Section: Referral Information
Name: Referral Date ID: 33
Definition: The date the patient referral was received at the service location.
Applicable to: All entries.
Valid Values: Must be a valid date (YYYY-MM-DD).
Instructions: Regardless of the form of communication of a referral, this is intended to represent the date the referral is received at the service location not the date the referral is assessed by the service location. In the case of a fax this is the date stamped by the fax machine.
In the case of an email this is the date on the email.
Section: Referral Information
Name: Referring Physician ID: 155
Definition: The name and number of the physician who referred the patient for a procedure.
Applicable to: All entries.
Valid Values: Must be a valid physician name and number according to the College of Physicians and Surgeons of Ontario (CPSO).
Instructions: None
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Name: Wait Location ID: 160
Definition: The name and number of the site or location where the patient waited for their procedure.
Applicable to: All entries.
Valid Values: Description Code Definition
Home 99998 The place where a patient resides, either
permanently or temporary, which includes long-term care facilities.
Medical Facility Outside of Country
99993 A facility providing medical services outside of Canada.
Medical Facility Outside of Ontario
99994 A facility providing medical services outside of Ontario and inside of Canada.
MNS Site Name MNS Site
Number
Must be a valid site name and number according to the Ministry of Health’s Master Number System (MNS).
Rehabilitation Facility 99992 A facility that may provide extensive and specialized inpatient rehabilitation services, commonly a freestanding facility or a specialized unit within a hospital.
Ref: Ontario Trauma Registry CIHI 2014 Instructions: If the wait location changes throughout the patient's wait (e.g., at referral or acceptance),
the wait location should be updated to reflect this change.
If the patient is admitted to the service location as an intended admission for the waitlisted service, this field should not be updated.
If the patient is admitted to any hospital (including the service location) prior to the intended admission for the waitlisted service, this field should be updated.
CorHealth DCIS Data Dictionary
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Name: Primary Reason for Referral ID: 38
Definition: The primary clinical condition for the procedure referral.
Applicable to: All entries.
Valid Values: Description Code Definition
Coronary Disease CD A condition caused by atherosclerosis that reduces blood flow through the coronary arteries of the heart and typically results in chest pain or heart damage.
Arrhythmia AR A condition in which the heart beats with an irregular or abnormal rhythm.
Valve Disease VD A condition characterized by damage to, or a defect of, one or more of the four valves of the heart.
Heart Transplant HT Assessment of a heart transplant.
Heart Failure HF A complex clinical syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of reduced cardiac output and/or pulmonary or systemic congestion at rest or with stress.
Cardiomyopathy CM A condition of the heart muscle in which it is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease, and congenital heart disease sufficient to explain the observed myocardial abnormality.
Congenital/Structural CS A defect in the structure of the heart or great vessels either developed or present at birth.
Other OT Other reasons.
CorHealth DCIS Data Dictionary
42 of 138 Instructions: For Coronary Angiogram waitlist entries, if the intention of the referral is to investigate
the presence and treatment of coronary disease, select Coronary Disease.
For Coronary Angiogram waitlist entries, if the intention of the referral is to ensure the coronary anatomy is normal in order to safely proceed to another service, do not select Coronary Disease, select the primary reason reflecting the condition being investigated or treated.
For CABG and Valve Repair/Replacement waitlist entries, if treatment of coronary disease is the primary driver of procedure, choose Coronary Disease, if treatment of valve
disease is the primary driver of procedure, choose Valve Disease, if both are equal, choose Coronary Disease.
For the value Coronary Disease:
• This is also referred to as coronary artery disease (CAD).
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Name: Primary Reason for Referral Type ID: 39
Definition: The description of the clinical condition as it relates to the primary reason for referral.
Applicable to: All entries.
Valid Values: Description Code Definition
Aortic Regurgitation AR A condition in which the aortic valve is malfunctioning causing a leakage backward from the aorta into the left ventricle.
Aortic Stenosis AS A condition in which the aortic valve is malfunctioning causing the obstruction of blood flow through it.
Atrial Flutter AF An abnormal heart rhythm originating in the upper chambers (atria) of the heart which results in atrial muscle contractions that are faster then and out of synchronization with the lower chambers (ventricles).
Atrial Tachycardia AT An abnormal heart rhythm originating in the upper chambers (atria) of the heart and outside of the sinus node.
Atrioventricular Nodal Re-entrant Tachycardia
AN A type of abnormal fast heart rhythm which originates from a location within the heart above the bundle of His.
Atypical Atrial Flutter AA An abnormal heart rhythm originating in the upper chambers (atria) of the heart including a wide range of macroreentrant tachycardias whereby the wave front does not travel around the tricuspid annulus.
Donor DO Assessment of suitability for transplantation of a donor heart.
Heart Disease of Other Etiology
OT Other heart disease not previously described or listed.
Non-ST-Segment Elevation Myocardial Infarction
NS Angina pectoris (or anginal equivalent) symptoms associated with positive biomarkers for myocardial necrosis but without ST elevation on electrocardiogram (ECG).
Other Valvular OV Other valvular disease or disorder excluding aortic stenosis and aortic regurgitation.
Paroxysmal Atrial Fibrillation
PA An episode of atrial fibrillation that terminates spontaneously or with intervention in less than seven days.
Persistent Atrial Fibrillation
PE An episode of atrial fibrillation that is not self-terminating within seven days or is terminated electrically or pharmacologically.
CorHealth DCIS Data Dictionary
44 of 138 Protocol (Research or
Employment)
PR Required for a research/study or employment.
Recipient RE Surveillance of a previously transplanted heart.
Stable Angina SA Angina pectoris (or anginal equivalent) without a recent change in frequency or pattern. Angina is relieved by rest and/or sublingual/transdermal medications.
ST-Segment Elevation Myocardial Infarction
ST Angina characterized by the presence of both criteria:
1. ECG evidence of STEMI: New or presumed new ST segment elevation or new left bundle branch block not documented to be resolved within 20 minutes. ST segment elevation is defined by new or presumed new sustained ST segment elevation at the J-point in two contiguous ECG leads with the cut-off points: ≥0.2 mV in men or ≥0.15 mV in women in leads V2-V3 and/or ≥ 0.1 mV in other leads and lasting ≥20 minutes. If no exact ST elevation measurement is recorded in the medical chart, physician's written documentation of ST elevation or Q waves is acceptable. If only one ECG is performed, then the assumption that the ST elevation persisted at least the required 20 minutes is acceptable. Left bundle branch block (LBBB) refers to new or presumed new LBBB on the initial ECG.
2. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I) exceed the upper limit of normal according to the individual hospital's laboratory
parameters a clinical presentation which is consistent or suggestive of ischemia.
Syncope SY A condition which is characterized as a transient loss (syncope) or imminent loss (presyncope) of
consciousness as a result of insufficient blood flow to the brain.
Unstable Angina UA Angina pectoris (or anginal equivalent) with any of the following features:
1. Symptoms at rest and prolonged, usually greater than 20 minutes
2. New-onset symptoms of Canadian Cardiovascular Society (CCS) class III or class IV severity
3. Recent acceleration of symptoms with an increase in severity of at least one CCS class to CCS class III or class IV severity
Ventricular Fibrillation
VF An abnormal heart rhythm originating in the lower chambers (ventricles) of the heart which results in ineffective heart muscle contraction and subsequent cardiac arrest.
CorHealth DCIS Data Dictionary
45 of 138 Ventricular
Tachycardia
VT An abnormal heart rhythm originating in the lower chambers (ventricles) of the heart which is characterized as fast (over 100 beats per minute) and lasting more than three beats in duration.
Wolff-Parkinson-White Syndrome
WP A syndrome in which there is an extra electrical pathway in the heart which can lead to periods of fast heart rhythm.
Instructions: For the value ST-Elevation MI (STEMI):
• Select this value if ST elevation in the posterior chest leads (V7 through V9), or ST depression that is maximal in V1-3, without ST segment elevation in other leads, demonstrating posterobasal myocardial infarction.
For the value Paroxysmal Atrial Fibrillation:
• This value is also referred to as intermittent atrial fibrillation.
For the value Atrioventricular Nodal Re-entrant Tachycardia:
• This value is also referred to as supraventricular tachycardia.
For the value Protocol (Research or Employment):
• If the follow-up protocol is related to a heart transplant, use the Heart Transplant reason and Recipient types.
For the value ST-Elevation MI (STEMI):
• Coronary Angiogram must be indicated in Service Detail 2 in order to indicate STEMI.
CorHealth DCIS Data Dictionary
46 of 138 Section: Referral Information
Name: Secondary Reason for Referral ID: 40
Definition: The secondary clinical condition for the procedure referral.
Applicable to: All entries.
Valid Values: Description Code Definition
Coronary Disease CD A condition caused by atherosclerosis that reduces blood flow through the coronary arteries of the heart and typically results in chest pain or heart damage.
Arrhythmia AR A condition in which the heart beats with an irregular or abnormal rhythm.
Valve Disease VD A condition characterized by damage to, or a defect of, one or more of the four valves of the heart.
Heart Transplant HT Assessment of a heart transplant.
Heart Failure HF A complex clinical syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of reduced cardiac output and/or pulmonary or systemic congestion at rest or with stress.
Cardiomyopathy CM A condition of the heart muscle in which it is structurally and functionally abnormal in the absence of coronary artery disease, hypertension, valvular disease, and congenital heart disease sufficient to explain the observed myocardial abnormality.
Congenital/Structural CS A defect in the structure of the heart or great vessels either developed or present at birth.
Other OT Other reasons.
Not Applicable X Secondary reason for referral is not applicable.
Instructions: For CABG and Valve Repair/Replacement waitlist entries, if treatment of coronary disease is the primary driver of procedure, choose Valve Disease, if treatment of valve disease is the primary driver of procedure, choose Coronary Disease, if both are equal, choose Valve Disease.
For the value Coronary Disease:
• This is also referred to as coronary artery disease (CAD).
CorHealth DCIS Data Dictionary
47 of 138 Section: Referral Information
Name: Secondary Reason for Referral Type ID: 41
Definition: The description of the clinical condition as it relates to the secondary reason for referral.
Applicable to: All entries.
Valid Values: Description Code Definition
Aortic Regurgitation AR A condition in which the aortic valve is malfunctioning causing a leakage backward from the aorta into the left ventricle.
Aortic Stenosis AS A condition in which the aortic valve is malfunctioning causing the obstruction of blood flow through it.
Atrial Flutter AF An abnormal heart rhythm originating in the upper chambers (atria) of the heart which results in atrial muscle contractions that are faster then and out of synchronization with the lower chambers (ventricles).
Atrial Tachycardia AT An abnormal heart rhythm originating in the upper chambers (atria) of the heart and outside of the sinus node.
Atrioventricular Nodal Re-entrant Tachycardia
AN A type of abnormal fast heart rhythm which originates from a location within the heart above the bundle of His.
Atypical Atrial Flutter AA An abnormal heart rhythm originating in the upper chambers (atria) of the heart which is characterized as a macro entrant tachycardia whereby the wave front does not travel around the tricuspid annulus.
Donor DO Assessment of suitability for transplantation of a donor heart.
Heart Disease of Other Etiology
OT Other heart disease not previously described or listed.
Non-ST-Segment Elevation Myocardial Infarction
NS Angina pectoris (or anginal equivalent) symptoms associated with positive biomarkers for myocardial necrosis but without ST elevation on electrocardiogram (ECG).
Other Valvular OV Other valvular disease or disorder excluding aortic stenosis and aortic regurgitation.
Paroxysmal Atrial Fibrillation
PA An episode of atrial fibrillation that terminates spontaneously or with intervention in less than seven days.
Persistent Atrial Fibrillation
PE An episode of atrial fibrillation that is not self-terminating within seven days or is terminated electrically or pharmacologically.
CorHealth DCIS Data Dictionary
48 of 138 Protocol (Research or
Employment)
PR Required for a research/study or employment.
Recipient RE Surveillance of a previously transplanted heart.
Stable Angina SA Angina pectoris (or anginal equivalent) without a recent change in frequency or pattern. Angina is relieved by rest and/or sublingual/transdermal medications.
ST-Segment Elevation Myocardial Infarction
ST Angina characterized by the presence of both criteria:
1. ECG evidence of STEMI: New or presumed new ST segment elevation or new left bundle branch block not documented to be resolved within 20 minutes. ST segment elevation is defined by new or presumed new sustained ST segment elevation at the J-point in two contiguous ECG leads with the cut-off points: ≥0.2 mV in men or ≥0.15 mV in women in leads V2-V3 and/or ≥ 0.1 mV in other leads and lasting ≥20 minutes. If no exact ST elevation measurement is recorded in the medical chart, physician's written documentation of ST elevation or Q waves is acceptable. If only one ECG is performed, then the assumption that the ST elevation persisted at least the required 20 minutes is acceptable. Left bundle branch block (LBBB) refers to new or presumed new LBBB on the initial ECG.
2. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I) exceed the upper limit of normal according to the individual hospital's laboratory
parameters a clinical presentation which is consistent or suggestive of ischemia.
Syncope SY A condition which is characterized as a transient loss (syncope) or imminent loss (presyncope) of
consciousness as a result of insufficient blood flow to the brain.
Unstable Angina UA Angina pectoris (or anginal equivalent) with any of the following features:
1. Symptoms at rest and prolonged, usually greater than 20 minutes
2. New-onset symptoms of Canadian Cardiovascular Society (CCS) class III or class IV severity
3. Recent acceleration of symptoms with an increase in severity of at least one CCS class to CCS class III or class IV severity
Ventricular Fibrillation
VF An abnormal heart rhythm originating in the lower chambers (ventricles) of the heart which results in ineffective heart muscle contraction and subsequent cardiac arrest.
CorHealth DCIS Data Dictionary
49 of 138 Ventricular
Tachycardia
VT An abnormal heart rhythm originating in the lower chambers (ventricles) of the heart which is characterized as fast (over 100 beats per minute) and lasting greater than three beats in duration.
Wolff-Parkinson-White Syndrome
WP A syndrome in which there is an extra electrical pathway in the heart which can lead to periods of fast heart rhythm.
Instructions: For the value Paroxysmal Atrial Fibrillation:
• This value is also referred to as intermittent atrial fibrillation.
For the value Atrioventricular Nodal Re-entrant Tachycardia:
• This value is also referred to as supraventricular tachycardia.
For the value Protocol (Research or Employment):
• If the follow-up protocol is related to a heart transplant, use the Heart Transplant reason and Recipient types.
CorHealth DCIS Data Dictionary
50 of 138 Section: Referral Information
Name: Race ID: 153
Definition: Race is a term used to classify people into groups based principally on physical traits (phenotypes) such as skin colour. Racial categories are not based on science or biology but on differences that society has created (i.e., “socially constructed”), with significant consequences for people’s lives. Racial categories may vary over time and place and can overlap with ethnic, cultural, or religious groupings.
Citation: Data Standards for the Identification and Monitoring of Systemic Racism, Page 72. URL https://files.ontario.ca/solgen_data-standards-en.pdf
Applicable to: All entries.
Valid Values: Description Code Definition
Black B
East/Southeast Asian A Indigenous (First Nations,
Métis, Inuk/Inuit)
I
Latino L
Middle Eastern M
South Asian S
White W
Other O Other race not previously described or listed.
Unknown U Race is not available or is incomplete.
Prefer Not to Answer P The question of Race was asked, and the respondent chose not to answer.
Not Collected N The question of Race was not asked.
CorHealth DCIS Data Dictionary
51 of 138 Instructions: The value(s) indicated for this data element should be self-identified by the patient.
This data element allows for multiple selections, and patients are advised to identify one or more Race values if applicable.
For the value Other:
• This value may be indicated alone, or in combination with any of the other Race values.
For the value Unknown:
• This value cannot be indicated in combination with any other Race value.
• If this value is indicated with any other Race value, use this value only.
For the value Prefer Not to Answer:
• This value cannot be indicated in combination with any other Race value.
• If this value is indicated with any other Race value, use this value only.
For the value Not Collected:
• This value cannot be indicated in combination with any other Race value.
• If this value is indicated with any other Race value, use this value only.
• Indicate this value for any scenario where it was inappropriate or not possible to request a response for this data element from the patient (e.g., emergent cases, cases where the patient is not conscious).
Notes:
The primary purpose of measuring race-based health inequalities is to identify, monitor and address inequities that potentially stem from bias and racism — including at systemic, interpersonal and internal levels. These levels of racism all have well-documented consequences on health care access, quality and outcomes that can influence the health and well-being of populations. Racism influences multiple opportunities across the lifespan, such as education, employment, housing and treatment by a variety of public services, including police, education, child welfare and health care. Because of the subtle, often unintentional nature of bias, health care
providers can be unaware of the impact their practices and actions have on patient care.
Standardized race-based data can help uncover health care inequalities and identify opportunities for health care quality improvement.
Citation: Proposed Standards for Race-Based and Indigenous Identity Data Collection and Health Reporting in Canada, Page 9. ISBN 978-1-77109-938-7 (PDF)
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