ID

16739

Description

Health sector data set specifications from METeOR, Australia's repository for national metadata standards, developed by the Australian Institute of Health and Welfare (http://meteor.aihw.gov.au/content/index.phtml/itemId/345165) Cancer (clinical) DSS The purpose of the Cancer (clinical) data set specification (C(C)DSS) is to define data standards for the national collection of clinical cancer data so that data collected is consistent and reliable. Collection of this data set specification is not mandated but it is recommended as best practice if clinical cancer data are to be collected. It will facilitate more consistent data collection while enabling individual treatment centres or health service areas to develop data extraction and collection processes and policies that are appropriate for their service settings. Mandatory reporting regulations have enabled population-based cancer registries in Australia to collect standard information on all incident cases of cancer apart from non-melanoma skin cancers, from which incidence, mortality and overall survival have been determined and trends monitored. The Cancer (clinical) data set specification provides a framework for the collection of more detailed and comprehensive clinical data such as stage of cancer at diagnosis, other prognostic characteristics, cancer treatment and patient outcomes. The Cancer (clinical) data set specification will support prospective data collection from the time a person with cancer symptoms is referred or first presents to a hospital or specialist through the entire duration of their illness. The majority of data items in the Cancer (clinical) data set specification are applicable to most solid tumours while many are also relevant to the haematopoietic malignancies such as leukaemia and lymphoma. Data set specifications for specialist tumour streams are also under development and these will contain supplementary data elements that will capture the special features of specific cancer types. The definitions used in this data set specification are designed to capture the provision of cancer care on a day-to-day level. They relate to the cancer care pathway and the need to optimise care by correctly diagnosing, evaluating and managing patients with cancer. In addition, end-points and patterns of care can be monitored to understand both the appropriateness and effectiveness of cancer care. The data elements specified provide a framework for: • promoting the delivery of evidence-based care to patients with cancer • facilitating the ongoing improvement in the quality and safety of cancer management in treatment settings • improving the epidemiological and public health understanding of cancer • informing treatment guidelines and professional education • guiding resource planning and the evaluation of cancer control activities They will facilitate the aggregation of data across different treatment centres. The underlying long-term goal is to provide data support to improve outcomes for patients by increasing the quality and length of life. For example, a comparison of the actual management of patients with best practice guidelines may identify shortfalls in treatment and limitations in access to treatment modalities for some patients. The working group formed under the stewardship of Cancer Australia was diverse and included representation from the following organisations: Cancer Australia, University of Sydney-Department of Gynaecological Oncology, Westmead Institute for Cancer Research, Cancer Council Victoria, Royal Brisbane & Women’s Hospital, National Breast and Ovarian Cancer Centre, The Royal Women's Hospital, Queensland Health, Ministry of Health, NSW Health, TROG Cancer Research, and the Cancer Institute NSW. To ensure the broad acceptance of the data set specification, the proposed list of data items was circulated to members of Cancer Australia’s National Cancer Data Strategy Advisory Group, a multidisciplinary group with a broad spectrum of epidemiological knowledge and expertise, and the inter-governmental Strategic Forum, comprising clinicians and senior health department officials from the Australian Government and from each state and territory government, and with strong community representation. The working group also sought consultation from cancer registry data managers, clinical leaders, pathologists, medical oncologists and radiation oncologists to achieve consensus when required. The Cancer (clinical) data set specification is intended to only describe data collected in relation to the initial course of cancer treatment. The initial course of treatment includes all treatments administered to the patient from diagnosis and before disease progression or recurrence. © Australian Institute of Health and Welfare 2015 Metadata and Classifications Unit Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601

Link

http://meteor.aihw.gov.au/content/index.phtml/itemId/345165

Keywords

  1. 8/3/16 8/3/16 -
Uploaded on

August 3, 2016

DOI

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License

Creative Commons BY-NC 3.0

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Cancer (clinical) DSS Metadata Online Registry (METeOR)

Cancer (clinical) DSS Metadata Online Registry (METeOR)

Chemotherapy for cancer cluster
Description

Chemotherapy for cancer cluster

Chemotherapy completion date
Description

Cancer treatment—chemotherapy completion date, DDMMYYYY Identifying and definitional attributes Short name: Chemotherapy completion date METeOR identifier: 561215 Registration status: Health, Standard 08/05/2014 Definition: The completion date of chemotherapy administered during treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—chemotherapy completion date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Chemotherapy is cancer treatment that achieves its antitumour effect through the use of antineoplastic drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. The completion date of chemotherapy is the date the last dose was administered during the course of treatment. The completion date of chemotherapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the chemotherapy. Multiple entries are not permitted. Dates relating to targeted therapies using a chemotherapy agent are included. Targeted therapies are treatments that use drugs or other substances to identify and attack specific cancer cells. Dates of surgery, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and a hormone therapy agent, record the completion date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: Supersedes Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Chemotherapy cycles administered
Description

Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Chemotherapy cycles administered METeOR identifier: 561248 Registration status: Health, Standard 08/05/2014 Definition: The total number of cycles of chemotherapy administered during the course of treatment for cancer. Data Element Concept: Cancer treatment—chemotherapy cycles administered Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[NN] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable-no chemotherapy was administered 998 Unknown whether chemotherapy was administered 999 Chemotherapy was administered but the number of cycles was not stated/inadequately described Data element attributes Collection and usage attributes Guide for use: Chemotherapy is a type of cancer treatment that achieves its antitumour effect through the use of antineoplastic drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. Chemotherapy may be administered as single-agent treatment or as a combination of drugs administered according to a prespecified regimen or protocol. The number of cycles of each course of single agent chemotherapy, regimen or protocol administered to the patient during the treatment of cancer should be recorded separately. The number of cycles of chemotherapy received is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the chemotherapy. If any part of a cycle is administered but the cycle is not completed, record as one cycle. Oral chemotherapy normally given on an outpatient basis should also be included. The number of cycles of targeted therapies using a chemotherapy agent is included. Targeted therapies are treatments that use drugs or other substances to identify and attack specific cancer cells. If a patient receives treatment with a protocol including both a chemotherapy agent and another systemic agent such as an immunotherapy or hormone therapy agent, record the number of cycles here. Collection methods: This information should be collected from the patient’s medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Cancer Institute NSW 2006. NSW Clinical Cancer Registration: Minimum Data Set Data Dictionary, version 1.9 draft Relational attributes Related metadata references: See also Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Superseded 08/05/2014 See also Cancer treatment—chemotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014

Data type

integer

Chemotherapy start date
Description

Cancer treatment—chemotherapy start date, DDMMYYYY Identifying and definitional attributes Short name: Chemotherapy start date METeOR identifier: 561273 Registration status: Health, Standard 08/05/2014 Definition: The start date of chemotherapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—chemotherapy start date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Chemotherapy is cancer treatment that achieves its antitumour effect through the use of antineoplastic drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. Record the first or earliest date chemotherapy was administered during the course of treatment. The start date of the chemotherapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of chemotherapy. Multiple entries are not permitted. Dates relating to targeted therapies using a chemotherapy agent are included. Targeted therapies are treatments that use drugs or other substances to identify and attack specific cancer cells. Dates of surgery, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and a hormone therapy agent, record the start date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Standard 08/05/2014 Supersedes Cancer treatment—chemotherapy start date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Systemic therapy agent or protocol, eviQ
Description

Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Obligation: Conditional, Maximum occurences: 3 Identifying and definitional attributes Short name: Systemic therapy agent or protocol, eviQ METeOR identifier: 561278 Registration status: Health, Standard 08/05/2014 Definition: The eviQ protocol identifier for the systemic therapy agent protocol administered during the course of treatment for cancer. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Identifier Data type: String Format: NNNNNN Maximum character length: 6 Collection and usage attributes Guide for use: The eviQ protocol identifier must always be recorded as a six digit number, with leading zeros if applicable, for example, 000123. Collection methods: eviQ protocol identifiers are available from the eviQ Cancer Treatments Online website. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW Commission on Cancer, American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision Stedman TL 2006. Stedman's Medical Dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Data set specification specific attributes Chemotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Hormone therapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Immunotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Data element attributes Collection and usage attributes Guide for use: eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. Record the six digit eviQ protocol identifier (where available) for each systemic therapy agent protocol administered to the patient during the treatment of the cancer. Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Systemic therapy may involve a single agent or a combination regimen of two or more drugs. They are administered in treatment cycles. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. The systemic therapy agent eviQ protocol identifier applies to chemotherapy, hormone therapy and immunotherapy administered for the treatment of cancer. Collection methods: This name of the protocol should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia. Origin: Cancer Institute NSW, eviQ Cancer Treatments Online. Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW. Relational attributes Related metadata references: Supersedes Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Systemic therapy agent or protocol
Description

Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Systemic therapy agent or protocol METeOR identifier: 561301 Registration status: Health, Standard 08/05/2014 Definition: The systemic therapy agent or protocol administered during the course of treatment for cancer, as represented by text. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(149)] Maximum character length: 150 Data element attributes Collection and usage attributes Guide for use: Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Each systemic therapy agent or protocol used during the treatment of the cancer should be recorded. The name of each systemic therapy agent or protocol given as treatment is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the treatment. Oral systemic therapy agents normally given on an outpatient basis should also be included. Systemic therapy agents may be administered as single-agent treatments or as a combination of drugs administered according to a prespecified regimen or protocol. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. A combination of drugs may be known by acronyms but since details of drugs and acronyms may vary it is recommended that the name of each agent be recorded. When recording systemic therapy protocol names, eviQ should be used wherever possible. eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. If a single agent is being used or a protocol is not included in eviQ, then the full, generic name of any agent should be recorded preferably using the Australian Medicines Terminology (AMT), or if necessary, the Australian Medicines Handbook (AMH) or MIMS. If a generic name is not available because the drug is experimental or under patent protection, record the brand name. The eviQ protocol identifier number should be recorded separately in the data element Cancer treatment—systemic therapy agent(s) or protocol, eviQ protocol identifier, NNNNNN. Systemic therapy agents are encompassed in the treatment modalities chemotherapy, immunotherapy and hormone therapy administered for the treatment of cancer. A patient may receive treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and an immunotherapy agent. Targeted therapies (treatments that use drugs or other substances to identify and attack specific cancer cells) using a chemotherapy agent are included. Other targeted therapies, such as monoclonal antibody therapy, are recorded in the data element Cancer treatment—other cancer treatment, text [X(150)]. Do not code prednisone as hormone therapy when it is administered for reasons other than chemotherapeutic treatment. Only record prednisone as hormone therapy when administered in combination with chemotherapy such as MOPP (mechlorethamine, vincristine, procarbazine, prednisone) or COPP (cyclophosphamide, vincristine, procarbazine, prednisone). Tumour involvement or cancer treatment may destroy hormone-producing tissue. Hormone replacement therapy will be given if the hormone is necessary to maintain normal metabolism and body function. Hormone replacement therapy should only be recorded as part of a subsequent course of treatment and not the initial course of treatment. Collection methods: This information should be collected from the patient’s medical record. Comments: Note the distinction between the administration of systemic agents or drugs and systemic therapy procedures that affect the hormonal or immunologic balance of the patient. The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Stedman TL 2006. Stedman's medical dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW The National Clinical Terminology and Information Service (NCTIS) 2011. Australian Medicines Terminology (AMT). Sydney: National E-Health Transition Authority (NEHTA). AMT releases are provided every month and are available from the NCTIS Secure Website Australian Medicines Handbook (AMH). Australian Medicines Handbook Pty Ltd MIMS Medicines Information. St Leonards, New South Wales: UBM Medica Pty Ltd Relational attributes Related metadata references: See also Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Standard 08/05/2014 Supersedes Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Hormone therapy for cancer cluster
Description

Hormone therapy for cancer cluster

Hormone therapy completion date
Description

Cancer treatment—hormone therapy completion date, DDMMYYYY Identifying and definitional attributes Short name: Hormone therapy completion date METeOR identifier: 561329 Registration status: Health, Standard 08/05/2014 Definition: The completion date of the hormone therapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—hormone therapy completion date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Hormone therapy is cancer treatment that achieves its antitumour effect through changes in hormonal balance. This includes the administration of hormones, agents acting via hormonal mechanisms, antihormones and steroids. The completion date of hormone treatment is the date of the last dose administered during the course of treatment. The completion date of hormone therapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of immunotherapy. Do not record the dates for prednisone as hormone therapy when it is administered for reasons other than chemotherapeutic treatment. Only record prednisone as hormone therapy when it is administered in combination with chemotherapy such as MOPP (mechlorethamine, vincristine, procarbazine, prednisone) or COPP (cyclophosphamide, vincristine, procarbazine, prednisone). Tumour involvement or cancer treatment may destroy hormone-producing tissue. Hormone replacement therapy will be given if the hormone is necessary to maintain normal metabolism and body function. Do not code hormone replacement therapy as part of the initial course of treatment. A patient may undergo hormone therapy for an extended period of time. Multiple entries are not permitted. Dates of surgery, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and a hormone therapy agent, record the completion date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: Supersedes Cancer treatment—hormone therapy completion date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—hormone therapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Hormone therapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Cancer treatment—hormone therapy start date
Description

Cancer treatment—hormone therapy start date, DDMMYYYY Identifying and definitional attributes Short name: Cancer treatment—hormone therapy start date METeOR identifier: 561335 Registration status: Health, Standard 08/05/2014 Definition: The start date of hormone therapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—hormone therapy start date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Hormone therapy is cancer treatment that achieves its antitumour effect through changes in hormonal balance. This includes the administration of hormones, agents acting via hormonal mechanisms, antihormones and steroids. Record the first or earliest date hormone therapy was administered during the course of treatment. The start date of hormone therapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of hormone therapy. Do not record the dates for prednisone as hormone therapy when it is administered for reasons other than chemotherapeutic treatment. Only record prednisone as hormone therapy when it is administered in combination with chemotherapy such as MOPP (mechlorethamine, vincristine, procarbazine, prednisone) or COPP (cyclophosphamide, vincristine, procarbazine, prednisone). Tumour involvement or cancer treatment may destroy hormone-producing tissue. Hormone replacement therapy will be given if the hormone is necessary to maintain normal metabolism and body function. Hormone replacement therapy should only be recorded as part of a subsequent course of treatment and not the initial course of treatment. A patient may undergo hormone therapy for an extended period of time. Multiple entries are not permitted. Dates of surgery, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and a hormone therapy agent, record the start date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—hormone therapy completion date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—hormone therapy start date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Hormone therapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Systemic therapy agent or protocol, eviQ
Description

Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Obligation: Conditional, Maximum occurences: 3 Identifying and definitional attributes Short name: Systemic therapy agent or protocol, eviQ METeOR identifier: 561278 Registration status: Health, Standard 08/05/2014 Definition: The eviQ protocol identifier for the systemic therapy agent protocol administered during the course of treatment for cancer. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Identifier Data type: String Format: NNNNNN Maximum character length: 6 Collection and usage attributes Guide for use: The eviQ protocol identifier must always be recorded as a six digit number, with leading zeros if applicable, for example, 000123. Collection methods: eviQ protocol identifiers are available from the eviQ Cancer Treatments Online website. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW Commission on Cancer, American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision Stedman TL 2006. Stedman's Medical Dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Data set specification specific attributes Chemotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Hormone therapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Immunotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Data element attributes Collection and usage attributes Guide for use: eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. Record the six digit eviQ protocol identifier (where available) for each systemic therapy agent protocol administered to the patient during the treatment of the cancer. Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Systemic therapy may involve a single agent or a combination regimen of two or more drugs. They are administered in treatment cycles. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. The systemic therapy agent eviQ protocol identifier applies to chemotherapy, hormone therapy and immunotherapy administered for the treatment of cancer. Collection methods: This name of the protocol should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia. Origin: Cancer Institute NSW, eviQ Cancer Treatments Online. Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW. Relational attributes Related metadata references: Supersedes Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Systemic therapy agent or protocol
Description

Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Systemic therapy agent or protocol METeOR identifier: 561301 Registration status: Health, Standard 08/05/2014 Definition: The systemic therapy agent or protocol administered during the course of treatment for cancer, as represented by text. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(149)] Maximum character length: 150 Data element attributes Collection and usage attributes Guide for use: Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Each systemic therapy agent or protocol used during the treatment of the cancer should be recorded. The name of each systemic therapy agent or protocol given as treatment is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the treatment. Oral systemic therapy agents normally given on an outpatient basis should also be included. Systemic therapy agents may be administered as single-agent treatments or as a combination of drugs administered according to a prespecified regimen or protocol. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. A combination of drugs may be known by acronyms but since details of drugs and acronyms may vary it is recommended that the name of each agent be recorded. When recording systemic therapy protocol names, eviQ should be used wherever possible. eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. If a single agent is being used or a protocol is not included in eviQ, then the full, generic name of any agent should be recorded preferably using the Australian Medicines Terminology (AMT), or if necessary, the Australian Medicines Handbook (AMH) or MIMS. If a generic name is not available because the drug is experimental or under patent protection, record the brand name. The eviQ protocol identifier number should be recorded separately in the data element Cancer treatment—systemic therapy agent(s) or protocol, eviQ protocol identifier, NNNNNN. Systemic therapy agents are encompassed in the treatment modalities chemotherapy, immunotherapy and hormone therapy administered for the treatment of cancer. A patient may receive treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and an immunotherapy agent. Targeted therapies (treatments that use drugs or other substances to identify and attack specific cancer cells) using a chemotherapy agent are included. Other targeted therapies, such as monoclonal antibody therapy, are recorded in the data element Cancer treatment—other cancer treatment, text [X(150)]. Do not code prednisone as hormone therapy when it is administered for reasons other than chemotherapeutic treatment. Only record prednisone as hormone therapy when administered in combination with chemotherapy such as MOPP (mechlorethamine, vincristine, procarbazine, prednisone) or COPP (cyclophosphamide, vincristine, procarbazine, prednisone). Tumour involvement or cancer treatment may destroy hormone-producing tissue. Hormone replacement therapy will be given if the hormone is necessary to maintain normal metabolism and body function. Hormone replacement therapy should only be recorded as part of a subsequent course of treatment and not the initial course of treatment. Collection methods: This information should be collected from the patient’s medical record. Comments: Note the distinction between the administration of systemic agents or drugs and systemic therapy procedures that affect the hormonal or immunologic balance of the patient. The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Stedman TL 2006. Stedman's medical dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW The National Clinical Terminology and Information Service (NCTIS) 2011. Australian Medicines Terminology (AMT). Sydney: National E-Health Transition Authority (NEHTA). AMT releases are provided every month and are available from the NCTIS Secure Website Australian Medicines Handbook (AMH). Australian Medicines Handbook Pty Ltd MIMS Medicines Information. St Leonards, New South Wales: UBM Medica Pty Ltd Relational attributes Related metadata references: See also Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Standard 08/05/2014 Supersedes Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Immunotherapy for cancer cluster
Description

Immunotherapy for cancer cluster

Immunotherapy completion date
Description

Cancer treatment—immunotherapy completion date, DDMMYYYY Identifying and definitional attributes Short name: Immunotherapy completion date METeOR identifier: 561360 Registration status: Health, Standard 08/05/2014 Definition: The completion date of immunotherapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—immunotherapy completion date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: The completion date of immunotherapy treatment is the date of the last dose administered during the course of treatment. The completion date of immunotherapy treatment is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the immunotherapy. A patient may undergo immunotherapy for an extended period of time. The completion date of the immunotherapy treatment is recorded even if the agent is experimental. Multiple entries are not permitted. Dates of surgical, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and an immunotherapy agent, record the completion date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda:National Cancer Institute, NIH Publication number 07-5581 Relational attributes Related metadata references: Supersedes Cancer treatment—immunotherapy completion date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—immunotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Immunotherapy start date
Description

Cancer treatment—immunotherapy start date, DDMMYYYY Identifying and definitional attributes Short name: Immunotherapy start date METeOR identifier: 561366 Registration status: Health, Standard 08/05/2014 Definition: The start date of immunotherapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—immunotherapy start date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Record the first or earliest date on which immunotherapy was administered during the course of treatment. The start date of immunotherapy treatment is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the immunotherapy. A patient may undergo immunotherapy for an extended period of time. The start date of the immunotherapy treatment is recorded even if the agent is experimental. Multiple entries are not permitted. Dates of surgery, radiotherapy and other systemic treatments are collected as separate items. However, if a patient receives treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and an immunotherapy agent, record the completion date of treatment in both relevant data items. Collection methods: The information should be obtained from the patient’s medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda:National Cancer Institute, NIH Publication number 07-5581 Relational attributes Related metadata references: See also Cancer treatment—immunotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—immunotherapy start date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Systemic therapy agent or protocol, eviQ
Description

Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Obligation: Conditional, Maximum occurences: 3 Identifying and definitional attributes Short name: Systemic therapy agent or protocol, eviQ METeOR identifier: 561278 Registration status: Health, Standard 08/05/2014 Definition: The eviQ protocol identifier for the systemic therapy agent protocol administered during the course of treatment for cancer. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Identifier Data type: String Format: NNNNNN Maximum character length: 6 Collection and usage attributes Guide for use: The eviQ protocol identifier must always be recorded as a six digit number, with leading zeros if applicable, for example, 000123. Collection methods: eviQ protocol identifiers are available from the eviQ Cancer Treatments Online website. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW Commission on Cancer, American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision Stedman TL 2006. Stedman's Medical Dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Data set specification specific attributes Chemotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Hormone therapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Immunotherapy for cancer cluster Conditional obligation: Conditional on the administration of systemic therapy agents according to a prespecified regimen or protocol, and on the availability of the protocol number on the eviQ website. Data element attributes Collection and usage attributes Guide for use: eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. Record the six digit eviQ protocol identifier (where available) for each systemic therapy agent protocol administered to the patient during the treatment of the cancer. Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Systemic therapy may involve a single agent or a combination regimen of two or more drugs. They are administered in treatment cycles. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. The systemic therapy agent eviQ protocol identifier applies to chemotherapy, hormone therapy and immunotherapy administered for the treatment of cancer. Collection methods: This name of the protocol should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia. Origin: Cancer Institute NSW, eviQ Cancer Treatments Online. Reference documents: Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW. Relational attributes Related metadata references: Supersedes Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Systemic therapy agent or protocol
Description

Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Systemic therapy agent or protocol METeOR identifier: 561301 Registration status: Health, Standard 08/05/2014 Definition: The systemic therapy agent or protocol administered during the course of treatment for cancer, as represented by text. Data Element Concept: Cancer treatment—systemic therapy agent or protocol Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(149)] Maximum character length: 150 Data element attributes Collection and usage attributes Guide for use: Systemic therapy agents are drugs that travel through the bloodstream and reach and effect cells all over the body. They are administered orally or intravenously. Each systemic therapy agent or protocol used during the treatment of the cancer should be recorded. The name of each systemic therapy agent or protocol given as treatment is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of the treatment. Oral systemic therapy agents normally given on an outpatient basis should also be included. Systemic therapy agents may be administered as single-agent treatments or as a combination of drugs administered according to a prespecified regimen or protocol. A protocol is a precise and detailed plan for therapy that includes the type, quantity, method and length of time of taking the drugs required for any treatment cycle. A combination of drugs may be known by acronyms but since details of drugs and acronyms may vary it is recommended that the name of each agent be recorded. When recording systemic therapy protocol names, eviQ should be used wherever possible. eviQ Cancer Treatments Online is a point of care clinical information resource that provides health professionals with current evidence based, peer maintained, best practice cancer treatment protocols and information. It was developed and is maintained by the Cancer Institute NSW. If a single agent is being used or a protocol is not included in eviQ, then the full, generic name of any agent should be recorded preferably using the Australian Medicines Terminology (AMT), or if necessary, the Australian Medicines Handbook (AMH) or MIMS. If a generic name is not available because the drug is experimental or under patent protection, record the brand name. The eviQ protocol identifier number should be recorded separately in the data element Cancer treatment—systemic therapy agent(s) or protocol, eviQ protocol identifier, NNNNNN. Systemic therapy agents are encompassed in the treatment modalities chemotherapy, immunotherapy and hormone therapy administered for the treatment of cancer. A patient may receive treatment with a protocol that includes different types of systemic therapy agents, for example, a chemotherapy agent and an immunotherapy agent. Targeted therapies (treatments that use drugs or other substances to identify and attack specific cancer cells) using a chemotherapy agent are included. Other targeted therapies, such as monoclonal antibody therapy, are recorded in the data element Cancer treatment—other cancer treatment, text [X(150)]. Do not code prednisone as hormone therapy when it is administered for reasons other than chemotherapeutic treatment. Only record prednisone as hormone therapy when administered in combination with chemotherapy such as MOPP (mechlorethamine, vincristine, procarbazine, prednisone) or COPP (cyclophosphamide, vincristine, procarbazine, prednisone). Tumour involvement or cancer treatment may destroy hormone-producing tissue. Hormone replacement therapy will be given if the hormone is necessary to maintain normal metabolism and body function. Hormone replacement therapy should only be recorded as part of a subsequent course of treatment and not the initial course of treatment. Collection methods: This information should be collected from the patient’s medical record. Comments: Note the distinction between the administration of systemic agents or drugs and systemic therapy procedures that affect the hormonal or immunologic balance of the patient. The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Stedman TL 2006. Stedman's medical dictionary. 28th edition. Maryland: Lippincott Williams & Wilkins Standard Cancer Treatment and Management Pathways Program, Cancer Services and Education Division. eviQ Cancer Treatments Online. Cancer Institute NSW The National Clinical Terminology and Information Service (NCTIS) 2011. Australian Medicines Terminology (AMT). Sydney: National E-Health Transition Authority (NEHTA). AMT releases are provided every month and are available from the NCTIS Secure Website Australian Medicines Handbook (AMH). Australian Medicines Handbook Pty Ltd MIMS Medicines Information. St Leonards, New South Wales: UBM Medica Pty Ltd Relational attributes Related metadata references: See also Cancer treatment—chemotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy cycles administered, number of cycles N[NN] Health, Standard 08/05/2014 See also Cancer treatment—chemotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—hormone therapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—immunotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—systemic therapy agent or protocol, eviQ protocol identifier NNNNNN Health, Standard 08/05/2014 Supersedes Cancer treatment—systemic therapy agent or protocol, text X[X(149)] Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Chemotherapy for cancer cluster Health, Standard 08/05/2014 Hormone therapy for cancer cluster Health, Standard 08/05/2014 Immunotherapy for cancer cluster Health, Standard 08/05/2014

Data type

text

Radiotherapy for cancer cluster
Description

Radiotherapy for cancer cluster

Radiation dose administered
Description

Cancer treatment—radiation dose administered, total Gray N[NN.NN] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiation dose administered METeOR identifier: 561384 Registration status: Health, Standard 08/05/2014 Definition: The largest prescribed dose of radiation administered during the course of treatment for cancer, measured in Gray (Gy). Data Element Concept: Cancer treatment—radiation dose administered Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[NN.NN] Maximum character length: 5 Supplementary values: Value Meaning 999.97 Not applicable-radiotherapy was not administered 999.98 Unknown whether radiotherapy was administered 999.99 Radiotherapy was administered but the dose is not stated/inadequately described Unit of measure: Gray (Gy) Unit of measure precision: 2 Collection and usage attributes Guide for use: One gray is equivalent to 100 centigray (cGy). For example, a radiation dose of 5040 cGy equates to 50.40 Gy. This would be recorded as 50.40. Data element attributes Collection and usage attributes Guide for use: The gray (Gy) is the SI (International System of Units) unit of absorbed radiation dose of ionizing radiation (for example, X-rays), and is defined as the absorption of one joule of ionizing radiation by one kilogram of matter (usually human tissue). The radiation dose administered records the largest prescribed dose to the target. This means that for patients that have a boost treatment, the largest prescribed dose is the addition of the boost to the other phases of treatment. Record the largest prescribed dose to the target site for all courses of radiotherapy delivered to the patient during the course of treatment. The patient may receive more than one course of radiotherapy during the course of treatment. For example, radiotherapy may be administered to the primary site and the site of a distant metastasis. Record the radiation dose received for each course of treatment. The radiation dose administered is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of treatment. The International Commission on Radiation Units and Measurements (ICRU) develops internationally acceptable recommendations regarding quantities and units of radiation and radioactivity, procedures suitable for the measurement and application of these quantities in clinical radiology and radiobiology, and physical data needed in the application of these procedures to support uniformity in reporting. The ICRU recommends recording doses at the axis point where applicable (opposed fields, four field box, wedged pairs and so on). The ICRU50 reference dose should be recorded for photon therapy if available, otherwise a description of the received dose at the centre of the planning target volume. The ICRU58 should be recorded for brachytherapy. For maximum consistency in this field, the ICRU recommendations should be followed whenever possible. Do not include treatment with unsealed radioisotopes. Collection methods: The radiation dose will typically be found in the radiation oncologist's summary letter for the course of treatment or in the radiotherapy treatment summary in the patient's medical record. Determining the total dose may require assistance from the radiation oncologist for consistent coding. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Patient outcomes are strongly related to the radiotherapy dose delivered. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—brachytherapy dose rate, code N Health, Standard 04/02/2015 Supersedes Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Superseded 08/05/2014 See also Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site for lung cancer, code N Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site, code N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy treatment type, code N[N] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

float

Measurement units
  • Gy
Gy
Radiotherapy completion date
Description

Cancer treatment—radiotherapy completion date, DDMMYYYY Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiotherapy completion date METeOR identifier: 561389 Registration status: Health, Standard 08/05/2014 Definition: The completion date of the radiotherapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—radiotherapy completion date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: The completion date for radiotherapy is the date the last dose was administered. Record the completion date of radiotherapy for all courses administered during the course of treatment for cancer. The patient may receive more than one course of radiotherapy during the course of treatment. For example, radiotherapy may be administered to the primary site and the site of a distant metastasis. Record the completion date for each course of treatment. The completion date of radiotherapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of treatment. Record the completion date for radiotherapy administered as external beam radiotherapy or brachytherapy. Do not include radiotherapy with unsealed radioisotopes. Dates of surgery, systemic agent therapies and systemic therapy procedures are collected as separate items. Collection methods: The radiotherapy completion date will typically be found in the radiation oncologist's summary letter for the course of treatment or in the radiotherapy treatment summary in the patient's medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Standard 08/05/2014 Supersedes Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site for lung cancer, code N Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site, code N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy treatment type, code N[N] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Radiotherapy fractions administered
Description

Cancer treatment—radiotherapy fractions administered, total fractions N[N] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiotherapy fractions administered METeOR identifier: 561464 Registration status: Health, Standard 08/05/2014 Definition: The total number of radiotherapy sessions (fractions) administered during the course of treatment for cancer. Data Element Concept: Cancer treatment—radiotherapy fractions administered Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 97 Not applicable-no radiotherapy was administered 98 Unknown whether radiotherapy was administered 99 Radiotherapy administered but the number of fractions not stated/inadequately described Collection and usage attributes Guide for use: Valid values are 1 to 96. Data element attributes Collection and usage attributes Guide for use: A total dose of radiation is delivered to the patient in a number of even parts or treatment sessions (fractions). Although a treatment session may include several treatment portals delivered within a confined period of time, usually a few minutes, it is still considered one fraction. Record the number of fractions of radiotherapy treatment for all courses delivered to the patient during the course of treatment for cancer. The patient may receive more than one course of radiotherapy during the course of treatment. For example, radiotherapy may be administered to the primary site and the site of a distant metastasis. Record the total radiation dose for each course of treatment. The number of fractions administered is recorded regardless of whether the course of treatment is completed as intended and regardless of the intent or timing of treatment. The number of radiotherapy fractions recorded should include any boost. Brachytherapy (or implants) may be delivered more than once, each treatment is recorded as a fraction. Do not include treatment with unsealed radioisotopes. Collection methods: The number of radiotherapy fractions delivered will typically be found in the radiation oncologist's summary letter for the initial course of treatment or in the radiotherapy treatment summary in the patient's medical record. Determining the number of fractions may require assistance from the radiation oncologist for consistent coding. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—brachytherapy dose rate, code N Health, Standard 04/02/2015 See also Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Superseded 08/05/2014 See also Cancer treatment—radiotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site for lung cancer, code N Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site, code N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy treatment type, code N[N] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

integer

Radiotherapy start date—cancer treatment
Description

Cancer treatment—radiotherapy start date, DDMMYYYY Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiotherapy start date—cancer treatment METeOR identifier: 561469 Registration status: Health, Standard 08/05/2014 Definition: The start date of the radiotherapy administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—radiotherapy start date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Record the first or earliest date radiotherapy commenced for all courses of radiotherapy administered during the course of treatment. The patient may receive more than one course of radiotherapy during the course of treatment. For example, in the treatment of cancer, radiotherapy may be administered to the primary site and the site of a distant metastasis. Record the start date for each course of treatment. The start date of radiotherapy is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of treatment. Record the start date for radiotherapy administered as external beam radiotherapy or brachytherapy. Do not include radiotherapy with unsealed radioisotopes. This item should be used when collecting information about cancer patient care for safety and quality monitoring and other public health purposes. If collecting radiotherapy start date to examine service volumes for the purpose of calculating radiotherapy waiting times use Patient—radiotherapy start date, DDMMYYYY. Collection methods: The radiotherapy commencement date(s) will typically be found in the radiation oncologist's summary letter for the course of treatment or in the radiotherapy treatment summary in the patient's medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—brachytherapy dose rate, code N Health, Standard 04/02/2015 See also Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Standard 08/05/2014 Supersedes Cancer treatment—radiotherapy start date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—radiotherapy target site, code N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy treatment type, code N[N] Health, Standard 08/05/2014 See also Patient—radiotherapy start date, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—radiotherapy start date, DDMMYYYY WA Health, Endorsed 19/03/2015 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

date

Radiotherapy target site
Description

Cancer treatment—radiotherapy target site, code N[N] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiotherapy target site METeOR identifier: 561476 Registration status: Health, Standard 08/05/2014 Definition: The target site of radiotherapy administered during the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—radiotherapy target site Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Primary site only 2 Regional nodes only 3 Distant metastases only 4 Primary site and regional nodes 5 Primary site and distant metastases 6 Primary site, regional nodes and distant metastases 7 Regional nodes and distant metastases Supplementary values: 97 Not applicable-radiotherapy was not administered 98 Unknown whether radiotherapy was administered 99 Radiotherapy was administered but the site not stated/inadequately described Collection and usage attributes Guide for use: More than one site may be targeted for radiotherapy during the course of treatment; select the appropriate code value. Source and reference attributes Submitting organisation: Cancer Australia Data element attributes Collection and usage attributes Guide for use: The target site is collected for all courses of radiotherapy administered to the patient during the course of treatment. The target site for radiotherapy is recorded regardless of whether the course of treatment is completed as intended, the intent or timing of the radiotherapy, and the radiation therapy treatment modality. Record the value representing all the sites targeted for radiotherapy during the course of treatment. There may be more than one site targeted for treatment. For example, the primary tumour site and the site of a distant metastasis may receive radiotherapy as part of the course of treatment. In this case code "5" would be recorded. The target site for surgery is collected as a separate data item. Collection methods: This information should be obtained from the patient's radiotherapy records. Determining the target site of radiotherapy may require assistance from the radiation oncologist for consistent coding. Comments: This is collected to identify which sites are targeted by radiotherapy and is useful in evaluating patterns of care and patient outcomes. Source and reference attributes Submitting organisation: Cancer Australia Relational attributes Related metadata references: See also Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy start date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—radiotherapy target site, code N[N] Health, Superseded 08/05/2014 See also Cancer treatment—radiotherapy treatment type, code N[N] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

integer

Radiotherapy treatment type
Description

Cancer treatment—radiotherapy treatment type, code N[N] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Radiotherapy treatment type Synonymous names: Radiotherapy treatment modality METeOR identifier: 561521 Registration status: Health, Standard 08/05/2014 Definition: The type of radiotherapy administered during the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—radiotherapy treatment type Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 External beam radiotherapy only 2 Brachytherapy only 3 Unsealed radioisotopes only 4 External beam radiotherapy and brachytherapy 5 External beam radiotherapy and unsealed radioisotopes 6 Brachytherapy and unsealed radioisotopes 7 External beam radiotherapy, brachytherapy and unsealed radioisotopes Supplementary values: 97 Not applicable-radiotherapy was not administered 98 Unknown whether radiotherapy was administered 99 Radiotherapy was administered but the treatment type not stated/inadequately described Collection and usage attributes Guide for use: More than one radiotherapy treatment type may be delivered during the course of treatment; select the appropriate code value. The difference between the types of radiotherapy relates to the position of the radiation source: • External beam radiotherapy (EBRT) is delivered by directing the radiation at the tumour from outside the body • Brachytherapy or sealed source radiotherapy is delivered by placing the radiation source in close proximity to the tumour site • Unsealed radioisotopes or systemic radioisotope therapy is delivered by infusion into the bloodstream or by ingestion and is a form of targeted therapy. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: DeVita VT, Hellman S, Rosenberg SA 2005. Cancer: Principles and practice of oncology, 7th edition. Philadelphia: Lippincott Williams & Wilkins Data element attributes Collection and usage attributes Guide for use: External beam radiotherapy (EBRT) is delivered by directing the radiation at the tumour from outside the body. Types of external beam radiotherapy include conventional EBRT, intensity modulated radiation therapy (IMRT) and 3-dimensional conformal radiotherapy (3D-CRT). Brachytherapy is delivered by placing the radiation source in close proximity to the tumour site. The radioactive isotopes are sealed in tiny pellets or “seeds” which are placed in the body using delivery devices such as needles or catheters. Types include interstitial brachytherapy, which uses a source placed within tumour tissue, for example, within a prostate tumour; and intracavitary brachytherapy, whereby the source is placed within a surgical cavity or a body cavity. Brachytherapy can involve the temporary or permanent placement of radioactive sources. Unsealed radioisotopes or systemic radioisotope therapy is delivered by infusion into the bloodstream or by ingestion and is a form of targeted therapy. Targeting can be due to the chemical properties of the isotope, for example, radioiodine is specifically absorbed by the thyroid gland. It can also be achieved by attaching the radioisotope to another molecule or antibody to guide it to the target tissue. Examples of treatment with unsealed radioisotopes include the infusion of metaiodobenzylguanidine (MIBG) to treat neuroblastoma and of oral iodine-131 to treat thyroid cancer. Radiotherapy treatment type is collected for all courses of radiotherapy delivered to the patient during the course of treatment. The radiotherapy treatment type is recorded regardless of whether the course of treatment is completed as intended, and regardless of the intent or timing of treatment. More than one radiotherapy treatment type may be administered during the course of treatment; select the appropriate code value. If external beam radiotherapy and/or brachytherapy were administered, the radiation dose received and number of fractions should also be collected as well as the start and finish dates of the radiotherapy. Most external beam radiotherapy is delivered on an outpatient basis. Brachytherapy is likely to be delivered to admitted patients. Collection methods: The radiotherapy treatment modality will typically be found in the radiation oncologist's summary letter for the course of treatment or in the radiotherapy treatment summary in the patient's medical record. Determining the treatment modality may require assistance from the radiation oncologist for consistent coding. Comments: To evaluate patterns of radiotherapy care and analyse patient outcomes, it is necessary to know which treatment modalities were employed in the delivery of treatment. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons New South Wales Health Department Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Cancer Institute NSW 2006. NSW Clinical Cancer Registration: Minimum Data Set Data Dictionary, version 1.9 draft Relational attributes Related metadata references: See also Cancer treatment—external beam radiotherapy type, code N[N] Health, Standard 04/02/2015 See also Cancer treatment—radiation dose administered, total Gray N[NN.NN] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy completion date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy fractions administered, total fractions N[N] Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy start date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—radiotherapy target site, code N[N] Health, Standard 08/05/2014 Supersedes Cancer treatment—radiotherapy treatment type, code N[N] Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Radiotherapy for cancer cluster Health, Standard 08/05/2014

Data type

integer

Surgery for cancer cluster
Description

Surgery for cancer cluster

Surgery target site
Description

Cancer treatment—surgery target site, topography code (ICD-O-3) ANN.N Maximum occurences: Unlimited Identifying and definitional attributes Short name: Surgery target site METeOR identifier: 561567 Registration status: Health, Standard 08/05/2014 Definition: The target site of cancer-directed surgery performed during the course of treatment for cancer, as represented by an ICD-O-3 code. Data Element Concept: Cancer treatment—surgery target site Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: String Format: ANN.N Maximum character length: 5 Collection and usage attributes Guide for use: Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Data element attributes Collection and usage attributes Guide for use: The target site is collected for all cancer-directed surgery performed during the course of treatment. Cancer-directed surgery refers to all surgery that destroys or modifies cancer tissue anywhere in the body. Cancer-directed surgery may be palliative, (to control symptoms, alleviate pain, or make the patient more comfortable), or curative. Target sites for biopsies that remove the entire tumour and/or leave only microscopic margins are to be recorded here. All sites or regions targeted for cancer-directed surgery during the course of treatment should be recorded. There may be more than one site targeted for treatment. For example, the primary tumour site and the site of a distant metastasis may receive cancer-directed surgery as part of the course of treatment. The target site for radiotherapy is collected as a separate item. Collection methods: This information should be obtained from the patient's medical record. Comments: This is collected to identify which anatomical structures are targeted by surgery and is useful in evaluating patterns of care and patient outcomes. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: Supersedes Cancer treatment—surgery target site, topography code (ICD-O-3) ANN.N Health, Superseded 08/05/2014 See also Cancer treatment—surgical procedure date, DDMMYYYY Health, Standard 08/05/2014 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 8th edn) NNNNN-NN Health, Superseded 08/05/2014 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 8th edn) NNNNN-NN Health, Superseded 14/05/2015 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 9th edn) NNNNN-NN Health, Standard 14/05/2015 Implementation in Data Set Specifications: Surgery for cancer cluster Health, Standard 14/05/2015

Data type

text

Surgical procedure date
Description

Cancer treatment—surgical procedure date, DDMMYYYY Maximum occurences: Unlimited Identifying and definitional attributes Short name: Surgical procedure date METeOR identifier: 561574 Registration status: Health, Standard 08/05/2014 Definition: The date on which a cancer-directed surgical procedure was performed during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—surgical procedure date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: The surgical procedure date is collected for all cancer-directed surgery delivered to the patient during treatment for cancer. Cancer-directed surgery refers to all surgery that destroys or modifies cancer tissue anywhere in the body. Cancer-directed surgery may be palliative (to control symptoms, alleviate pain, or make the patient more comfortable), or curative. The date of each surgical treatment episode should be entered separately. Procedure dates for biopsies that remove all of the tumour and/or leave only microscopic margins are to be recorded here. Dates for radiotherapy and systemic treatments are collected as separate items. Collection methods: This information should be obtained from the patient's medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—surgery target site, topography code (ICD-O-3) ANN.N Health, Standard 08/05/2014 Supersedes Cancer treatment—surgical procedure date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 8th edn) NNNNN-NN Health, Superseded 08/05/2014 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 8th edn) NNNNN-NN Health, Superseded 14/05/2015 See also Cancer treatment—surgical procedure for cancer, procedure code (ACHI 9th edn) NNNNN-NN Health, Standard 14/05/2015 Implementation in Data Set Specifications: Surgery for cancer cluster Health, Standard 14/05/2015

Data type

date

Surgical procedure for cancer
Description

Cancer treatment—surgical procedure for cancer, procedure code (ACHI 9th edn) NNNNN-NN Maximum occurences: Unlimited Identifying and definitional attributes Short name: Surgical procedure for cancer METeOR identifier: 603484 Registration status: Health, Standard 14/05/2015 Definition: The cancer-directed surgical procedure performed during the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—surgical procedure for cancer Value domain attributes Representational attributes Classification scheme: Australian Classification of Health Interventions (ACHI) 9th edition Representation class: Code Data type: Number Format: NNNNN-NN Maximum character length: 7 Data element attributes Collection and usage attributes Guide for use: The procedure code is collected for all cancer-directed surgery performed during treatment for cancer. Cancer-directed surgery refers to all surgery that destroys or modifies cancer tissue anywhere in the body. Cancer-directed surgery may be palliative (to control symptoms, alleviate pain, or make the patient more comfortable), or curative. Biopsies that remove the entire tumour and/or leave only microscopic margins are to be recorded here. The procedure code for each surgical treatment episode should be entered separately. Endocrine surgery for the purpose of modifying hormone levels is recorded with data element Cancer treatment—systemic therapy procedure, code N[N]. Collection methods: This information should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Submitting organisation: Cancer Australia Origin: National Centre for Classification in Health New South Wales Department of Health, Public Health Division Reference documents: Public Health Division 2001. NSW Clinical Cancer Data Collection for Outcomes and Quality: Data Dictionary, Version 1. Sydney:NSW Health Department American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—surgery target site, topography code (ICD-O-3) ANN.N Health, Standard 08/05/2014 See also Cancer treatment—surgical procedure date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—surgical procedure for cancer, procedure code (ACHI 8th edn) NNNNN-NN Health, Superseded 14/05/2015 Implementation in Data Set Specifications: Surgery for cancer cluster Health, Standard 14/05/2015

Data type

text

Systemic therapy procedure for cancer cluster
Description

Systemic therapy procedure for cancer cluster

Systemic therapy procedure date
Description

Cancer treatment—systemic therapy procedure date, DDMMYYYY Maximum occurences: Unlimited Identifying and definitional attributes Short name: Systemic therapy procedure date METeOR identifier: 561606 Registration status: Health, Standard 08/05/2014 Definition: The date on which a systemic therapy procedure was administered during the course of treatment for cancer, expressed as DDMMYYYY. Data Element Concept: Cancer treatment—systemic therapy procedure date Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: The date is collected for all systemic therapy procedures administered to the patient during the treatment for cancer. A systemic therapy procedure is a medical, surgical or radiation procedure that has an effect on the hormonal or immunologic balance of the patient, and refers to haematologic transplant and endocrine procedures. Haematologic transplants are bone marrow or stem cell transplants performed to protect patients from myelosuppression or bone marrow ablation associated with the administration of high-dose chemotherapy or radiotherapy. Endocrine therapy is cancer therapy that achieves its antitumour effect through the use of radiation or surgical procedures that suppress the naturally occurring hormonal activity of the patient (when the cancer occurs at another site) and, therefore, alter or affect the long-term control of the cancer's growth. Haematologic transplant or endocrine procedures may be provided to prolong a patient's life by controlling symptoms, to alleviate pain, or make the patient more comfortable. The date of each treatment episode should be entered separately. The date of cancer-directed surgery, radiotherapy and treatment with systemic agents are collected as separate items. Collection methods: This information should be obtained from the patient's medical record. Comments: Collecting the start and finish dates for treatment modalities will enable an estimate of treatment duration. Note the distinction between the administration of systemic agents or drugs and systemic therapy procedures that affect the hormonal or immunologic balance of the patient. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: Supersedes Cancer treatment—systemic therapy procedure date, DDMMYYYY Health, Superseded 08/05/2014 See also Cancer treatment—systemic therapy procedure, code N[N] Health, Standard 08/05/2014 Implementation in Data Set Specifications: Systemic therapy procedure for cancer cluster Health, Standard 08/05/2014

Data type

date

Systemic therapy procedure
Description

Cancer treatment—systemic therapy procedure, code N[N] Maximum occurences: Unlimited Identifying and definitional attributes Short name: Systemic therapy procedure Synonymous names: Haematologic transplant, endocrine procedures METeOR identifier: 561612 Registration status: Health, Standard 08/05/2014 Definition: The systemic therapy procedure administered during the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—systemic therapy procedure Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 A bone marrow transplant procedure was administered but the type was not specified 2 Bone marrow transplant—autologous only 3 Bone marrow transplant—allogeneic only 4 Stem cell harvest and infusion only 5 Endocrine surgery and/or endocrine radiation therapy only 6 Combination of endocrine surgery and/or radiation with a transplant procedure 96 Other systemic therapy procedure Supplementary values: 97 Not applicable-no systemic therapy procedures were administered 98 Unknown whether systemic therapy procedures were administered 99 Systemic therapy procedures were administered but were not stated/inadequately described Collection and usage attributes Guide for use: Systemic therapy procedures are medical, surgical or radiation procedures that have an effect on the hormonal or immunological balance of the patient, and refers to haematologic transplant and endocrine procedures. Source and reference attributes Submitting organisation: Cancer Australia. Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer, 28D-28E, 182-183. Data element attributes Collection and usage attributes Guide for use: Systemic therapy procedures refers to haematologic transplant and endocrine procedures. Haematologic transplants are bone marrow or stem cell transplants performed to protect patients from myelosuppression or bone marrow ablation associated with the administration of high-dose chemotherapy or radiotherapy. Endocrine therapy is cancer therapy that achieves its antitumour effect through the use of radiation or surgical procedures that suppress the naturally occurring hormonal activity of the patient (when the cancer occurs at another site) and, therefore, alter or affect the long-term control of the cancer's growth. Haematologic transplant or endocrine procedures may be provided to prolong a patient's life by controlling symptoms, to alleviate pain, or make the patient more comfortable. Each systemic therapy procedure delivered to the patient during the treatment for cancer should be recorded. The procedure code for each treatment episode should be entered separately. Bone marrow transplants should be coded as either autologous (bone marrow originally taken from the patient) or allogeneic (bone marrow donated by a person other than the patient). For cases in which the marrow transplant was syngeneic (transplanted marrow from an identical twin), the item is coded as allogeneic. Stem cell harvests involve the collection of immature blood cells from the patient and the reintroduction by transfusion of the harvested cells following chemotherapy or radiation therapy. Endocrine procedures must be bilateral to qualify as endocrine surgery or endocrine radiation. If only one gland is intact at the start of treatment, surgery and/or radiation to that remaining gland qualifies as endocrine surgery or endocrine radiation. Collection methods: This information should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Note the distinction between the administration of systemic agents or drugs and systemic therapy procedures that affect the hormonal or immunologic balance of the patient. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer treatment—surgical procedure for prostate cancer, code N Health, Standard 14/05/2015 See also Cancer treatment—systemic therapy procedure date, DDMMYYYY Health, Standard 08/05/2014 Supersedes Cancer treatment—systemic therapy procedure, code N[N] Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Systemic therapy procedure for cancer cluster Health, Standard 08/05/2014

Data type

integer

Cancer staging
Description

Cancer staging

Cancer staging scheme source edition number
Description

Cancer staging—cancer staging scheme source edition number, code N[N] Identifying and definitional attributes Short name: Cancer staging scheme source edition number METeOR identifier: 393398 Registration status: Health, Standard 07/12/2011 Definition: The edition number of the cancer staging scheme used to determine the extent or stage of the cancer, as represented by a code. Data Element Concept: Cancer staging—cancer staging scheme source edition number Value domain attributes Representational attributes Representation class: Text Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 97 Not applicable 98 Unknown 99 Not stated/inadequately described Collection and usage attributes Guide for use: Record the edition number, valid entries are from 1 to 96. CODE 97 Not applicable To be used for cases that do not have a recommended staging scheme or when the staging scheme source does not have edition number. Source and reference attributes Submitting organisation: Cancer Australia Data element attributes Collection and usage attributes Guide for use: Record for any staging classification system that has an edition number. For example, record the edition number when the TNM Classification of Malignant Tumours (International Union Against Cancer (UICC)) or the American Joint Committee on Cancer (AJCC) Cancer Staging Manual is used for the purpose of staging the cancer. Comments: Collected to identify the edition number of the staging scheme source. Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Origin: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: Supersedes Cancer staging—cancer staging scheme source edition number, code N[N] Health, Superseded 07/12/2011 See also Cancer staging—cancer staging scheme source, code N[N] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, stage grouping other, code X[XXXXX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Staging scheme source
Description

Cancer staging—cancer staging scheme source, code N[N] Identifying and definitional attributes Short name: Staging scheme source METeOR identifier: 393364 Registration status: Health, Standard 07/12/2011 Definition: The reference which describes in detail the methods of staging and the definitions for the classification system used in determining the extent of cancer, as represented by a code. Data Element Concept: Cancer staging—cancer staging scheme source Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 TNM Classification of Malignant Tumours (UICC) 2 Durie & Salmon for multiple myeloma staging 3 French-American-British (FAB) for leukaemia classification 4 Australian Clinico-Pathological Staging (ACPS) System for colorectal cancer 5 International Federation of Gynecologists & Obstetricians (FIGO) for gynaecological cancers 6 Dukes/Modified Dukes for colorectal cancer 7 Ann Arbor staging system for lymphomas 8 Binet Staging Classification for chronic lymphocytic leukaemia 9 Rai staging system for chronic lymphocytic leukaemia 10 Chronic Myeloid Leukaemia (CML) staging system 11 International Staging System (ISS) for myeloma 12 American Joint Committee on Cancer (AJCC) Cancer Staging Manual 96 Other reference Supplementary values: 97 Not applicable 98 Unknown 99 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 10 Chronic Myeloid Leukaemia (CML) staging system Criteria for diagnosing the transition from the chronic phase into the accelerated phase in patients with Chronic Myeloid Leukaemia (CML) is variable. The WHO criteria (Vardiman et al. 2002) are perhaps the most widely used and are recommended. Source and reference attributes Reference documents: American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. Springer: New York Astler VB & Coller FA 1954. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg 139:846 Australian Cancer Network Colorectal Cancer Guidelines Revision Committee 2005. Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. Sydney: The Cancer Council Australia and Australian Cancer Network Benedet JL & Pecorelli S 2000. Staging classifications and clinical practice guidelines of gynaecologic cancers. FIGO Committee on Gynaecologic Oncology Bennett JM et al. 1985. Proposed revised criteria for the classification of acute myeloid leukaemia. French-American-British (FAB) co-operative group. Ann Intern Med 103(4):620-625 Binet JL et al. 1981. A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer 48:198-206 Binet JL et al. 1981. Proposals for a revised staging system. Br J Haematol 48:365-7 Carbone PA, Kaplan HS, Musshoff K, Smithers, DW, Tubiana M 1971. Report of the committee on Hodgkin’s disease staging classification. Cancer Research 31:1860-1861 Davis NC & Newland RC 1983. The reporting of colorectal cancer: the Australian Clinico-pathological Staging (ACPS) System. Med J Aust 1(6):282 Dukes CE 1932. The classification of cancer of the rectum. J Pathol Bacteriol 35:323 Durie BG & Salmon SE 1975. A clinical staging system for multiple myeloma: correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer 36(3):842-54 Greipp PR et al. 2005. International Staging System for Multiple Myeloma. J Clin Oncol 23(15):3412-20 International Myeloma Working Group 2003. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 121:749-757 Lister TA et al. 1989. Report of a committee convened to discuss the evaluation and staging of patients with Hodgkin’s disease: Cotswolds meeting. J Clin Oncol 7(11):1630-6 Rai KR, Sawitsky A, Cronkite EP, Chanana AD, Levy RN 1975. Clinical staging of chronic lymphocytic leukaemia. Blood 46(2):219-34 Rosenberg SA 1977. Validity of the Ann Arbor staging classification for the non-Hodgkin’s lymphomas. Cancer Treat Rev 61:1023-27 Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell Vardiman JW, Harris NL, Brunning RD 2002. The World Health Organization (WHO) classification of the myeloid neoplasms. Blood 100(7):2292-2302 Data element attributes Collection and usage attributes Guide for use: It is recommended that the TNM Classification of Malignant Tumours (International Union Against Cancer (UICC)) or the American Joint Committee on Cancer (AJCC) Cancer Staging Manual be used whenever it is applicable. The classifications published in the AJCC Cancer Staging Manual are identical to the TNM classifications of the UICC. TNM is not applicable to all tumour sites. Staging is of limited use in some cancers, for example, haematological malignancies. In these cases use the most appropriate classification system. The Cancer Council Australia and Australian Cancer Network Guidelines for the prevention, early detection and management of colorectal cancer (2005, pp. 159-162) support the use of the Australian Clinico-Pathological Staging (ACPS) System. They recommend that both TNM and ACPS staging data be recorded to enable national and international comparisons. A table of correspondences between ACPS and TNM classifications is available. The current edition of each staging scheme should be used. Comments: Collected to identify which classification system is used to determine the extent of cancer at the time of diagnosis. Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Union Against Cancer (UICC) FAB (French-American-British) Group NSW Health Department National Health & Medical Research Council Clinical Oncological Society of Australia Australian Cancer Network Relational attributes Related metadata references: See also Cancer staging—cancer staging scheme source edition number, code N[N] Health, Standard 07/12/2011 Supersedes Cancer staging—cancer staging scheme source, code N Health, Superseded 07/12/2011 See also Person with cancer—extent of primary cancer, stage grouping other, code X[XXXXX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 08-Cancer clinico-pathological stage distribution Health, Standard 29/08/2014

Data type

integer

Staging basis of cancer
Description

Cancer staging—staging basis of cancer, code A Identifying and definitional attributes Short name: Staging basis of cancer METeOR identifier: 422604 Registration status: Health, Standard 07/12/2011 Definition: The timing and evidence for cancer stage values, as represented by a code. Data Element Concept: Cancer staging—staging basis of cancer Value domain attributes Representational attributes Representation class: Code Data type: String Format: A Maximum character length: 1 Permissible values: Value Meaning P Pathological C Clinical Collection and usage attributes Guide for use: CODE P Pathological Pathological stage is based on histological evidence acquired before treatment, supplemented or modified by additional evidence acquired from surgery and from pathological examination. CODE C Clinical Clinical stage is based on evidence obtained prior to treatment from physical examination, imaging, endoscopy, biopsy, surgical exploration or other relevant examinations. Refer to the latest edition of the manual containing the appropriate classification system for the cancer. For example, refer to the latest edition of the International Union Against Cancer (UICC) reference manual TNM Classification of Malignant Tumours or the American Joint Committee on Cancer (AJCC) Cancer Staging Manual for coding rules for those tumours classified using the TNM system. Source and reference attributes Submitting organisation: Australian Institute of Health and Welfare Data element attributes Collection and usage attributes Collection methods: From information provided by the treating doctor and recorded on the patient's medical record. Comments: For survival analysis adjusted by stage at diagnosis and distribution of cancer case by type and stage. Relational attributes Related metadata references: Supersedes Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, stage grouping other, code X[XXXXX] Health, Standard 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 08-Cancer clinico-pathological stage distribution Health, Standard 29/08/2014

Data type

text

Cancer treatment
Description

Cancer treatment

Cancer treatment type
Description

Cancer treatment—cancer treatment type, code N[N] Identifying and definitional attributes Short name: Cancer treatment type METeOR identifier: 561618 Registration status: Health, Standard 08/05/2014 Definition: The type of treatment administered during the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—cancer treatment type Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Surgery only 2 Radiotherapy only 3 Systemic agent therapy only 4 Surgery and radiotherapy 5 Surgery and systemic agent therapy 6 Radiotherapy and systemic agent therapy 7 Surgery, radiotherapy and systemic agent therapy Supplementary values: 97 Not applicable—treatment was not administered 98 Unknown whether treatment was administered 99 Treatment was administered but the type was not stated/inadequately described Collection and usage attributes Guide for use: More than one treatment type may be administered during a course of cancer treatment; select the appropriate code value. Systemic agent therapy refers to: • chemotherapy • hormone therapy • immunotherapy Surgery includes: • surgical procedure for cancer • systemic therapy procedure involving surgery A systemic therapy procedure is a medical, surgical or radiation procedure that has an effect on the hormonal or immunologic balance of the patient. Treatments other than surgery, radiotherapy or systemic agent therapy administered as part of the treatment are recorded separately. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer, 28E Data element attributes Collection and usage attributes Guide for use: All treatments administered to the patient during the course of cancer treatment should be recorded. When the patient has received treatment for cancer and codes 1 to 7 are recorded, the relevant treatment information for each treatment modality should also be collected. Cancer-directed treatments administered to the patient during the course of treatment that cannot be characterised as surgery, radiotherapy or systemic therapy according to the definitions in this data set specification, are recorded separately in the data element Other cancer treatment description Collection methods: This information should be obtained from the patient's medical record. Comments: The collection of specific treatment information is useful to evaluate patterns of care, the effectiveness of different treatment modalities, and treatment by patient outcome. Source and reference attributes Origin: Commission on Cancer, American College of Surgeons New South Wales Health Department Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Public Health Division 2001. NSW Clinical Cancer Data Collection for Outcomes and Quality. Data Dictionary Version 1. Sydney: NSW Health Department Relational attributes Related metadata references: Supersedes Cancer treatment—cancer treatment type, code N[N] Health, Superseded 08/05/2014 See also Cancer treatment—other cancer treatment, text X[X(149)] Health, Standard 08/05/2014 See also Chemotherapy for cancer cluster Health, Standard 08/05/2014 See also Hormone therapy for cancer cluster Health, Standard 08/05/2014 See also Immunotherapy for cancer cluster Health, Standard 08/05/2014 See also Radiotherapy for cancer cluster Health, Standard 08/05/2014 See also Surgery for cancer cluster Health, Standard 14/05/2015 See also Surgery for cancer cluster Health, Superseded 14/05/2015 See also Systemic therapy procedure for cancer cluster Health, Standard 08/05/2014 Implementation in Data Set Specifications: Adolescent and young adult cancer (clinical) DSS Health, Standard 14/05/2015 Cancer (clinical) DSS Health, Standard 14/05/2015 Gynaecological cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Multidisciplinary team review indicator
Description

Cancer treatment—multidisciplinary team review indicator, yes/no/unknown code N Identifying and definitional attributes Short name: Multidisciplinary team review indicator Synonymous names: MDT review indicator; Multidisciplinary care indicator METeOR identifier: 428137 Registration status: Health, Standard 08/05/2014 Definition: An indicator of whether a patient's cancer treatment is discussed and a treatment plan developed by a multidisciplinary team, as represented by a code. Data Element Concept: Cancer treatment—multidisciplinary team review indicator Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Supplementary values: 8 Unknown Data set specification specific attributes Cancer (clinical) DSS DSS specific information: This item is to be collected in relation to the initial course of treatment for cancer. A multidisciplinary team is a team of medical professionals and/or allied health professionals who are working to provide multidisciplinary care to a patient. The specific disciplines represented in a multidisciplinary team will vary based on the disease type. In relation to cancer treatment, the disciplines represented in a core multidisciplinary team should minimally include surgery, oncology (radiation and medical oncology), pathology, radiology and supportive care, and may be expanded or contracted to include services, such as genetics, psychiatry, physiotherapy and nuclear medicine. Data element attributes Collection and usage attributes Guide for use: Record a multidisciplinary team (MDT) review that occurs prior to the implementation of, or during the course of treatment for cancer. The initial treatment for cancer includes all treatments administered to the patient from diagnosis and before disease progression or recurrence. Access to a unit offering multidisciplinary care is recommended for patients with cancer. Multidisciplinary care (MDC) is defined as an integrated team approach to health care in which medical and allied health care professionals consider all relevant treatment options and develop collaboratively an individual treatment plan for each patient. (National Breast Cancer Centre 2005, page 5.) There are a number of models of MDC in Australia. These include: • A 'tumour board' model in which the patient's case is discussed by the team, a recommendation for treatment is made, and the treating clinician informs the patient of the recommendation and makes the appropriate referrals. • A variation of this model in which the patient attends a clinic after the discussion and meets the members of the team who will be involved in their ongoing care. The MDT review may be conducted according to any of these models; the essential component is that the multidisciplinary team assesses the patient’s treatment options and develops a treatment plan. Multidisciplinary team membership will vary depending on the cancer type but should consist of the core disciplines required for the provision of good care, and reflect both the clinical and psychosocial aspects of care. For example, for lung cancer the core team would ideally be represented by respiratory medicine, cardiothoracic surgery, medical oncology, radiation oncology, pathology, radiology, nurse specialist and palliative care, while non-core team membership would consist of nuclear medicine, social work, physiotherapy, psychiatry/psychology, dietetics and occupational therapy. Collection methods: This information should be sought from the patient's medical record, referral letters or attending medical clinician. Comments: There is increasing evidence that a multidisciplinary team approach to health care improves patient satisfaction with treatment and outcomes. Furthermore, decisions made using this approach are more likely to accord with evidence-based guidelines than those made by individual clinicians. Multidisciplinary care also benefits clinicians by, for example, providing opportunities to interact with colleagues, enhanced educational opportunities and streamlining of referral pathways. There is currently little provision in patient's medical records for the formal recording of multidisciplinary team review. The development of specific forms to capture this information is strongly recommended. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Australian Cancer Network 2004. Clinical practice guidelines for the prevention, diagnosis and management of lung cancer. Approved by the National Health & Medical Research Council 2004. Sydney: The Cancer Council Australia National Breast Cancer Centre 2005. Multidisciplinary meeting for cancer care: a guide for health service providers. Camperdown, NSW: National Breast Cancer Centre Relational attributes Implementation in Data Set Specifications: Adolescent and young adult cancer (clinical) DSS Health, Standard 14/05/2015 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Other cancer treatment description
Description

Cancer treatment—other cancer treatment, text X[X(149)] Obligation: Conditional, Maximum occurrences: Unlimited Identifying and definitional attributes Short name: Other cancer treatment description METeOR identifier: 561623 Registration status: Health, Standard 08/05/2014 Definition: The cancer-directed treatment administered during the course of treatment for cancer, other than surgery, radiotherapy or systemic therapy, as represented by text. Data Element Concept: Cancer treatment—other cancer treatment Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(149)] Maximum character length: 150 Source and reference attributes Submitting organisation: Cancer Australia Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient having treatment that cannot be defined as surgery, radiotherapy or systemic therapy according to the definitions of those data items in this data set specification. Data element attributes Collection and usage attributes Guide for use: This data item is to record cancer-directed treatments that cannot be appropriately assigned to the specific treatment codes in the cancer treatment data items for surgery, radiotherapy, systemic therapy agents and systemic therapy procedures. Cancer-directed treatments refer to those treatments that destroy or modify cancer tissue anywhere in the body. The exception to this is treatments for hematopoietic diseases (refer to additional notes below). Cancer-directed treatments may be palliative (to control symptoms, alleviate pain, or make the patient more comfortable) or curative. Record all other treatments administered during the course of treatment. Each treatment event delivered to the patient should be recorded; multiple entries are permitted. Record antibody treatments, vaccine treatments, and those targeted therapies that use drugs or substances other than chemotherapy agents in this data item. Targeted therapies using chemotherapy agents are recorded in the data items for chemotherapy. Targeted therapies are treatments that use drugs or other substances to identify and attack specific cancer cells. Do not record ancillary drugs. For example, allopurinol, which is commonly used as prophylaxis with chemotherapy agents to prevent severe hyperuricemia. A list of drugs regarded as ancillary is available in the SEER*Rx-Interactive Antineoplastic Drugs Database Version 1.4.1. Treatment events may include (for example): • Treatment unique to hematopoietic diseases, for example, phlebotomy, transfusions or aspirin. ONLY record aspirin therapy used to thin the blood for symptomatic control of thrombocythemia. Do not record aspirin used for pain or cardiovascular protection. • Embolisation that is performed using alcohol as an embolising agent or for embolisation to a site other than the liver where the embolising agent is unknown. Embolisation using chemotherapeutic agents is coded separately with chemotherapy, and embolisation using a radioactive agent or seeds is coded with brachytherapy-radiation treatment. • Any experimental or newly developed treatment that cannot be appropriately assigned to other specific treatment data items. • A double-blind clinical trial. Record the treatment actually administered to the patient in the appropriate treatment data item when the double-blind trial code is broken. • Cancer treatments administered by non-medical personnel. This includes unconventional methods whether administered as single therapy or in combination with conventional therapies. Record alternative therapies only if the patient doesn’t receive any other type of treatment. Collection methods: The information should be obtained from the patient’s medical record. Comments: Information on other cancer treatments is used to describe and evaluate the quality of care and treatment practices. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda:National Cancer Institute, NIH Publication number 07-5581 Relational attributes Related metadata references: See also Cancer treatment—cancer treatment type, code N[N] Health, Standard 08/05/2014 Supersedes Cancer treatment—other cancer treatment, text [X(150)] Health, Superseded 08/05/2014 See also Cancer treatment—surgical procedure for prostate cancer, code N Health, Standard 14/05/2015 Implementation in Data Set Specifications: Adolescent and young adult cancer (clinical) DSS Health, Standard 14/05/2015 Cancer (clinical) DSS Health, Standard 14/05/2015 Gynaecological cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Outcome of treatment
Description

Cancer treatment—outcome of treatment, code N.N Identifying and definitional attributes Short name: Outcome of treatment METeOR identifier: 561665 Registration status: Health, Standard 08/05/2014 Definition: The response of the tumour at the completion of the course of treatment for cancer, as represented by a code. Data Element Concept: Cancer treatment—outcome of treatment Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N.N Maximum character length: 2 Permissible values: Value Meaning 1.0 Complete response/no evidence of disease 2.1 Partial response 2.2 Stable or static disease 2.3 Progressive disease Supplementary values: 7.0 Not assessed or unable to be assessed 8.0 Unknown 9.0 Not stated/inadequately described Collection and usage attributes Guide for use: The outcome of treatment is recorded at the completion of the course of treatment for the cancer. CODE 1.0 Complete response/no evidence of disease Complete disappearance of all measurable disease, including tumour markers, for at least four weeks. No new lesions or new evidence of disease. For breast cancer, this reflects "No evidence of disease". CODE 2.1 Partial response A decrease by at least 50% of the sum of the products of the maximum diameter and perpendicular diameter of all measurable lesions, for at least four weeks. No new lesions or worsening of disease. CODE 2.2 Stable or static disease No change in measurable lesions qualifying as partial response or progression and no evidence of new lesions. CODE 2.3 Progressive disease An increase by at least 25% of the sum of the products of the maximum diameter and a perpendicular diameter of any measurable lesion, or the appearance of new lesions. CODE 9.0 Not stated/inadequately described The tumour was assessed but the percentage of increase or decrease in the tumour size is not stated or is inadequately described. Source and reference attributes Submitting organisation: Cancer Australia Data element attributes Collection and usage attributes Collection methods: This information should be obtained from the patient's medical record. Comments: Information regarding the outcome of treatment is required for patient follow-up and outcomes studies. Source and reference attributes Submitting organisation: Cancer Australia Origin: New South Wales Health Department Reference documents: Public Health Division 2001. NSW Clinical Cancer Data Collection for Outcomes and Quality: Data Dictionary, Version 1. Sydney:NSW Health Department Relational attributes Related metadata references: See also Cancer treatment—date of treatment outcome, DDMMYYYY Health, Standard 04/02/2015 Supersedes Cancer treatment—outcome of treatment, code N.N Health, Superseded 08/05/2014 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 Gynaecological cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Date
Description

Date

Date accuracy indicator
Description

Date—accuracy indicator, code AAA Identifying and definitional attributes Short name: Date accuracy indicator METeOR identifier: 294429 Registration status: Housing assistance, Standard 23/08/2010 Health, Standard 04/05/2005 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Disability, Standard 07/10/2014 Community Services (retired), Standard 30/09/2005 Definition: An indicator of the accuracy of the components of a reported date, as represented by a code. Data Element Concept: Date—accuracy indicator Value domain attributes Representational attributes Representation class: Code Data type: String Format: AAA Maximum character length: 3 Permissible values: Value Meaning AAA Day, month and year are accurate AAE Day and month are accurate, year is estimated AAU Day and month are accurate, year is unknown AEA Day is accurate, month is estimated, year is accurate AEE Day is accurate, month and year are estimated AEU Day is accurate, month is estimated, year is unknown AUA Day is accurate, month is unknown, year is accurate AUE Day is accurate, month is unknown, year is estimated AUU Day is accurate, month and year are unknown EAA Day is estimated, month and year are accurate EAE Day is estimated, month is accurate, year is estimated EAU Day is estimated, month is accurate, year is unknown EEA Day and month are estimated, year is accurate EEE Day, month and year are estimated EEU Day and month are estimated, year is unknown EUA Day is estimated, month is unknown, year is accurate EUE Day is estimated, month is unknown, year is estimated EUU Day is estimated, month and year are unknown UAA Day is unknown, month and year are accurate UAE Day is unknown, month is accurate, year is estimated UAU Day is unknown, month is accurate, year is unknown UEA Day is unknown, month is estimated, year is accurate UEE Day is unknown, month and year are estimated UEU Day is unknown, month is estimated, year is unknown UUA Day and month are unknown, year is accurate UUE Day and month are unknown, year is estimated UUU Day, month and year are unknown Collection and usage attributes Guide for use: Any combination of the values A, E, U representing the corresponding level of accuracy of each date component of the reported date. This data element consists of a combination of three codes, each of which denotes the accuracy of one date component: A – the referred date component is accurate E – the referred date component is not known but is estimated U – the referred date component is not known and not estimated. This data element contains positional fields (DMY) that reflects the order of the date components in the format (DDMMYYYY) of the reported date: Field 1 (D) – refers to the accuracy of the day component; Field 2 (M) – refers to the accuracy of the month component; Field 3 (Y) – refers to the accuracy of the year component. Data domain Date component (for a format DDMMYYYY) (D)ay (M)onth (Y)ear Accurate A A A Estimated E E E Unknown U U U This data element is valid only for use with dates that are reported/exchanged in the format (DDMMYYYY). Example 1: A date has been sourced from a reliable source and is known as accurate then the Date accuracy indicator should be informed as (AAA). Example 2: If only the age of the person is known and there is no certainty of the accuracy of this, then the Date accuracy indicator should be informed as (UUE). That is the day and month are “unknown” and the year is “estimated”. Example 3: If a person was brought in unconscious to an emergency department of a hospital and the only information available was from a relative who was certain of the age and the birthday’s 'month' then the Date accuracy indicator should be informed as (UAA). A year derived from an accurate month and accurate age is always an accurate year. The Date accuracy indicator can be useful for operational purposes to indicate the level of accuracy that a date has been collected at any point in time. It can indicate whether the stored date needs to be followed up until it reaches the intended minimal required accuracy. For example, if a person was brought in unconscious to an emergency department of a hospital the level of accuracy of the date collected at that point may not be satisfactory. It is likely that the correct date of birth can be obtained at a later date. The Date accuracy indicator provides information on the accuracy of the entered dates that may require further action. For future users of the data it may also be essential they know the accuracy of the date components of a reported date. Data element attributes Collection and usage attributes Collection methods: Collection constraints: If constraints for the collection of the date are imposed, such as ‘a valid date must be input in an information system for unknown date components’, the Date accuracy indicator should be used along with the date as a way of avoiding the contamination of the valid dates with the same value on the respective date components. Example: Some jurisdictions use 0107YYYY and some use 0101YYYY when only the year is known. When month and year are known some use the 15th day as the date i.e. 15MMYYYY. Where this occurs in a data collection that is used for reporting or analysis purposes there will be dates in the collection with the attributes 0107YYYY etc., that are accurate and some that are not accurate. Without a corresponding flag to determine this accuracy the analysis or report will be contaminated by those estimated dates. Comments: Provision of a date is often a mandatory requirement in data collections. Most computer systems require a valid date to be recorded in a date field i.e. the month part must be an integer between 1 and 12, the day part must be an integer between 1 and 31 with rules about the months with less than 31 days, and the year part should include the century. Also in many systems, significant dates (e.g. date of birth) are mandatory requirements. However, in actual practice, the date or date components are often not known (e.g. date of birth, date of injury) but, as stated above, computer systems require a valid date. This means that a date MUST be included and it MUST follow the rules for a valid date. It therefore follows that, while such a date will contain valid values according to the rules for a date, the date is in fact an ‘unknown’ or ‘estimated’ date. For future users of the data it is essential they know that a date is accurate, unknown or estimated and which components of the date are accurate, unknown or estimated. Source and reference attributes Submitting organisation: Standards Australia Reference documents: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia Relational attributes Related metadata references: See also Health-care incident—date health-care incident occurred, DDMMYYYY Health, Standard 07/12/2011 See also Individual service provider—occupation end date, DDMMYYYY Health, Standard 04/05/2005, Community Services (retired), Standard 30/09/2005 See also Individual service provider—occupation start date, DDMMYYYY Health, Standard 04/05/2005, Community Services (retired), Standard 30/09/2005 See also Medical indemnity claim management episode—medical indemnity claim finalisation date, DDMMYYYY Health, Superseded 21/11/2013 See also Medical indemnity claim management episode—medical indemnity claim finalisation date, DDMMYYYY Health, Standard 21/11/2013 See also Medical indemnity claim management episode—reserve placement date, DDMMYYYY Health, Standard 07/12/2011 See also Medical indemnity claim—medical indemnity claim commencement date, DDMMYYYY Health, Standard 07/12/2011 See also Person—date of birth, DDMMYYYY Housing assistance, Standard 20/06/2005, Health, Standard 04/05/2005, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Tasmanian Health, Final 30/06/2014, WA Health, Endorsed 19/03/2015, Independent Hospital Pricing Authority, Standard 01/11/2012, Indigenous, Endorsed 11/08/2014, National Health Performance Authority, Standard 07/11/2013, Commonwealth Department of Health, Candidate 25/05/2015, Disability, Standard 07/10/2014, Community Services (retired), Standard 25/08/2005 See also Person—date of birth, MMYYYY Health, Standard 10/12/2009, National Health Performance Authority, Standard 12/12/2013 See also Record—linkage key, code 581 XXXXXDDMMYYYYN Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 21/05/2010 See also Statistical linkage key 581 cluster Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 21/05/2010 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 Medical indemnity DSS 2014- Health, Standard 21/11/2013 Statistical linkage key 581 cluster Housing assistance, Standard 23/08/2010 Health, Standard 07/12/2011 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Disability, Standard 07/10/2014 Community Services (retired), Standard 21/05/2010

Data type

text

Establishment
Description

Establishment

Establishment number
Description

Establishment—organisation identifier (state/territory), NNNNN Identifying and definitional attributes Short name: Establishment number METeOR identifier: 269975 Registration status: Health, Standard 01/03/2005 National Health Performance Authority, Standard 27/11/2013 Commonwealth Department of Health, Candidate 16/07/2015 Definition: An identifier for an establishment, unique within the state or territory. Data Element Concept: Establishment—organisation identifier (state/territory) Value domain attributes Representational attributes Representation class: Identifier Data type: Number Format: NNNNN Maximum character length: 5 Data element attributes Collection and usage attributes Comments: Identifier should be a unique code for the health care establishment used in that state/territory. Relational attributes Related metadata references: Supersedes Establishment number, version 4, DE, NHDD, NHIMG, Superseded 01/03/2005 .pdf (14.6 KB) Is used in the formation of Establishment—organisation identifier (Australian), NNX[X]NNNNN Health, Standard 01/03/2005, WA Health, Endorsed 19/03/2015, Independent Hospital Pricing Authority, Standard 31/10/2012, Indigenous, Draft 18/10/2012, National Health Performance Authority, Standard 25/07/2013, Commonwealth Department of Health, Candidate 30/07/2015 See also Hospital—hospital identifier, XXXXX Health, Standard 07/12/2011 Implementation in Data Set Specifications: Admitted patient care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Local Hospital Networks DSS 2015-16 Health, Standard 04/02/2015 Public hospital establishments NMDS 2015-16 Health, Standard 04/02/2015 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012

Data type

text

Healthcare provider
Description

Healthcare provider

HPI-O
Description

Healthcare provider—organisation identifier, N(16) Identifying and definitional attributes Short name: HPI-O METeOR identifier: 426830 Registration status: Health, Standard 03/12/2011 Definition: The Healthcare provider identifier—organisation (HPI-O) is the numerical identifier that uniquely identifies organisations in Australia where healthcare is provided. Data Element Concept: Healthcare provider—organisation identifier Value domain attributes Representational attributes Representation class: Identifier Data type: Number Format: N(16) Maximum character length: 16 Source and reference attributes Submitting organisation: Cancer Australia Reference documents: National E-Health Transition Authority 2010. HI service: concept of operations. Version 2.0-final release. Sydney: National E-Health Transition Authority Data element attributes Collection and usage attributes Guide for use: A Healthcare Provider Identifier-Organisation (HPI-O) identifies organisations where healthcare services are provided. For example, state health departments, hospitals, medical practices, pathology or radiology laboratories or pharmacies. Each organisation's HPI-O is unique within the Australian healthcare system. The HPI-O is part of the government's e-health initiative developed to enhance the way information is exchanged, shared and managed in the Australian health sector. Electronic identifiers and the systems underpinning them were developed and are maintained by Medicare Australia. All organisations that provide healthcare services will be able to apply for a HPI-O. As part of establishing their eligibility, an organisation will need to provide evidence to the HI Service Operator that it is a legal entity and employs or contracts one or more individual healthcare providers or sole traders who are employed for the purpose of providing a health service. Registration is optional though desirable and the information guides and forms are available online at Medicare. Organisations registered directly with the HI Service are referred to as "seed" organisations. Once registered, they can obtain identifiers for subordinate organisations or departments known as "network" organisations. For example, the seed organisation The North Shore Hospital may declare their radiology department as a network organisation so it will have its own unique identifier. Record the full Healthcare Provider Identifier-Organisation (HPI-O) for an organisation. All healthcare identifiers use the International Standard ISO 7812-1:2006 that specifies the numbering system for identification cards. The format of the number is as follows: • Digits N1-N6 consist of the issuer identification number • N1-N2 Major industry identifier: 80 = health • N3-N5 Country code: 036 = Australia • N6 Number type: 2 = HPI-O • Digits N7-N15 Individual account identification (9 digits for the unique identifier) • Digit N16 Check digit Comments: The Healthcare Provider Identifier-Organisation is part of the government's e-health initiative and supports healthcare providers in their decision making by improving the quality and accessibility of patient information, facilitates communication between clinicians and patients, and advances policy development and healthcare planning by assisting in the collection of national, high quality health information. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: National E-Health Transition Authority 2010. HI service: concept of operations. Version 2.0-final release. Sydney: National E-Health Transition Authority Relational attributes Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Patient
Description

Patient

Cancer status
Description

Patient—cancer status, code N Identifying and definitional attributes Short name: Cancer status METeOR identifier: 394071 Registration status: Health, Standard 07/12/2011 Definition: The absence or presence of clinical evidence of cancer in the patient, as represented by a code. Data Element Concept: Patient—cancer status Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 No evidence of cancer 2 Evidence of cancer Supplementary values: 8 Unknown whether there is evidence of cancer 9 Not stated/inadequately described Data element attributes Collection and usage attributes Guide for use: Record whether or not there is clinical evidence of cancer in the patient at the date of last contact or death. Cancer status changes if the patient has a recurrence or relapse and the record should be updated. The patient’s cancer status should be changed only if new information is received from an official source. If information is obtained from the patient, a family member or other non-physician, then cancer status is not updated. If the patient has multiple primary cancers, each primary should have the appropriate cancer status recorded. For patients with hematopoietic disease who are in remission, code as 1-no evidence of this cancer. Collection methods: This information should be collected from the patient's medical record. Comments: This information is used for patient follow-up and outcome studies. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Patient—date of last contact, DDMMYYYY Health, Standard 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnostic assessment cluster Health, Standard 29/08/2014 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Date of last contact—cancer patient
Description

Patient—date of last contact, DDMMYYYY Identifying and definitional attributes Short name: Date of last contact—cancer patient METeOR identifier: 394060 Registration status: Health, Standard 07/12/2011 Definition: The date of last contact with the patient, expressed as DDMMYYYY. Data Element Concept: Patient—date of last contact Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Record the date on which the patient was last known to be alive. The date of last contact may be used for administrative purposes in conjunction with the patient's last known cancer status to identify how complete the treatment information is. The last contact date may, for example, be the discharge date of an inpatient stay, the date of an outpatient appointment, the date of an investigation such as a scan or the date of a home visit by, for instance, a palliative care nurse or occupational therapist. The last contact date may also be derived from an official source, for example, a letter from a physician detailing the patient's last follow-up appointment. Many hospitals conduct routine follow-up of patients and the last contact date may result from a phone call to the patient. The date of last contact should be updated as required. If the patient has multiple primary cancers, all records should have the same date of last contact. The date of death is collected as a separate item. The date of last contact must be: • Greater than the date of diagnosis, and • Less than or equal to the date of death. Collection methods: The information should be collected from the patient’s medical record. Comments: This information is used for patient follow-up and outcome studies. Source and reference attributes Submitting organisation: Cancer Australia Relational attributes Related metadata references: See also Patient—cancer status, code N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

date

Date of diagnosis of cancer
Description

Patient—diagnosis date of cancer, DDMMYYYY Identifying and definitional attributes Short name: Date of diagnosis of cancer METeOR identifier: 416129 Registration status: Health, Standard 07/12/2011 Definition: The date on which the patient was first diagnosed with cancer (whether at its primary site or as a metastasis), expressed as DDMMYYYY. Data Element Concept: Patient—diagnosis date of cancer Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Date of diagnosis must be: • Greater than or equal to date of birth • Less than or equal to date of death Diagnosis of cancer after death: If the patient is first diagnosed with the cancer in an autopsy report the date of diagnosis is the date of death as stated on the patient's death certificate. Incidental diagnosis of cancer: If a patient is admitted for another condition (for example a broken leg or pregnancy), and a cancer is diagnosed incidentally then the date of diagnosis is the date the cancer was diagnostically determined, not the admission date. Collection methods: Reporting rules: The date of diagnosis is the date of the pathology report, if any, that first confirmed the diagnosis of cancer. This date may be found attached to a letter of referral or a patient's medical record from another institution or hospital. If this date is unavailable, or if no pathological test was done, then the date may be determined from one of the sources listed in the following sequence: • Date of the consultation at, or admission to, the hospital, clinic or institution when the cancer was first diagnosed. Note: DO NOT use the admission date of the current admission if the patient had a prior diagnosis of this cancer. • Date of first diagnosis as stated by a recognised medical practitioner or dentist. Note: This date may be found attached to a letter of referral or a patient's medical record from an institution or hospital. • Date the patient states they were first diagnosed with cancer. Note: This may be the only date available in a few cases (for example, patient was first diagnosed in a foreign country). If components of the date are not known, an estimate should be provided with an estimated date flag to indicate that it is estimated. If an estimated date is not possible, a standard date of 15 June 1900 should be used with a flag to indicate the date is not known. Additionally, a date accuracy indicator should be recorded in conjunction with the estimated date. Comments: Patient administration system, cancer notification system, population cancer statistics, research. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Agency for Research on Cancer World Health Organization International Association of Cancer Registries Reference documents: Modified from the definition presented by the New South Wales Inpatient Statistics Collection Manual 2000/2001 Relational attributes Related metadata references: See also Cancer staging—date of cancer staging, DDMMYYYY Health, Standard 04/02/2015 Supersedes Patient—diagnosis date (cancer), DDMMYYYY Health, Superseded 07/12/2011 See also Person with cancer—date of initial primary health care consultation, DDMMYYYY Health, Standard 04/02/2015 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 06b-Positive predictive value of diagnostic assessment for detecting colorectal cancer Health, Standard 29/08/2014 National Bowel Cancer Screening Program: PI 07-Interval cancer rate Health, Standard 29/08/2014

Data type

date

Date of diagnosis of first recurrence as distant metastasis
Description

Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Obligation: Conditional Identifying and definitional attributes Short name: Date of diagnosis of first recurrence as distant metastasis METeOR identifier: 393841 Registration status: Health, Standard 07/12/2011 Definition: The date on which a patient is diagnosed with the first recurrence as a distant metastasis of the same histology as the primary cancer, expressed as DDMMYYYY. Data Element Concept: Patient—diagnosis date of first recurrence as distant metastasis Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient being diagnosed with recurrence involving a distant metastasis. Data element attributes Collection and usage attributes Guide for use: Record the date the first recurrence as distant metastasis is diagnosed. The term recurrence defines the return, reappearance or metastasis of cancer (of the same histology) after a disease-free intermission or remission. Distant metastasis refers to the spread of cancer of the same histology as the original (primary) tumour to distant organs or distant lymph nodes. The date is based on the most definitive diagnostic information available and ideally will correspond to the date of the investigation recorded in data element Person with cancer—most valid basis of diagnosis of the first recurrence, code N. For instance, record the date of the first histological or, if unavailable, cytological investigation confirming the diagnosis of recurrence. If these investigations have not been performed, record the date of confirmation by clinical investigation. This information should be obtained from the patient's medical record. In the first instance, the diagnosis date should be derived from the relevant investigation report; for example, tissue diagnosis from the pathology report and imaging from the imaging reports. If the diagnosis is made on the basis of clinical examination, record the date this is performed. For example, this may be the date of a consultation, an outpatient appointment or the date the patient is admitted to hospital. If the patient was diagnosed by clinical examination and/or investigations performed elsewhere, the date may be found in a letter of referral from a recognised medical practitioner or dentist. Usually the relevant test result, if applicable, will be attached to this. In some cases, the date the patient states they were diagnosed with recurrence will be the only date available and should be recorded here. For example, the patient may have been diagnosed whilst overseas. If components of the date are not known, an estimate should be provided where possible with an estimated date flag to indicate that it is estimated. If an estimated date is not possible, a standard date of 15 June 1900 should be used with a flag to indicate the date is not known. Collection methods: This information should be obtained from the patient's medical record. Comments: This data item is used to measure the efficacy of the initial course of treatment through evaluating the time interval from diagnosis to recurrence, treatment to recurrence and recurrence to death. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—most valid basis of diagnosis of the first recurrence, code N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Identifying and definitional attributes Short name: Date of diagnosis of first recurrence as distant metastasis METeOR identifier: 393841 Registration status: Health, Standard 07/12/2011 Definition: The date on which a patient is diagnosed with the first recurrence as a distant metastasis of the same histology as the primary cancer, expressed as DDMMYYYY. Data Element Concept: Patient—diagnosis date of first recurrence as distant metastasis Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient being diagnosed with recurrence involving a distant metastasis. Data element attributes Collection and usage attributes Guide for use: Record the date the first recurrence as distant metastasis is diagnosed. The term recurrence defines the return, reappearance or metastasis of cancer (of the same histology) after a disease-free intermission or remission. Distant metastasis refers to the spread of cancer of the same histology as the original (primary) tumour to distant organs or distant lymph nodes. The date is based on the most definitive diagnostic information available and ideally will correspond to the date of the investigation recorded in data element Person with cancer—most valid basis of diagnosis of the first recurrence, code N. For instance, record the date of the first histological or, if unavailable, cytological investigation confirming the diagnosis of recurrence. If these investigations have not been performed, record the date of confirmation by clinical investigation. This information should be obtained from the patient's medical record. In the first instance, the diagnosis date should be derived from the relevant investigation report; for example, tissue diagnosis from the pathology report and imaging from the imaging reports. If the diagnosis is made on the basis of clinical examination, record the date this is performed. For example, this may be the date of a consultation, an outpatient appointment or the date the patient is admitted to hospital. If the patient was diagnosed by clinical examination and/or investigations performed elsewhere, the date may be found in a letter of referral from a recognised medical practitioner or dentist. Usually the relevant test result, if applicable, will be attached to this. In some cases, the date the patient states they were diagnosed with recurrence will be the only date available and should be recorded here. For example, the patient may have been diagnosed whilst overseas. If components of the date are not known, an estimate should be provided where possible with an estimated date flag to indicate that it is estimated. If an estimated date is not possible, a standard date of 15 June 1900 should be used with a flag to indicate the date is not known. Collection methods: This information should be obtained from the patient's medical record. Comments: This data item is used to measure the efficacy of the initial course of treatment through evaluating the time interval from diagnosis to recurrence, treatment to recurrence and recurrence to death. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—most valid basis of diagnosis of the first recurrence, code N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

date

Date of diagnosis of first recurrence as locoregional cancer
Description

Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Obligation: Conditional, Maximum occurrences: Unlimited Identifying and definitional attributes Short name: Date of diagnosis of first recurrence as locoregional cancer METeOR identifier: 393837 Registration status: Health, Standard 07/12/2011 Definition: The date on which a patient is diagnosed with the first recurrence as locoregional cancer of the same histology as the primary cancer, expressed as DDMMYYYY. Data Element Concept: Patient—diagnosis date of first recurrence as locoregional cancer Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient being diagnosed with recurrence of locoregional cancer. Data element attributes Collection and usage attributes Guide for use: Record the date the first recurrence as locoregional cancer is diagnosed. The term recurrence defines the return, reappearance or metastasis of cancer (of the same histology) after a disease free period. Locoregional recurrence refers to the recurrence of cancer cells at the same site as the original (primary) tumour or the regional lymph nodes. A list of those lymph nodes defined as regional lymph nodes for each cancer site can be found in the TNM Classification of Malignant Tumours International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC) Cancer Staging Manual; the latest editions are recommended. The date is based on the most definitive diagnostic information available and ideally should correspond to the date of the investigation recorded in data element Person with cancer-most valid basis of diagnosis of the first recurrence, code N. For instance, record the date of the first histological or if unavailable, cytological investigation confirming the diagnosis of recurrence. If these investigations have not been performed, record the date of confirmation by clinical investigation. This information should be obtained from the patient's medical record. In the first instance, the diagnosis date should be derived from the relevant investigation report; for example, tissue diagnosis from the pathology report and imaging from the imaging reports. If the diagnosis is made on the basis of clinical examination, record the date this is performed. For example, this may be the date of a consultation, an outpatient appointment or the date the patient is admitted to hospital. If the patient was diagnosed by clinical examination and/or investigations performed elsewhere, the date may be found in a letter of referral from a recognised medical practitioner or dentist. Usually the relevant test result, if applicable, will be attached to this. In some cases, the date the patient states they were diagnosed with recurrence will be the only date available and should be recorded here. For example, the patient may have been diagnosed whilst overseas. If components of the date are not known, an estimate should be provided where possible with an estimated date flag to indicate that it is estimated. If an estimated date is not possible, a standard date of 15 June 1900 should be used with a flag to indicate the date is not known. Collection methods: This information should be obtained from the patient's medical record. Comments: This data item is used to measure the efficacy of the initial course of treatment through evaluating the time interval from diagnosis to recurrence, treatment to recurrence and recurrence to death. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—most valid basis of diagnosis of the first recurrence, code N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

date

Person (address)
Description

Person (address)

Address line (person)
Description

Person (address)—address line, text X[X(179)] Identifying and definitional attributes Short name: Address line (person) Synonymous names: Australian address line METeOR identifier: 286620 Registration status: Health, Standard 04/05/2005 Community Services (retired), Standard 30/09/2005 Definition: A composite of one or more standard address components that describes a low level of geographical/physical description of a location, as represented by text. Used in conjunction with the other high-level address components i.e. Suburb/town/locality, Postcode—Australian, Australian state/territory, and Country, forms a complete geographical/physical address of a person. Data Element Concept: Person (address)—address line Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(179)] Maximum character length: 180 Data element attributes Collection and usage attributes Guide for use: A high-level address component is defined as a broad geographical area that is capable of containing more than one specific physical location. Some examples of a broad geographical area are: - Suburb, town or locality - Postcode—Australian or international - State, Territory, local government area, electorate, statistical local area - Postal delivery point identifier - Countries, provinces, etc other than in Australia These components of a complete address do not form part of the Address line. When addressing an Australian location, following are the standard address data elements that may be concatenated in the Address line: - Building/complex sub-unit type - Building/complex sub-unit number - Building/property name - Floor/level number - Floor/level type - House/property number - Lot/section number - Street name - Street type code - Street suffix code One complete identification/description of a location/site of an address can comprise one or more than one instance of address line. Instances of address lines are commonly identified in electronic information systems as Address-line 1, Address-line 2, etc. The format of data collection is less important than consistent use of conventions in the recording of address data. Hence, address may be collected in an unstructured manner but should ideally be stored in a structured format. Where Address line is collected as a stand-alone item, software may be used to parse the Address line details to separate the sub-components. Multiple Address lines may be recorded as required. Collection methods: The following concatenation rules should be observed when collecting address lines addressing an Australian location. - Building/complex sub-unit type is to be collected in conjunction with Building/complex sub-unit number and vice versa. - Floor/level type is to be collected in conjunction with Floor/level number and vice versa. - Street name is to be used in conjunction with Street type code and Street suffix code. - Street type code is to be used in conjunction with Street name and Street suffix code. - Street suffix code is to be used in conjunction with Street name and Street type code. - House/property number is to be used in conjunction with Street name. Source and reference attributes Submitting organisation: Standards Australia Origin: Health Data Standards Committee AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia. Reference documents: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2006, Sydney: Standards Australia Relational attributes Related metadata references: Is formed using Person (address)—building/complex sub-unit identifier, [X(7)] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—building/complex sub-unit type, code A[AAA] Health, Standard 01/03/2005, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—building/property name, text X[X(29)] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—floor/level identifier, [NNNA] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—floor/level type, code A[A] Health, Standard 01/03/2005, Community Services (retired), Superseded 06/02/2012 Supersedes Person (address)—health address line, text X[X(179)] Health, Superseded 04/05/2005 Is formed using Person (address)—house/property identifier, text X[X(11)] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—lot/section identifier, N[X(14)] Health, Standard 01/03/2005, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—street name, text A[A(29)] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—street suffix, code A[A] Health, Standard 01/03/2005, Community Services (retired), Superseded 06/02/2012 Is formed using Person (address)—street type, code A[AAA] Health, Superseded 07/12/2011, Community Services (retired), Superseded 06/02/2012 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012

Data type

text

Person (name)
Description

Person (name)

Family name
Description

Person (name)—family name, text X[X(39)] Identifying and definitional attributes Short name: Family name Synonymous names: Surname; Last name METeOR identifier: 286953 Registration status: Housing assistance, Standard 20/06/2005 Health, Standard 04/05/2005 Tasmanian Health, Draft 23/07/2012 Community Services (retired), Superseded 06/02/2012 Definition: That part of a name a person usually has in common with some other members of his/her family, as distinguished from his/her given names, as represented by text. Data Element Concept: Person (name)—family name Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(39)] Maximum character length: 40 Data element attributes Collection and usage attributes Guide for use: The agency or establishment should record the person's full family name on their information systems. National Community Services Data Dictionary specific: In instances where there is uncertainty about which name to record for a person living in a remote Aboriginal or Torres Strait Islander community, Centrelink follows the practice of recording the Indigenous person's name as it is first provided to Centrelink. Or, where proof of identity is required, as the name that is recorded on a majority of the higher point scoring documents that are produced as proof of identity. Collection methods: This metadata item should be recorded for all persons who receive services from or are of interest to an organisation. For the purposes of positive identification, it may also be recorded for providers of those services who are individuals. Mixed case should be used. Family name should be recorded in the format preferred by the person. The format should be the same as that written by the person on a (pre) registration form or in the same format as that printed on an identification card, such as a Medicare card, to ensure consistent collection of name data. It is acknowledged that some people use more than one family name (e.g. formal name, birth name, married/maiden name, tribal name) depending on the circumstances. Each name should be recorded against the appropriate Name type (see Comments). A person is able to change his or her name by usage in all States and Territories of Australia with the exception of Western Australia, where a person may only change his or her name under the Change of Name Act. Care should be taken when recording a change of name for a minor. Ideally, the name recorded for the minor should be known to both of his/her parents, so the minor's records can be retrieved and continuity of care maintained, regardless of which parent accompanies the minor to the agency or establishment. A person should generally be registered using their preferred name as it is more likely to be used in common usage and on subsequent visits to the agency or establishment. The person's preferred name may in fact be the name on their Medicare card. The Person name type metadata item can be used to distinguish between the different types of names that may be used by the person. The following format may assist with data collection: What is your family name? _______________________________________ Are you known by any other family names that you would like recorded? If so, what are they ___________________________________________________ Please indicate, for each name above, the 'type' of family name that is to be recorded: (a) Medicare card name (if different to preferred name). (b) Alias (any other name that you are known by). Whenever a person informs the agency or establishment of a change of family name (e.g. following marriage or divorce), the former name should be recorded as an alias name. A full history of names should be retained. e.g. 'Mary Georgina Smith' informs the hospital that she has been married and changed her family name to 'Jones'. Record 'Jones' as her preferred family name and record 'Smith' as an alias name. Hyphenated family names: Sometimes persons with hyphenated family names use only one of the two hyphenated names. It is useful to record each of the hyphenated names as an alias. If the person has a hyphenated family name, e.g. 'Wilson-Phillips' record 'Wilson-Phillips' in the preferred family name field and record 'Wilson' and 'Phillips' separately as alias family names. Punctuation: If special characters form part of the family name they should be included, e.g. hyphenated names should be entered with a hyphen. Examples: - hyphen, e.g. Wilson-Phillips Do not leave a space before or after a hyphen, i.e. between the last letter of 'Wilson' and the hyphen, nor a space between the hyphen and the first letter of 'Phillips'. - apostrophe, e.g. O'Brien, D'Agostino Do not leave a space before or after the apostrophe, i.e. between the 'O' and the apostrophe, or a space between the apostrophe and 'Brien'. - full stop, e.g. St. John, St. George Do not leave a space before a full stop, i.e. between 'St' and the full stop. Do leave a space between the full stop and 'John'. - space, e.g. van der Humm, Le Brun, Mc Donald If the health care client has recorded their family name as more than one word, displaying spaces in between the words, record their family name in the same way leaving one space between each word. Registered unnamed newborn babies: When registering a newborn, use the mother's family name as the baby's family name unless instructed otherwise by the mother. Record unnamed babies under the newborn Name type. Persons with only one name: Some people do not have a family name and a given name, they have only one name by which they are known. If the person has only one name, record it in the 'Family name' field and leave the 'Given name' field blank. Registering an unidentified person: The default for unknown family name should be unknown in all instances and the name recorded as an alias name. Don't create a 'fictitious' family name such as 'Doe' as this is an actual family name. When the person's name becomes known, record it as the preferred family name and do not overwrite the alias name of unknown. Registering health care clients from disaster sites: Persons treated from disaster sites should be recorded under the alias Name Type. Local business rules should be developed for consistent recording of disaster site person details. Care should be taken not to use identical dummy data (family name, given name, date of birth, sex) for two or more persons from a disaster site. If the family name needs to be shortened: If the length of the family name exceeds the length of the field, truncate the family name from the right (that is, dropping the final letters). Also, the last character of the name should be a hash (#) to identify that the name has been truncated. Use of incomplete names or fictitious names: Some health care facilities permit persons to use a pseudonym (fictitious or partial name) in lieu of their full or actual name. It is recommended that the person be asked to record both the pseudonym (Alias name) in addition to the person's Medicare card name. Baby for adoption: The word adoption should not be used as the family name, given name or alias for a newborn baby. A newborn baby that is for adoption should be registered in the same way that other newborn babies are registered. However, if a baby born in the hospital is subsequently adopted, and is admitted for treatment as a child, the baby is registered under their adopted (current) name, and the record should not be linked to the birth record. This should be the current practice. Any old references to adoption in client registers (for names) should also be changed to unknown. Contact your State or Territory adoption information service for further information. Prefixes: Where a family name contains a prefix, such as one to indicate that the person is a widow, this must be entered as part of the 'Family name' field. When widowed, some Hungarian women add 'Ozvegy' (abbreviation is 'Ozy') before their married family name, e.g. 'Mrs Szabo' would become 'Mrs Ozy Szabo'. That is, 'Mrs Szabo' becomes an alias name and 'Mrs Ozy Szabo' becomes the preferred name. Ethnic Names: The Centrelink publication, Naming Systems for Ethnic Groups, provides the correct coding for ethnic names. Misspelled family name: If the person's family name has been misspelled in error, update the family name with the correct spelling and record the misspelled family name as an alias name. Recording misspelled names is important for filing documents that may be issued with previous versions of the person's name. Discretion should be used regarding the degree of recording that is maintained. Comments: Often people use a variety of names, including legal names, married/maiden names, nicknames, assumed names, traditional names, etc. Even small differences in recording - such as the difference between MacIntosh and McIntosh - can make record linkage impossible. To minimise discrepancies in the recording and reporting of name information, agencies or establishments should ask the person for their full (formal) 'Given name' and 'Family name'. These may be different from the name that the person may prefer the agency or establishment workers to use in personal dealings. Agencies or establishments may choose to separately record the preferred names that the person wishes to be used by agency or establishment workers. In some cultures it is traditional to state the family name first. To overcome discrepancies in recording/reporting that may arise as a result of this practice, agencies or establishments should always ask the person to specify their first given name and their family name or surname separately. These should then be recorded as 'Given name' and 'Family name' as appropriate, regardless of the order in which they may be traditionally given. National Community Services Data Dictionary specific: Selected letters of the family name in combination with selected letters of the given name, date of birth and sex, may be used for record linkage for statistical purposes only. Source and reference attributes Submitting organisation: Australian Institute of Health and Welfare Standards Australia Origin: National Health Data Committee National Community Services Data Committee Commonwealth Department of Health and Family Services 1998. Home and Community Care Data Dictionary Version 1.0. Canberra: DHFS Standards Australia 2002. Australian Standard AS5017-2002 Health Care Client Identification. Sydney: Standards Australia Reference documents: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia Relational attributes Related metadata references: Supersedes Person (name)—family name, text X[X(39)] Health, Superseded 04/05/2005, Community Services (retired), Superseded 25/08/2005 Has been superseded by Person (name)—family name, text X[X(39)] Indigenous, Endorsed 05/09/2014, Disability, Standard 13/08/2015, Community Services (retired), Standard 06/02/2012 See also Person (name)—given name, text X[X(39)] Housing assistance, Standard 20/06/2005, Health, Standard 04/05/2005, Tasmanian Health, Draft 23/07/2012, Community Services (retired), Superseded 06/02/2012 Is used in the formation of Person—letters of family name, text XXX Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 27/03/2007 Is used in the formation of Person—letters of given and family name, text XXXXX Health, Standardisation pending 04/08/2015, Community Services (retired), Standard 14/09/2009 Is used in the formation of Person—letters of given name, text XX Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 27/03/2007 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012

Data type

text

Given name(s)
Description

Person (name)—given name, text X[X(39)] Identifying and definitional attributes Short name: Given name(s) METeOR identifier: 287035 Registration status: Housing assistance, Standard 20/06/2005 Health, Standard 04/05/2005 Tasmanian Health, Draft 23/07/2012 Community Services (retired), Superseded 06/02/2012 Definition: The person's identifying name within the family group or by which the person is socially identified, as represented by text. Data Element Concept: Person (name)—given name Value domain attributes Representational attributes Representation class: Text Data type: String Format: X[X(39)] Maximum character length: 40 Data element attributes Collection and usage attributes Guide for use: A person may have more than one Given name. All given names should be recorded. The agency or establishment should record the person's full given name(s) on their information systems. National Community Services Data Dictionary specific: In instances where there is uncertainty about which name to record for a person living in a remote Aboriginal or Torres Strait Islander community, Centrelink follows the practice of recording the Indigenous person's name as it is first provided to Centrelink. In situations where proof of identity is required, the name is that recorded on a majority of the higher point scoring documents that are produced as proof of identity. National Health Data Dictionary specific: Each individual Given name should have a Given name sequence number associated with it. Health care establishments may record given names (first and other given names) in one field or several fields. This metadata item definition applies regardless of the format of data recording. A full history of names is to be retained. Collection methods: This metadata item should be recorded for all clients. Given name(s) should be recorded in the format preferred by the person. The format should be the same as that indicated by the person (for example written on a form) or in the same format as that printed on an identification card, such as Medicare card, to ensure consistent collection of name data. It is acknowledged that some people use more than one given name (for example formal name, birth name, nickname or shortened name, or tribal name) depending on the circumstances. A person is able to change his or her name by usage in all States and Territories of Australia with the exception of Western Australia, where a person may only change his or her name under the Change of Name Act. A person should generally be registered using their preferred name as it is more likely to be used in common usage and on subsequent visits to the agency or establishment. The person's preferred name may in fact be their legal (or Medicare card) name. The Person name type metadata item (see Comments) can be used to distinguish between the different types of names that may be used by the person. The following format may assist with data collection: What is the given name you would like to be known by? _______________________ Are you known by any other given names that you would like recorded? If so, what are they _____________________________________________________________ Please indicate the 'type' of given name that is to be recorded: (a) Medicare card name (if different to preferred name). (b) Alias (any other name that you are known by). Whenever a person informs the agency or establishment of a change of given name (for example prefers to be known by their middle name), the former name should be recorded according to the appropriate name type. Do not delete or overwrite a previous given name. For example 'Mary Georgina Smith' informs the hospital that she prefers to be known as 'Georgina'. Record 'Georgina' as her preferred given name and record 'Mary' as the Medicare card given name. Similarly the establishment is informed that 'Baby of Louise Jones' has been named 'Mary Jones'. Retain 'Baby of Louise' as the newborn name and also record 'Mary' as the preferred 'Given name'. Registering an unidentified health care client: If the person is a health care client and her/his given name is not known record unknown in the 'Given name' field and use alias Name type. When the person's name becomes known, add the actual name as preferred Name type (or other as appropriate). Do not delete or overwrite the alias name of unknown. Use of first initial: If the person's given name is not known, but the first letter (initial) of the given name is known, record the first letter in the preferred 'Given name' field. Do not record a full stop following the initial. Persons with only one name: Some people do not have a family name and a given name: they have only one name by which they are known. If the person has only one name, record it in the 'Family name' field and leave the 'Given name' blank. Record complete information: All of the person's given names should be recorded. Shortened or alternate first given name: If the person uses a shortened version or an alternate version of their first given name, record their preferred name, the actual name as their Medicare card name and any alternative versions as alias names as appropriate. Example - The person's given name is Jennifer but she prefers to be called Jenny. Record 'Jenny' as the preferred 'Given name' and 'Jennifer' as her Medicare card name. Example - The person's given name is 'Giovanni' but he prefers to be called 'John'. Record 'John' as the preferred 'Given name' and 'Giovanni' as the Medicare card name. Punctuation: If special characters form part of the given names they shall be included, e.g. hyphenated names shall be entered with the hyphen. • Hyphen, for example Anne-Maree, Mary-Jane Do not leave a space before or after the hyphen, that is between last letter of 'Anne' and the hyphen, nor a space between the hyphen and the first letter of 'Maree'. • spaces, for example Jean Claude Marcel Moreaux If the person has recorded their given name as more than one word, displaying spaces in between the words, record their given names in data collection systems in the same way (that is Jean Claude is one given name and Marcel is another given name). Names not for continued use: For cultural reasons, a person such as an Aboriginal or Torres Strait Islander may advise that they are no longer using the given name they previously used and are now using an alternative current name. Record their current name as their preferred given name and record their previously used name as an alias name (with a Name conditional use flag of ‘not for continued use’). Composite name: If a person identifies their first name as being a composite word, both parts should be recorded under the first Given Name (rather than the first and second Given Name). If ‘Anne Marie Walker’ notes her preferred Given Name to be ‘Anne Marie’, then ‘Anne Marie’ is recoded as (first) Given Name, and (second) Given Name is left blank. Registering an unnamed newborn baby: An unnamed (newborn) baby is to be registered using the mother's given name in conjunction with the prefix 'Baby of'. For example, if the baby's mother's given name is Fiona, then record 'Baby of Fiona' in the preferred 'Given name' field for the baby. This name is recorded under the newborn Name type. If a name is subsequently given, record the new name as the preferred given name and retain the newborn name. Registering unnamed multiple births: An unnamed (newborn) baby from a multiple birth should use their mother's given name plus a reference to the multiple births. For example, if the baby's mother's given name is 'Fiona' and a set of twins is to be registered, then record 'Twin 1 of Fiona' in the Given name field for the first born baby, and 'Twin 2 of Fiona' in the 'Given name' field of the second born baby. Arabic numbers (1, 2, 3 ...) are used, not Roman Numerals (I, II, III ......). In the case of triplets or other multiple births the same logic applies. The following terms should be use for recording multiple births: • Twin: use Twin, that is Twin 1 of Fiona • Triplet: use Trip, that is Trip 1 of Fiona • Quadruplet: use Quad, that is Quad 1 of Fiona • Quintuplet: use Quin, that is Quin 1 of Fiona • Sextuplet: use Sext, that is Sext 1 of Fiona • Septuplet: use Sept, that is Sept 1 of Fiona. These names should be recorded under the newborn Person name type. When the babies are named, the actual names should be recorded as the preferred name. The newborn name is retained. Ethnic Names: The Centrelink Naming Systems for Ethnic Groups publication provides the correct coding for ethnic names. Refer to Ethnic Names Condensed Guide for summary information. Misspelled given names: If the person's given name has been misspelled in error, update the Given name field with the correct spelling and record the misspelled given name as an Alias name. Recording misspelled names is important for filing documents that may be issued with previous versions of the client's name. Discretion should be used regarding the degree of recording that is maintained. Comments: Often people use a variety of names, including legal names, married/maiden names, nicknames, assumed names, traditional names, etc. Even small differences in recording - such as the difference between Thomas and Tom - can make Record linkage impossible. To minimise discrepancies in the recording and reporting of name information, agencies or establishments should ask the person for their full (formal) Given name and Family name. These may be different from the name that the person may prefer the agency or establishment workers to use in personal dealings. Agencies or establishments may choose to separately record the preferred name that the person wishes to be used by agency or establishment workers. In some cultures it is traditional to state the family name first. To overcome discrepancies in recording/reporting that may arise as a result of this practice, agencies or establishments should always ask the person to specify their first given name and their family or surname separately. These should then be recorded as Given name and Family name as appropriate, regardless of the order in which they may be traditionally given. National Community Services Data Dictionary specific: Selected letters of the given name in combination with selected letters of the family name, date of birth and sex may be used for record linkage for statistical purposes only. National Health Data Dictionary specific: Health care provider identification DSS and Health care client identification DSS For the purpose of positive identification or contact, agencies or establishments that collect Given name should also collect Given name sequence number. Given name sequence number is also a metadata item in Australian Standard AS4846-2004 Health care provider identification and is proposed for inclusion in the review of Australian Standard AS5017-2002 Health care client identification. AS5017 and AS4846 use alternative alphabetic codes for Given name sequence number. Refer to the current standards for more details. Source and reference attributes Submitting organisation: Australian Institute of Health and Welfare Standards Australia Origin: National Health Data Committee National Community Services Data Committee Commonwealth Department of Health and Family Services 1998. Home and Community Care Data Dictionary Version 1.0. Canberra: DHFS Standards Australia 2002. Australian Standard AS5017-2002 Health Care Client Identification. Sydney: Standards Australia Reference documents: AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia Relational attributes Related metadata references: See also Person (name)—family name, text X[X(39)] Housing assistance, Standard 20/06/2005, Health, Standard 04/05/2005, Tasmanian Health, Draft 23/07/2012, Community Services (retired), Superseded 06/02/2012 Has been superseded by Person (name)—given name, text X[X(39)] WA Health, Draft 23/08/2012, Indigenous, Endorsed 05/09/2014, Disability, Standard 13/08/2015, Community Services (retired), Standard 06/02/2012 Supersedes Person (name)—given name, text X[X(39)] Health, Superseded 04/05/2005, Community Services (retired), Superseded 25/08/2005 Is used in the formation of Person—letters of given and family name, text XXXXX Health, Standardisation pending 04/08/2015, Community Services (retired), Standard 14/09/2009 Is used in the formation of Person—letters of given name, text XX Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 27/03/2007 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012

Data type

text

Person with cancer
Description

Person with cancer

Cancer staging—M stage code
Description

Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—M stage code METeOR identifier: 403720 Registration status: Health, Standard 07/12/2011 Definition: The absence or presence of distant metastasis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—distant metastasis status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid M codes from the current edition of the UICC TNM Classification of Malignant Tumours. Refer to the TNM Supplement: A commentary on uniform use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the absence or presence of distant metastasis at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) M category when there is any uncertainty. The current edition of the AJCC Cancer Staging Manual provides an equivalent and alternative source of M stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Union Against Cancer (UICC) Commission on Cancer, American College of Surgeons Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 Supersedes Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 6th edn) code XX Health, Superseded 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Cancer staging—stage grouping other
Description

Person with cancer—extent of primary cancer, stage grouping other, code X[XXXXX] Identifying and definitional attributes Short name: Cancer staging—stage grouping other METeOR identifier: 393377 Registration status: Health, Standard 07/12/2011 Definition: The anatomical extent of disease in a person with cancer based on stage categories of a staging classification other than the standard TNM classification, as represented by a code. Data Element Concept: Person with cancer—extent of primary cancer Value domain attributes Representational attributes Representation class: Code Data type: String Format: X[XXXXX] Maximum character length: 6 Supplementary values: Value Meaning 999997 Not applicable 999998 Unknown 999999 Not stated/inadequately described Collection and usage attributes Guide for use: Record valid stage grouping codes from the current edition of the appropriate staging source for the particular cancer. Convert all Roman numerals in the stage grouping to Arabic numbers. For example, stage IIIA would convert to 3A. Data element attributes Collection and usage attributes Guide for use: Record the extent of the primary cancer at the time of diagnosis of the cancer. Applies to all cancer stage groupings where a staging classification other than the standard TNM classification is used. Choose the lower (less advanced) stage category when there is any uncertainty. The relevant cancer stage grouping source will be indicated in the data element Cancer staging-cancer staging scheme source, code N[N] and if applicable, the related edition number will be recorded in data element Cancer staging-cancer staging scheme sourceedition number, code N[N]. A separate data element captures the extent of the primary cancer based on the TNM stage classification. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Relational attributes Related metadata references: See also Cancer staging—cancer staging scheme source edition number, code N[N] Health, Standard 07/12/2011 See also Cancer staging—cancer staging scheme source, code N[N] Health, Standard 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Cancer staging—TNM stage grouping code
Description

Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—TNM stage grouping code METeOR identifier: 403726 Registration status: Health, Standard 07/12/2011 Definition: The anatomical extent of disease in a person with cancer based on the previously coded T, N and M stage categories, as represented by a code. Data Element Concept: Person with cancer—extent of primary cancer Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "stage". For example, record Stage IIA2 for cancer of the cervix uteri as "2A2". Valid stage grouping codes from the current edition of the UICC TNM Classification of Malignant Tumours. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the extent of the primary cancer at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. The current edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual provides an equivalent and alternative source of TNM stage grouping codes. Stage groupings using classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Supersedes Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XXXX{[X]XX} Health, Superseded 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 08-Cancer clinico-pathological stage distribution Health, Standard 29/08/2014

Data type

text

Histopathological grade
Description

Person with cancer—histopathological grade, code N Identifying and definitional attributes Short name: Histopathological grade METeOR identifier: 422555 Registration status: Health, Standard 07/12/2011 Definition: The histopathological grade or differentiation in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—histopathological grade Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Grade 1: Low grade; well differentiated, differentiated, NOS 2 Grade 2: Intermediate grade, moderately differentiated, moderately well differentiated, intermediate differentiation 3 Grade 3: High grade, poorly differentiated 4 Grade 4: Undifferentiated, anaplastic Supplementary values: 9 Grade or differentiation not determined, not stated or not applicable Data element attributes Collection and usage attributes Guide for use: Histopathological grade or differentiation describes how little the tumour resembles the normal tissue from which it arose. Only malignant tumours are graded and only one code can be recorded. When more than one grade is documented for the primary tumour within the same specimen report, use the highest grade. For example, if grade 2-3 is documented, record the grade as 3. If the grades differ on multiple pathology reports for the same tumour, use the value from the larger specimen (for example, the grade from a surgical excision specimen would be used over the grade from a specimen from a diagnostic biopsy). Breast cancer coding rules: Use the Nottingham grade (Elston-Ellis modification of Bloom-Richardson grading system). This classification only uses grades 1-3, 9. For an invasive tumour with an in situ component, record the grade for the invasive component only. If the grade of the invasive component is not reported, record the grade as unknown. Collection methods: Cancer registry use: Collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Only malignant tumours are graded. Source and reference attributes Origin: World Health Organization Commission on Cancer American College of Surgeons Reference documents: Fritz A et al. 2000. International Classification of Diseases for Oncology, Third edition (ICD-O), 3rd edition. Geneva: World Health Organization American College of Surgeons 1998. Standards of the Commission on Cancer Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007. MD 2007. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Relational attributes Related metadata references: Supersedes Person with cancer—histopathological grade, code N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Laterality of primary cancer
Description

Person with cancer—laterality of primary cancer, code A Identifying and definitional attributes Short name: Laterality of primary cancer METeOR identifier: 422769 Registration status: Health, Standard 07/12/2011 Definition: The side of a paired organ that is the origin of the primary cancer in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—laterality of primary cancer Value domain attributes Representational attributes Representation class: Code Data type: String Format: A Maximum character length: 1 Permissible values: Value Meaning R Right L Left B Bilateral Supplementary values: N Not applicable U Unknown Data element attributes Collection and usage attributes Guide for use: Record the appropriate code at the time of diagnosis. Definitions Right: Origin of primary site is on the right side of a paired organ. Left: Origin of primary site is on the left side of a paired organ. Bilateral: Origin of primary site is on both sides of a paired organ. (When tumours of the same morphology are diagnosed simultaneously in both sides of a paired organ.) Includes organs that are bilateral as a single primary (e.g. bilateral retinoblastoma (M9510/3, C69.2), (M9511/3, C69.2), (M9512/3, C69.2), (C69.6, C48.0), bilateral Wilms tumours (C64.9, M8960/3)) Note: Bilateral cancers are very rare. Unknown: It is unknown whether, for a paired organ the origin of the cancer was on the left or right side of the body. Paired organs and structures The valid International Classification of Diseases for Oncology values for paired organs are provided in the list below: C02.4 Lingual tonsil C07.9 Parotid gland C08.0 Submandibular gland C08.1 Sublingual gland C09.0 Tonsillar fossa C09.1 Tonsillar pillar C09.8 Overlapping lesion of tonsil C09.9 Tonsil, NOS C11.1 Posterior wall of nasopharynx C30.0 Nasal cavity (excluding nasal cartilage and nasal septum) C30.1 Middle ear C31.0 Maxillary sinus C31.2 Frontal sinus C34.0 Main bronchus (excluding carina) C34.1-C34.9 Lung C38.4 Pleura C40.0 Long bones of upper limb and scapula C40.1 Short bones of upper limb C40.2 Long bones of lower limb C40.3 Short bones of lower limb C41.3 Rib and clavicle (excluding sternum) C41.4 Pelvic bones (excluding sacrum, coccyx and symphysis pubis) C44.1 Skin of eyelid C44.2 Skin of external ear C44.3 Skin of other and unspecified parts of face C44.5 Skin of trunk C44.6 Skin of upper limb and shoulder C44.7 Skin of lower limb and hip C47.1 Peripheral nerves and autonomic nervous system of upper limb and shoulder C47.2 Peripheral nerves and autonomic nervous system of lower limb and hip C49.1 Connective, subcutaneous and other soft tissues of upper limb and shoulder C49.2 Connective, subcutaneous and other soft tissues of lower limb and hip C50.0-C50.9 Breast C56.9 Ovary C57.0 Fallopian tube C62.0-C62.9 Testis C63.0 Epididymis C63.1 Spermatic cord C64.9 Kidney, NOS C65.9 Renal pelvis C66.9 Ureter C69.0-C69.9 Eye and lacrimal gland C70.0 Cerebral meninges, NOS C71.0 Cerebrum C71.1 Frontal lobe C71.2 Temporal lobe C71.3 Parietal lobe C71.4 Occipital lobe C72.2 Olfactory nerve C72.3 Optic nerve C72.4 Acoustic nerve C72.5 Cranial nerve, NOS C74.0-C74.9 Adrenal gland C75.0 Parathyroid glands C75.4 Carotid body C76.4 Upper limb, NOS C76.5 Lower limb, NOS C77.3 Lymph nodes of axilla or arm C77.4 Lymph nodes of inguinal region or leg Collection methods: This information should be obtained from the patient's medical record and pathology report. Comments: The laterality of the primary tumour may have implications for treatment and prognosis, and can be of assistance to cancer registries for the coding of subsequent tumours in paired organs. Source and reference attributes Origin: World Health Organization Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2010 revision. Commission on Cancer Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—laterality of primary cancer, code [N] Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Morphology of cancer
Description

Person with cancer—morphology of cancer, code (ICD-O-3) NNNN/N Identifying and definitional attributes Short name: Morphology of cancer METeOR identifier: 399491 Registration status: Health, Standard 07/12/2011 Definition: The histological classification of the cancer tissue (histopathological type) in a person with cancer, and a description of the course of development that a tumour is likely to take: benign or malignant (behaviour), as represented by a code. Data Element Concept: Person with cancer—morphology of cancer Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: Number Format: NNNN/N Maximum character length: 5 Collection and usage attributes Guide for use: ICD-O morphology describes histology and behaviour as separate variables, recognising that there are a large number of possible combinations. In ICD-O, morphology is a 4-digit number ranging from 8000 to 9989, and behaviour is a single digit which can be 0, 1, 2, 3, 6 or 9. When the morphology is unknown, record 8000 and the appropriate behaviour code. For example, a tumour of unknown morphology with a behaviour code of "3" for a malignant primary site tumour would be recorded as 8000/3. Source and reference attributes Origin: International Classification of Diseases for Oncology, Third Edition (ICD-O-3) Data element attributes Collection and usage attributes Guide for use: Tumour morphology refers to the type of cell (histology) that has become neoplastic and its biologic activity (behaviour). Record the tumour morphology for patients who have been diagnosed with cancer. Record the tumour morphology relating to the initial diagnosis and not for recurrent disease. Record morphology codes in accordance with ICD-O-3 coding standards. Use the 5th-digit to record behaviour. Refer to the coding guidelines for morphology in ICD-O-3, pp 27-34. If the morphology differs on multiple pathology reports for the same tumour, use the value from the most representative tumour specimen examined. For example, if the tumour is described as ductal on core biopsy but undifferentiated carcinoma on the excision specimen, the morphology would be coded as undifferentiated carcinoma (a lower code) which has a less favourable diagnosis. Collection methods: This information should be obtained from the patient's pathology reports or, in the case of cancer registries, from the notification reports. Comments: The information is collected so that tumours can be classified into clinically relevant groups based on their primary site and morphology. This provides a basis for staging and the determination of treatment options. The morphology of the cancer also affects the course of the disease and prognosis. Source and reference attributes Submitting organisation: Cancer Australia Origin: World Health Organization New South Wales Health Department State and Territory Cancer Registries Reference documents: New South Wales Inpatient Statistics Collection Manual. 2000/2001 Esteban D, Whelan S, Laudico A, Parkin DM (Editors) 1995. World Health Organization and International Association of Cancer Registries: Manual for cancer registry personnel, IARC Technical Report No 10. Lyon: International Agency for Research on Cancer Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—morphology of cancer, code (ICDO-3) NNNN/N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 02-Incidence of selected cancers, 2015 Health, Standard 14/01/2015

Data type

integer

Most valid basis of diagnosis of cancer
Description

Person with cancer—most valid basis of diagnosis of a cancer, code N Identifying and definitional attributes Short name: Most valid basis of diagnosis of cancer METeOR identifier: 422772 Registration status: Health, Standard 07/12/2011 Definition: The most valid basis of diagnosis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—most valid basis of diagnosis of a cancer Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 0 Death certificate only: Information provided is from a death certificate 1 Clinical: Diagnosis made before death, but without any of the following (codes 2-7) 2 Clinical investigation: All diagnostic techniques, including x-ray, endoscopy, imaging, ultrasound, exploratory surgery (e.g. laparotomy), and autopsy, without a tissue diagnosis 4 Specific tumour markers: Including biochemical and/or immunological markers that are specific for a tumour site 5 Cytology: Examination of cells from a primary or secondary site, including fluids aspirated by endoscopy or needle; also includes the microscopic examination of peripheral blood and bone marrow aspirates 6 Histology of metastasis: Histological examination of tissue from a metastasis, including autopsy specimens 7 Histology of a primary tumour: Histological examination of tissue from primary tumour, however obtained, including all cutting techniques and bone marrow biopsies; also includes autopsy specimens of primary tumour 8 Histology: either unknown whether of primary or metastatic site, or not otherwise specified Supplementary values: 9 Unknown. Collection and usage attributes Guide for use: CODES 1 - 4 Non-microscopic. CODES 5 - 8 Microscopic. CODE 9 Other. Comments: In a hospital setting this metadata item should be collected on the most valid basis of diagnosis at this admission. If more than one diagnosis technique is used during an admission, select the higher code from 1 to 8. Data element attributes Collection and usage attributes Guide for use: The most valid basis of diagnosis may be the initial histological examination of the primary site, or it may be the post-mortem examination (sometimes corrected even at this point when histological results become available). In a cancer registry setting, this metadata item should be revised if later information allows its upgrading. When considering the most valid basis of diagnosis, the minimum requirement of a cancer registry is differentiation between neoplasms that are verified microscopically and those that are not. To exclude the latter group means losing valuable information; the feasibility of making a morphological (histological) diagnosis is dependent upon a variety of factors, such as the health and age of the patient, accessibility of the tumour, availability of medical services, and the beliefs and decisions of the patient. A biopsy of the primary tumour should be distinguished from a biopsy of a metastasis, for example, at laparotomy; a biopsy of cancer of the head of the pancreas versus a biopsy of a metastasis in the mesentery. However, when insufficient information is available, Code 8 should be used for any histological diagnosis. Cytological and histological diagnoses should be distinguished. Morphological confirmation of the clinical diagnosis of malignancy depends on the successful removal of a piece of tissue that is cancerous. Especially when using endoscopic procedures (bronchoscopy, gastroscopy, laparoscopy, etc.), the clinician may miss the tumour with the biopsy forceps. These cases must be registered on the basis of endoscopic diagnosis and not excluded through lack of a morphological diagnosis. Care must be taken in the interpretation and subsequent coding of autopsy findings, which may vary as follows: a) the post-mortem report includes the post-mortem histological diagnosis (in which case, one of the histology codes should be recorded instead); b) the autopsy is macroscopic only, histological investigations having been carried out only during life (in which case, one of the histology codes should be recorded instead); c) the autopsy findings are not supported by any histological diagnosis. Comments: Knowledge of the basis of the diagnosis underlying a cancer code is one of the most important elements in assessing the reliability of cancer statistics. Source and reference attributes Origin: International Agency for Research on Cancer International Association of Cancer Registries Relational attributes Related metadata references: Supersedes Person with cancer—most valid basis of diagnosis of a cancer, code N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Most valid basis of diagnosis of recurrence
Description

Person with cancer—most valid basis of diagnosis of the first recurrence, code N Obligation: Conditional Identifying and definitional attributes Short name: Most valid basis of diagnosis of recurrence METeOR identifier: 394047 Registration status: Health, Standard 07/12/2011 Definition: The most valid basis of diagnosis of the first recurrence of locoregional cancer or distant metastasis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—most valid basis of diagnosis of a cancer Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 0 Death certificate only: Information provided is from a death certificate 1 Clinical: Diagnosis made before death, but without any of the following (codes 2-7) 2 Clinical investigation: All diagnostic techniques, including x-ray, endoscopy, imaging, ultrasound, exploratory surgery (e.g. laparotomy), and autopsy, without a tissue diagnosis 4 Specific tumour markers: Including biochemical and/or immunological markers that are specific for a tumour site 5 Cytology: Examination of cells from a primary or secondary site, including fluids aspirated by endoscopy or needle; also includes the microscopic examination of peripheral blood and bone marrow aspirates 6 Histology of metastasis: Histological examination of tissue from a metastasis, including autopsy specimens 7 Histology of a primary tumour: Histological examination of tissue from primary tumour, however obtained, including all cutting techniques and bone marrow biopsies; also includes autopsy specimens of primary tumour 8 Histology: either unknown whether of primary or metastatic site, or not otherwise specified Supplementary values: 9 Unknown. Collection and usage attributes Guide for use: CODES 1 - 4 Non-microscopic. CODES 5 - 8 Microscopic. CODE 9 Other. Comments: In a hospital setting this metadata item should be collected on the most valid basis of diagnosis at this admission. If more than one diagnosis technique is used during an admission, select the higher code from 1 to 8. Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the return, reappearance or metastasis of cancer of the same histology after a disease-free intermission or remission. Data element attributes Collection and usage attributes Guide for use: Record the most valid basis of diagnosis that identifies the first recurrence of locoregional cancer or a distant metastasis. The term recurrence refers to the return, reappearance or metastasis of cancer of the same histology after a disease-free period. It may be locoregional or a distant metastasis. The information is collected for the first recurrence of cancer at any site. The coding system is based on that recommended by the International Agency for Research on Cancer (IARC) and the International Association of Cancer Registries (IACR). The value "3" is not represented. If more than one investigation identifying the recurrence is conducted at the same time, select the higher number code from 1 to 8 reflecting the most definitive method of diagnosis. For example, if the patient has both imaging (Code 2) and histology of a primary tumour (Code 7) to verify the cancer, record Code 7 as the most valid basis of diagnosis. When considering the most valid basis of diagnosis, the minimum requirement of a cancer registry is differentiation between neoplasms that are verified microscopically and those that are not. To exclude the latter group means losing valuable information; the feasibility of making a morphological (histological) diagnosis is dependent upon a variety of factors, such as the health and age of the patient, accessibility of the tumour, availability of medical services, and the beliefs and decisions of the patient. A biopsy of the primary tumour should be distinguished from a biopsy of a metastasis, for example, at laparotomy; a biopsy of cancer of the head of the pancreas versus a biopsy of a metastasis in the mesentery. However, when insufficient information is available to determine whether the site of the biopsy is primary or metastatic, Code 8. Cytological and histological diagnoses should also be distinguished. Morphological confirmation of the clinical diagnosis of malignancy depends on the successful removal of a piece of tissue that is cancerous. When using endoscopic procedures such as bronchoscopy, gastroscopy or laparoscopy, the clinician may miss the tumour with the biopsy forceps. These cases must be registered on the basis of endoscopic diagnosis and not excluded through lack of a morphological diagnosis. Care must be taken in the interpretation and subsequent coding of autopsy findings, which may vary as follows: (a) The post-mortem report includes the post-mortem histological diagnosis (in which case, one of the histology codes should be recorded instead); (b) The autopsy is macroscopic only, histological investigations having been carried out only during life (in which case, one of the histology codes should be recorded instead); (c) The autopsy findings are not supported by any histological diagnosis. Collection methods: The information should be obtained from the patient's medical record. Comments: Information regarding the basis of diagnosis is important for determining how definitively the malignancy was confirmed and subsequently the reliability of cancer statistics. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Agency for Research on Cancer (IARC) International Association of Cancer Registries (IACR) Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Health, Standard 07/12/2011 See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011

Data type

integer

Regional lymph nodes positive
Description

Person with cancer—number of positive regional lymph nodes, total N[N] Obligation: Conditional Identifying and definitional attributes Short name: Regional lymph nodes positive METeOR identifier: 415959 Registration status: Health, Standard 07/12/2011 Definition: The total number of regional lymph nodes reported to contain tumour in a person with cancer. Data Element Concept: Person with cancer—number of positive regional lymph nodes Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 99 Not stated/inadequately described Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the regional lymph nodes being excised and examined by a pathologist and demonstrated to be positive for malignancy. Data element attributes Collection and usage attributes Guide for use: A list of which lymph nodes are defined as regional lymph nodes for each cancer site may be found in the current edition of the TNM Classification of Tumours, UICC (International Union Against Cancer) and the AJCC (American Joint Committee on Cancer) Cancer Staging Manual. The number includes all positive nodes regardless of whether they were removed and examined at a single or multiple procedures. For example, for breast cancer, record the sum of positive nodes detected in node sampling/sentinel node biopsy and those removed at axillary clearance. Collection methods: The information should be obtained from the patient's medical record. For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Source and reference attributes Origin: Australian Cancer Network Commission on Cancer American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer American Joint Committee on Cancer 2010. AJCC Staging Manual, 7th edition. New York: Springer Australian Cancer Network 2001. The pathology reporting of breast cancer: A guide for pathologists, surgeons and radiologists, 2nd Edition. Sydney: Australian Cancer Network Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell Relational attributes Related metadata references: See also Number of regional lymph nodes examined Health, Standard 07/12/2011 Supersedes Person with cancer—number of positive regional lymph nodes, total N[N] Health, Superseded 07/12/2011 See also Person with cancer—number of regional lymph nodes examined, total N[N] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Number of regional lymph nodes examined
Description

Person with cancer—number of regional lymph nodes examined, total N[N] Obligation: Conditional Identifying and definitional attributes Short name: Number of regional lymph nodes examined METeOR identifier: 415971 Registration status: Health, Standard 07/12/2011 Definition: The total number of regional lymph nodes examined by a pathologist in a person with cancer. Data Element Concept: Person with cancer—number of regional lymph nodes examined Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 99 Not stated/inadequately described Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the regional lymph nodes being excised and examined by a pathologist. Data element attributes Collection and usage attributes Guide for use: A list of which lymph nodes are defined as regional lymph nodes for each cancer site may be found in the current edition of the TNM Classification of Tumours, UICC (International Union Against Cancer) or the AJCC (American Joint Committee on Cancer) Cancer Staging Manual. The number includes all nodes examined regardless of whether they were removed and examined at a single or multiple procedures. For example, for breast cancer, record the sum of regional lymph nodes examined from node sampling, sentinel node biopsy and axillary clearance. The number of regional lymph nodes is cumulative from all procedures that removed lymph nodes through the completion of surgeries for the initial treatment of the cancer. The initial course of treatment includes all treatments administered to the patient from diagnosis and before disease progression or recurrence. Breast cancer: Regional lymph nodes include all ipsilateral axillary nodes (levels 1, 2 and 3), ipsilateral internal mammary nodes, supraclavicular nodes and intramammary lymph nodes. All other nodes (including contralateral axillary, contralateral internal mammary nodes and cervical nodes) are considered to be distant metastases and should not be recorded in this data item. Definitions are from the UICC TNM Classification of Malignant Tumours, 7th Edition. Collection methods: For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Source and reference attributes Origin: Australian Cancer Network Commission on Cancer American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer Australian Cancer Network & National Breast and Ovarian Cancer Network 2001. The pathology reporting of breast cancer: A guide for pathologists, surgeons, radiologists and oncologists, 3rd edition. Sydney: Australian Cancer Network & National Breast and Ovarian Cancer Network Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell Relational attributes Related metadata references: See also Person with cancer—number of positive regional lymph nodes, total N[N] Health, Standard 07/12/2011 Supersedes Person with cancer—number of regional lymph nodes examined, total code N[N] Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Primary site of cancer (ICD-O-3 code)
Description

Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N Identifying and definitional attributes Short name: Primary site of cancer (ICD-O-3 code) METeOR identifier: 396090 Registration status: Health, Standard 07/12/2011 Definition: The site in which the tumour originated in a person with cancer, as opposed to the secondary or metastatic sites, as represented by a code. Data Element Concept: Person with cancer—primary site of cancer Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: String Format: ANN.N Maximum character length: 5 Collection and usage attributes Guide for use: Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Data element attributes Collection and usage attributes Guide for use: Record the primary site of cancer, if known, for patients who have been diagnosed with cancer. When the primary site is unknown, record C80.9. The primary site of the tumour is the site of origin, as opposed to the secondary or metastatic site. Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Refer to the coding guidelines for topography in ICD-O-3, pp 23-26. Refer to the coding guidelines for multiple tumours in ICD-O-3, pp 35-37. If the patient is diagnosed with more than one primary tumour, record the site of each primary separately. If the primary site differs on multiple pathology or other notification reports for the same tumour, use the most specific value. For example, one report may state the breast (C50.9) is the site of the primary while another report records the lower-inner quadrant of the breast (C50.3) as the primary site; record C50.3 here as the primary site. Collection methods: This information should be obtained from the patient's medical record. Comments: The information is collected so that tumours can be classified into clinically relevant groups based on their primary site and histological type. This provides a basis for staging and the determination of treatment options. The primary site of the cancer also affects the course of the disease and prognosis. Source and reference attributes Submitting organisation: Cancer Australia Origin: World Health Organization Reference documents: Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—primary site of cancer, code (ICDO-3) ANN{.N[N]} Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 02-Incidence of selected cancers, 2015 Health, Standard 14/01/2015

Data type

text

Cancer staging—T stage code
Description

Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Identifying and definitional attributes Short name: Cancer staging—T stage code METeOR identifier: 403564 Registration status: Health, Standard 07/12/2011 Definition: The size and extent of the primary tumour in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—primary tumour status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XXX] Maximum character length: 4 Supplementary values: Value Meaning 9997 Not applicable 9998 Unknown 9999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid T codes from the current edition of the UICC TNM Classification of Malignant Tumours. Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "T". For example, record stage T2a for lung cancer as "2a". Record if the T stage value has a prefix of “c” or “p”; for example, record retinoblastoma T stage pT2b as “p2b”. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the size and extent of the primary tumour at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) T category when there is any uncertainty. The T stage value is derived from the size of the tumour and its relationship (extension) to other structures. The size is reflected in the value of data element Person with cancer—solid tumour size (at diagnosis), total millimetres NNN; the usage attributes provide additional detail. The extent of the primary cancer at diagnosis is usually recorded. An exception is malignant melanoma of the skin; by convention T stage is recorded after tumour excision and is based on tumour thickness with T subcategories based on ulceration and the number of mitoses seen. Ovarian cancer is also surgically/pathologically staged. The current edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual provides an equivalent and alternative source of T stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Supersedes Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XX[X] Health, Superseded 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Region of first recurrence as distant metastasis
Description

Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Obligation: Conditional, Maximum occurrences: Unlimited Identifying and definitional attributes Short name: Region of first recurrence as distant metastasis METeOR identifier: 393854 Registration status: Health, Standard 07/12/2011 Definition: The region of first recurrence as a distant metastasis in a person with cancer, after a disease-free period, as represented by a code. Data Element Concept: Person with cancer—region of first recurrence as distant metastasis Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: String Format: ANN.N Maximum character length: 5 Collection and usage attributes Guide for use: Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient being diagnosed with recurrence of distant metastasis. Data element attributes Collection and usage attributes Guide for use: This information is collected for the site or region of first recurrence as distant metastasis. The term recurrence refers to the return, reappearance or metastasis of cancer of the same histology after a disease-free period. Distant metastasis refers to the spread of cancer of the same histology as the original (primary) tumour to distant organs or distant lymph nodes. Site or region refers to the anatomical location that the cancer has spread to. Distant metastasis may occur in more than one site; record all relevant distant metastatic sites. The region of locoregional recurrence is collected as a separate item. The record should not be updated with subsequent recurrences. Collection methods: The information should be obtained from the patient's medical record. Comments: This is collected to identify in which anatomical structures recurrence occurs, and is useful for evaluating patterns of care and patient outcomes. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Health, Standard 07/12/2011 See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—most valid basis of diagnosis of the first recurrence, code N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Region of first recurrence as locoregional cancer
Description

Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Obligation: Conditional, Maximum occurrences: Unlimited Identifying and definitional attributes Short name: Region of first recurrence as locoregional cancer METeOR identifier: 393848 Registration status: Health, Standard 07/12/2011 Definition: The region of first recurrence as locoregional cancer in a person with cancer, after a disease-free period, as represented by a code. Data Element Concept: Person with cancer—region of first recurrence as locoregional cancer Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: String Format: ANN.N Maximum character length: 5 Collection and usage attributes Guide for use: Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the patient being diagnosed with recurrence of locoregional cancer. Data element attributes Collection and usage attributes Guide for use: This information is collected for the site or region of the first recurrence as locoregional cancer. The term recurrence refers to the return, reappearance or metastasis of cancer of the same histology after a disease-free period. Locoregional recurrence refers to the appearance of cancer cells at the same site as the original (primary) tumour or the regional lymph nodes. A list of those lymph nodes defined as regional lymph nodes for each cancer site can be found in the TNM Classification of Malignant Tumours International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC) Cancer Staging Manual; the latest editions are recommended. Site or region refers to the anatomical position that the cancer has reappeared, record all relevant locoregional sites. The region of recurrence of distant metastasis is collected as a separate item. The record should not be updated with subsequent recurrences. Collection methods: The information should be obtained from the patient's medical record. Comments: This is collected to identify in which anatomical structures recurrence occurs, and is useful for evaluating patterns of care and patient outcomes. Source and reference attributes Submitting organisation: Cancer Australia Origin: Commission on Cancer, American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II. Commission on Cancer Relational attributes Related metadata references: See also Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Health, Standard 07/12/2011 See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011 See also Person with cancer—most valid basis of diagnosis of the first recurrence, code N Health, Standard 07/12/2011 See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011 Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Cancer staging—N stage code
Description

Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—N stage code METeOR identifier: 403661 Registration status: Health, Standard 07/12/2011 Definition: The absence or presence and extent of regional lymph node metastasis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—regional lymph node metastasis status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid N codes from the current edition of the UICC TNM Classification of Malignant Tumours. Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "N". For example, record stage N1b for malignant melanoma of the skin as "1b". Record if the N stage value has a prefix of “c” or “p”. For example, record retinoblastoma N stage pN1 as “p1”. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the absence or presence and extent of regional lymph node metastasis at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) N category when there is any uncertainty. The current edition of the AJCC (American Joint Committee on Cancer) Cancer Staging Manual provides an equivalent and alternative source of N stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 Supersedes Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XX Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Tumour size at diagnosis (solid tumours)
Description

Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Obligation: Conditional Identifying and definitional attributes Short name: Tumour size at diagnosis (solid tumours) METeOR identifier: 422642 Registration status: Health, Standard 07/12/2011 Definition: The largest dimension of a solid tumour, measured in millimetres. Data Element Concept: Person with cancer—solid tumour size Value domain attributes Representational attributes Representation class: Total Data type: String Format: NNN Maximum character length: 3 Supplementary values: Value Meaning 999 Unknown Unit of measure: Millimetre (mm) Collection and usage attributes Guide for use: Size in millimetres with valid values 001 to 997. Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Conditional on the histopathological examination of the tumour, and excludes Phyllodes tumours, sarcomas or lymphomas. Data element attributes Collection and usage attributes Guide for use: The reporting standard for the size of solid tumours is: • Breast cancer or other solid neoplasms - the largest tumour dimension, measured to a precision of 1mm • Round to the nearest millimetre, rounding up if size is ≥ .5 mm (e.g. 1.50mm, 1.54mm recorded as 2mm, 1.47mm recorded as 1mm). General coding rules: Recorded size: • Only record measured size if stated, otherwise record size as unknown. Do not attempt to estimate size from descriptions of the tumour, such as 'tumour occupying three quarters of tissue' • Do not take values for size from sources other than histopathology (such as imaging, mammography or clinical examination). Size reported for multiple specimens: • If tumour is removed in more than one procedure (e.g. biopsy and excision, local excision and re-excision) do not sum the sizes across multiple pathology reports but rather use the larger of the measured sizes from the separate pathology reports • If tumour is divided into several parts (in the same pathology report), do not sum sizes together but rather use the larger of the measured sizes. However, if the pathologist states an aggregate or composite size, record that size. Multifocal tumour: • If the tumour is multifocal, record the size of the largest measured focus. Do not attempt to sum sizes of different foci. Macroscopic size: • If only macroscopic size is given, record this value • If the macroscopic and microscopic measurements differ, the microscopic measurement should be recorded. Exclusions: • Size is not recorded for Phyllodes tumours, sarcomas, or lymphomas. Invasive breast cancer coding rules: Note: These rules are to be used only when the record pertains to an invasive breast cancer (as per Person with cancer-primary site of cancer, topography code (ICD-O-3) ANN.N. Invasive tumours with an in situ component: • When an invasive tumour contains an in situ component, only record the size of the invasive component as stated • If the size of the invasive tumour is not recorded separately to the in situ component, then record the total size of the tumour without any attempt to estimate the invasive component using percentage or size of the in situ component. Microinvasive tumour: • For microinvasive tumours, record size in millimetres if stated. If microinvasion is stated but no size is recorded, enter 990 in size field to enable these very small tumours to be differentiated from other tumours without measured sizes. Bilateral breasts tumours: • Bilateral tumours are recorded as two separate primary tumours each having their own size (and other data elements). Multifocal tumours with different morphology: • Foci with different morphology should be considered to be separate primary tumours each having their own size (and other data elements). The coder needs to ascertain whether two foci with differing morphology are separate primaries with different morphology or a single multifocal primary with a mixed histology. In the latter case the rule of taking the size from the larger focus would apply as stated. Collection methods: This information should be obtained from the patient's pathology reports. Comments: The diameter of the largest dimension of solid neoplasms is collected for patient management, population cancer statistics and research. Source and reference attributes Reference documents: Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007. MD 2007. Bethesda:National Cancer Institute, NIH Publication number 07-5581 National Breast and Ovarian Cancer Centre and Australian Cancer Network 2008. The pathology reporting of breast cancer: A guide for pathologists, surgeons, radiologists and oncologists, 3rd edition. Surry Hills, NSW: National Breast and Ovarian Cancer Centre Relational attributes Related metadata references: Supersedes Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Measurement units
  • mm
mm
Person
Description

Person

Date of birth
Description

Person—date of birth, DDMMYYYY Identifying and definitional attributes Short name: Date of birth METeOR identifier: 287007 Registration status: Housing assistance, Standard 20/06/2005 Health, Standard 04/05/2005 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Tasmanian Health, Final 30/06/2014 WA Health, Endorsed 19/03/2015 Independent Hospital Pricing Authority, Standard 01/11/2012 Indigenous, Endorsed 11/08/2014 National Health Performance Authority, Standard 07/11/2013 Commonwealth Department of Health, Candidate 25/05/2015 Disability, Standard 07/10/2014 Community Services (retired), Standard 25/08/2005 Definition: The date of birth of the person, expressed as DDMMYYYY. Data Element Concept: Person—date of birth Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: If date of birth is not known or cannot be obtained, provision should be made to collect or estimate age. Collected or estimated age would usually be in years for adults, and to the nearest three months (or less) for children aged less than two years. Additionally, an estimated date flag or a date accuracy indicator should be reported in conjunction with all estimated dates of birth. For data collections concerned with children's services, it is suggested that the estimated date of birth of children aged under 2 years should be reported to the nearest 3 month period, i.e. 0101, 0104, 0107, 0110 of the estimated year of birth. For example, a child who is thought to be aged 18 months in October of one year would have his/her estimated date of birth reported as 0104 of the previous year. Again, an estimated date flag or date accuracy indicator should be reported in conjunction with all estimated dates of birth. Collection methods: Information on date of birth can be collected using the one question: What is your/(the person's) date of birth? In self-reported data collections, it is recommended that the following response format is used: Date of birth: _ _ / _ _ / _ _ _ _ This enables easy conversion to the preferred representational layout (DDMMYYYY). For record identification and/or the derivation of other metadata items that require accurate date of birth information, estimated dates of birth should be identified by a date accuracy indicator to prevent inappropriate use of date of birth data. The linking of client records from diverse sources, the sharing of patient data, and data analysis for research and planning all rely heavily on the accuracy and integrity of the collected data. In order to maintain data integrity and the greatest possible accuracy an indication of the accuracy of the date collected is critical. The collection of an indicator of the accuracy of the date may be essential in confirming or refuting the positive identification of a person. For this reason it is strongly recommended that the data element Date—accuracy indicator, code AAA also be recorded at the time of record creation to flag the accuracy of the data. Comments: Privacy issues need to be taken into account in asking persons their date of birth. Wherever possible and wherever appropriate, date of birth should be used rather than age because the actual date of birth allows a more precise calculation of age. When date of birth is an estimated or default value, national health and community services collections typically use 0101 or 0107 or 3006 as the estimate or default for DDMM. It is suggested that different rules for reporting data may apply when estimating the date of birth of children aged under 2 years because of the rapid growth and development of children within this age group which means that a child's development can vary considerably over the course of a year. Thus, more specific reporting of estimated age is suggested. Source and reference attributes Origin: National Health Data Committee National Community Services Data Committee Reference documents: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia Relational attributes Related metadata references: See also Date—accuracy indicator, code AAA Housing assistance, Standard 23/08/2010, Health, Standard 04/05/2005, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 30/09/2005 See also Date—estimate indicator, code N Tasmanian Health, Draft 23/07/2012, Community Services (retired), Standard 27/04/2007 Is used in the formation of Episode of admitted patient care (antenatal)—length of stay (including leave days), total N[NN] Health, Superseded 04/07/2007 Is used in the formation of Episode of admitted patient care (postnatal)—length of stay (including leave days), total N[NN] Health, Superseded 04/07/2007 Is used in the formation of Episode of admitted patient care—diagnosis related group, code (AR-DRG v 6) ANNA Health, Standard 30/06/2013, Tasmanian Health, Draft 23/07/2012, Commonwealth Department of Health, Candidate 16/07/2015 Is used in the formation of Episode of admitted patient care—diagnosis related group, code (AR-DRG v5.1) ANNA Health, Superseded 22/12/2009 Is used in the formation of Episode of admitted patient care—length of stay (including leave days) (antenatal), total N[NN] Health, Standard 04/07/2007 Is used in the formation of Episode of admitted patient care—length of stay (including leave days) (postnatal), total N[NN] Health, Standard 04/07/2007 Is used in the formation of Episode of admitted patient care—major diagnostic category, code (AR-DRG v 6) NN Health, Standard 30/06/2013, Tasmanian Health, Draft 23/07/2012, Commonwealth Department of Health, Candidate 16/07/2015 Is used in the formation of Episode of admitted patient care—major diagnostic category, code (AR-DRG v5.1) NN Health, Superseded 22/12/2009 See also Person with cancer—date of initial medical specialist consultation, DDMMYYYY Health, Standard 04/02/2015 See also Person with cancer—date of initial primary health care consultation, DDMMYYYY Health, Standard 04/02/2015 Supersedes Person—date of birth, DDMMYYYY Health, Superseded 04/05/2005, Community Services (retired), Superseded 25/08/2005 Is used in the formation of Record—linkage key, code 581 XXXXXDDMMYYYYN Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 21/05/2010 Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Admitted patient care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Admitted patient mental health care NMDS 2015-16 Health, Standard 04/02/2015 Admitted patient palliative care NMDS 2015-16 Health, Standard 04/02/2015 Alcohol and other drug treatment services NMDS 2015- Health, Standard 13/11/2014 Audiology assessment client cluster Indigenous, Endorsed 11/08/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Child protection and support services (CPSS) client cluster Community Services (retired), Standard 30/04/2008 Child protection and support services (CPSS) sibling cluster Community Services (retired), Standard 30/04/2008 Closing the Gap in the Northern Territory: Dental Services DSS, 2011 Indigenous, Endorsed 08/10/2014 Community mental health care NMDS 2015-16 Health, Standard 13/11/2014 Computer Assisted Telephone Interview demographic module DSS Health, Standard 03/12/2008 Diabetes (clinical) DSS Health, Standard 21/09/2005 Ear nose and throat services patient cluster Indigenous, Endorsed 05/09/2014 Early Childhood Education and Care: Unit Record Level NMDS 2015 Early Childhood, Standard 01/06/2015 Home purchase assistance DSS 2012-13 Housing assistance, Standard 03/07/2014 Household file cluster (Indigenous community housing) Housing assistance, Standard 01/05/2013 Indigenous, Endorsed 01/05/2013 Juvenile Justice Client file cluster Community Services (retired), Standard 14/09/2009 Medical indemnity DSS 2014- Health, Standard 21/11/2013 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Non-admitted patient DSS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 23/07/2014 Non-admitted patient emergency department care DSS 2015-16 Health, Standard 04/02/2015 Non-admitted patient emergency department care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Perinatal NMDS 2014- Health, Standard 07/03/2014 Person (housing assistance) cluster Housing assistance, Standard 01/05/2013 Person details data dictionary Disability, Standard 13/08/2015 Community Services (retired), Standard 06/02/2012 Person file cluster (Mainstream community housing) Housing assistance, Standard 01/05/2013 Prison clinic contact DSS Health, Standard 25/08/2011 Prison entrants DSS Health, Standard 25/08/2011 Prisoners in custody repeat medications DSS Health, Standard 25/08/2011 Private rent assistance DSS 2012-13 Housing assistance, Standard 03/07/2014 Public dental waiting times NMDS 2013- Health, Standard 09/11/2012 Radiotherapy waiting times NMDS 2015- Health, Standard 13/11/2014 Residential mental health care NMDS 2015-16 Health, Standard 13/11/2014 Statistical linkage key 581 cluster Housing assistance, Standard 23/08/2010 Health, Standard 07/12/2011 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Disability, Standard 07/10/2014 Community Services (retired), Standard 21/05/2010 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2013-14 WA Health, Endorsed 19/03/2015 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2014-15 WA Health, Endorsed 24/04/2015 Implementation in Indicators: Used as numerator National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2012 National Health Performance Authority, Standard 27/03/2014 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2013 National Health Performance Authority, Standard 27/08/2015 National Health Performance Authority, Healthy Communities: Immunisation rates for children, 2012–13 National Health Performance Authority, Standard 27/03/2014 National Health Performance Authority, Healthy Communities: Number of selected potentially avoidable hospitalisations per 100,000 people, 2011–12 National Health Performance Authority, Standard 07/11/2013 National Indigenous Reform Agreement: PI 02-Mortality rate by leading causes, 2014 Indigenous, Endorsed 13/12/2013 National Indigenous Reform Agreement: PI 03-Rates of current daily smokers, 2014 Indigenous, Endorsed 13/12/2013 National Indigenous Reform Agreement: PI 06-Under five mortality rate by leading cause, 2014 Indigenous, Endorsed 13/12/2013 National Indigenous Reform Agreement: PI 10-The proportion of Indigenous children aged 4 and 5 years who are enrolled in, and attending, a preschool program in the year before full-time schooling, by remoteness, 2014 Indigenous, Endorsed 13/12/2013 Used as denominator National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2012 National Health Performance Authority, Standard 27/03/2014 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2013 National Health Performance Authority, Standard 27/08/2015 National Health Performance Authority, Healthy Communities: Immunisation rates for children, 2012–13 National Health Performance Authority, Standard 27/03/2014 National Indigenous Reform Agreement: PI 03-Rates of current daily smokers, 2014 Indigenous, Endorsed 13/12/2013

Data type

date

Alias
UMLS CUI [1]
C0421451
Date of death
Description

Person—date of death, DDMMYYYY Obligation: Conditional Identifying and definitional attributes Short name: Date of death METeOR identifier: 287305 Registration status: Health, Standard 04/05/2005 Tasmanian Health, Draft 23/07/2012 WA Health, Endorsed 19/03/2015 Disability, Standard 13/08/2015 Community Services (retired), Standard 30/09/2005 Definition: The date of death of the person, expressed as DDMMYYYY. Data Element Concept: Person—date of death Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Recorded when the patient has died. DSS specific information: This field must be greater than or equal to Date of diagnosis of primary cancer. Data element attributes Collection and usage attributes Guide for use: Recorded for persons who have died. Where Date of birth is collected, Date of death must be equal to or greater than Date of birth for the same person. Collection methods: It is recommended that in cases where all components of the date of death are not known or where an estimate is arrived at from age, a valid date be used together with a flag to indicate that it is an estimate. For record identification and/or the derivation of other metadata items that require accurate date of death information, estimated dates of death should be identified by a date accuracy indicator to prevent inappropriate use of date of death data. The linking of client records from diverse sources, the sharing of patient data, and data analysis for research and planning all rely heavily on the accuracy and integrity of the collected data. In order to maintain data integrity and the greatest possible accuracy an indication of the accuracy of the date collected is critical. The collection of Date accuracy indicator may be essential in confirming or refuting the positive identification of a person. For this reason it is strongly recommended that the data element Date accuracy indicator also be recorded at the time of record creation to flag the accuracy of the data. Source and reference attributes Submitting organisation: Australian Institute of Health and Welfare Origin: Health Data Standards Committee Relational attributes Related metadata references: Supersedes Date of death, version 1, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (13.5 KB) See also Person with cancer—date of initial medical specialist consultation, DDMMYYYY Health, Standard 04/02/2015 See also Person with cancer—date of initial primary health care consultation, DDMMYYYY Health, Standard 04/02/2015 Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Cancer (clinical) DSS Health, Standard 14/05/2015 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Person details data dictionary Disability, Standard 13/08/2015 Community Services (retired), Standard 06/02/2012 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2013-14 WA Health, Endorsed 19/03/2015 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2014-15 WA Health, Endorsed 24/04/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 11-Colorectal cancer mortality rate Health, Standard 29/08/2014 National Healthcare Agreement: PI 24-Survival of people diagnosed with notifiable cancers, 2015 Health, Standard 14/01/2015 National Indigenous Reform Agreement: PI 02-Mortality rate by leading causes, 2014 Indigenous, Endorsed 13/12/2013 National Indigenous Reform Agreement: PI 06-Under five mortality rate by leading cause, 2014 Indigenous, Endorsed 13/12/2013

Data type

date

Alias
UMLS CUI [1]
C1148348
Medicare card number
Description

Person—government funding identifier, Medicare card number N(11) Identifying and definitional attributes Short name: Medicare card number METeOR identifier: 270101 Registration status: Health, Standard 01/03/2005 Tasmanian Health, Draft 23/07/2012 WA Health, Endorsed 19/03/2015 Indigenous, Endorsed 05/09/2014 Community Services (retired), Recorded 27/03/2007 Definition: Person identifier, allocated by the Health Insurance Commission to eligible persons under the Medicare scheme, that appears on a Medicare card. Context: Medicare utilisation statistics. Persons eligible for Medicare services. Data Element Concept: Person—government funding identifier Value domain attributes Representational attributes Representation class: Identifier Data type: Number Format: N(11) Maximum character length: 11 Collection and usage attributes Guide for use: Full Medicare number for an individual (i.e. family number plus person (individual reference) number). Comments: The Medicare card number is printed on a Medicare card and is used to access Medicare records for an eligible person. Up to 9 persons can be included under the one Medicare card number with up to five persons appearing on one physical card. Persons grouped under one Medicare card number are often a family, however, there is no requirement for persons under the same Medicare card number to be related. A person may be shown under separate Medicare card numbers where, for example, a child needs to be included on separate Medicare cards held by their parents. As a person can be identified on more than one Medicare card this is not a unique identifier for a person. Data element attributes Collection and usage attributes Guide for use: The Medicare card number should only be collected from persons eligible to receive health services that are to be funded by the Commonwealth government. The number should be reported to the appropriate government agency to reconcile payment for the service provided. The data should not be used by private sector organisations for any other purpose unless specifically authorised by law. For example, data linkage should not be carried out unless specifically authorised by law. Comments: Note: Veterans may have a Medicare card number and a Department of Veterans' Affairs (DVA) number or only a DVA number. Source and reference attributes Submitting organisation: Standards Australia Origin: AS5017 Health care client identification Relational attributes Related metadata references: Supersedes Medicare card number, version 2, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (15.6 KB) Implementation in Data Set Specifications: Cancer (clinical) DSS Health, Standard 14/05/2015 Ear nose and throat services patient cluster Indigenous, Endorsed 05/09/2014 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2013-14 WA Health, Endorsed 19/03/2015 WA Health Non-Admitted Patient Activity and Wait List Data Collection (NAPAAWL DC) 2014-15 WA Health, Endorsed 24/04/2015 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 17-Treatment rates for mental illness, 2015 Health, Standard 14/01/2015

Data type

integer

Indigenous status
Description

Person—Indigenous status, code N Identifying and definitional attributes Short name: Indigenous status METeOR identifier: 291036 Registration status: Housing assistance, Standard 15/04/2010 Health, Standard 04/05/2005 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Tasmanian Health, Final 30/06/2014 WA Health, Endorsed 04/03/2014 Independent Hospital Pricing Authority, Standard 01/11/2012 Indigenous, Endorsed 11/09/2012 Commonwealth Department of Health, Candidate 16/07/2015 Disability, Standard 07/10/2014 Community Services (retired), Standard 25/08/2005 Definition: Whether a person identifies as being of Aboriginal or Torres Strait Islander origin, as represented by a code. This is in accord with the first two of three components of the Commonwealth definition. Data Element Concept: Person—Indigenous status Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Aboriginal but not Torres Strait Islander origin 2 Torres Strait Islander but not Aboriginal origin 3 Both Aboriginal and Torres Strait Islander origin 4 Neither Aboriginal nor Torres Strait Islander origin Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: This metadata item is based on the Australian Bureau of Statistics (ABS) standard for Indigenous status. For detailed advice on its use and application please refer to the ABS Website as indicated in the Reference documents. The classification for Indigenous status has a hierarchical structure comprising two levels. There are four categories at the detailed level of the classification which are grouped into two categories at the broad level. There is one supplementary category for 'not stated' responses. The classification is as follows: Indigenous: • Aboriginal but not Torres Strait Islander origin. • Torres Strait Islander but not Aboriginal origin. • Both Aboriginal and Torres Strait Islander origin. Non-Indigenous: • Neither Aboriginal nor Torres Strait Islander origin. Not stated/ inadequately described: This category is not to be available as a valid answer to the questions but is intended for use: • Primarily when importing data from other data collections that do not contain mappable data. • Where an answer was refused. • Where the question was not able to be asked prior to completion of assistance because the client was unable to communicate or a person who knows the client was not available. Only in the last two situations may the tick boxes on the questionnaire be left blank. Data element attributes Collection and usage attributes Collection methods: The standard question for Indigenous Status is as follows: [Are you] [Is the person] [Is (name)] of Aboriginal or Torres Strait Islander origin? (For persons of both Aboriginal and Torres Strait Islander origin, mark both 'Yes' boxes.) No.................................................... Yes, Aboriginal............................... Yes, Torres Strait Islander............ This question is recommended for self-enumerated or interview-based collections. It can also be used in circumstances where a close relative, friend, or another member of the household is answering on behalf of the subject. It is strongly recommended that this question be asked directly wherever possible. When someone is not present, the person answering for them should be in a position to do so, i.e. this person must know well the person about whom the question is being asked and feel confident to provide accurate information about them. This question must always be asked regardless of data collectors' perceptions based on appearance or other factors. The Indigenous status question allows for more than one response. The procedure for coding multiple responses is as follows: If the respondent marks 'No' and either 'Aboriginal' or 'Torres Strait Islander', then the response should be coded to either Aboriginal or Torres Strait Islander as indicated (i.e. disregard the 'No' response). If the respondent marks both the 'Aboriginal' and 'Torres Strait Islander' boxes, then their response should be coded to 'Both Aboriginal and Torres Strait Islander Origin'. If the respondent marks all three boxes ('No', 'Aboriginal' and 'Torres Strait Islander'), then the response should be coded to 'Both Aboriginal and Torres Strait Islander Origin' (i.e. disregard the 'No' response). This approach may be problematical in some data collections, for example when data are collected by interview or using screen based data capture systems. An additional response category Yes, both Aboriginal and Torres Strait Islander... may be included if this better suits the data collection practices of the agency or establishment concerned. Comments: The following definition, commonly known as 'The Commonwealth Definition', was given in a High Court judgement in the case of Commonwealth v Tasmania (1983) 46 ALR 625. 'An Aboriginal or Torres Strait Islander is a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which he or she lives'. There are three components to the Commonwealth definition: • descent; • self-identification; and • community acceptance. In practice, it is not feasible to collect information on the community acceptance part of this definition in general purpose statistical and administrative collections and therefore standard questions on Indigenous status relate to descent and self-identification only. Source and reference attributes Origin: National Health Data Committee National Community Services Data Committee Reference documents: Australian Bureau of Statistics 1999. Standards for Social, Labour and Demographic Variables. Cultural Diversity Variables, Canberra. Viewed 3 August 2005. Relational attributes Related metadata references: See also Person—Indigenous status, code AAA WA Health, Endorsed 19/03/2015 Supersedes Person—Indigenous status, code N Health, Superseded 04/05/2005, Community Services (retired), Superseded 25/08/2005 Has been superseded by Person—Indigenous status, code N Health, Standardisation pending 05/03/2015 See also Service provider organisation—number of Indigenous children attending a preschool program, total number N[NNNN] Early Childhood, Superseded 28/05/2014, Indigenous, Endorsed 11/09/2012 See also Service provider organisation—number of Indigenous children attending an early childhood education program, total number N[NNNN] Early Childhood, Superseded 01/06/2015 See also Service provider organisation—number of Indigenous children attending an early childhood education program, total number N[NNNN] Early Childhood, Standard 01/06/2015 See also Service provider organisation—number of Indigenous children enrolled in a preschool program, total N[NNNN] Early Childhood, Superseded 28/05/2014, Indigenous, Endorsed 08/04/2013 See also Service provider organisation—number of Indigenous children enrolled in a preschool program, total N[NNNN] Early Childhood, Superseded 08/04/2013, Indigenous, Archived 08/04/2013 See also Service provider organisation—number of Indigenous children enrolled in an early childhood education program, total N[NNNN] Early Childhood, Standard 01/06/2015 See also Service provider organisation—number of Indigenous children enrolled in an early childhood education program, total N[NNNN] Early Childhood, Superseded 01/06/2015 Implementation in Data Set Specifications: Aboriginal and Torres Strait Islander primary health-care services client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander primary health-care services episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander primary health-care services paid full-time equivalent positions cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander primary health-care services unpaid full-time equivalent positions cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services client numbers clusterIndigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services non-residential/follow-up/aftercare client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services non-residential/follow-up/aftercare episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services paid full-time equivalent positions cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services residential treatment/rehabilitation client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services residential/rehabilitation episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services sobering up/residential respite/short-term care client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services sobering-up/residential respite/short term care episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services unpaid full-time equivalent positions cluster Indigenous, Endorsed 16/09/2014 Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Admitted patient care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Admitted patient mental health care NMDS 2015-16 Health, Standard 04/02/2015 Admitted patient palliative care NMDS 2015-16 Health, Standard 04/02/2015 Adoptions DSS 2011-13 Community Services (retired), Standard 20/05/2013 Alcohol and other drug treatment services NMDS 2015- Health, Standard 13/11/2014 Bringing Them Home/Link Up Counselling Program client contacts cluster Indigenous, Endorsed 16/09/2014 Bringing them Home/Link Up Counselling Program client numbers cluster Indigenous, Endorsed 16/09/2014 Bringing them Home/Link Up Counsellors cluster Indigenous, Endorsed 16/09/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Child protection and support services (CPSS) client cluster Community Services (retired), Standard 30/04/2008 Community mental health care NMDS 2015-16 Health, Standard 13/11/2014 Computer Assisted Telephone Interview demographic module DSS Health, Standard 03/12/2008 Cultural and language diversity cluster Disability, Standard 13/08/2015 Community Services (retired), Standard 10/04/2013 Diabetes (clinical) DSS Health, Standard 21/09/2005 Disability services client details cluster Disability, Standard 13/08/2015 Community Services (retired), Standard 10/04/2013 Disability Services NMDS 2012-14 Community Services (retired), Standard 13/03/2013 Disability Services NMDS 2014-15 Disability, Standard 07/10/2014 Community Services (retired), Proposed 23/04/2014 Early Childhood Education and Care: Aggregate NMDS 2015 Early Childhood, Standard 01/06/2015 Early Childhood Education and Care: Unit Record Level NMDS 2015 Early Childhood, Standard 01/06/2015 Elective surgery waiting times (census data) NMDS 2015- Health, Standard 12/06/2015 Elective surgery waiting times (removals data) NMDS 2015- Health, Standard 12/06/2015 Estimated resident population (ERP) cluster (early childhood education and care) Early Childhood, Standard 21/05/2010 Indigenous primary health care DSS 2015- Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Juvenile Justice Client file cluster Community Services (retired), Standard 14/09/2009 Medical indemnity DSS 2014- Health, Standard 21/11/2013 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Non-admitted patient DSS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 23/07/2014 Non-admitted patient emergency department care DSS 2015-16 Health, Standard 04/02/2015 Non-admitted patient emergency department care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Perinatal NMDS 2014- Health, Standard 07/03/2014 Person (housing assistance) cluster Housing assistance, Standard 01/05/2013 Prison clinic contact DSS Health, Standard 25/08/2011 Prison entrants DSS Health, Standard 25/08/2011 Prisoners in custody repeat medications DSS Health, Standard 25/08/2011 Public dental waiting times NMDS 2013- Health, Standard 09/11/2012 Radiotherapy waiting times NMDS 2015- Health, Standard 13/11/2014 Registered chiropractic labour force DSS Health, Standard 10/12/2009 Registered dental and allied dental health professional labour force DSS Health, Standard 10/12/2009 Registered medical professional labour force DSS Health, Standard 10/12/2009 Registered midwifery labour force DSS Health, Standard 10/12/2009 Registered nursing professional labour force DSS Health, Standard 10/12/2009 Registered optometry labour force DSS Health, Standard 10/12/2009 Registered osteopathy labour force DSS Health, Standard 10/12/2009 Registered pharmacy labour force DSS Health, Standard 10/12/2009 Registered physiotherapy labour force DSS Health, Standard 10/12/2009 Registered podiatry labour force DSS Health, Standard 10/12/2009 Registered psychology labour force DSS Health, Standard 10/12/2009 Residential mental health care NMDS 2015-16 Health, Standard 13/11/2014 Specialist Homelessness Services NMDS 2014-15 Housing assistance, Standard 30/06/2014 Homelessness, Standard 30/06/2014 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012 WA Abortion Notification System WA Health, Endorsed 04/03/2014 Implementation in Indicators: Used as numerator Indigenous primary health care: PI01a-Number of Indigenous babies born within the previous 12 months whose birth weight has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI01b-Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI02a-Number of Indigenous babies born within the previous 12 months whose birth weight results were low, normal or high, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI02b-Proportion of Indigenous babies born within the previous 12 months whose birth weight results were low, normal or high, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI03a-Number of regular clients for whom an MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI03b-Proportion of regular clients for whom an MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715)) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI04a-Number of Indigenous children who are fully immunised, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI04b-Proportion of Indigenous children who are fully immunised, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI05a-Number of regular clients with Type II diabetes who have had an HbA1c measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI05b-Proportion of regular clients with Type II diabetes who have had an HbA1c measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI06a-Number of regular clients with Type II diabetes whose HbA1c measurement result was within a specified level, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI06b-Proportion of regular clients with Type II diabetes whose HbA1c measurement result was within a specified level, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI07a-Number of regular clients with a chronic disease for whom a GP Management Plan (MBS Item 721) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI07b-Proportion of regular clients with a chronic disease for whom a GP Management Plan (MBS Item 721) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI08a-Number of regular clients with a chronic disease for whom a Team Care Arrangement (MBS Item 723) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI08b-Proportion of regular clients with a chronic disease for whom a Team Care Arrangement (MBS Item 723) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI09a-Number of regular clients whose smoking status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI09b-Proportion of regular clients whose smoking status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI10a-Number of regular clients with a smoking status result, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI10b-Proportion of regular clients with a smoking status result, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI11a-Number of regular clients who gave birth within the previous 12 months with a smoking status of 'current smoker', 'ex-smoker' or 'never smoked', 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI11b-Proportion of regular clients who gave birth within the previous 12 months with a smoking status of 'current smoker', 'ex-smoker' or 'never smoked', 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI12a-Number of regular clients who are classified as overweight or obese, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI12b-Proportion of regular clients who are classified as overweight or obese, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI13a-Number of regular clients who had their first antenatal care visit within specified periods, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI13b-Proportion of regular clients who had their first antenatal care visit within specified periods, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI14a-Number of regular clients aged 50 years and over who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI14b-Proportion of regular clients aged 50 years and over who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI15a-Number of regular clients with Type II diabetes or COPD who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI15b-Proportion of regular clients with Type II diabetes or COPD who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI16a-Number of regular clients whose alcohol consumption status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI16b-Proportion of regular clients whose alcohol consumption status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI17a-Number of regular clients who had an AUDIT-C with result within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI17b-Proportion of regular clients who had an AUDIT-C with result within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI18a-Number of regular clients with a selected chronic disease who have had a kidney function test, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI18b-Proportion of regular clients with a selected chronic disease who have had a kidney function test, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI19a-Number of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI19b-Proportion of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20a-Number of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20b-Proportion of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI21a-Number of regular clients aged 35 to 74 years who have had an absolute cardiovascular disease risk assessment with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI21b-Proportion of regular clients aged 35 to 74 years who have had an absolute cardiovascular disease risk assessment with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22a-Number of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22b-Proportion of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI23a-Number of regular clients with Type II diabetes who have had a blood pressure measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI23b-Proportion of regular clients with Type II diabetes who have had a blood pressure measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI24a-Number of regular clients with Type II diabetes whose blood pressure measurement result was less than or equal to 130/80 mmHg, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI24b-Proportion of regular clients with Type II diabetes whose blood pressure measurement result was less than or equal to 130/80 mmHg, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 National Disability Agreement: f(1)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 National Disability Agreement: f(2)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 National Disability Agreement: f(3)-Number of non-Indigenous persons and Indigenous persons who separated from permanent residential aged care to return home/family, 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Healthcare Agreement: PI 09-Incidence of heart attacks (acute coronary events), 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 64a-Indigenous Australians in the health workforce, 2012 Health, Retired 25/06/2013 Indigenous, Endorsed 11/09/2012 National Healthcare Agreement: PI 64b-Indigenous Australians in the health workforce, 2012 Health, Retired 25/06/2013 Indigenous, Endorsed 11/09/2012 National Indigenous Reform Agreement: PI 10-The proportion of Indigenous children aged 4 and 5 years who are enrolled in, and attending, a preschool program in the year before full-time schooling, by remoteness, 2014 Indigenous, Endorsed 13/12/2013 Used as denominator Indigenous primary health care: PI01b-Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI02b-Proportion of Indigenous babies born within the previous 12 months whose birth weight results were low, normal or high, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI03b-Proportion of regular clients for whom an MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI04b-Proportion of Indigenous children who are fully immunised, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI05b-Proportion of regular clients with Type II diabetes who have had an HbA1c measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI06b-Proportion of regular clients with Type II diabetes whose HbA1c measurement result was within a specified level, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI07b-Proportion of regular clients with a chronic disease for whom a GP Management Plan (MBS Item 721) was claimed, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI09b-Proportion of regular clients whose smoking status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI10b-Proportion of regular clients with a smoking status result, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI11b-Proportion of regular clients who gave birth within the previous 12 months with a smoking status of 'current smoker', 'ex-smoker' or 'never smoked', 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI12b-Proportion of regular clients who are classified as overweight or obese, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI13b-Proportion of regular clients who had their first antenatal care visit within specified periods, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI14b-Proportion of regular clients aged 50 years and over who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI15b-Proportion of regular clients with Type II diabetes or COPD who are immunised against influenza, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI16b-Proportion of regular clients whose alcohol consumption status has been recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI17b-Proportion of regular clients who had an AUDIT-C with result within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI18b-Proportion of regular clients with a selected chronic disease who have had a kidney function test, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI19b-Proportion of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20b-Proportion of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI21b-Proportion of regular clients aged 35 to 74 years who have had an absolute cardiovascular disease risk assessment with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22b-Proportion of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI23b-Proportion of regular clients with Type II diabetes who have had a blood pressure measurement result recorded, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI24b-Proportion of regular clients with Type II diabetes whose blood pressure measurement result was less than or equal to 130/80 mmHg, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 National Disability Agreement: d(1)-Proportion of the potential population who used State/Territory delivered disability support services, 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: d(2)-Proportion of people with a disability with an employment restriction who used Disability Employment Services (Open Employment), 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: d(3)-Proportion of the potential population who used Australian Disability Enterprises (Supported Employment), 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: f(1)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 National Disability Agreement: f(1)-Rate of non-Indigenous persons and Indigenous persons admitted to permanent residential aged care, 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: f(2)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 -

Data type

integer

Person identifier
Description

Person—person identifier, XXXXXX[X(14)] Identifying and definitional attributes Short name: Person identifier METeOR identifier: 290046 Registration status: Health, Standard 04/05/2005 Early Childhood, Standard 08/04/2013 Independent Hospital Pricing Authority, Standard 01/11/2012 Indigenous, Endorsed 11/08/2014 National Health Performance Authority, Standard 28/05/2014 Commonwealth Department of Health, Candidate 16/07/2015 Disability, Standard 13/08/2015 Community Services (retired), Standard 25/08/2005 Definition: Person identifier unique within an establishment or agency. Data Element Concept: Person—person identifier Value domain attributes Representational attributes Representation class: Identifier Data type: String Format: XXXXXX[X(14)] Maximum character length: 20 Data element attributes Collection and usage attributes Guide for use: Individual agencies, establishments or collection authorities may use their own alphabetic, numeric or alphanumeric coding systems. Field cannot be blank. Source and reference attributes Reference documents: AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia Relational attributes Related metadata references: Supersedes Person—person identifier (within establishment/agency), XXXXXX[X(14)] Health, Superseded 04/05/2005, Community Services (retired), Superseded 25/08/2005 See also Person—person identifier, X(8) WA Health, Endorsed 19/03/2015 See also Person—unique identifier used indicator, yes/no code N Health, Standard 07/02/2013, Community Services (retired), Standard 19/09/2013 Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Admitted patient care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Admitted patient mental health care NMDS 2015-16 Health, Standard 04/02/2015 Admitted patient palliative care NMDS 2015-16 Health, Standard 04/02/2015 Alcohol and other drug treatment services NMDS 2015- Health, Standard 13/11/2014 Audiology assessment client cluster Indigenous, Endorsed 11/08/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Closing the Gap in the Northern Territory: Dental Services DSS, 2011 Indigenous, Endorsed 08/10/2014 Community mental health care NMDS 2015-16 Health, Standard 13/11/2014 Disability services client details cluster Disability, Standard 13/08/2015 Community Services (retired), Standard 10/04/2013 Ear nose and throat services patient cluster Indigenous, Endorsed 05/09/2014 Early Childhood Education and Care DSS 2015 Early Childhood, Standard 01/06/2015 Juvenile Justice Client file cluster Community Services (retired), Standard 14/09/2009 Juvenile Justice Detention file cluster Community Services (retired), Standard 14/09/2009 Juvenile Justice Order file cluster Community Services (retired), Standard 14/09/2009 Non-admitted patient DSS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 23/07/2014 Non-admitted patient emergency department care DSS 2015-16 Health, Standard 04/02/2015 Non-admitted patient emergency department care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Perinatal NMDS 2014- Health, Standard 07/03/2014 Prison clinic contact DSS Health, Standard 25/08/2011 Prison entrants DSS Health, Standard 25/08/2011 Prisoners in custody repeat medications DSS Health, Standard 25/08/2011 Radiotherapy waiting times NMDS 2015- Health, Standard 13/11/2014 Residential mental health care NMDS 2015-16 Health, Standard 13/11/2014 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 20a-Waiting times for elective surgery: waiting times in days, 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 20b-Waiting times for elective surgery: proportion seen on time, 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 23-Unplanned hospital readmission rates, 2015 Health, Standard 14/01/2015 Used as denominator National Health Performance Authority, Hospital Performance: Percentage of patients who commenced treatment within clinically recommended time 2014 National Health Performance Authority, Standard 28/05/2014 National Health Performance Authority, Hospital Performance: Waiting times for emergency hospital care: Percentage completed within four hours, 2014 National Health Performance Authority, Standard 28/05/2014 National Healthcare Agreement: PI 21a-Waiting times for emergency hospital care: Proportion seen on time, 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 21b-Waiting times for emergency hospital care: Proportion completed within four hours, 2015 Health, Standard 14/01/2015 National Partnership Agreement on Improving Public Hospital Services: National Emergency Access Target Health, Standard 21/11/2013

Data type

text

Sex
Description

Person—sex, code N Identifying and definitional attributes Short name: Sex METeOR identifier: 287316 Registration status: Housing assistance, Standard 10/02/2006 Health, Standard 04/05/2005 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 WA Health, Draft 23/08/2012 Independent Hospital Pricing Authority, Standard 01/11/2012 Indigenous, Endorsed 11/08/2014 National Health Performance Authority, Standard 07/11/2013 Commonwealth Department of Health, Candidate 16/07/2015 Disability, Standard 07/10/2014 Community Services (retired), Standard 25/08/2005 Definition: The biological distinction between male and female, as represented by a code. Data Element Concept: Person—sex Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Male 2 Female 3 Intersex or indeterminate Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: Diagnosis and procedure codes should be checked against the national ICD-10-AM sex edits, unless the person is undergoing, or has undergone a sex change or has a genetic condition resulting in a conflict between sex and ICD-10-AM code. CODE 3 Intersex or indeterminate Intersex or indeterminate, refers to a person, who because of a genetic condition, was born with reproductive organs or sex chromosomes that are not exclusively male or female or whose sex has not yet been determined for whatever reason. Intersex or indeterminate, should be confirmed if reported for people aged 90 days or greater. Comments: The definition for Intersex in Guide for use is sourced from the ACT Legislation (Gay, Lesbian and Transgender) Amendment Act 2003. Source and reference attributes Origin: Australian Capital Territory 2003. Legislation (Gay, Lesbian and Transgender) Amendment Act 2003 Reference documents: Legislation (Gay, Lesbian and Transgender) Amendment Act 2003. See http://www.legislation.act.gov.au/a/2003-14/20030328-4969/pdf/2003-14.pdf. Data element attributes Collection and usage attributes Collection methods: Operationally, sex is the distinction between male and female, as reported by a person or as determined by an interviewer. When collecting data on sex by personal interview, asking the sex of the respondent is usually unnecessary and may be inappropriate, or even offensive. It is usually a simple matter to infer the sex of the respondent through observation, or from other cues such as the relationship of the person(s) accompanying the respondent, or first name. The interviewer may ask whether persons not present at the interview are male or female. A person's sex may change during their lifetime as a result of procedures known alternatively as sex change, gender reassignment, transsexual surgery, transgender reassignment or sexual reassignment. Throughout this process, which may be over a considerable period of time, the person's sex could be recorded as either Male or Female. In data collections that use the ICD-10-AM classification, where sex change is the reason for admission, diagnoses should include the appropriate ICD-10-AM code(s) that clearly identify that the person is undergoing such a process. This code(s) would also be applicable after the person has completed such a process, if they have a procedure involving an organ(s) specific to their previous sex (e.g. where the patient has prostate or ovarian cancer). CODE 3 Intersex or indeterminate Is normally used for babies for whom sex has not been determined for whatever reason. Should not generally be used on data collection forms completed by the respondent. Should only be used if the person or respondent volunteers that the person is intersex or where it otherwise becomes clear during the collection process that the individual is neither male nor female. CODE 9 Not stated/inadequately described Is not to be used on primary collection forms. It is primarily for use in administrative collections when transferring data from data sets where the item has not been collected. Source and reference attributes Origin: Australian Institute of Health and Welfare (AIHW) National Mortality Database 1997/98 AIHW 2001 National Diabetes Register, Statistical Profile, December 2000 (Diabetes Series No. 2.) Reference documents: Australian Bureau of Statistics AS4846 Health Care Provider Identification, 2004, Sydney: Standards Australia AS5017 Health Care Client Identification, 2002, Sydney: Standards Australia In AS4846 and AS5017 alternative codes are presented. Refer to the current standard for more details. Relational attributes Related metadata references: Is used in the formation of Episode of admitted patient care—diagnosis related group, code (AR-DRG v 6) ANNA Health, Standard 30/06/2013, Tasmanian Health, Draft 23/07/2012, Commonwealth Department of Health, Candidate 16/07/2015 Is used in the formation of Episode of admitted patient care—diagnosis related group, code (AR-DRG v5.1) ANNA Health, Superseded 22/12/2009 Is used in the formation of Episode of admitted patient care—major diagnostic category, code (AR-DRG v 6) NN Health, Standard 30/06/2013, Tasmanian Health, Draft 23/07/2012, Commonwealth Department of Health, Candidate 16/07/2015 Is used in the formation of Episode of admitted patient care—major diagnostic category, code (AR-DRG v5.1) NN Health, Superseded 22/12/2009 See also Person—gender, code N Housing assistance, Proposed 28/06/2013, Health, Proposed 28/06/2013, Early Childhood, Proposed 28/06/2013, Homelessness, Proposed 28/06/2013, Indigenous, Endorsed 05/09/2014, Community Services (retired), Candidate 02/09/2013 Supersedes Person—sex (housing assistance), code N Housing assistance, Superseded 10/02/2006 See also Person—sex, code A WA Health, Endorsed 19/03/2015 Supersedes Person—sex, code N Health, Superseded 04/05/2005, Community Services (retired), Superseded 31/08/2005 Is used in the formation of Record—linkage key, code 581 XXXXXDDMMYYYYN Housing assistance, Standard 23/08/2010, Health, Standard 07/12/2011, Early Childhood, Standard 21/05/2010, Homelessness, Standard 23/08/2010, Disability, Standard 07/10/2014, Community Services (retired), Standard 21/05/2010 Implementation in Data Set Specifications: Aboriginal and Torres Strait Islander primary health-care services episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander primary health-care services individual client contacts cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services non-residential/follow-up/aftercare client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services non-residential/follow-up/aftercare episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services residential treatment/rehabilitation client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services residential treatment/rehabilitation length of stay cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services residential/rehabilitation episodes of care cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services sobering up/residential respite/short-term care client numbers cluster Indigenous, Endorsed 16/09/2014 Aboriginal and Torres Strait Islander standalone substance use services sobering-up/residential respite/short term care episodes of care cluster Indigenous, Endorsed 16/09/2014 Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Admitted patient care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Admitted patient mental health care NMDS 2015-16 Health, Standard 04/02/2015 Admitted patient palliative care NMDS 2015-16 Health, Standard 04/02/2015 Adoptions DSS 2011-13 Community Services (retired), Standard 20/05/2013 Alcohol and other drug treatment services NMDS 2015- Health, Standard 13/11/2014 Audiology assessment client cluster Indigenous, Endorsed 11/08/2014 Bringing Them Home/Link Up Counselling Program client contacts cluster Indigenous, Endorsed 16/09/2014 Bringing them Home/Link Up Counselling Program client numbers cluster Indigenous, Endorsed 16/09/2014 Cancer (clinical) DSS Health, Standard 14/05/2015 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Child protection and support services (CPSS) client cluster Community Services (retired), Standard 30/04/2008 Child protection and support services (CPSS) sibling cluster Community Services (retired), Standard 30/04/2008 Closing the Gap in the Northern Territory: Dental Services DSS, 2011 Indigenous, Endorsed 08/10/2014 Community mental health care NMDS 2015-16 Health, Standard 13/11/2014 Computer Assisted Telephone Interview demographic module DSS Health, Standard 03/12/2008 Diabetes (clinical) DSS Health, Standard 21/09/2005 Early Childhood Education and Care: Unit Record Level NMDS 2015 Early Childhood, Standard 01/06/2015 Household file cluster (Indigenous community housing) Housing assistance, Standard 01/05/2013 Indigenous, Endorsed 01/05/2013 Indigenous primary health care DSS 2015- Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Juvenile Justice Client file cluster Community Services (retired), Standard 14/09/2009 Medical indemnity DSS 2014- Health, Standard 21/11/2013 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Non-admitted patient DSS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 23/07/2014 Non-admitted patient emergency department care DSS 2015-16 Health, Standard 04/02/2015 Non-admitted patient emergency department care NMDS 2015-16 Health, Standard 13/11/2014 Independent Hospital Pricing Authority, Proposed 15/09/2014 Perinatal NMDS 2014- Health, Standard 07/03/2014 Person (housing assistance) cluster Housing assistance, Standard 01/05/2013 Person details data dictionary Disability, Standard 13/08/2015 Community Services (retired), Standard 06/02/2012 Person file cluster (Mainstream community housing) Housing assistance, Standard 01/05/2013 Prison clinic contact DSS Health, Standard 25/08/2011 Prison entrants DSS Health, Standard 25/08/2011 Prisoners in custody repeat medications DSS Health, Standard 25/08/2011 Private rent assistance DSS 2012-13 Housing assistance, Standard 03/07/2014 Public dental waiting times NMDS 2013- Health, Standard 09/11/2012 Radiotherapy waiting times NMDS 2015- Health, Standard 13/11/2014 Registered chiropractic labour force DSS Health, Standard 10/12/2009 Registered dental and allied dental health professional labour force DSS Health, Standard 10/12/2009 Registered medical professional labour force DSS Health, Standard 10/12/2009 Registered midwifery labour force DSSHealth, Standard 10/12/2009 Registered nursing professional labour force DSS Health, Standard 10/12/2009 Registered optometry labour force DSS Health, Standard 10/12/2009 Registered osteopathy labour force DSS Health, Standard 10/12/2009 Registered pharmacy labour force DSS Health, Standard 10/12/2009 Registered physiotherapy labour force DSS Health, Standard 10/12/2009 Registered podiatry labour force DSS Health, Standard 10/12/2009 Registered psychology labour force DSS Health, Standard 10/12/2009 Residential mental health care NMDS 2015-16 Health, Standard 13/11/2014 Sex of prison entrants cluster Health, Standard 25/08/2011 Statistical linkage key 581 cluster Housing assistance, Standard 23/08/2010 Health, Standard 07/12/2011 Early Childhood, Standard 21/05/2010 Homelessness, Standard 23/08/2010 Disability, Standard 07/10/2014 Community Services (retired), Standard 21/05/2010 Surveillance of healthcare associated infection: Staphylococcus aureus bacteraemia DSS Health, Standard 15/11/2012 Implementation in Indicators: Used as numerator Indigenous primary health care: PI19a-Number of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI19b-Proportion of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20a-Number of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20b-Proportion of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22a-Number of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22b-Proportion of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2012 National Health Performance Authority, Standard 27/03/2014 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2013 National Health Performance Authority, Standard 27/08/2015 National Healthcare Agreement: PI 24-Survival of people diagnosed with notifiable cancers, 2015 Health, Standard 14/01/2015 Used as denominator Indigenous primary health care: PI13b-Proportion of regular clients who had their first antenatal care visit within specified periods, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI19b-Proportion of regular clients with a selected chronic disease who have had a kidney function test with results within specified levels, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI20b-Proportion of regular clients who have had the necessary risk factors assessed to enable CVD assessment, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 Indigenous primary health care: PI22b-Proportion of regular clients who have had a cervical screening, 2015 Health, Standard 13/03/2015 Indigenous, Endorsed 13/03/2015 National Disability Agreement: d(1)-Proportion of the potential population who used State/Territory delivered disability support services, 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: d(2)-Proportion of people with a disability with an employment restriction who used Disability Employment Services (Open Employment), 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreemennt: d(3)-Proportion of the potential population who used Australian Disability Enterprises (Supported Employment), 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: f(1)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 National Disability Agreement: f(1)-Rate of non-Indigenous persons and Indigenous persons admitted to permanent residential aged care, 2013 Disability, Standard 13/08/2015 Community Services (retired), Standard 23/05/2013 National Disability Agreement: f(2)-Number of Indigenous people with disability receiving disability services as a proportion of the Indigenous potential population requiring services, 2012 Indigenous, Endorsed 11/09/2012 Community Services (retired), Superseded 23/05/2013 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2012 National Health Performance Authority, Standard 27/03/2014 National Health Performance Authority, Healthy Communities: Human papillomavirus (HPV) vaccination rates for girls turning 15 years in 2013 National Health Performance Authority, Standard 27/08/2015 National Healthcare Agreement: PI 02-Incidence of selected cancers, 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 24-Survival of people diagnosed with notifiable cancers, 2015 Health, Standard 14/01/2015

Data type

integer

Underlying cause of death
Description

Person—underlying cause of death, code (ICD-10 2nd edn) ANN-ANN Obligation: Conditional Identifying and definitional attributes Short name: Underlying cause of death Synonymous names: UCOD code METeOR identifier: 307931 Registration status: Health, Standard 01/10/2008 Definition: The disease or injury which initiated the train of morbid events leading directly to a person's death or the circumstances of the accident or violence which produced the fatal injury, as represented by a code. (WHO 2004) Data Element Concept: Person—underlying cause of death Value domain attributes Representational attributes Classification scheme: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, (2nd edition) Representation class: Code Data type: String Format: ANN-ANN Maximum character length: 6 Data set specification specific attributes Cancer (clinical) DSS Conditional obligation: Recorded when the patient has died. Data element attributes Collection and usage attributes Guide for use: Underlying cause of death is central to mortality coding and comparable international mortality reporting. Comments: The Australian Bureau of Statistics (ABS) codes and classifies the underlying cause of death (UCOD) according to the rules and guidelines for mortality coding adopted by the World Health Assembly and set out in the World Health Organisation's International Classification of Diseases and Related Health Problems (ICD). The ABS uses the Mortality Medical Data System (MMDS) to process and code cause-of-death information reported on death certificates. Source and reference attributes Submitting organisation: Australian Bureau of Statistics Origin: Australian Bureau of Statistics 2004. Information Paper: Cause of death certification. Catalogue no. 1205.0.55.001. Canberra: Australian Bureau of Statistics. Viewed 31 August 2005. National Center for Health Statistics 2005. About the Mortality Medical Data System. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Viewed 31 August 2005. World Health Organisation 2004. The International statistical classification of diseases and related health problems, tenth revision, (2nd edn). Geneva: World Health Organisation. Reference documents: Australian Bureau of Statistics 2004. Information Paper: Cause of death certification. Catalogue no. 1205.0.55.001. Canberra: Australian Bureau of Statistics. Viewed 31 August 2005. World Health Organisation 2004. The International statistical classification of diseases and related health problems, tenth revision, (2nd edn). Geneva: World Health Organisation. Relational attributes Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Cancer (clinical) DSS Health, Standard 14/05/2015 National Bowel Cancer Screening Program DSS 2014- Health, Standard 29/08/2014 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 11-Colorectal cancer mortality rate Health, Standard 29/08/2014 National Healthcare Agreement: PI 08-Major causes of death, 2015 Health, Standard 14/01/2015 National Healthcare Agreement: PI 09-Incidence of heart attacks (acute coronary events), 2015 Health, Standard 14/01/2015

Data type

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Similar models

Cancer (clinical) DSS Metadata Online Registry (METeOR)

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Chemotherapy for cancer cluster
Chemotherapy completion date
Item
Chemotherapy completion date
date
Number of chemotherapy cycles administered
Item
Chemotherapy cycles administered
integer
Chemotherapy start date
Item
Chemotherapy start date
date
Systemic therapy agent or protocol, eviQ protocol identifier
Item
Systemic therapy agent or protocol, eviQ
text
Systemic therapy agent or protocol
Item
Systemic therapy agent or protocol
text
Item Group
Hormone therapy for cancer cluster
Hormone therapy completion date
Item
Hormone therapy completion date
date
Hormone therapy start date
Item
Cancer treatment—hormone therapy start date
date
Systemic therapy agent or protocol, eviQ protocol identifier
Item
Systemic therapy agent or protocol, eviQ
text
Systemic therapy agent or protocol
Item
Systemic therapy agent or protocol
text
Item Group
Immunotherapy for cancer cluster
Immunotherapy completion date
Item
Immunotherapy completion date
date
Immunotherapy start date
Item
Immunotherapy start date
date
Systemic therapy agent or protocol, eviQ protocol identifier
Item
Systemic therapy agent or protocol, eviQ
text
Systemic therapy agent or protocol
Item
Systemic therapy agent or protocol
text
Item Group
Radiotherapy for cancer cluster
Radiation dose administered
Item
Radiation dose administered
float
Radiotherapy completion date
Item
Radiotherapy completion date
date
Radiotherapy fractions administered
Item
Radiotherapy fractions administered
integer
Radiotherapy start date
Item
Radiotherapy start date—cancer treatment
date
Item
Radiotherapy target site
integer
Code List
Radiotherapy target site
CL Item
Primary site only (1)
CL Item
Regional nodes only (2)
CL Item
Distant metastases only (3)
CL Item
Primary site and regional nodes (4)
CL Item
Primary site and distant metastases (5)
CL Item
Primary site, regional nodes and distant metastases (6)
CL Item
Regional nodes and distant metastases (7)
CL Item
Not applicable-radiotherapy was not administered (97)
CL Item
Unknown whether radiotherapy was administered  (98)
CL Item
Radiotherapy was administered but the site not stated/inadequately described (99)
Item
Radiotherapy treatment type
integer
Code List
Radiotherapy treatment type
CL Item
External beam radiotherapy only (1)
CL Item
Brachytherapy only (2)
CL Item
Unsealed radioisotopes only (3)
CL Item
External beam radiotherapy and brachytherapy  (4)
CL Item
External beam radiotherapy and unsealed radioisotopes (5)
CL Item
Brachytherapy and unsealed radioisotopes  (6)
CL Item
External beam radiotherapy, brachytherapy and unsealed radioisotopes (7)
CL Item
Not applicable-radiotherapy was not administered (97)
CL Item
Unknown whether radiotherapy was administered  (98)
CL Item
Radiotherapy was administered but the treatment type not stated/inadequately described (99)
Item Group
Surgery for cancer cluster
Surgery target site (ICD-O-3)
Item
Surgery target site
text
Surgical procedure date
Item
Surgical procedure date
date
Surgical procedure for cancer (ACHI 9th edn)
Item
Surgical procedure for cancer
text
Item Group
Systemic therapy procedure for cancer cluster
Systemic therapy procedure date
Item
Systemic therapy procedure date
date
Item
Systemic therapy procedure
integer
Code List
Systemic therapy procedure
CL Item
A bone marrow transplant procedure was administered but the type was not specified (1)
CL Item
Bone marrow transplant—autologous only (2)
CL Item
Bone marrow transplant—allogeneic only (3)
CL Item
Stem cell harvest and infusion only (4)
CL Item
Endocrine surgery and/or endocrine radiation therapy only (5)
CL Item
Combination of endocrine surgery and/or radiation with a transplant procedure (6)
CL Item
Other systemic therapy procedure (96)
CL Item
Not applicable-no systemic therapy procedures were administered  (97)
CL Item
Unknown whether systemic therapy procedures were administered (98)
CL Item
Systemic therapy procedures were administered but were not stated/inadequately described (99)
Item Group
Cancer staging
Cancer staging scheme source edition number
Item
Cancer staging scheme source edition number
integer
Item
Staging scheme source
integer
Code List
Staging scheme source
CL Item
1 TNM Classification of Malignant Tumours (UICC) (1)
CL Item
2 Durie & Salmon for multiple myeloma staging (2)
CL Item
3 French-American-British (FAB) for leukaemia classification (3)
CL Item
4 Australian Clinico-Pathological Staging (ACPS) System for colorectal cancer (4)
CL Item
5 International Federation of Gynecologists & Obstetricians (FIGO) for gynaecological cancers (5)
CL Item
6 Dukes/Modified Dukes for colorectal cancer (6)
CL Item
7 Ann Arbor staging system for lymphomas (7)
CL Item
8 Binet Staging Classification for chronic lymphocytic leukaemia (8)
CL Item
9 Rai staging system for chronic lymphocytic leukaemia (9)
CL Item
10 Chronic Myeloid Leukaemia (CML) staging system (10)
CL Item
11 International Staging System (ISS) for myeloma (11)
CL Item
12 American Joint Committee on Cancer (AJCC) Cancer Staging Manual (12)
CL Item
96 Other reference (13)
CL Item
97 Not applicable (14)
CL Item
98 Unknown (15)
CL Item
99 Not stated/inadequately described (16)
Item
Staging basis of cancer
text
Code List
Staging basis of cancer
CL Item
Pathological (P)
CL Item
Clinical (C)
Item Group
Cancer treatment
Item
Cancer treatment type
integer
Code List
Cancer treatment type
CL Item
Surgery only (1)
CL Item
Radiotherapy only (2)
CL Item
Systemic agent therapy only (3)
CL Item
Surgery and radiotherapy (4)
CL Item
Surgery and systemic agent therapy (5)
CL Item
Radiotherapy and systemic agent therapy (6)
CL Item
Surgery, radiotherapy and systemic agent therapy (7)
CL Item
Not applicable—treatment was not administered (97)
CL Item
Unknown whether treatment was administered (98)
CL Item
Treatment was administered but the type was not stated/inadequately described (99)
Item
Multidisciplinary team review indicator
integer
Code List
Multidisciplinary team review indicator
CL Item
Yes (1)
CL Item
No (2)
CL Item
Unknown (8)
Other cancer treatment
Item
Other cancer treatment description
text
Item
Outcome of treatment
integer
Code List
Outcome of treatment
CL Item
Complete response/no evidence of disease (1.0)
CL Item
Partial response (2.1)
CL Item
Stable or static disease (2.2)
CL Item
Progressive disease (2.3)
CL Item
Not assessed or unable to be assessed (7.0)
CL Item
Unknown (8.0)
CL Item
Not stated/inadequately described (9.0)
Item Group
Date
Item
Date accuracy indicator
text
Code List
Date accuracy indicator
CL Item
Day, month and year are accurate (AAA)
CL Item
Day and month are accurate, year is estimated (AAE)
CL Item
Day and month are accurate, year is unknown (AAU)
CL Item
Day is accurate, month is estimated, year is accurate (AEA)
CL Item
Day is accurate, month and year are estimated (AEE)
CL Item
Day is accurate, month is estimated, year is unknown (AEU)
CL Item
Day is accurate, month is unknown, year is accurate (AUA)
CL Item
Day is accurate, month is unknown, year is estimated (AUE)
CL Item
Day is accurate, month and year are unknown (AUU)
CL Item
Day is estimated, month and year are accurate (EAA)
CL Item
Day is estimated, month is accurate, year is estimated (EAE)
CL Item
Day is estimated, month is accurate, year is unknown (EAU)
CL Item
Day and month are estimated, year is accurate (EEA)
CL Item
Day, month and year are estimated (EEE)
CL Item
Day and month are estimated, year is unknown (EEU)
CL Item
Day is estimated, month is unknown, year is accurate (EUA)
CL Item
Day is estimated, month is unknown, year is estimated (EUE)
CL Item
Day is estimated, month and year are unknown (EUU)
CL Item
Day is unknown, month and year are accurate (UAA)
CL Item
Day is unknown, month is accurate, year is estimated (UAE)
CL Item
Day is unknown, month is accurate, year is unknown (UAU)
CL Item
Day is unknown, month is estimated, year is accurate (UEA)
CL Item
Day is unknown, month and year are estimated (UEE)
CL Item
Day is unknown, month is estimated, year is unknown (UEU)
CL Item
Day and month are unknown, year is accurate (UUA)
CL Item
Day and month are unknown, year is estimated (UUE)
CL Item
Day, month and year are unknown (UUU)
Item Group
Establishment
Organisation identifier (state/territory)
Item
Establishment number
text
Item Group
Healthcare provider
Organisation identifier
Item
HPI-O
integer
Item Group
Patient
Item
Cancer status
integer
Code List
Cancer status
CL Item
No evidence of cancer (1)
CL Item
Evidence of cancer (2)
CL Item
Unknown whether there is evidence of cancer (8)
CL Item
Not stated/inadequately described (9)
Date of last contact
Item
Date of last contact—cancer patient
date
Diagnosis date of cancer
Item
Date of diagnosis of cancer
date
Diagnosis date of first recurrence as distant metastasis
Item
Date of diagnosis of first recurrence as distant metastasis
date
Diagnosis date of first recurrence as locoregional cancer
Item
Date of diagnosis of first recurrence as locoregional cancer
date
Item Group
Person (address)
Address line
Item
Address line (person)
text
Item Group
Person (name)
Family name
Item
Family name
text
Given name
Item
Given name(s)
text
Item Group
Person with cancer
Distant metastasis status, M stage
Item
Cancer staging—M stage code
text
Extent of primary cancer, stage grouping other
Item
Cancer staging—stage grouping other
text
Extent of primary cancer, TNM stage
Item
Cancer staging—TNM stage grouping code
text
Item
Histopathological grade
integer
Code List
Histopathological grade
CL Item
Grade 1: Low grade; well differentiated, differentiated, NOS (1)
CL Item
Grade 2: Intermediate grade, moderately differentiated, moderately well differentiated, intermediate differentiation (2)
CL Item
Grade 3: High grade, poorly differentiated (3)
CL Item
Grade 4: Undifferentiated, anaplastic (4)
CL Item
Grade or differentiation not determined, not stated or not applicable (9)
Item
Laterality of primary cancer
text
Code List
Laterality of primary cancer
CL Item
Right (R)
CL Item
Left (L)
CL Item
Bilateral (B)
CL Item
Not applicable (N)
CL Item
Unknown (U)
Morphology of cancer (ICD-O-3)
Item
Morphology of cancer
integer
Item
Most valid basis of diagnosis of cancer
integer
Code List
Most valid basis of diagnosis of cancer
CL Item
Death certificate only: Information provided is from a death certificate (0)
CL Item
Clinical: Diagnosis made before death, but without any of the following (codes 2-7) (1)
CL Item
Clinical investigation: All diagnostic techniques, including x-ray, endoscopy, imaging, ultrasound, exploratory surgery (e.g. laparotomy), and autopsy, without a tissue diagnosis (2)
CL Item
Specific tumour markers: Including biochemical and/or immunological markers that are specific for a tumour site (4)
CL Item
Cytology: Examination of cells from a primary or secondary site, including fluids aspirated by endoscopy or needle; also includes the microscopic examination of peripheral blood and bone marrow aspirates (5)
CL Item
Histology of metastasis: Histological examination of tissue from a metastasis, including autopsy specimens (6)
CL Item
Histology of a primary tumour: Histological examination of tissue from primary tumour, however obtained, including all cutting techniques and bone marrow biopsies; also includes autopsy specimens of primary tumour (7)
CL Item
Histology: either unknown whether of primary or metastatic site, or not otherwise specified (8)
CL Item
Unknown (9)
Item
Most valid basis of diagnosis of recurrence
integer
Code List
Most valid basis of diagnosis of recurrence
CL Item
Death certificate only: Information provided is from a death certificate (0)
CL Item
Clinical: Diagnosis made before death, but without any of the following (codes 2-7) (1)
CL Item
Clinical investigation: All diagnostic techniques, including x-ray, endoscopy, imaging, ultrasound, exploratory surgery (e.g. laparotomy), and autopsy, without a tissue diagnosis (2)
CL Item
Specific tumour markers: Including biochemical and/or immunological markers that are specific for a tumour site (4)
CL Item
Cytology: Examination of cells from a primary or secondary site, including fluids aspirated by endoscopy or needle; also includes the microscopic examination of peripheral blood and bone marrow aspirates (5)
CL Item
Histology of metastasis: Histological examination of tissue from a metastasis, including autopsy specimens (6)
CL Item
Histology of a primary tumour: Histological examination of tissue from primary tumour, however obtained, including all cutting techniques and bone marrow biopsies; also includes autopsy specimens of primary tumour (7)
CL Item
Histology: either unknown whether of primary or metastatic site, or not otherwise specified (8)
CL Item
Unknown (9)
Number of positive regional lymph nodes
Item
Regional lymph nodes positive
integer
Number of regional lymph nodes examined
Item
Number of regional lymph nodes examined
integer
Primary site of cancer, topography code (ICD-O-3)
Item
Primary site of cancer (ICD-O-3 code)
text
Primary tumour status, T stage
Item
Cancer staging—T stage code
text
Region of first recurrence as distant metastasis
Item
Region of first recurrence as distant metastasis
text
Region of first recurrence as locoregional cancer
Item
Region of first recurrence as locoregional cancer
text
Regional lymph node metastasis status, N stage
Item
Cancer staging—N stage code
text
Solid tumour size (at diagnosis)
Item
Tumour size at diagnosis (solid tumours)
integer
Item Group
Person
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Date of death
Item
Date of death
date
C1148348 (UMLS CUI [1])
Medicare card number
Item
Medicare card number
integer
Item
Indigenous status
integer
Code List
Indigenous status
CL Item
Aboriginal but not Torres Strait Islander origin (1)
CL Item
Torres Strait Islander but not Aboriginal origin (2)
CL Item
Both Aboriginal and Torres Strait Islander origin (3)
CL Item
Neither Aboriginal nor Torres Strait Islander origin (4)
CL Item
Not stated/inadequately described (9)
Person identifier
Item
Person identifier
text
Item
Sex
integer
Code List
Sex
CL Item
Male (1)
CL Item
Female (2)
CL Item
Intersex or indeterminate (3)
CL Item
Not stated/inadequately described (9)
Underlying cause of death (ICD-10 2nd edn)
Item
Underlying cause of death
text

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