Healthy Child Programme: final report

3.2. Newly Developed Record Headings (page 14 of 5) in 3. Recommendations (chapter 5 of 9) within Healthy Child Programme: final report

This section contains headings which have been newly developed for this project.

3.2.1. Birth Details

Following the consultation the project team recommend that the following headings and definitions are used to record details about the birth.

Birth details (these will be obtained from maternity records)
Maternal problems in pregnancy	Maternal medical conditions or infectious diseases arising in pregnancy which may have an impact on the foetus, e.g. gestational diabetes, rubella etc.
Foetal problems diagnosed before birth	Problems with the foetus diagnosed with screening or ultrasound e.g. Down syndrome, congenital heart disease etc.
Length of gestation	Gestational age in weeks and days (usually equivalent to length of pregnancy).
Type of delivery	Type of delivery for the baby, e.g. vacuum extraction, breech extraction, elective caesarean section etc.
Type(s) of delivery (attempted)	The type(s) of delivery for the baby that was attempted, but was not the final delivery method.
Problems during delivery	Problems experienced by the baby during delivery e.g. cord prolapse, meconium aspiration, foetal distress etc.
Birth order	The sequence in which this baby was born (one of one, one of two etc).
Multiple birth	Where the baby is one of a multiple birth, to include the total number of offspring and to include whether the baby is identical to one of the siblings.
Birth weight	Numeric value for weight at birth.
Location of birth	The place of birth (including the address and organisation name where relevant).
Delivery place type	The type of place in which the baby was born (e.g. private health facility, domestic address, NHS hospital, midwifery led unit etc.)
Neonatal resuscitation	Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.
Spontaneous respiration	The length of time between delivery of the baby and the time spontaneous respiration began.
Put to breast	Whether or not the baby was put to the breast.
APGAR score	A set of observations made on the baby following birth to check adaptation to life outside the womb.
Physical problems detected at birth	Physical problems identified with the baby at, or shortly after, birth. E.g. cleft lip/palate, extensive bruising, cephalohaematoma etc.

3.2.1.1. Babies Admitted to Neonatal Intensive Care Units

The project team recommends that NHS Digital considers additional work on an event related to baby admissions to Neonatal Intensive Care Units (NICU). Existing PRSB headings for admission and discharge could be used for this purpose.

3.2.1.2. Place, Date and Time of Birth

Some survey respondents felt that place of birth, date/time of birth should be included in the birth details section. The project team recommendation is that these items should form part of the person demographics but can be carried as part of the birth details.

3.2.1.3. Type of Delivery

Following the consultation, the project team recommends that the following values are used for type of delivery (these are aligned with the “delivery method” national codes from the Maternity Services Dataset): * Spontaneous vertex * Spontaneous other cephalic * Low forceps, not breech * Other forceps, not breech * Ventouse, vacuum extraction * Breech * Breech extraction * Elective caesarean section * Emergency caesarean section

In line with the expert reference group consensus, the project team recommends that a heading is created for ‘attempted deliveries’ to capture methods attempted which did not result in the birth of the child.

3.2.1.4. Multiple Births

Following the consultation, the project team recommends that implementation guidance should explain how testing would determine whether siblings are identical or not in the case of multiple births. In most cases identical siblings will be identified before birth by ultrasound scan.

3.2.1.5. Maternal Problems in Pregnancy

Following the consultation, the project team recommends that the following values are used for maternal problems in pregnancy which may have an impact on the foetus (these are based upon the “maternity medical diagnosis type” national codes from the Maternity Services Dataset, but have been amended in line with the PRSB consultation): * Gestational diabetes * Diabetes * Systemic lupus erythematosus (SLE) * Mother taking opioids * Thyrotoxicosis * Hypothyroidism * Anti - D positive * Immune thrombocytopenia * Vitamin D deficiency/osteoporosis * Myotonic dystrophy * Achondroplasia * Rubella * Cytomegalovirus (CMV) * Chicken Pox * Hepatitis B antigen/antibody * Hepatitis C * Toxoplasmosis * Group B streptococcus colonisation * HIV * Anticonvulsant therapy * Alcohol abuse * Myasthenia gravis

The project team recognises that consent would be needed for this information to appear in the child’s record and this needs to be considered as part of the related maternity record project.

3.2.1.6. Problems During Delivery

Following the consultation, the project team recommends that the following values are used for problems during delivery (these are based upon the “baby complication at birth diagnosis” national codes from the Maternity Services Dataset, but have been amended in line with the PRSB consultation): * Shoulder dystocia * Cord prolapse * Foetal distress * Meconium aspiration * Acute foetal blood loss

3.2.1.7. APGAR Scores

Due to the high level of consensus the project team recommends that all three APGAR scores are included (1, 5 and 10 minutes) however implementation guidance should specify that the 10 minute score should only be recorded where the score is poor at 1 and 5 minutes.

3.2.1.8. Physical Problems Detected at Birth

Following the consultation the project team recommends that the following values are used for physical problems detected at birth: * Cephalohaematoma * Extensive bruising * Talipes equina varus * Laceration * Erb’s Palsy * Cleft lip * Cleft palate * Anal atresia * Fractured clavicle

3.2.2. Measurements

Following the consultation the project team recommend the following headings and definitions are used:

Measurements
Weight	Numeric value for weight.
Height/ length	Numeric value for the body length.
Head circumference	Numeric value for head circumference.
BMI centile	Child BMI centile calculated using the height/weight/gender and age of the child.

The NHSD information models will contain a separate heading for the National Child Measurement Programme (NCMP) which includes additional information, such as the school where the measurement takes place. However, all measurements taken as part of the NCMP would appear in the above measurements section.

3.2.3. Feeding Status

Following the consultation, the project team recommend that the following headings and definitions are used:

Feeding status
First milk feed	Whether or not the baby's first feed was breast milk.
Milk feeding status of the baby	Whether the baby is totally breast milk fed, partially breast milk fed, or not breast milk fed. To be recorded each time a baby has contact with a health professional.
Date breast milk feeding stopped	Date of last breast milk feed to the nearest month and year.
Introduction of solids	Whether the baby has been introduced to solid foods at the time seen.
Feeding method	A record of the predominant feeding method for the baby, e.g., breast fed, bottle/cup fed, gastrostomy, nasogastric feeds etc.
Feeding concerns	A record of any concerns about the baby’s feeding.

In line with the consultation, the project team recommend that implementation guidance explains that duration of breastfeeding is calculated by asking mothers if they breastfed their child. If so, they should be asked when the last date of breast milk feeding was (to the nearest month and year). Implementation guidance should also make clear that ‘feeding method’ and ‘feeding concerns’ should be recorded each time the child is seen.

3.2.4. National Screening Reviews

Following the consultation the project team has recommended the following headings and definitions are used to record national screening reviews:

National screening reviews
National screening programme	The overarching screening programme. e.g.
	Newborn blood spot screening, newborn hearing screening, newborn and infant physical examination (72 hours), newborn and infant physical examination (6-8 weeks).
Specific test performed	The specific screening test performed, e.g. examination of heart, phenylketonuria (PKU) screening, automated otoacoustic emission (AOAE) test etc.
	This may include site and laterality where applicable e.g. left ear, right eye etc.
Screening test result	The result or outcome of the specific test (this may include the status e.g. declined, deferred etc.).
Screening review outcome	The overall outcome of the screening test (this may include the status e.g. declined, deferred etc.).
Comments	Supporting text may be given regarding the screening test, outcome and actions taken.

Implementation guidance should explain that this generic information model can be used for any type of screening review. System design should allow templates with the appropriate subheadings for the various reviews to be generated by selecting the type of review from a drop-down list. The NHS Digital information models have developed specific models for each screening review, but these align with the generic model.

3.2.5. Parent / Guardian / Personal Comments

Following the consultation, the project team recommend the following headings and definitions are used to record parent / guardian/ personal comments:

Parent / guardian/ personal comments
Parent / guardian / personal comment	Free text comment made by the parent / guardian of the child, or the child themselves.

3.2.6. Personal Contacts

Following the consultation the project team recommend the following headings and definitions are used to record personal contacts:

Personal contacts

| Name | The name of the person. | |---|---| | NHS number | The NHS number of the personal contact. | | Relationship | The personal relationship the individual has to the child (e.g. father, grandmother, family friend etc.). | | Parental responsibility | Flag to indicate whether the personal contact has parental responsibility. | | Contact details | Contact details of the person (e.g. telephone number, email address etc.). |

3.2.7. Professional Contacts

Following the consultation the project team recommend the following headings and definitions are used to record professional contacts:

| Professional contacts | |---| | Name / team | The name of the person or the team responsible. | | Role | The professional role the individual has in relation to the child (e.g. nursery nurse, health visitor, school nurse etc.). | | Speciality | The speciality of the professional responsible (e.g. health visiting, school nursing etc.). | | Team | The name of the team, if the name of the person has been entered. | | Organisation | The name of the organisation responsible. | | Contact details | Contact details of the person (e.g. telephone number, email address etc.). | | Start date | The start date of the relationship with the health professional. | | End date | The end date of the relationship with the health professional. |

3.2.8. Immunisations

Following the consultation the project team recommend the following headings and definitions are used to record immunisations:

| Immunisations | |---| | Name of immunisation | Which immunisation has been administered (SNOMED CT code – list of available immunisations) | | Vaccine product | Vaccine product administered. | | Manufacturer | The vaccine manufacturer. | | Batch number | The batch number of the vaccine. | | Site | Body site vaccine was administered into. | | Route | How vaccine entered the body. | | Dose amount | Amount of vaccine administered. | | Dose sequence | Nominal position in a series of vaccines. | | Outcome status | Whether the vaccine was administered or not, including the reason why. | | Reported | A flag to indicate the information was reported to a healthcare professional. | | Indication | The clinical indication or reason for administering the immunisation. |

3.2.9. Developmental Skills

Following the consultation the project team recommend the following headings and definitions are used for recording developmental skills:

Developmental skills
Developmental skill	The name of the developmental skill (e.g. walks independently, smiles, finger feeds etc.).
Date first achieved	The date the developmental skill was first achieved (developmental first) as reported by the parent. This is primarily for parent reporting as part of parent child health record at the time the skill is acquired.
Date of enquiry	The date the parent or carer was asked by a health professional about the developmental skill (milestone).
Result of enquiry	Whether the developmental skill was achieved, not achieved or equivocal.
Date of observation	The date a health professional observed or tested a developmental skill (milestone).
Result of observation	Whether the developmental skill was achieved, not achieved or equivocal.
Comments	Supporting text may be given regarding the developmental skill.

Implementation guidance should specify that a partial date can be entered if the parent is unsure of the exact date the developmental skill was achieved.

In the online survey for work package 2/3, respondents were asked whether the developmental skills included in the Personal Child Health Record should be changed. Although some respondents suggested changes, the response rate for this question was small. Our framework allows for other developmental skills to be added or removed as required.

The project team recommends that a list of SNOMED CT developmental skills is defined by the UKTC working with parents and the PRSB. The subset should include developmental skills for children up to the age of five years, for use by the wider child health community. This subset should also include the following developmental skills which survey respondents suggested should be recorded to indicate that the child is ready to start school:

Listening skills
Communication skills
Ability to dress/undress
Ability to follow instructions
Toilet trained

3.2.10. Health and Wellbeing Reviews

Following the consultation the project team recommended the following headings and definitions are used for health and wellbeing reviews:

Health and wellbeing reviews
Type of review	The type of health and wellbeing review:
	Post-birth review New baby review 6-8 week health visitor review 1 year review 2-2 ½ year health and development review School entry review Ad-hoc health review Other reviews
Examination findings	(Use of existing examination findings headings)
Problems and issues	(Use of existing problems and issues headings)
Feeding status	(Use of existing feeding status headings)
Social context	(Use of existing social context headings)
Developmental skills	(Use of existing developmental skills headings)
Measurements	(Use of existing measurements headings)
Safety alerts	(Use of existing safety alerts headings)
Assessment scales	(Use of existing assessment scales headings)
Information and advice given	(Use of existing information and advice given headings)
Other progress reports	A summary of other progress reports e.g. early years progress reports, school progress reports etc.
Comments	Supporting text may be given regarding the health and wellbeing review.

Implementation guidance should explain that this generic information model can be used for any type of health and wellbeing review, the examples covered by ‘type of review’ above are consistent with English requirements, however the model is flexible to allow other reviews which may be carried out in other countries of the UK. System design should allow templates with the appropriate subheadings for the various reviews to be generated by selecting the type of review from a drop-down list. The NHS Digital information models have developed specific models for each health and wellbeing review, but these align with the generic model.

Implementation guidance should also explain that problems which are detected with the baby prior to discharge from the post-natal ward, which may include reasons for admission to a neonatal intensive care unit (NICU), e.g. respiratory distress, neonatal fits, hypothermia, etc. should be recorded as examination findings in the post-birth review.

3.2.11. Educational History

The project team were not able to consult widely on a model for ‘educational history’ however the NHS Digital team suggested the following model which is aligned with the Children and Young People’s Dataset. The project team recognises that the educational aspects of a child health record are much broader than educational history but support the following NHS Digital developed model:

Educational history
Educational establishment	Name of educational establishment including the unique reference number.
Type of educational establishment	Phase/type of education establishment.
Year from	The year the child attended the school from.
Year to	The year the child left the school.
Educational assessment	The outcome of an educational assessment.
Type of special educational need	The type of special educational needs for the child.

Page last updated: 18 June 2026