  babies  SMR02 

b

Baby CHI - Babies 1 to 3

Field Length
2

Priority
Conditional

Definition
A score based on assessment of 5 variables in the baby, each rated from 0-2 (0 worst, 2 best).
(A = Appearance, P = Pulse, G = Grimace, A = Activity, R = Respiration)

Recording Rules
The appropriate code should be entered for a live birth as follows:

NR not recorded
00-10 actual Apgar score at 5 minutes (or death before 5 minutes)
RR Baby being actively resuscitated at the 5 minute check (therefore Apgar score cannot be accurately taken)
Points to Note

The Apgar score is the common scoring method of the babys well being after the birth, and is based on a combination of the heartbeat, respiration, skin colour, muscle tone and movement.
For stillborn babies the field should be left blank or recorded as 00.
For liveborn babies who just live for one or two minutes a score should be entered; it may be 00 or 01.
If the baby is receiving active resuscitation (intubation) the Apgar score is probably not valid and the boxes should be infilled with ‘RR‘.
Provision is made for coding the Apgar score of three babies. In singleton pregnancies only the first field should be completed.
Cross Checks

Apgar score is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
See checks under Outcome of Pregnancy.
Apgar score is cross-checked with Resuscitation e.g. if Apgar = RR then Resuscitation must = 2-6 or 8.
SMR Validation - APGAR at 5 mins


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Resuscitation - Babies 1 to 3
Tags:
assessment  variables  baby  code  live  birth  resuscitated  stillborn  liveborn  condition  discharge  pregnancy  SMR02

Apgar Score - Babies 1 to 3

Field Length
2

Priority
Mandatory

Definitions
The total number of live babies born prior to the current pregnancy who died within the first 28 days of life.

Recording Rules
The appropriate number of Previous neonatal deaths should be entered. If there are less than 10 previous neonatal deaths preceding zeros should be entered.

Points to Note
None.

Cross Checks

If total Previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.
SMR Validation - Previous Neonatal Deaths

Tags:
live  babies  prior  current  pregnancy  died  number  28  days  life  SMR02

Previous Neonatal Deaths

Field Length
2

Priority
Conditional

Definition
The number of completed weeks of pregnancy, as judged by the clinician (doctor or midwife), usually on the basis of an ultrasound measurement.

Recording Rules
Enter the Estimated Gestation in the boxes provided. If the Estimated Gestation is not known enter 99 however, as gestation is only required for delivery and abortion episodes, this should be very uncommon

Points to Note

This field should be completed for Delivery and Abortion episodes and may be completed for Other (includes missed abortion) episodes, otherwise it should be left blank.
For episodes that involve the delivery of a stillborn infant, the gestation recorded should be the gestation at delivery (not the gestation at confirmation of intrauterine death, which may be earlier)
Records staff must not base this Estimated Gestation simply on the interval between the dates of LMP and delivery. The clinicians estimate will take account of other factors, including scans.
Cross Checks

Estimated Gestation MUST be present if Certainty of Gestation is present.
The record will be queried if the Estimated Gestation falls outwith the range 01-45 weeks.
Gestation is cross-checked with Birthweight.
Gestation is cross-checked with Outcome of Pregnancy.
Gestation is cross-checked with Condition on Discharge and MUST be completed if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).
SMR Validation - Estimated Gestation


Related items:

Birthweight - Babies 1 to 3
Certainty of Gestation (Based on the Scan)
Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
number  completed  weeks  pregnancy  clinician  ultrasound  measurement  LMP  delivery  SMR02

Estimated Gestation

Field Length
1

Priority
Conditional

Definition
This denotes the pattern of obstetric care planned.

Points to Note

There is great interest, not only in the choice of where the woman will deliver, but also in the planned management of her care.
Cross Checks

This item MUST ONLY be present if Condition on Discharge = 2 or 3 (abortion or delivery episode).
Delivery Plan - Management is cross-checked with other Proposals for Delivery fields.

Original Booking	Delivery Plan - Place	Delivery Plan - Management
Home Birth	D201N	0	0
Consultant, GP or Midwife Unit	Hospital Code	1,2 or 3	3
Not Booked	00000	8	8
Not Known	99999	9	9

Codes and Values: Delivery Plan - Codes (Code order)
0 Home
3 Inpatient
8 Not booked/other
9 Not Known

SMR Validation - Delivery Plan - Management

Tags:
care  planned  obstetric  home  inpatient  SMR02

Delivery plan - Management

Field Length
1

Priority
Conditional

Definition
Whether or not the mother has been given a course of antenatal steroids where it is anticipated the baby will be delivered at less than 36 weeks gestation.

Recording Rules

It is important in cases where the baby is delivered at less than 36 weeks gestation, that the mother has a course of antenatal steroids. This helps to mature the babys lungs reducing the risk of respiratory distress syndrome.
The obstetricians have requested that this is recorded, as it helps with auditing care of premature labour.
Points to Note

This field should be completed for delivery episodes only.
If gestation is greater than 35 weeks and there has been a threat of early delivery in a previous episode, it is correct to enter a value of 0 or 1 in this field, but the record will be queried.
Cross Checks

Antenatal steroids MUST ONLY be present if Condition on Discharge = 3.
Antenatal steroids are cross-checked with Estimated gestation. Antenatal steroids should = 0,1 or 9 if Estimated gestation < 36 weeks. If Estimated gestation > 35 weeks and Antenatal Steroids is not 8, the record will be queried.
Codes and Values: Antenatal Steroids (Code order)

0 Antenatal steroids not given
1 Antenatal steroids given (complete 48hr course); or Incomplete (less than 48hr course)
8 Not applicable (gestations of 36 weeks or over with no previous threat of delivery)
9 Not known whether given or not
SMR Validation - Antenatal Steroids

Tags:
baby  gestation  delivered  mother  premature  SMR02

Antenatal Steroids

Field Length
5

Priority
Conditional

Definitions
Original Booking is the location at which the patient originally intended to deliver her baby. (Please note that it is not necessarily the location of the booking clinic).

Points to Note

Code 99999 should only be used as a last resort. An example of when it could be used is when a visitor to Scotland comes in as an emergency, in premature labour and delivers while on holiday. However, there is a dummy hospital code that you can use - E999H - if you know that she was booked for hospital delivery elsewhere in the UK.
Home delivery has a single Domiciliary Code D201N and this should be used for all home births in Scotland.
Cross Checks

This item MUST be present if Condition on Discharge = 2 or 3 (abortion or delivery episode).
Original Booking is cross-checked with Condition on Discharge
Original Booking is cross-checked with Booking Date.
Original Booking is cross-checked with all other Proposals for Delivery fields.
Codes and Values: Original Booking
00000 - Not booked
99999 - Not known if booked
D201N - Home delivery
E888H - Hospital outwith UK
E999H - UK hospital outwith Scotland
Location code - Scottish Hospital

SMR Validation - Original Booking


Related items:

Booking Change - Management
Booking Change - Place
Booking Date
Condition on Discharge
Delivery Plan - Management
Delivery Plan - Place
Tags:
location  patient  deliver  baby  intended  planned  SMR02

Original Booking

Field Length
1

Priority
Conditional

Definition
Length of admission (or non admission) to a neonatal unit following delivery.

Points to Note

A Neonatal Unit is a nursery in which the accommodation, equipment, staffing, spacing, temperature, and other support facilities are such as to permit the care of babies who require a level of care above that associated with healthy babies.
Code 0 should be used if the hospital has no Neonatal Unit, even if it is known that the baby was ill.
If it is not clear from the maternal record whether the baby remained in Neonatal Unit for up to or more than 48 hours, and the baby and mother went home at an appropriate time, Code 1 should be used.
Code 9 should only be used rarely when there is doubt whether the baby was admitted to Neonatal Care Unit or not.
Provision is made for coding Neonatal Unit for three babies. In the commonest circumstances (Singleton Pregnancies) only the first field should be completed.
Cross Checks

Neonatal Indicator is cross-checked with Condition on Discharge, and MUST ONLY be present if Condition on Discharge = 3
See checks under Outcome of Pregnancy.
For Stillbirths this field should be left blank.
Codes and Values: Admission (Code order)

0 Not admitted
1 Admitted - for up to 48 hours
2 Admitted - for more than 48 hours
9 Not Known
SMR Validation - Neonatal-Indicator


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
length  admission  unit  delivery  admitted  SMR02

Neonatal Indicator - Babies 1 to 3

Field Length
2

Priority
Mandatory

Definition
The total number of pregnancies experienced by the woman, prior to the current one including ectopic pregnancy and pregnancies ending in therapeutic or spontaneous abortion.

Recording Rules
A pregnancy with multiple births should be COUNTED AS ONE.

The code entered should include ALL previous pregnancies even though some may have ended early in therapeutic abortion or miscarriage. If there are less than 10 previous pregnancies preceding zeros should be entered.

Points to Note

One pregnancy may result in more than one delivery - but, nevertheless, the event must be COUNTED AS ONE pregnancy.
Cross Checks

If total previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.
SMR Validation - Previous Pregnancies

Tags:
number  prior  delivery  current  pregnancy  ectopic  therapeutic  spontaneous  abortion  SMR02

Previous Pregnancies

Field Length
2

Priority
Mandatory

Definition
The total number of pregnancies prior to the current one which ended spontaneously with the loss of a non-registerable Fetus.

Recording Rules
The appropriate number of previous spontaneous abortions (miscarriages) should be entered. If there are less than 10 previous spontaneous abortions preceding zeros should be entered.

Points to Note

Previous missed abortions, ectopic pregnancies and molar pregnancies should be included in Previous Spontaneous Abortions.
Cross Checks

If total previous pregnancies is equal to ‘00’, then the following fields must be equal to ‘00’: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.
SMR Validation - Previous Spontaneous Abortions

Tags:
number  pregnancies  loss  missed  non-registerable  fetus  ectopic  molar  SMR02

Previous Spontaneous Abortions

Field Length
1

Priority
Optional

Definition
A measure of accuracy of gestation.

Points to Note

This field should only be entered for abortion or delivery episodes, when the Estimated Gestation is also completed.
Code 1 should only be used when the completed date of the LMP is known and the clinician believes that the clinical and scan findings correspond to the gestation based on the Scan. If there is no routine recording of this item in the antenatal record Code 1 should be used, if all indications are that gestation based on Scan is accurate.
Code 2 should be used either when:
- the date of the LMP is unknown or the woman is unsure of her dates; or
- the date of the LMP is certain, but the clinician has reason to believe that it does not reflect the true length of gestation. This is likely to happen with women who have an irregular cycle, or in cases of post-pill amenorrhea.
Code 9 should only be used rarely, for example, in the case of a woman transferred from another hospital, and the previous notes are not available.
If the date of the last menstrual period has been forgotten by the patient or if the menstrual cycle is markedly different from the normal 28 days, the Certainty of Gestation should be coded Uncertain 2.
This information is usually noted most extensively in the medical record when there is uncertainty about dates, but notes on the reliability of the LMP and the consequent calculation of gestation are usually recorded as a routine at the first antenatal visit.
The calculated number of weeks between the LMP and Date of Delivery is a derived item held on computer; the quality of that item can be judged by the Certainty of Gestation based on the LMP.
Cross Checks

Certainty of Gestation must not be present if Condition on Discharge is not equal to 2 or 3 or 8.
Codes and Values
1 Certain
2 Uncertain
3 No scan given
9 Not known

SMR Validation - Certainty of Gestation


Related items:

Condition on Discharge
Tags:
measure  accuracy  certain  scan  uncertain  delivery  abortion  LMP  antenatal  inpatient  hospital  SMR02

Certainty of Gestation (Based on the Scan)

Field Length
2

Priority
Mandatory

Definition
The definition of ‘illicit drugs’ includes illegal drugs (e.g. heroin), solvents and gases (e.g. butane), drugs prescribed for someone else‘s use (i.e. ‘street use’). Also include drugs prescribed to the woman by a doctor as a substitute for the drug(s) of addiction (e.g. prescribed methadone) or to alleviate the symptoms of withdrawal (e.g. prescribed diazepam).

Recording Rules

List any illicit drugs, or drugs prescribed for the treatment of drug misuse/dependence, used in this pregnancy.
Where data on the type of drug(s) used is not available, code 99 should be recorded.
Where the mother is drug free, code 00 should be recorded.
Points to Note

Codes containing the description ‘prescribed only’ should be used where the drug has been prescribed for the woman‘s personal use. Codes containing the description ‘other’ should be used if all, or some, of the amount being taken was not prescribed for the woman‘s personal use, or if the prescribing details are not known.
Since there is space only for a maximum of four drugs to be recorded, it may be necessary to make a judgement about which should be recorded. In doing so, it may be helpful to consider whether the mother has changed her drug using behaviour as a result of pregnancy (e.g. from ’illicit drugs’ to prescribed alternatives). Where possible, both should be recorded.
Cross Checks

Drugs Used is cross - checked against Drug Misuse.
Codes and Values: Drugs (illicit)

Cannabis
50 Cannabis

Drug Free
00 None

Hallucinogens (e.g.LSD, ketamine, magic mushrooms)
40 Hallucinogens

Not Known
99 N/A

Opiates
10 Heroin
11 Morphine
12 Methadone - prescribed only
13 Methadone - other
14 Dihydrocodeine - prescribed only
15 Dihydrocodeine - other
16 Dipipanone
17 Buprenorphine
19 Other opiates

Other drugs
70 Other drugs

Sedatives
20 Diazepam - prescribed only
21 Diazepam - other
22 Temazepam - prescribed only
23 Temazepam - other
24 Nitrazepam
25 Other benzodiazepines
29 Other sedatives

Solvents and Gases (e.g. glue, butane, amyl nitrate)
60 Solvents and gases

Stimulants
30 Amphetamines
31 Cocaine
32 Crack cocaine
33 Ecstacy
39 Other stimulants

SMR Validation - Drugs Used

Tags:
illicit  illegal  solvents  gases  dependence  misuse  pregnancy  opiates  stimulants  cannabis  SMR02

Drugs Used

Field Length
1

Priority
Conditional

Definition
Sterilisation after delivery indicates the method of sterilisation used.

Points to Note

Sterilisation at the time of Caesarean Section should be coded 3.
Sterilisation except during Caesarean Section is fairly rare, and if there is no statement about sterilisation Code 0 should be used.
Only use code 8 if the records only have Sterilisation NOS and the woman has been sterilised, but the method of sterilisation is unknown.
Use code 0 if it cannot be ascertained from the case notes whether the woman was sterilised.
Cross Checks

Sterilisation After Delivery is cross-checked with Condition on Discharge and can only be present when Condition on Discharge = 3 (Delivered).
Sterilisation After Delivery is cross-checked with Mode of Delivery. If Sterilisation After Delivery =3, then Mode of Delivery must = 7 (Elective Caesarean) or 8 (Emergency Caesarean).
Codes and Values: Sterilisation (Code order)
0 None
1 Laparoscopy
2 Laparotomy
3 Sterilisation with caesarean section
7 Other Method
8 Sterilised, but method not stated

SMR Validation - Sterilisation After Delivery


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Tags:
method  caesarean  section  code  laparoscopy  laparotomy  method  sterilised  SMR02

Tears

Field Length
2

Priority
Conditional

Definition
Duration of labour is the length of time the state of labour lasts from its onset to the delivery of the placenta, expressed as the number of completed hours.

Recording Rules
Enter the appropriate number of completed hours.

Examples

First stage	12 hours 35 minutes
Second stage	45 minutes
Third stage	15 minutes
Total	13 hours 35 minutes = 13

First stage	11 hours 20 minutes
Second stage	40 minutes
Third stage	20 minutes
Total	12 hours 20 minutes = 12

Points to Note

The Duration of Labour is usually found in the midwifes record in the delivery section of the case note.
Only short labour lasting less than one hour should be recorded as 00 hours. This could occur with an elective section, or an emergency section before the onset of labour.
If the Duration of Labour has not been recorded in any of the available records, 99 (Not known) should be entered.
When an emergency section has been carried out, duration of stages 1 and 2 must be recorded where applicable.
Cross Checks

Duration of Labour is cross-checked with Condition on Discharge and MUST only be present where Condition on Discharge = 3 (Delivered).
Duration of Labour is cross-checked with Mode of Delivery.
SMR Validation - Duration of Labour


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Tags:
length  time  onset  delivery  placenta  number  hours  SMR02

Duration of Labour

Field Length
1

Priority
Mandatory

Definition
The condition of the mother on discharge.

Points to Note

Condition on Discharge code 8 (Other) can also be used associated with Admission Reason 21 (Abortion), when the Type of Abortion is missed abortion and the woman is discharged without having undergone an evacuation.
Condition on discharge code 2 (Aborted) should be used for all types of completed abortion, including spontaneous abortions at <24 weeks gestation and terminations of pregnancy at any gestation
Cross Checks

Condition on discharge is cross-checked with admission reason:

Condition on Discharge	Admission Reason
1	22, 23, 28
2	21, 22, 28
3	20-26, 28
4	25, 26
5	28
8	21, 22, 28

Condition on Discharge is cross-checked with Management of Patient.
Certain data items may, must or must not be present depending on the value of the Condition on Discharge code. Click here to view table.
Codes and Values: Discharge condition
1 - Still pregnant
2 - Aborted (all types of completed abortion)
3 - Delivered
4 - Postnatal care only
5 - Pregnancy not confirmed
8 - Other (includes missed abortion)

SMR Validation - Condition on Discharge


Related items:

Admission Reason
Management of Patient
Tags:
mother  pregnant  aborted  delivered  postnatal  pregnancy  recording  termination  postnatal  SMR02

Condition on Discharge

Field Length
3

Priority
Mandatory

Definition
The weight of the woman in kilograms recorded at the booking clinic.

Recording Rules
The weight should be specified in kilograms. Preceding zeroes should be entered if the weight is less than 100Kg.

Examples:

65Kg	065
101Kg	101
55.5Kg	056
55.4Kg	055
Points to Note

Weight recorded in stones and pounds must be converted to kilograms.
Weight held in the case notes as kilograms and grams should be rounded to the nearest kilo, not truncated. (See examples 3 & 4 above).
If the mothers weight is not known, enter 999.
Cross Checks

Weights outwith the range 032 - 127 Kg will be queried
SMR Validation - Weight of Mother at Booking

Weight of Mother at Booking

Field Length
1

Priority
Conditional

Definition
This indicates the disposal of the baby on the mother‘s DISCHARGE.

Points to Note

Code 2 should be used if a sick baby remains in the Neonatal Unit after the mothers discharge.
Code 6 should be used for babies who are discharged to a foster home even though the local authority retains legal responsibility (fostering prior to adoption).
Code 7 should be used when the baby is discharged to an institution under local authority care.
Code 8 should be used when a healthy baby remains in hospital but not in the Neonatal Unit after the mothers discharge. This might occur when the baby is awaiting adoption, or when the home circumstances do not allow the baby to be taken home at that time.
For Stillbirths this field should be coded 9.
Cross Checks

Baby Discharged To is cross-checked with Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).
See checks under Outcome of Pregnancy.
Codes and Values: Baby Discharge To
1 - Home with mother
2 - Remaining in neonatal care
3 - Underwent neonatal care, but home with mother
4 - Transfer to other hospital
5 - Other unit in same hospital
6 - Foster Home
7 - Local Authority Care
8 - Healthy baby remaining in hospital after mothers discharge
9 - Dead
0 - Other

SMR Validation - Baby Discharged To


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
disposal  birth  neonatal  unit  stillbirth  condition  outcome  pregnancy  SMR02

Baby Discharged To - Babies 1 to 3

Field Length
6

Priority
Optional

Definition
The date on which the last menstrual period before the woman conceived began.

Recording Rules
The date on which the LMP started should be entered as DD MM YY.

Points to Note

If only the month and year is known, the day should be infilled with zeros.
If the LMP is not known the field should be left blank.
If the woman has not had a period since her last pregnancy, or since coming off the pill, the field should be left blank.
If the woman is not pregnant the field should be left blank. This will occur in postnatal admissions (Condition on Discharge = 4, Postnatal care only) or when the woman was found not to be pregnant (Condition on Discharge = 5, Pregnancy not confirmed).
Because the LMP is frequently in the calendar year prior to the year of delivery, please take care to record the CORRECT YEAR when transcribing the date.
Cross Checks
None.

SMR Validation - LMP (Last Menstrual Period)

Tags:
SMR02  period  began  date  conceived  woman  pregnant

LMP(Last Menstrual Period)

Field Length
4

Priority
Conditional

Definition
The weight of the baby at birth specified in grams.

Recording Rules
The weight should be specified in grams. Four boxes are provided and preceding zeros should be entered if the weight is less than 1000g.

Points to Note

If birthweight is still recorded in pounds and ounces in your hospital, please convert to grams.
For pregnancies with an abortive outcome, the weight of the fetus should be recorded if possible.
If the baby has not been weighed at birth, the birthweight should be recorded as 9999. This may happen if the baby needs immediate medical attention.
Provision is made for coding the birthweight of three babies. In singleton pregnancies only the first field should be completed.
Cross Checks

Birthweight is cross-checked against Estimated Gestation and Outcome, and live born babies who appear to be implausibly heavy (or light) for the Gestation will be queried.
Birthweight is cross-checked against Condition on Discharge and MUST be present if Condition on Discharge = 3 (Delivered).
SMR Validation - Birthweight - Babies 1 to 3


Related items:

Condition on Discharge
Estimated Gestation
Outcome of Pregnancy - Babies 1 to 3
Tags:
weight  grams  estimated  gestation  outcome  condition  discharge  SMR02

Birthweight - Babies 1 to 3

Field Length
1

Priority
Mandatory

Definition
Drug misuse at any time during the current pregnancy. Includes use of illegal drugs, solvents and gases, drugs prescribed for someone elses use (i.e. 'street use'). Also included are drugs which are prescribed to the woman by a doctor as a substitute for the drug(s) of addiction (e.g. prescribed methadone) or to alleviate the symptoms of withdrawal (e.g. prescribed diazepam). Excludes tobacco, alcohol or 'over the counter' medicines.

Points to Note

Drug misuse during pregnancy may cause harm to both mother and baby.
If it not known whether there has been any drug misuse code 9 should be used and Drugs Used coded to 99 (Not Known).
Cross Checks

Drug Misuse is cross - checked with Drugs Used. If no drug use has been recorded (code 0), Drugs Used must = 00.
Codes and Values: Drugs Misuse Codes (Code order)
0 No
1 Yes
9 Not Known

SMR Validation - Drug Misuse During Pregnancy


Related items:

Drugs Used
Tags:
illegal  solvents  gases  prescribed  substitute  addiction  mother  baby  SMR02

Drugs Misuse During This Pregnancy

Field Length
1

Priority
Conditional

Definition
An abortion is a pregnancy which ends spontaneously prior to 24 completed weeks gestation with the delivery of a dead fetus (miscarriage) or which ends following therapeutic abortion at any gestation (termination of pregnancy).

Points to Note

The threatened abortion that progresses to a(n) (in)complete abortion should be coded 1.
A threatened abortion where patient continues with pregnancy : DO NOT complete Type of Abortion.
Code 2 should be used for missed abortion, which may include the following terms:
carneous mole; fleshy mole; haemorrhagic mole.
Code 3, Trophoblastic disease, should also be used with the following terms:
molar pregnancy; cystic mole.
Code 6 should be used where the pregnancy has ended before 24 weeks in an abdominal pregnancy (with a dead Fetus); and for cervical, infundibular or tubal pregnancy.
Cross Checks

This field MUST be completed if Condition on Discharge = 2 (Abortion or Other).
This field will be cross-checked with Admission Reason 21 (Abortion) and Condition on Discharge, which should be 2 (Aborted, all types of completed abortion).
Type of Abortion is cross-checked with Birthweight.
Type of Abortion is cross-checked with Estimated gestation.
If Type of Abortion is completed, Management of Abortion must also be completed.
Codes and Values: Type of Abortion
1 Spontaneous or incomplete abortion
2 Missed abortion
3 Trophoblastic disease
4 Therapeutic abortion
5 Suspected illegal abortion
6 Ectopic pregnancy
8 Other abortion
9 Unspecified

SMR Validation - Type of Abortion


Related items:

Admission Reason
Birthweight - Babies 1 to 3
Condition on Discharge
Estimated Gestation
Management of Abortion
Tags:
pregnancy  24  weeks  gestation  fetus  recording  termination  therapeutic  spontaneous  missed  trophoblastic  disease  ectopic  SMR02

Type of Abortion

Field Length
2

Priority
Mandatory

Definitions
The total number of Caesarean sections prior to the current pregnancy carried out to effect delivery of the Fetus.

Recording Rules
The appropriate number of previous Caesarean Sections should be entered. If there are less than 10 previous caesarean sections preceding zeros should be entered.

Points to Note

A previous twin pregnancy in which both twins were delivered by Caesarean Section, only counts as 1 Caesarean Section.
Cross checks

The number of Previous Caesarean Sections, plus Therapeutic Abortions plus Spontaneous Abortions should never equal more than the number of total Previous Pregnancies.
If number of Previous Caesarean Sections = 02 or more and Condition on Discharge is 3 (delivered) Mode of Delivery should = 7 or 8 (Caesarean).
SMR Validation - Previous Caesarean Sections

Tags:
number  prior  delivery  fetus  current  pregnancy  SMR02

Previous Caesarean Sections

Field Length
1

Priority
Conditional

Definition
The method of feeding at the time of the mother’s discharge.

Points to Note

Use code 3 (Not applicable) if the baby has died or is stillborn.
Cross Checks

Feed on Discharge is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
See checks under Outcome of Pregnancy.
Codes and Values: Feed on Discharge (Code order)
1 Breast only
2 Formula only
3 Not Applicable
4 Mixed (Breast and Formula)
8 Other (non-milk feed)
9 Not Known

SMR Validation - Feed on Discharge


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
mother  breast  milk  formula  condition  SMR02

Feed on Discharge - Babies 1 to 3

For the data items not listed, completion on discharge is mandatory and the code is determined by type of episode.

Condition on Discharge Code	1	2	3	4	5	8
Data Item	Still Pregnant	Aborted (all types of completed abortion)	Delivered	Postnatal care only	Pregnancy not confirmed	Other (includes missed abortion)
Booking Date	May	May	Must	May	May	May
Booking change - place	Must not	Must	Must	Must Not	Must not	Must not
Booking change - management	Must not	Must	Must	Must Not	Must not	Must not
Delivery plan - place	Must not	Must	Must	Must Not	Must not	Must not
Delivery plan - management	Must not	Must	Must	Must Not	Must not	Must not
Original booking	Must not	Must	Must	Must Not	Must not	Must not
Antenatal steroids	Must not	Must Not	Must	Must Not	Must not	Must not
Certainty of gestation	Must not	May	May	Must Not	Must not	Must not
Diabetes	Must not	Must not	Must	Must Not	Must not	Must not
Estimated Gestation	Must not	Must	Must	Must Not	Must not	May
Management of abortion	Must not	Must	Must not	Must Not	Must not	May
Type of abortion	Must not	Must	Must not	Must Not	Must not	May
Analgesia during labour/delivery	Must not	Must not	Must	Must Not	Must not	Must not
Date of delivery	Must not	Must not	Must	Must Not	Must not	Must not
Doctor present at delivery	Must not	Must not	Must	Must Not	Must not	Must not
Duration of labour	Must not	Must not	Must	Must Not	Must not	Must not
Episiotomy	Must not	Must not	Must	Must Not	Must not	Must not
Indication for operative delivery	Must not	Must not	May	Must Not	Must not	Must not
Induction of labour	Must not	Must not	Must	Must Not	Must not	Must not
Midwife present at delivery	Must not	Must not	Must	Must Not	Must not	Must not
Midwife to consultant transfer	Must not	Must not	Must	Must Not	Must not	Must not
No. of births this pregnancy	Must not	Must not	Must	Must Not	Must not	Must not
Sterilisation after delivery	Must not	Must not	Must	Must Not	Must not	Must not
Tear	Must not	Must not	Must	Must Not	Must not	Must not
Apgar score*	Must not	Must not	May	Must Not	Must not	Must not
Baby CHI*	Must not	Must not	May	Must Not	Must not	Must not
Baby discharged to*	Must not	Must not	Must	Must Not	Must not	Must not
Birthweight*	Must not	May	Must	Must Not	Must not	Must not
Crown-Heel*	Must not	Must not	May	Must Not	Must not	Must not
Feed on discharge*	Must not	Must not	Must	Must Not	Must not	Must not
First feed given*	Must not	Must not	May	Must Not	Must not	Must not
Mode of delivery*	Must not	Must not	Must	Must Not	Must not	Must not
Neonatal indicator*	Must not	Must not	May	Must Not	Must not	Must not
OFC (occipito-frontal circumference)*	Must not	Must not	May	Must Not	Must not	Must not
Outcome of pregnancy*	Must not	Must not	Must	Must Not	Must not	Must not
Presentation at delivery*	Must not	Must not	Must	Must Not	Must not	Must not
Resuscitation*	Must not	Must not	May	Must Not	Must not	Must not
Sex (Gender)*	Must not	Must not	Must	Must Not	Must not	Must not

* see also checks under Outcome of Pregnancy

Tags:
still  pregnant  aborted  abortion  delivered  postnatal  care  pregnancy  missed

Condition on Discharge Code Table

Field Length
1

Priority
Optional

Definition
This denotes the patient type and/or pattern of obstetric care to which the patient is re-designated following a change of management under a patients DELIVERY PLAN.

Points to Note

In the majority of cases there will be no change in management and code 7 should be used.

Location (hospcode)	Original Booking	Delivery Plan Place	Delivery Plan Management	Booking Change Place	Booking Place Management
T202H	T202H	1	3	7	7

If a woman is discovered to have a fetal abnormality that requires specialist treatment for the baby after delivery and her booking is changed from a GP Obstetric Unit to a Specialist Obstetric Unit at around 32 weeks, the coding will be as follows:

Location (hospcode)	Original Booking	Delivery Plan Place	Delivery Plan Management	Booking Change Place	Booking Place Management
N161H	N335H	2	3	1	7

This type of planned change can be assessed analysing these codes. However, in order to distinguish clearly the potentially more dangerous emergency transfers in labour - for fetal distress perhaps - from the planned antenatal booking changes, booking change place and booking change management should be coded to 8 (See example below).

A woman with a twin pregnancy who had been booked in the consultant unit in Princess Royal Maternity Unit as an inpatient, and who came in in premature labour at 29 weeks and was then transferred to Glasgow Royal Infirmary, (in utero transfer) would be coded by GRI thus:

Location (hospcode)	Original Booking	Delivery Plan Place	Delivery Plan Management	Booking Change Place	Booking Place Management
G107H	G108H	1	3	8	8
Cross Checks

Booking Change - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or Delivery episode).
Booking Change - Management is cross-checked with all other Proposals for Delivery fields.
Codes and Values: Booking Change
0 - Home Birth
3 - Inpatient
7 - No change
8 - Not booked/Other
9 - Not known

SMR Validation - Booking Change - Management


Related items:

Booking Change - Place
Condition on Discharge
Delivery Plan - Management
Delivery Plan - Place
Tags:
obstetric  care  patient  designated  delivery  plan  original  SMR02

Booking change - Management

Field Length
1

Priority
Mandatory

Definition
History of smoking recorded at the booking clinic.

Points to Note

Code 9 should only be used if there is no comment on the booking clinic notes about the smoking status.
If a woman is admitted as an unbooked emergency for delivery and it is noted on her admission notes that she is a smoker, it may be reasonably inferred that she smoked also at the start of pregnancy and code 1 should be entered.
The use of e-cigarettes should be recorded within the following codes:
- If only e-cigarettes used, this should be recorded as 0 - Never Smoked
- If a combination of e-cigarettes and traditional cigarettes are used, this should be recorded as 1 - Current Smoker
Cross Checks
None.

Codes and Values: Smoking history (Code order)
0 Never smoked
1 Current smoker
2 Former smoker
9 Not known

SMR Validation - Smoking History at Booking

Tags:
code  never  smoked  current  smoker  former  e-cigarettes  SMR02

Smoking History at Booking

Field Length
1

Priority
Conditional

Definition
The method by which the baby is delivered.

Points to Note

Code 0 - The terms used may include, Normal delivery or SVD (spontaneous vertex delivery).
Code 1 - An abnormal presentation may occur with a spontaneous delivery at term, or more usually perhaps, with a premature delivery when the babys head is small enough to be delivered without assistance. The abnormal presentation may be persistent occipito posterior (POP).
If ‘low’, ‘mid’ or ‘high’ cavity is mentioned, this should take priority over the type of forceps.
Code 2 - should be used when forceps are specified, but no further information is provided (i.e. forceps NOS.); also for Wrigley’s Forceps, where no note of the position of the forceps is available. (Haig-Ferguson forceps will now be considered as usually denoting mid.)
If more than one type of forceps is used, only the most resource intensive should be recorded. Code B – Rotational is most important, followed by A – Mid cavity and lastly, 2 – Low forceps, no rotation.
Code B - should be used for Kiellands forceps rotation and where there has been a manual rotation of the head before forceps are applied.
Code 5 - should be used for a breech delivery that is specified as spontaneous (usually in a very premature delivery), assisted and with (or without) forceps to the aftercoming head (FACH).
Codes 7 and 8 - The reason for having two categories of delivery by Caesarean section is to have the capability of comparing the outcome in the best circumstances - i.e. a planned caesarean section (7), during the day with both patient and staff fully prepared, with the less favourable circumstance of an emergency section (8).

Note: A woman for whom a caesarean section is planned may go into labour and require an emergency caesarean section: this is coded to 8.

Code 9 - should rarely be used and will be queried. The only circumstance when a Mode of Delivery is likely to be truly ‘not known’ is an unattended delivery. But such a delivery must have been spontaneous/unassisted and should be coded to 0.
Provision is made for the coding of Mode of Delivery in the first three babies in a multiple pregnancy. In singleton pregnancies the second and third fields should be left blank. The fourth and subsequent babies in quadruplet and higher order pregnancies should not be coded.
Cross Checks

Mode of Delivery is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
Mode of Delivery is also cross-checked with the following fields: Tears, Episiotomy, Analgesia During Labour/Delivery, Method of Induction.
See checks under Outcome of Pregnancy.
Codes and Values: Delivery (Code order)
0 Normal, spontaneous vertex vaginal delivery, occipito-anterior.
1 Cephalic vaginal delivery, with abnormal presentation of the head at delivery, without instruments, with or without manipulation
2 Low forceps, no rotation, forceps NOS (incl. Wrigleys).
5 Breech delivery, spontaneous, assisted or unspecified partial breech extraction.
6 Breech extraction, NOS. Version with breech extraction.
7 Elective (planned) caesarean section.
8 Emergency and unspecified caesarean section.
9 Other and unspecified method of delivery.
A Mid cavity forceps, no rotation (incl. Haig Fergusson, Neville-Barnes etc).
B Rotational forceps (incl Kiellands)
C Ventouse, no rotation or unspecified
D Ventouse with rotation
E Other forceps delivery (includes ‘high-cavity’, high forceps)

SMR Validation - Mode of Delivery - (Babies 1 to 3)

Tags:
method  baby  delivered  normal  abnormal  presentation  premature  SMR02

Mode of Delivery - Babies 1 to 3

Field Length
1

Priority
Conditional

Definition
Pain relief given during labour and/or delivery.

Recording Rules
This item must be completed for delivery episodes.

Points to Note

More than one method of analgesia may be used in labour. The highest method in the following hierarchy should be used for coding this item.
- General anaesthetic
- Spinal (includes ‘combined spinal epidural’)
- Epidural
- Pethidine/Morphine or other opiates/opioids
- Gas/Air
- None
Code 8 should be used for other types of analgesia such as TENS, waterbirths and other complementary medicines.
There is no requirement to code analgesia in OPCS4.
If ‘combined spinal epidural’ is identified, code to ‘5’ – Spinal.
Cross Checks

Analgesia During Labour/Delivery is cross-checked with Condition on Discharge and MUST ONLY be present where Condition on Discharge = 3 (Delivered).
Analgesia During Labour/Delivery is cross-checked with Management of Patient.
Codes and Values: Analgesia (Code order)
0 None
1 Pethidine/morphine or other opiates/opioids
2 Epidural
3 Gas and air only
4 General anaesthetic
5 Spinal (includes ‘combined spinal epidural’)
8 Other
9 Not Known

SMR Validation - Analgesia During Labour and/or Delivery


Related items:

Condition on Discharge
Management of Patient
Tags:
pain  relief  analgesia  spinal  epidural  pethidine  morphine  opiates  gas/air  TENS  SMR02

Analgesia During Labour and/or Delivery

Field Length
1

Priority
Conditional

Definition
Outcome of pregnancy indicates whether the baby was liveborn or stillborn (or fetus was aborted in multiple pregnancy).

Recording Rules
Coding Examples:

Code 3 - Baby born at 3pm on 6 August dies at 1pm on 13 August = 6 days.
Code 4 - Baby born at 3pm on 6 August dies at 4pm on 13 August = 7 days.
Code 4 - Baby born at 3pm on 6 August dies at 2.15pm on 3 September = 27 days.
Code 5 - Baby born at 3pm on 6 August dies at 5pm on 3 September = 28 days.

Points to Note

Provision is made for coding the outcome of three babies. In single births the first field only should be coded.
A live born infant who is still alive at 28 days (to the best of ones knowledge) should be coded to 1; a live born infant who dies within 7 days should be coded 3.
For the purposes of recording on SMR02, Outcome of pregnancy code 2 [Stillbirth] is used when a baby is born at ?24 completed weeks of gestation (not following a termination of pregnancy) showing no signs of life. On SMR02, pregnancies ending following termination of pregnancy at any gestation (and those ending following a spontaneous abortion at <24 weeks gestation) are coded to Condition on discharge 2 [Aborted] hence the Outcome of pregnancy variable is not applicable to these records.
There are occasions where a multiple pregnancy, ending before 24 completed weeks, has one or more babies born alive and the other(s) dead. In such cases the liveborn(s) should be coded to 1 (or 3, 4 or 5 as appropriate) and the dead fetus(es) should be coded 8.
Cross Checks

Outcome of Pregnancy is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
Outcome of Pregnancy is cross-checked with Baby Discharged To, e.g. if Outcome is 1 (Livebirth) then Baby Discharged To should not be coded 9 (Died).
Outcome of Pregnancy is cross-checked with Estimated Gestation, e.g. if Outcome is 2 (Stillbirth) then Estimated Gestation should be coded to 24 weeks or over.
The following data items can only be present if a delivery is recorded. Although Condition on Discharge (code 3) and Number of Births (>0) are used to determine whether a delivery has occurred, outcome of pregnancy further determines whether or not the record of baby data items may, must or must not be present.
These rules apply to Baby 1, 2, 3 where appropriate.
Codes and Values: Outcome of Pregnancy (Code order)
1 Livebirth
2 Stillbirth
3 Livebirth dying within the first 6 days (early neonatal death).
4 Livebirth dying on or after the 7th completed day but before the 28th day (late neonatal eath).
5 Livebirth dying on or after the 28th completed day, but before the end of the first year of life (post-neonatal death).
8 Abortion of a dead fetus of a multiple pregnancy ending before 24 wks of gestation in which the other babies are live born.

SMR Validation - Outcome of Pregnancy


Related items:

Baby Discharged To - Babies 1 to 3
Condition on Discharge
Estimated Gestation
Number of Births this Pregnancy
Tags:
baby  liveborn  stillborn  aborted  recording  code  born  dies  SMR02

Outcome of Pregnancy - Babies 1 to 3

Field Length
1

Priority
Conditional

Definition
Induction of labour indicates the type of induction used actively to start labour by clinical intervention.

Recording Rules
Some of the means used to induce labour can also be used to augment pre-existing labour that is not progressing. Induction designed to start labour must not be confused with the augmentation of labour.

Points to Note

It is important to note that Induction of Labour is a procedure to start labour off and is usually a planned procedure. The admission reason in these cases will probably be Code 22 (pregnant but not in labour).
Code 0 should be used when any of these procedures are used to assist or augment labour. Do not confuse induction methods with similar procedures used to assist or augment labour which has already started.
Cross Checks

Induction of Labour is cross-checked with Condition on Discharge and MUST be present where Condition on Discharge = 3 (Delivered).
Induction of Labour is cross-checked with Mode of Delivery, e.g. if Mode of Delivery is 7 (Planned Caesarean Section) then Induction of Labour must be 0 (None).
Codes and Values: Induction of Labour (Code order)
0 None
1 Artificial rupture of membranes (ARM)
2 Oxytocics
3 ARM + Oxytocics
4 Prostaglandins (includes cervical priming)
5 Prostaglandins + ARM
6 Prostaglandins and Oxytocics
7 Prostaglandins and ARM and Oxytocics
8 Other
9 Not Known

SMR Validation - Induction of Labour


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Tags:
start  type  clinical  intervention  induced  planned  procedure  oxytocics  prostaglandins  ARM  SMR02

Induction of Labour

Field Length
2

Priority
Mandatory

Definitions
The total number of pregnancies prior to the current one terminated under the Abortion Acts (1967 & 1991) by medical or surgical means.

Recording Rules
The appropriate number of previous therapeutic abortions should be entered. If there are less than 10 previous therapeutic abortions preceding zeros should be entered.

Points to Note
None.

Cross checks

If total previous pregnancies is equal to 00, then the following fields must be equal to 00: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.
SMR Validation - Previous Therapeutic Abortions

Tags:
total  number  pregnancies  prior  current  acts  medical  surgical  terminate  SMR02

Previous Therapeutic Abortions

Field Length
1

Priority
Mandatory

Definition
‘Ever’ been administered illegal drugs (e.g. heroin, amphetamines), by self or by another, using a hypodermic needle/hypodermic syringe. Include also inappropriate injection of prescribed drugs (e.g. diazepam).

Points to Note

Injecting drug use carries serious risks of infection to both mother and baby. Even if the mother has not injected drugs during the current pregnancy, previous injecting behaviour (and sharing of injecting equipment) may have put them at risk of infection from blood-borne viruses such as HIV and hepatitis B and C.
Cross Checks
None.

Codes and Values: Injected drugs (Code order)
0 No
1 Yes, during current pregnancy
2 Yes, prior to current pregnancy
3 Yes, but it is not known when
9 Not known

SMR Validation - Ever Injected Illicit Drugs

Tags:
illegal  administered.  hypodermic  needle  injection  prescribed  syringe  mother  baby  SMR02

Ever Injected Illicit Drugs

Field Length
1

Priority
Conditional

Definition
Whether or not a doctor was present at the delivery.

Points to Note

Doctors will be present for an assisted delivery but are unlikely to be present for a spontaneous delivery.
Cross Checks

This field is cross-checked with Mode of Delivery e.g. record will be queried if an assisted delivery and no doctor present at delivery.
This field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).
Codes and Values: Doctor Present (Code order)
0 No
1 Yes
9 Not Known

SMR Validation - Doctor Present at Delivery


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Tags:
assisted  spontaneous  SMR02

Doctor Present at Delivery

Field Length
1

Priority
Mandatory (where applicable)

Definition
History of smoking at any point during pregnancy.

Points to Note

Smoking during pregnancy is one of the relatively few preventable known risk factors in pregnancy.
The two smoking fields were provided as a means of recording the success of anti-smoking health education.
Most health education is given by midwives who have agreed to make readily available in the case notes whether the woman has smoked throughout pregnancy (code 1) or not (code 0).
If the woman has smoked at any point during the pregnancy then this should be recorded as 1 - Yes. This applies even though the woman may have stopped once the pregnancy was confirmed but had been a smoker between LMP and confirmation of pregnancy.
The use of e-cigarettes should be recorded within the following codes:
- If only e-cigarettes used, this should be recorded as 0 - No
- If a combination of e-cigarettes and traditional cigarettes are used, this should be recorded as 1 - Yes.
Cross Checks
None.

Codes and Values: Smoker
0 -No
1 -Yes
9 - Not Known

SMR Validation - Smoker During Pregnancy

Tags:
smoking  health  education  preventable  risk  factors  e-cigarettes  SMR02

Smoker during pregnancy

Field Length
3

Priority
Mandatory

Definition
This is the height of the mother measured in centimetres.

Recording Rules
The height of the mother should be recorded in centimetres. There is space on the SMR02 for recording the height of the mother in feet and inches, if this is required for local use.

Points to Note

If the height is not available in the notes, 999 should be recorded.
Cross Checks

Extremes of the normal height range are checked and heights outwith the range 138-185cm are queried.
SMR Validation - Height

Tags:
mother  centimetres  measure  SMR02

Height

Sterilisation after delivery

Field Length
1

Priority
Optional

Definition
The first feed given to the baby immediately following delivery.

Points to Note

Use code 3 (Not applicable) if the baby is stillborn.
Cross Checks

First Feed Given is cross-checked with Condition on Discharge and MAY ONLY be present if Condition on Discharge = 3.
See checks under Outcome of Pregnancy.
Codes and Values: First Feed Given (Code order)
1 Breast only
2 Formula only
3 Not Applicable
4 Mixed (Breast & Formula)
8 Other (non milk feed)
9 Not Known

SMR Validation - First Feed Given


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
delivery  breast  formula  milk  condition  discharge  outcome  pregnancy  SMR02

First Feed Given - Babies 1 - 3

Field Length
1

Priority
Conditional

Definition
When a midwife formally and definitively passes responsibility for a woman‘s obstetric care to a consultant during an EPISODE of CARE with no expectation that the midwife will resume responsibility during that episode.

Recording Rules
SMR02 episodes during which such transfers occur are attributed to the specialty of Obstetrics. Data on the transfers is contained in the SMR02 records for such episodes.

Points to Note

This field is another that is designed to help monitor emerging changes in the care of women, along with the more planned changes in the booking plans.
This field should be completed for delivery episodes only.
A Midwife to Consultant Transfer does not generate a further SMR02.
This field is used to capture the cases when a mother is transferred from midwifery care to a consultant and should be completed when the HCP Responsible for Care and Specialty are both attributed to a midwife. This transfer can only happen from an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU).
When a transfer has occurred Specialty should NOT be attributed to Obstetrics.
Where NO transfer has taken place then this field should be completed with No transfer (mother remains under Midwifery) or Not Applicable (mother remains under Obstetrics).
Cross Checks

This field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3 (Delivered).
This field is cross-checked with Delivery Plan - Place.
This field is cross-checked with Booking Change - Place.
Codes and Values: Transfer (Code order)
0 No transfer - midwife retains responsibility throughout the delivery episode
1 Midwife to consultant transfer in labour/delivery
2 Midwife to consultant transfer after delivery
8 Not applicable
9 Not known

SMR Validation - Transfer of Responsibility: Midwife to Consultant


Related items:

Booking Change - Place
Condition on Discharge
Delivery Plan - Place
Tags:
episode  care  obstetric  SMR02  delivery  condition  discharge  alongside  midwifery  unit  freestanding

Transfer of Responsibility Midwife to Consultant

Field Length
1

Priority
Conditional

Definition
The form of resuscitation used.

Points to Note

If the baby does not breath spontaneously, or after its mouth is cleared it requires some form of resuscitation to maintain oxygenation until spontaneous breathing starts.
Oxygen may be given by:
· A constant stream via a mask
· Intermittent puffs again by a mask (Intermittent Positive Pressure Ventilation (IPPV))
· A tube inserted into the trachea (Intubation)
An injection of a drug to overcome the analgesics given to the mother during labour and which may depress the reflex which starts breathing in the baby.
Cross Checks

Resuscitation is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
See checks under Outcome of Pregnancy.
Codes and Values: Resuscitation (Code order)
1 Nil/Facial oxygen (includes ‘mask only‘)
2 Bag and mask (no drugs)
3 Bag and mask (with drugs)
4 Intubation for IPPV (no drugs)
5 Intubation for IPPV (with drugs)
6 Drugs only (usually Nalaxone)
8 Other
9 Not Known

SMR Validation - Resuscitation - Babies 1 to 3


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
breath  spontaneously  oxygen  IPPV  discharge  outcome  pregnancy  codes  SMR02

Resuscitation - Babies 1 to 3

Field Length
1

Priority
Conditional

Definition
The number of babies delivered this episode.

Recording Rules
The number of babies delivered should be entered as follows:

Single Birth	1
Twin Birth	2
Triplets	3
Quads	4
Quins	5
Six to Nine	6-9
Points to Note

There is space to record the details of up to three babies. In the rare circumstances where quads, quins etc. are born, enter the appropriate number of babies born under number of births (4, 5 etc.) and complete the details for the first three babies.
Although up to 9 births can be recorded here there is only space to record further details of up to 3 babies.
This field includes stillbirths but excludes abortion of dead Fetus.
Where number of births >0, the following items must be present (for Baby 1, 2, 3 as appropriate): Presentation at Delivery, Mode of Delivery, Outcome of Pregnancy, Birthweight, Sex, Baby Discharged To and Feed on Discharge.
Cross Checks

This field is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 3.
This field is checked against all the fields where provision is made for baby 1, baby 2 and baby 3 to be recorded. If the number of births is shown as 2, then all the baby 2 fields must be completed and baby 3 fields completed for number of births 3 or more.
This field is cross-checked with Birthweight, e.g. if more than 4 births this delivery the birthweight of babies 1, 2 ,3 should be in the range 0001 - 3000 grams.
This field is cross-checked with Estimated Gestation.
SMR Validation - Number of Births this Pregnancy


Related items:

Condition on Discharge
Tags:
delivered  episode  twin  triplets  quads  quins  SMR02

Number of births this pregnancy

Field Length
6

Priority
Conditional

Definitions
The booking date is the "Date of booking appointment" as recorded just below the "history taken by" field on page 5 of the Demographic information and EDD page in the SWHMR Combined Pregnancy and Postnatal Record

Recording Rules
The date should be entered as in the following example:

11th December 2004 = 11 12 04
Points to Note

If the woman has been referred from another hospital, or from GP/Midwife antenatal care, the Booking Date is the date she originally booked (not the date she was first seen in your hospital).
The Booking Date, together with the Estimated Gestation and the Date of Delivery is used to calculate the gestation at booking, which is important in reviewing outcomes such as participation in screening programmes.
If the episode is not a delivery episode and if the date of Original Booking is not known, the item should be left blank.
If only the month and year of booking is known, the day should be in filled with zeros, for example May 2004 = 00 05 04
If the woman is previously unbooked prior to her first hospital antenatal admission and she books during that episode, the actual booking date should be entered and Original Booking coded as "not Booked" (00000). If she has an appointment to attend a future booking clinic following discharge, the Booking Date should be left blank.
If Condition on Discharge = Delivered and Booking Date is unknown, a Booking Date less than or equal to the Date of Delivery should be entered.
If Booking Date is between 294 and 307 days before Date of Delivery record will be queried (Q3502)
If Booking Date is more than 307 days before Date of Delivery record will error (E7000)
Cross Checks

All dates on SMR02 are checked against each other to make sure they are in the correct sequence.
If present, Booking Date must be after the date of LMP, and if present it must be before the date of discharge. If the booking date is after the date of admission, the Original Booking field should be not booked (code 1).
Booking date must be present if Condition on Discharge is "Delivered".
Booking date is cross checked against admission date, delivery date and discharge date.
SMR Validation - Booking Date

Tags:
appointment  history  taken  demographic  SWHMR  hospital  SMR02

Booking Date

Field Length
1

Priority
Conditional

Definition
This indicates whether or not this procedure is carried out.

Points to Note

Episiotomy is an incision made in the perineum just before the baby is born, in order to facilitate the delivery, and to try to prevent uncontrolled tearing of the tissues around the exit to the birth canal. Episiotomy can co-exist with tears.
Cross Checks

Episiotomy is cross-checked with Mode of Delivery e.g. record will be queried if assisted delivery and no Episiotomy.
Episiotomy is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge =3 (Delivered).
Codes and Values: Episiotomy (Code order)
0 No
1 Yes
9 Not Known

SMR Validation - Episiotomy


Related items:

Condition on Discharge
Mode of Delivery - Babies 1 to 3
Tags:
incision  perineum  baby  born  delivery  tearing  tears  tissue  procedure  SMR02

Episiotomy

Field Length
1

Priority
Conditional

Definition
This denotes the type of location at which the patient is booked to be delivered.

Points to Note

The code of the hospital in which the consultant unit, GP unit, or midwife unit is housed will be captured by the item Original Booking.
Cross Checks

Delivery Plan - Place is cross-checked with Condition on Discharge and MUST ONLY be present if Condition on Discharge = 2 or 3 (Abortion or delivery episode).
Delivery Plan - Place is cross-checked with all other Proposals for Delivery fields.
Codes and Values: Delivery plan - Locations (Code order)
0 Home birth
1 Consultant Unit
2 GP Unit
3 Midwife Unit
8 Not booked/Other
9 Not Known

SMR Validation - Delivery Plan - Place


Related items:

Booking Change - Management
Booking Change - Place
Condition on Discharge
Delivery Plan - Management
Original Booking
Tags:
location  patient  booked  hospital  consultant  GP  midwife  unit  home  birth  SMR02

Delivery plan - Place

Field Length
6

Priority
Conditional

Definition
The reason given for an assisted delivery coded to ICD10.

Recording Rules
Operative deliveries include:

Forceps (mode of delivery = 2, A, B or E)
Ventouse (mode of delivery = C or D)
Caesarean Section (mode of delivery = 7 or 8)
Breech Deliveries (mode of delivery = 5 or 6)
Usually the obstetrician will include the indication for an operative delivery in the delivery notes.

Points to Note
None.

Cross Checks

An Indication for Operative Delivery will be expected if the Mode of Delivery is 2, A, B, C, D, E, 7 or 8 and may be present if Mode of Delivery is 5 or 6.
SMR Validation - Indication for Operative Delivery


Related items:

Mode of Delivery - Babies 1 to 3
Tags:
assisted  forceps  ventouse  caesarean  breech  ICD10  obstetrician  SMR02

Indication for operative delivery (ICD10)

Format
Characters

Field Length
3

Priority
Mandatory

Definitions

Specialty
A 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.

Click here for a complete list of Specialties

Discipline
A Discipline is a non-medical profession related to healthcare, for which a formal training leading to a recognised professional qualification is undertaken. Examples of disciplines are physiotherapy, nursing, pharmacology.

Recording Rules
This field should be coded to the Specialty/Discipline of the consultant/GP/HCP who is in charge of the patient episode. If the consultant is formally recognised and contracted to work in more than one specialty then the patients problem or condition should dictate the specialty.

Note that this is the ONLY rule for completing this field. The designation of the beds is not used.

Specialty/Discipline comprises four characters, the first three of which are allocated by ISD for each specialty, and is mandatory for completion. For the majority of Specialty/Discipline codes, which are two characters, the 3rd character space must be left blank if the 4th character extension is used. The 4th character is an Optional extension of the code for local special interests.

The Specialty/Discipline code should be entered in the character spaces provided and left justified.

Points to Note

A separate SMR record is prepared when a patient changes Specialty, Significant Facility or Consultant on medical grounds
GPs: Patients under the care of a GP in a GP hospital must be given the Specialty code E12 (GP other than Obstetrics) regardless of whether the patients are in a short stay or long stay facility.
Staff Wards: The Specialty recorded is that of the consultant/GP in charge of the patient. Record Significant Facility as 11 (Other: including all Standard Specialty Wards, Clinical Facility 1K, Day Bed Unit 1J).
Younger Physically Disabled: Record the Specialty of the consultant in charge of the patient, which will usually be geriatric medicine. Record Significant Facility as 18 (Ward for Younger Physically Disabled) or 1E (Long Stay Unit for Care of the Elderly).
See additional notes under Significant Facility.
For SMR02 records this should reflect the speciality of the person who was responsible for the care for the mother on original admission.
Example 1- If the mother was originally admitted under the care of a midwife in an Alongside Midwifery Unit (AMU) or Freestanding Midwifery Unit (FMU), then the midwifery specialty should be recorded in this section, irrespective of whether the mother was then transferred to an Obstetric unit during labour/delivery. When a transfer has occurred Speciality should NOT be attributed to Obstetrics.

Example 2 - If the mother was originally admitted under the care of a Consultant in an Obstetric Unit then the Obstetrics specialty should be recorded here.

Cross Checks

Specialty is checked against Location Code.
Specialty is checked against Consultant.
Specialty is checked against the Patients Age (at Date of Admission).
Specialty is checked against Duration of Stay calculated between Date of Admission and Date of Discharge.
Specialty is checked against Record Type
Specialty is checked against Significant Facility.
SMR Validation - Specialty/Discipline


Related items:

HCP Responsible for Care
Location Code
Significant Facility
SMR Record Type
Tags:
division  medicine  dentistry  clinical  activity  royal  college  faculties  consultant  GP  HCP  patient  episode  alongside  midwifery  unit  AMU  freestanding  FMU  SMR00  SMR01  SMR02  SMR04

Specialties and Codes for SMR02

Field Length
2

Priority
Mandatory

Definitions
The total number of stillbirths prior to the current pregnancy.

Recording Rules

A stillbirth occurs when a baby is born dead at 24 weeks gestation or over
All Previous Stillbirths must be counted. Thus, if triplets in a Previous Pregnancy were all born dead, 3 Previous Stillbirths must be noted.
The appropriate number of previous stillbirths should be entered. If there are less than 10 previous stillbirths preceding zeros should be entered.
Points to Note
None.

Cross Checks

If total Previous Pregnancies is equal to ‘00’, then the following fields must be equal to ‘00’: Spontaneous Abortions, Therapeutic Abortions, Caesarean Sections, Stillbirths and Neonatal Deaths.
SMR Validation - Previous Stillbirths

Tags:
number  pregnancy  baby  born  dead  24  weeks  prior  SMR02

Previous Stillbirths

Field Length
3

Priority
Optional

Definition
The circumference of the babys head at the widest part.

Recording Rules
Enter the measurement in centimetres, (preferably on the third day of life).

Points to Note
None.

Cross Checks

OFC is cross-checked with Condition on Discharge, and MAY ONLY be present if Condition on Discharge = 3.
The record will be queried if Occipito-Frontal Circumference (OFC) is outwith the range 19.9 - 40.0cm.
See checks under Outcome of Pregnancy.
For stillbirths this field should be left blank.
SMR Validation - OFC


Related items:

Condition on Discharge
Outcome of Pregnancy - Babies 1 to 3
Tags:
occipito-frontal  circumference  baby  head  measurement  centimetres  SMR02

OFC - Babies 1 to 3

Format
Characters

Field Length
6

Priority
Local

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 health care. 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.

For further information on co-morbidities and other conditions, please refer to the Scottish Clinical Coding Standards, (in particular Coding Guidelines 21 November 2007) as held on the Terminology Website

Points to Note

Up to five other significant conditions may be recorded for SMR01 returns.
Other conditions should be recorded according to the rules outlined in Coding Guidelines 21 November 2007.
From April 2020,this data item is no longer required for national collection on SMR00, though may still be collected locally.
Priority changed from Mandatory (where applicable) to Local.
Cross Checks

As for main condition.
A main condition must be recorded before the Other Condition fields can be completed.
SMR Validation - Other Conditions

Tags:
addition  main  episode  problem  management  patient  coding  guidelines  care  significant  ICD10  SMR00  SMR01  SMR02  SMR04

Other Condition/Co-morbidity and Complication ICD10 5

General Clinical Information

Other Condition/Co-morbidity and Complication ICD10 6

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the other operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.
SMR Validation - Date of Other Operation

Tags:
performed  sequence  recorded  SMR00  SMR01  SMR02  SMR06

Date of Other Operation/Treatment/Intervention/Investigative Procedures 4

Format
Characters

Field Length
8

Priority
Conditional

Definition
These are the additional procedures performed on an individual patient at a particular time.

Points to Note

Up to three pairs of procedures, in addition to the main procedure, may be recorded for an inpatient or day case episode on the central return. Therefore, if more than four procedures are performed during an episode of care, the clinicians opinion should be sought on which are the most significant. Local systems may allow more than four procedures to be recorded.
Cross Checks

These are detailed in Main Operation/Treatment/Investigative Procedure/Intervention.
SMR Validation - Other Operation

Tags:
additional  patient  inpatient  day  case  episode  performed  SMR00  SMR01  SMR02  SMR06

Other Operation/Treatment/Intervention/Investigative Procedures (4) - OPCS4

Format
Date (ddmmyy)

Field Length
6

Priority
Conditional

Definition
This reflects the date the other operation was performed.

Recording Rules
The full date should be entered thus: 5 July 2004 = 05/07/04

Cross Checks

Date of Other Operation is checked to ensure it is in the correct sequence with other dates recorded.
SMR Validation - Date of Other Operation

Tags:
performed  sequence  recorded  SMR00  SMR01  SMR02  SMR05

Date of Other Operation/Treatment/Intervention/Investigative Procedures 3

Format
Characters

Field Length
8

Priority
Conditional

Definition
This is the identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.

Points to Note

The "Clinician Responsible for Main Operation" is the most senior medical or health care professional in attendance in theatre during the main operation.
The code entered may not necessarily be the code of the consultant responsible for the episode of care if, for example, the operation is performed by a doctor in training or in a case where the consultant from another specialty attends the patient on the territory of the admitting specialty for the purposes of carrying out a procedure (e.g. endoscopy).
For guidance on recording clinician responsible for main operation for operation of different specialties in one theatre session, see Rules for Recording Operation/ Procedures.
The 7 digit GMC number allocated to each doctor is used as the clinician code. The GMC number can consist of 7 numeric, L + 6 numeric. The "L" format is used for limited registrations, usually overseas doctors, and in time the doctors number could be superseded by a permanent number, usually 7 numeric.
The General Dental Council (GDC) Number consists of D + 0 + 5 numeric.
The code number of the clinician should be right justified in the character spaces provided.
Cross Checks

It must be a valid GMC/GDC number.
Clinician Responsible for Main Operation/Treatment/ Investigative Procedure is cross checked against SMR record type. If it is 8 characters, it is a Health Care Professional Identifier and SMR record type must be SMR00, 01 or 02 (7 character General Medical Council/General Dental Council identifiers may appear on all record types).
SMR Validation - Clinician Responsible for Main Operation

Tags:
identification  doctor  GMC  registration  number  discipline  specialty  procedure  GDC  code  HCP  SMR00  SMR01  SMR02  SMR04

Maternity Inpatient and Day Case - Scottish Morbidity Record (SMR02)

Documentation

Coverage

Provenance

Origin

Temporal

Accessibility

Access

Usage

Format and Standards

Observations

Origin