Health record standards

HISO 10065:2018 Allied Health Data Standard

Published 1 March 2018

This standard sets out the minimum data needed to classify and describe clinical activity undertaken for patients by allied health services in New Zealand.

HISO 10065:2018 Allied Health Data Standard

HISO 10052:2015 Ambulance Care Summary Standard

Published 28 May 2015

This standard describes the structure of an ambulance care summary document used to communicate patient information at transfer of care.

HISO 10052:2015 Ambulance Care Summary Standard

The New Zealand Cancer Action Plan | Te Mahere mō te Mate Pukupuku o Aotearoa 2019-2029 provides a pathway to improve cancer outcomes for all New Zealanders with the objectives of building a system that delivers consistent and modern cancer care, equitable cancer outcomes, fewer cancers and better cancer survival, supportive care and end of life care.

New Zealand Cancer Action Plan 2019–2029 | Ministry of Health NZ (external link)

Te Aho o Te Kahu, the Cancer Control Agency is an independent departmental agency that was established to lead and unite efforts to deliver better cancer outcomes for Aotearoa. Te Aho o Te Kahu is responsible for developing cancer-specific data standards.

Data standards that Te Aho o Te Kahu creates are approved by HISO providing assurance to the health sector that a robust standards development process has been followed. New cancer-related standards can be found on Te Aho o Te Kahu's website (external link).

Please note the following preface and interim standards have been withdrawn:

• HISO 10038.0.2017 Preface to the Cancer Data Standards
• HISO 10038.1:2011 Interim National Cancer Core Data Business Process Standard
• HISO 10038.3:2011 Interim National Cancer Core Data Definitions Standard

HISO 10071:2019 Cardiovascular Disease Risk Assessment (CVDRA) Data Standard

This standard supports the implementation of cardiovascular disease risk assessment using the agreed primary prevention equations.

Improving the accuracy and consistency of cardiovascular disease (CVD) risk assessment and management is an opportunity for significantly improving equity in health outcomes for New Zealanders. We want to see CVD risk being assessed, understood and managed to ensure that morbidity and mortality for key New Zealand population groups continue to improve over time.

HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard supports the frontline implementation of two new sex-specific CVD risk equations for primary prevention; for the general population and for patients who have diabetes. It provides a data set specification for the inputs to the calculation, and the algorithms used.

HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard

The clinical aspects of CVD risk assessment are covered by the following publication: Cardiovascular Disease Risk Assessment and Management for Primary Care.

Risk calculators will need to provide a good user experience for both the patient and the clinician. This includes integration with patient management systems, and consideration being given to health literacy, risk communication and consumer interfaces.

Test cases and worked examples 

We have posted a set of test cases and updated the main document to include worked examples to support implementation of the new sex-specific CVD risk equations for primary prevention. The test cases and worked examples have been developed to assist software suppliers to check the behaviour of their calculators. The set of test cases, although not exhaustive, represents a reasonable clinical range of patient profiles.

Acknowledgements to the HRC-VIEW Research Team, School of Population Health, University of Auckland for preparing the test cases, worked examples and accompanying guidance.

• Test cases [XLSX, 112 KB]

Also see:

• Cardiovascular Disease Risk Assessment (CVDRA) Tool
• Cardiovascular Disease Risk Assessment (CVDRA) API
• HISO 10071:2019 Cardiovascular Disease Risk Assessment (CVDRA) Data Standard (external link)

Learn more:

• Health records standards – CVDRA
• API standards (external link)

HISO 10047:2013 Clinical Document Architecture Templates for Comprehensive Clinical Assessments

Published: 31 October 2013

This standard provides an electronic format for sharing comprehensive clinical assessment reports created using the interRAI methodology.

HISO 10047:2013 Clinical Document Architecture Templates for Comprehensive Clinical Assessments

HISO 10067:2021 COVID-19 Contact Tracing QR Code and NFC Tag Specification

Published: 11 November 2021

The NZ COVID Tracer app has been operational in New Zealand since May 2020.

HISO 10067:2021 COVID-19 Contact Tracing QR Code and NFC Tag Specification

HISO 10085:2020 COVID-19 Contact Tracing Data Standard

Published 21 May 2020

This standard has been produced as part of the COVID-19 epidemic response in New Zealand.

HISO 10085:2020 COVID-19 Contact Tracing Data Standard

HISO 10082:2020 COVID-19 Assessment and Testing Data Standard

Please note the use of this standard is contained as the document will no longer be updated.

For the most up to date list of COVID-19 symptoms, refer to the Clinical criteria for COVID-19.

The creation of a SNOMED CT New Zealand Reference set for COVID-19 symptoms is under development. This will be released in the SNOMED CT New Zealand Edition in April 2022.

Case definition and clinical testing guidelines for COVID-19

Guidance for health professionals to identify and test those individuals who may have COVID-19.

Case definition and clinical testing guidelines for COVID-19

HISO 10048 Emergency Care Data Standard

Health New Zealand has set standards for improved recording of emergency department visits. For every emergency department (ED) patient, the chief presenting complaint and any diagnoses are recorded. These data elements are coded using SNOMED CT, our clinical terminology standard. This requirement has been mandatory for all public hospitals since 1 July 2021.

Origin of the change

The National Collections Annual Maintenance Project (NCAMP) set the requirement for emergency departments to collect and submit SNOMED-coded ED visit data to the National Non-Admitted Patient Collection (NNPAC).

• NCAMP 2019 introduced the change for voluntary early adopters Nelson-Marlborough DHB, Auckland DHB, Canterbury DHB and Bay of Plenty DHB. The Annual Plan Guidelines for 2019/20 asked all other DHBs to plan for adoption.
• NCAMP 2020 set the mandatory implementation date of 1 July 2021 for all DHBs.
• NCAMP 2021 archive affirmed the mandatory implementation date of 1 July 2021.

Supporting materials

To enable this process, we have introduced SNOMED reference sets for chief presenting complaint and diagnosis concepts in emergency care. These reference sets can be accessed in a variety of ways to suit different needs:

1. Excel spreadsheets ED chief presenting complaint reference set [XLSX, 17 KB] and ED diagnosis reference set [XLSX, 99 KB] for simple use
2. SNOMED NZ Edition release files from our SNOMED Member Licensing and Distribution Service (external link) to load your ED information system or terminology server
3. NZ Health Terminology Service for code set lookups via FHIR API
4. SNOMED International reference set library (external link) for browsing or downloading the emergency care chief presenting complaint reference set (external link) and emergency care diagnosis reference set (external link)

While the other methods are preferred, we will continue to maintain the spreadsheets as long as there is demand.

Ongoing management

A clinical leadership group meets with the SNOMED National Release Centre ahead of each six-monthly release of the SNOMED NZ Edition to determine updates to the reference sets. 

In 2013 emergency medicine specialists at Nelson and Wairau Hospitals led the way to develop and implement the reference sets in the 'ED at a Glance' information system.

The use of SNOMED in EDs is endorsed by the Australasian College of Emergency Medicine.

HISO 10058.1 Infection Surveillance Data Standard

This standard defines the format and structure for capturing the information used to undertake surveillance of health care-associated infections.

HISO 10058.1 Infection Surveillance Data Standard

Summary of public comment

The Ministry of Health sought public comment on the draft HISO 10058.1 Infection Surveillance Data Standard from 2 October 2020 through to 13 November 2020. This document summarises the responses received and provides an overview of the decisions made by the subject matter experts.

• Summary of the Review of Public Comment Feedback on the Draft HISO 10058.1 Infection Surveillance Data Standard (Word, 300 KB) [DOCX, 300 KB]
• Summary of the Review of Public Comment Feedback on the Draft HISO 10058.1 Infection Surveillance Data Standard (PDF, 193 KB) [PDF, 193 KB]

Contact

Email: standards@tewhatuora.govt.nz 

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols

Published: 01 June 2022

This document sets out standard protocols for collecting and recording Māori descent and iwi affiliation in the health and disability system.

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols – Public Comment Outcomes

Published 01 June 2022

This document records the outcome of feedback received from a public comment round held on the Health Consultation Hub between 27 September and 6 December 2021. The consultation was on the development of standard protocols for the collection and recording of Māori descent and iwi affiliation data in the health and disability system.

HISO 10094:2022 Māori Descent and Iwi Affiliation Data Protocols – Public Comment Outcomes

HISO 10050:2023 Maternity Care Summary Standard

The maternity care summary standard defines the minimum data set to be recorded about each pregnancy by maternity service providers in New Zealand. The standard covers the time from first contact with a health professional in regard to the pregnancy up until six weeks after the birth of the baby or babies.

The standard was first published in May 2020. This publication includes changes to some data elements in response to feedback from users to ensure the standard is fit for purpose.

HISO 10059:2023 Oral Health Data Standard

Published September 2023

This standard defines the minimum dataset for administrative and clinical data elements and service codes for Community Oral Health Services (COHS), Māori Oral Health Services and Hospital Dental Services (HDS).

HISO 10059:2023 Oral Health Data Standard

HISO 10039.1:2011 National Specialist Palliative Care Data Business Process Standard

This standard ensures that minimum agreed palliative care data is collected and stored in a consistent manner wherever it is collected and stored. In June 2013, the status of these standards was changed from ‘interim’ to 'full'.

HISO 10039.1:2011 National Specialist Palliative Care Data Business Process Standard


HISO 10039.2:2011 National Specialist Palliative Care Data Definitions Standard 

This standard ensures that minimum agreed specialist palliative care data is collected and stored in a consistent manner wherever it is collected and stored. The Standard encompasses and defines essential elements of service delivery.

HISO 10039.2:2011 National Specialist Palliative Care Data Definitions Standard