NACR DATASET - RECORD FORM (mandatory fields are shown in red) Patient Information NHS No. Date of Birth: Forename: Surname: Hospital No. Date of Death: Gender: Not Known Male Female Not specified Marital Status: Single Married Permanent Partnership Divorced Widowed Separated Unknown Ethnic Group: British Irish White (other) White/Black Caribb African White/Asian Any other mixed Indian Pakistani Bangladeshi Other Asian Black Caribbean African Black Other Chinese Other Ethnic Group Not Stated Not Known Address: Postcode: Telephone No: GP Practice Code: Did you measure Patient Satisfaction? Yes No Initiating Event Initiating (IE) MI Unknown MI Stemi MI (NStemi) MI with Heart Failure Angina Unstable Angina Heart Failure Disease CHD Arrhythmia Cardiac Arrest Cardiomyopathy Congenital Heart High Risk Prehab Other Use Treatment Peripheral Arterial Disease Unknown IE Date: Ankle Brachial Indice Ratio (assoc. with PAD) Treatment associated with IE PCI PPCI CABG Mitral Valve Repair/Replace Aortic Valve Repair/Replace Tricuspid Repair/Replace Medical Management Pacemaker Transplant LV Assist Device ICD Staged PCI TAVI Other Surgery Other Treatment Date: Discharge Date: Invited to Join Date: Source of Referral: BMI Hospital Private Hospital GP NHS Trust Referring Trust (Initiating Event): Referred by: Consultant Cardiac Nurse GP PC Nurse Other Risk Ass Low Medium High Acute Events During Rehab MI Bypass Surgery Angioplasty/PCI Cardiac Arrest Angina Other Surgery Heart Failure Pacemaker ICD Congenital Heart Transplant LV Assist Device Readmission CHD Readmission other cause Unknown Period Acute Non Card Illness Previous Events MI Cardiac Arrest Pacemaker LV Assist Device Angina ICD Bypass Surgery Other Surgery Congenital Heart Angioplasty/PCI Heart Failure Transplant Other No/None Arrhythmia Unknown Angina Arthritis (Osteo) Comorbidity
NACR DATASET - RECORD FORM (mandatory fields are shown in red) Patient Information NHS No. Date of Birth: Forename: Surname: Hospital No. Date of Death: Gender: Female Not Known Not specified Male Marital Status: Permanent Partnership Separated Single Divorced Unknown Married Widowed Ethnic Group: British White/Black Caribb Any other mixed Bangladeshi African Other Ethnic Group Irish African Indian Other Asian Black Other Not Stated White (other) White/Asian Pakistani Black Caribbean Chinese Not Known Address: Postcode: Telephone No: GP Practice Code: Did you measure Patient Satisfaction? Yes No Initiating Event Initiating (IE) MI (NStemi) Unstable Angina CHD Cardiomyopathy Prehab Peripheral Arterial Disease MI Unknown MI with Heart Failure Heart Failure Arrhythmia Congenital Heart Other Unknown MI Stemi Angina Disease Cardiac Arrest High Risk Use Treatment IE Date: Ankle Brachial Indice Ratio (assoc. with PAD) Treatment associated with IE CABG Tricuspid Repair/Replace Transplant Staged PCI Other PCI Mitral Valve Repair/Replace Medical Management LV Assist Device TAVI PPCI Aortic Valve Repair/Replace Pacemaker ICD Other Surgery Treatment Date: Discharge Date: Invited to Join Date: Source of Referral: BMI Hospital Private Hospital GP NHS Trust Referring Trust (Initiating Event): Referred by: Consultant Cardiac Nurse GP PC Nurse Other Risk Ass Low Medium High Acute Events During Rehab Angioplasty/PCI Other Surgery ICD LV Assist Device Readmission other cause MI Cardiac Arrest Heart Failure Congenital Heart Period Acute Non Card Illness Bypass Surgery Angina Pacemaker Transplant Readmission CHD Unknown Previous Events Pacemaker ICD Congenital Heart Transplant Arrhythmia MI LV Assist Device Bypass Surgery Angioplasty/PCI Other Unknown Cardiac Arrest Angina Other Surgery Heart Failure No/None Comorbidity Angina Arthritis (Osteo)
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