| Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link |
|
The person's details and contact information.
|
 |
|
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link |
|
Details of the person's name |
|
|
0 … 1 |
prsb03-dataelement-10870 link |
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.Free text
|
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=D&ID=186&Title=Date%20of%20Birth
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary: - Person gender code
NHS Wales : - https://fhir.standards.wales/CodeSystem/GenderIdentity
|
|
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link |
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic catergory code 2001
NHS Wales: - https://fhir.standards.wales/CodeSystem/DataStandardsWales-Ethnicity
NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnic%20Group
|
|
|
Religion |
|
0 … 1 |
prsb03-dataelement-10876 link |
|
The religious affiliation as specified by the person.SNOMED CT :- ^999000531000000100 Religious or other belief system affiliation simple
reference set (foundation metadata concept)
NHS NSS: - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=R&ID=795&Title=Religion
|
|
|
Sex |
|
0 … 1 |
prsb03-dataelement-10877 link |
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary:- person phenotypic sex classification
NHS Wales : - https://fhir.standards.wales/CodeSystem/DataStandardsWales-Sex
NHS NSS: - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=S&ID=1277&Title=Sex
|
|
|
NHS number |
|
0 … 1 |
prsb03-dataelement-10879 link |
|
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
|
|
|
Other identifier |
|
0 … 1 |
prsb03-dataelement-10880 link |
|
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier,
HEALTH AND CARE NUMBER
(NI only),
COMMUNITY HEALTH INDEX NUMBER
(Scotland only)
|
|
|
Person's address |
|
0 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
0 … 1 |
prsb03-dataelement-13082 link |
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
|
0 … 1 |
prsb03-dataelement-13083 link |
|
Person's second line of address.NHS data dictionary :- Address line 2 |
|
|
0 … 1 |
prsb03-dataelement-13084 link |
|
Person's third line of address. NHS data dictionary :- Address line 3 |
|
|
0 … 1 |
prsb03-dataelement-13085 link |
|
Person's fourth line of address.NHS data dictionary :- Address line 4 |
|
|
0 … 1 |
prsb03-dataelement-13086 link |
|
Person's fifth line of address.NHS data dictionary:- Address line 5 |
|
|
0 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.NHS data dictionary : - Postcode
NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=P&ID=399&Title=Postcode
|
|
|
Person's email address |
|
0 … 1 |
prsb03-dataelement-10882 link |
|
Email address of the person.NHS data dictionary :- Email address
|
|
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-10883 link |
|
Telephone contact details of the person. To include, e.g. mobile, work and home number
if available.NHS data dictionary :- Person's telephone number
|
|
|
Preferred contact method |
|
0 … 1 |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Place of birth |
|
0 … 1 |
prsb03-dataelement-10884 link |
|
The country of birth of the person.NHS data dictionary :- Country code (birth)
|
|
|
Organ and tissue donation |
|
0 … 1 |
prsb03-dataelement-10430 link |
|
Whether the person has given consent for organ and/or tissue donation or opted out
of automatic donation where applicable. This is information provided by the national
register. Free text
|
|
GP practice |
|
0 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … * |
prsb03-dataelement-10643 link |
|
This is an GP practice record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-10003 link |
|
The name of the person's GP. If the person is registered with a GP practice, their
usual GP name will be something volunteered by the person or their representative.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10002 link |
|
Name and address of the person's registered GP practice Registered GP practice details
are available from the Patient Demographics Service (PDS), or volunteered from the
person or their representative. Include details of the practice name and address.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
About me |
|
0 … 1 |
prsb03-dataelement-466 link |
|
About me |
|
|
About me |
|
0 … 1 |
prsb03-dataelement-10366 link |
|
This is a record of the things that a person feels it is important to communicate
about their needs, strengths, values, concerns and preferences to others providing
support and care.
|
 |
|
|
What is most important to me |
|
0 … 1 |
prsb03-dataelement-12964 link |
|
A description
of what is most important to you
Emergency Information
Include any
essential
information that any professional in health and social care should know about
the you in any situation, including emergencies.
Other Information
This could
include:
•
Values
•
Spirituality/religion
•
Ethnicity
•
Culture
•
Pets
•
Goals and aspirations
•
Meaningful activities including
leisure activities, visiting places, sport and
exercise, listening to music, employment, education, volunteering
Free text or multimedia file
|
|
|
|
People who are important to me |
|
0 … 1 |
prsb03-dataelement-13009 link |
|
Details of who is important to you and why. They could be family
members, carers, friends,
members of staff etc
.
Include how you want the people important to you to be engaged and
involved in your care and support in both emergency and normal situations.
Who should not be
contacted or consulted about your care and support and why, if
you wish to say
Free text or multimedia file
|
|
|
|
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-13006 link |
|
A description of how
you communicate normally including any communication aids you use, for example
a hearing aid.
- Include your preferred
language of communication, if your first language is not English.
- Include how you would communicate when you are in pain or
distress.
- Include how you communicate choices.
- Include how you give feedback or raise a concern.
Describe how you
would like others to engage and communicate with you
, including how you would like to be addressed.
Free text or multimedia file
|
|
|
|
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-13008 link |
|
A description of things you want someone supporting you to
do or not to do.
For example, this might include:
- Talk to me not to my carer
- Remind me to take my medication
- Encourage me to wash my hands regularly
- Explain to me what is happening and why
- Respond to my communication
A description of things you do not want someone supporting
for you to do. For example, this might include:
- Asking questions about certain topics
- Making assumptions about something
- Providing support when it is not wanted
- Talking to you in a certain way
Free text or multimedia file
|
|
|
0 … 1 |
prsb03-dataelement-13005 link |
|
A description covering
what you are able to do, how you engage with others and how you feel on a
typical day through to on a day when you are unwell.
- Include any causes that might result in you becoming unwell and
strategies for avoiding or addressing the causes. For example, not drinking
enough water could cause constipation.
- Include any signs
that indicate you might be becoming unwell.
- On a bad day describe what is different about what you are able
to do, how you engage with others and how you feel.
- Include
any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough,
pain that you are living with and that that affect your everyday life and how
you manage those conditions.
- Include past health
issues or experiences that need to be considered
Free text or multimedia file
|
|
|
|
How and when to support me |
|
0 … 1 |
prsb03-dataelement-13007 link |
|
A description of how and when you want someone caring for
you to support you.
This could include support needs in an emergency situation
(for example taking blood)
This could include support you need to maintain important
routines or to carry out particular activities, for example:
- Personal care routines
- Eating and drinking
- Bedtime routines
- Taking medications
- Moving and transitioning
This could also include support needed with:
- wearing
glasses/hearing aids/false teeth etc.
- making informed choices
or understanding dangers and risks.
- managing your emotions, moods
and behaviours.
- memory or confusion.
Include how your support needs change in different environments.
Include any triggers that might result in you needing
further support and strategies for avoiding or addressing the triggers.
Include how you want the support to be provided.
Free text or multimedia file
|
|
|
|
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-13094 link |
|
A description of what is also worth knowing about you for
people caring or supporting you.
This could include a short history of your life (where you
have worked, where you lived, important events in your life, important people
in your past life).
This could include a short profile of your current life:
- your work / study
- your aspirations
- your skills
- your networks
- things you like e.g. particular
foods, places, a football team and things you like to talk about.
- things you dislike
This could also include any care and support preferences
that have not been included elsewhere.
Free text or multimedia file
|
|
|
Date |
|
0 … 1 |
prsb03-dataelement-10367 link |
|
This is a record of the date that this information was last updated.Date and Time |
|
|
Supported to write this by |
|
0 … 1 |
prsb03-dataelement-10368 link |
|
Where relevant, this is a record of name, relationship/role and contact details of
the individual who supported the person to write this section e.g. carer, family member,
advocate, professional.Free text
|
|
Individual requirements |
|
0 … 1 |
prsb03-dataelement-160 link |
|
The individual requirements of the person.
|
|
|
Reasonable adjustment |
|
0 … 1 |
prsb03-dataelement-12991 link |
|
A record of reasonable adjustments that must be provided by the service to comply
with the Equality Act 2010.
|
|
|
|
Reasonable adjustment record entry |
|
0 … 1 |
prsb03-dataelement-13061 link |
|
This is a reasonable adjustment record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-13098 link |
|
The location where the reasonable adjustment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13357 link |
|
The coded value for location.
NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13358 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13017 link |
|
The reasonable adjustment required e.g. requires specific contact method, requires
communication professional
|
|
|
0 … 1 |
prsb03-dataelement-13505 link |
|
The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information
- communication support simple reference set (foundation metadata concept)|^999002151000000104
|Accessible information - requires communication professional simple reference set
(foundation metadata concept)|^999002131000000106 |Accessible information - requires
specific contact method simple reference set (foundation metadata concept)|^999002141000000102
|Accessible information - requires specific information format simple reference set
(foundation metadata concept)|Refsets for other categories in development
|
|
|
0 … 1 |
prsb03-dataelement-13506 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Reasonable adjustment additional detail |
|
0 … 1 |
prsb03-dataelement-13018 link |
|
Further detail about the support required and the consequence of not providing it.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13020 link |
|
The date the reasonable adjustment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13027 link |
|
The professional who confirmed the need for the reasonable adjustment. |
|
|
0 … 1 |
prsb03-dataelement-13028 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13029 link |
|
The role the professional has in relation to the person.NHS data dictionary: - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13030 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13031 link |
|
The specialty of the professional.NHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13032 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13033 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13034 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-13035 link |
|
A record of the details of the person that entered the reasonable adjustment and the
date on which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13036 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13037 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13038 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13039 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-13040 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13041 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13042 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13043 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Impairment |
|
0 … 1 |
prsb03-dataelement-13001 link |
|
A record of any impairments for the person relating to reasonable adjustments. |
|
|
0 … 1 |
prsb03-dataelement-13062 link |
|
This is a reasonable adjustment record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-13099 link |
|
The location where the impairment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13429 link |
|
The coded value for location.
NHS data dictionary: - Organisation code service
|
|
|
0 … 1 |
prsb03-dataelement-13430 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13022 link |
|
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory
disability - such as sight or hearing, Long-term condition
|
|
|
0 … 1 |
prsb03-dataelement-13507 link |
|
The coded value for impairment.SNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13508 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Impairment additional detail |
|
0 … 1 |
prsb03-dataelement-13023 link |
|
Description of what the person can do with the impairment, what they want to be able
to do and how they should be supported to do it and what the consequences are of not
providing the support.
Where there is a sensory disability include sensory processing difficulties (e.g.
affects to balance and movement, oversensitive, under-sensitive).
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13024 link |
|
The date the impairment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13044 link |
|
The professional who confirmed the impairment. |
|
|
0 … 1 |
prsb03-dataelement-13045 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13046 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13047 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13048 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13049 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13050 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13051 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-13052 link |
|
A record of the details of the person that entered the impairment and the date on
which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13053 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13054 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13055 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13056 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-13057 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13058 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13059 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13060 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Mobility |
|
0 … 1 |
prsb03-dataelement-10067 link |
|
Details of the person's mobility needs. |
|
|
0 … 1 |
prsb03-dataelement-11707 link |
|
The date when the mobility needs were identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11710 link |
|
The location where the mobility needs were identified. |
|
|
0 … 1 |
prsb03-dataelement-13433 link |
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13434 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-13670 link |
|
The mobility needs of the person that allows movement between two spaces and achieves
participation and a degree of independence.
|
|
|
0 … 1 |
prsb03-dataelement-13671 link |
|
The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation
metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13672 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11487 link |
|
The professional who identified the mobility needs. |
|
|
0 … 1 |
prsb03-dataelement-11488 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11489 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11490 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11491 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11492 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11493 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11494 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11495 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11496 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11497 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11498 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11499 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11500 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11501 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11502 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11503 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Other individual requirements |
|
0 … 1 |
prsb03-dataelement-10835 link |
|
Details of any other individual requirements the person may have |
|
|
0 … 1 |
prsb03-dataelement-11711 link |
|
The date when the other individual requirements were identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11712 link |
|
The location where the other individual requirements were identified. |
|
|
0 … 1 |
prsb03-dataelement-13435 link |
|
The coded value for location.NHS data dictionary : - Organisation service code
|
|
|
0 … 1 |
prsb03-dataelement-13436 link |
|
Free text field to be used if no coded text available
|
|
|
|
Other individual requirement |
|
0 … 1 |
prsb03-dataelement-13673 link |
|
Other individual requirements that a person may have.Free text |
|
|
0 … 1 |
prsb03-dataelement-11504 link |
|
The professional who identified the other individual requirements. |
|
|
0 … 1 |
prsb03-dataelement-11505 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11506 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11507 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11508 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11509 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11510 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11511 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11512 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11513 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11514 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11515 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11516 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11517 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11518 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11519 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11520 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Alerts |
|
0 … 1 |
prsb03-dataelement-10741 link |
|
Details of alerts. |
|
|
Alerts record entry |
|
0 … * |
prsb03-dataelement-10916 link |
|
This is an alerts record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-10742 link |
|
Any significant information meriting a specific and highly visible warning to any
user (e.g. metallic implant, potential dangerous pet).Free text
|
|
|
0 … 1 |
prsb03-dataelement-12399 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12400 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12401 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12402 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12403 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12404 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12405 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12406 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12407 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Legal information |
|
0 … 1 |
prsb03-dataelement-520 link |
|
The legal information relating to the person. |
|
|
Mental capacity assessment |
|
0 … 1 |
prsb03-dataelement-10424 link |
|
Details of the persons mental capacity assessment |
|
|
0 … 1 |
prsb03-dataelement-11688 link |
|
The date when the mental capacity assessment was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11689 link |
|
The location where the mental capacity assessment was made. |
|
|
0 … 1 |
prsb03-dataelement-13449 link |
|
The coded value for location
NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13450 link |
|
Free text field to be used if no code is available
Free text
|
|
|
|
Mental capacity assessment |
|
0 … 1 |
prsb03-dataelement-13724 link |
|
Whether an assessment of the mental capacity of the (adult) person has been undertaken,
if so, what capacity the decision relates to and the outcome of the assessment.
Also record best interests decision if person lacks capacity.Free text
|
|
|
0 … 1 |
prsb03-dataelement-13779 link |
|
The location of the mental capacity assessment information.Free text or URL |
|
|
0 … 1 |
prsb03-dataelement-11281 link |
|
The professional who made the mental capacity assessment. |
|
|
0 … 1 |
prsb03-dataelement-11282 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11283 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11288 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11284 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11285 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11286 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13521 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13522 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11287 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11289 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11290 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11291 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11292 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11293 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11294 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13523 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13524 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11295 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11296 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11297 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent) |
|
0 … 1 |
prsb03-dataelement-10425 link |
|
Details of the person's LPA record or equivalent |
|
|
0 … 1 |
prsb03-dataelement-13630 link |
|
The date the LPA was recordedDate and time |
|
|
0 … 1 |
prsb03-dataelement-13631 link |
|
The location where the LPA was given |
|
|
0 … 1 |
prsb03-dataelement-13632 link |
|
The coded value for location
NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13633 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Lasting power of attorney for personal welfare or court appointed deputy (or equivalent) |
|
0 … 1 |
prsb03-dataelement-13634 link |
|
Record of one or more people who have been given power (LPA) by the person when they
had capacity to make decisions about their health and welfare should they lose capacity
to make those decisions. To be valid, an LPA must have been registered with the Court
of Protection. If life-sustaining treatment is being considered the LPA document must
state specifically that the attorney has been given power to consent to or refuse
life-sustaining treatment. Details of any person (deputy) appointed by the court to
make decisions about the person’s health and welfare. A deputy does not have the power
to refuse life-sustaining treatment.
|
|
|
0 … 1 |
prsb03-dataelement-13636 link |
|
The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings
simple reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13776 link |
|
The location of the LPA information Free text or URL |
|
|
0 … 1 |
prsb03-dataelement-13635 link |
|
The names of any appointed people or deputies
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13637 link |
|
The contact details of the LPAFree text |
|
|
0 … 1 |
prsb03-dataelement-13638 link |
|
The professional who took the details of the LPA or equivalent |
|
|
0 … 1 |
prsb03-dataelement-13639 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13640 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13641 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13642 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13643 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13644 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13645 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-13646 link |
|
Details of the person who recorded the ADRT. |
|
|
0 … 1 |
prsb03-dataelement-13647 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13648 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13649 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13650 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-13651 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13652 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13653 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13654 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Deprivation of Liberty Safeguards or equivalent |
|
0 … 1 |
prsb03-dataelement-10426 link |
|
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
|
|
|
0 … 1 |
prsb03-dataelement-13068 link |
|
The date the application was made Date and time |
|
|
0 … 1 |
prsb03-dataelement-13069 link |
|
The status of the DOLs application.Requested or authorised |
|
|
|
Deprivation of liberty safeguards or equivalent |
|
0 … 1 |
prsb03-dataelement-13626 link |
|
Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason
for this.
Free text
|
|
|
|
Start date of authorisation |
|
0 … 1 |
prsb03-dataelement-13071 link |
|
The date the DOLs was authorised.Data and time |
|
|
|
Planned or actual end date of authorisation |
|
0 … 1 |
prsb03-dataelement-13072 link |
|
The planned or actual end date of authorisation.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13073 link |
|
The professional who applied for the DOLs. |
|
|
0 … 1 |
prsb03-dataelement-13074 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13075 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13076 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13077 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13078 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13079 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13080 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
Mental health act or equivalent status |
|
0 … 1 |
prsb03-dataelement-10427 link |
|
Details of the persons mental health act record |
|
|
0 … 1 |
prsb03-dataelement-10920 link |
|
The date the person was detained.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10921 link |
|
The date the person was no longer detained. Date and time |
|
|
0 … 1 |
prsb03-dataelement-11692 link |
|
The location where the decision to detain the person was made under the mental health
act.
|
|
|
0 … 1 |
prsb03-dataelement-13453 link |
|
The coded value for location
NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13454 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Mental health act or equivalent status |
|
0 … 1 |
prsb03-dataelement-13627 link |
|
Record where a person diagnosed with a mental disorder is formally detained under
the Mental health act or equivalent, including the section number. If person subject
to Community Treatment Order or Conditional Discharge (or equivalent) record here.
|
|
|
0 … 1 |
prsb03-dataelement-13628 link |
|
The coded value for mental health actNHS data dictionary: - Mental health act classification code
|
|
|
0 … 1 |
prsb03-dataelement-13629 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13755 link |
|
If person subject to Community Treatment Order or Conditional Discharge (or equivalent)
record here.
NHS data dictionary : - Community treatment order
|
|
|
0 … 1 |
prsb03-dataelement-11315 link |
|
The professional who made the decision to detain the person under the mental health
act.
|
|
|
0 … 1 |
prsb03-dataelement-11316 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11317 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11318 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11319 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11320 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11321 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11322 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11323 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11324 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11325 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11326 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11327 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11328 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11329 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11330 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11331 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Advance decision to refuse treatment (ADRT) |
|
0 … 1 |
prsb03-dataelement-10428 link |
|
Details of the person's ADRT status. |
|
|
0 … 1 |
prsb03-dataelement-13479 link |
|
The date the ADRT was recorded.Date |
|
|
0 … 1 |
prsb03-dataelement-13480 link |
|
The location where the ADRT was recorded. |
|
|
0 … 1 |
prsb03-dataelement-13481 link |
|
The coded value of location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13482 link |
|
Free text field to be used if no coded text available
|
|
|
|
Advance decision to refuse treatment |
|
0 … 1 |
prsb03-dataelement-13502 link |
|
A record of an advance decision to refuse one or more specific types of future treatment,
made by a person who had capacity at the time of recording the decision. The decision
only applies when the person no longer has the capacity to consent to or refuse the
specific treatment being considered. An ADRT must be in writing, signed and witnessed.
If the ADRT is refusing life-sustaining treatment it must state specifically that
the treatment is refused even if the person’s life is at risk.
|
|
|
0 … 1 |
prsb03-dataelement-13503 link |
|
The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings
simple reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13504 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13484 link |
|
The professional who recorded the ADRT |
|
|
0 … 1 |
prsb03-dataelement-13485 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13486 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13487 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13488 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13489 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13490 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13491 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-13492 link |
|
Details of the person who recorded the ADRT. |
|
|
0 … 1 |
prsb03-dataelement-13493 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13494 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-13495 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13496 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-13497 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13498 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-13499 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13500 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Safeguarding |
|
0 … 1 |
prsb03-dataelement-271 link |
|
The safeguarding details of the person. |
|
|
Safeguarding concerns |
|
0 … * |
prsb03-dataelement-10821 link |
|
Details of the safeguarding concerns |
|
|
|
Safeguarding concerns date |
|
0 … 1 |
prsb03-dataelement-10172 link |
|
The date the safeguarding concerns were identified.Date and time |
|
|
|
Safeguarding concerns end date |
|
0 … 1 |
prsb03-dataelement-10766 link |
|
The date safeguarding concerns ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10173 link |
|
The location where the safeguarding concerns were identified. |
|
|
0 … 1 |
prsb03-dataelement-13437 link |
|
The coded value of locationNHS data dictionary :- Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13438 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10171 link |
|
Identified safeguarding concerns. |
|
|
0 … 1 |
prsb03-dataelement-13756 link |
|
The coded value for safeguarding concernsSNOMED CT
|
|
|
0 … 1 |
prsb03-dataelement-13757 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11358 link |
|
The professional who identified the safeguarding concerns. |
|
|
0 … 1 |
prsb03-dataelement-11359 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11360 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11361 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11362 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11363 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11364 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11365 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11366 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11367 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11368 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11369 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11370 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11371 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11372 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11373 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11374 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10175 link |
|
Further details on safeguarding concerns.Free text |
|
Professional contacts |
|
0 … 1 |
prsb03-dataelement-452 link |
|
The details of the person’s professional contacts. |
|
|
Professional contacts record entry |
|
0 … * |
prsb03-dataelement-10767 link |
|
This is a professional contacts record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10352 link |
|
The name of the professional with responsibility for the care of the person.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10353 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcNHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12973 link |
|
A flag that identifies the personal contact is the key worker assigned to the person.Yes or No |
|
|
0 … 1 |
prsb03-dataelement-10354 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-10355 link |
|
The name of the team.Free text |
|
|
0 … 1 |
prsb03-dataelement-10356 link |
|
The name of the organisation. |
|
|
0 … 1 |
prsb03-dataelement-13564 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13565 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10357 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
0 … 1 |
prsb03-dataelement-10358 link |
|
The start date of the professional relationship with the person.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10359 link |
|
The end date of the professional relationship with the person.Date and time |
|
Personal contacts |
|
0 … 1 |
prsb03-dataelement-445 link |
|
The details of the individual's personal contacts. |
|
|
Personal contacts record entry |
|
0 … * |
prsb03-dataelement-10768 link |
|
This is personal contacts record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10345 link |
|
The name of the personal contact.Free text |
|
|
0 … 1 |
prsb03-dataelement-10346 link |
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
|
0 … 1 |
prsb03-dataelement-12968 link |
|
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin,
Emergency Contact, Dependent, etc.)
Free text
|
|
|
0 … 1 |
prsb03-dataelement-10349 link |
|
A flag that identifies the personal contact is the next of kinYes or No |
|
|
0 … 1 |
prsb03-dataelement-10350 link |
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
|
0 … 1 |
prsb03-dataelement-10937 link |
|
Notes on the significance of the personal contact to the person.Free text |
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … * |
prsb03-dataelement-10917 link |
|
This is the referral details record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10006 link |
|
The date of referralDate and time |
|
|
0 … 1 |
prsb03-dataelement-10005 link |
|
The details of the referrer.
This could be the person, GP surgery, department, specialty, sub-specialty, educational
institution, mental health team etc.
|
|
|
0 … 1 |
prsb03-dataelement-10971 link |
|
The name of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-10972 link |
|
Role of the referrer.NHS data dictionary : - Care professional type
|
|
|
0 … 1 |
prsb03-dataelement-10973 link |
|
The grade of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-12409 link |
|
The team or department of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-12410 link |
|
The specialty of the referrer.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12411 link |
|
The service of the referrer. |
|
|
0 … 1 |
prsb03-dataelement-13397 link |
|
The coded value for serviceSNOMED CT : - ^999000191000000106 |Care planning patient outgoing referral simple
reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13398 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10974 link |
|
The organisation of the referrer.
|
|
|
0 … 1 |
prsb03-dataelement-13399 link |
|
The coded value for organisation code
NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13400 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10975 link |
|
The contact details of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-10007 link |
|
The method in which a referral is sent and received. This may be a letter, email,
transcript of a telephone conversation, Choose and Book, in person (self-referral)
etc.Allow National Codes only
1
Fax
2
Phone
3
Secure Messaging
4
Secure Email
5
Letter
6
NHS E-Referral Service
7
Self Referral
|
|
|
0 … 1 |
prsb03-dataelement-10011 link |
|
The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation,
investigation, second opinion, management of the patient (e.g. palliative care), or
carer's concerns.
Free text
|
|
|
|
Clinical urgency of referral |
|
0 … 1 |
prsb03-dataelement-10010 link |
|
Referrer’s assessment of urgency (e.g. urgent, routine).
NHS data dictionary : - PRIORITY TYPE
|
|
|
|
|
Reason for urgency of referral |
|
0 … 1 |
prsb03-dataelement-10976 link |
|
The reason for urgency of referral if not routine.Free text |
|
|
0 … 1 |
prsb03-dataelement-10008 link |
|
Details of where the referral is to be sent.
If not an individual, this could be a service, e.g. GP surgery, department, specialty,
subspecialty, educational institution, mental health etc.
|
|
|
0 … 1 |
prsb03-dataelement-10977 link |
|
Name of person the referral is to be sent to.Free text |
|
|
0 … 1 |
prsb03-dataelement-10978 link |
|
Role of person where the referral is to be sent to.NHS data dictionary : - Care professional type
|
|
|
0 … 1 |
prsb03-dataelement-10979 link |
|
The grade of the person where the referral is sent to.Free text |
|
|
0 … 1 |
prsb03-dataelement-10982 link |
|
The team or department of the person where the referral is being sent toFree text. |
|
|
0 … 1 |
prsb03-dataelement-10983 link |
|
The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health
etc NHS data dictionary - Main speciality
|
|
|
0 … 1 |
prsb03-dataelement-12412 link |
|
The service of where the referral is sent to. |
|
|
0 … 1 |
prsb03-dataelement-13509 link |
|
The coded value for serviceSNOMED CT:- ^999000191000000106 |Care planning patient outgoing referral simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13510 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10980 link |
|
The organisation of where the referral is to be sent. |
|
|
0 … 1 |
prsb03-dataelement-13511 link |
|
The coded value for organisation NHS data dictionary :- Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13512 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10981 link |
|
The contact details of where the referral is to be sent.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10014 link |
|
Records whether specific criteria required for referral, to a particular service,
have been met (may be nationally or locally determined).Free text. This field is used to outline which criteria have been met where a service
has indicated specific criteria and to explain the rationale for referral where criteria
have not been met.
|
|
|
0 … 1 |
prsb03-dataelement-10015 link |
|
Name of professional to be communicated with, if not the referrerFree text. |
|
Contacts with professionals |
|
0 … 1 |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
0 … * |
prsb03-dataelement-10718 link |
|
This is a contacts record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10069 link |
|
Date and time of the contact. Date and time. |
|
|
0 … 1 |
prsb03-dataelement-10075 link |
|
The location where the contact took place. |
|
|
0 … 1 |
prsb03-dataelement-13513 link |
|
The coded value for location NHS data dictionary : - Organisation service code
|
|
|
0 … 1 |
prsb03-dataelement-13514 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10077 link |
|
The professional that saw the person.
|
|
|
0 … 1 |
prsb03-dataelement-13515 link |
|
The name of the professional that saw the personFree text |
|
|
0 … 1 |
prsb03-dataelement-13758 link |
|
The role of the person providing the service. |
|
|
0 … 1 |
prsb03-dataelement-10072 link |
|
The name and role of the professional that had overall responsibility for the person
e.g. consultant, nurse consultant, midwife, allied health professional (may not have
actually seen the person).
|
|
|
0 … 1 |
prsb03-dataelement-10988 link |
|
The name of the responsible professional. Free text |
|
|
0 … 1 |
prsb03-dataelement-10989 link |
|
The role of the responsible professionalNHS data dictionary:- Care professional type
|
|
|
0 … 1 |
prsb03-dataelement-10076 link |
|
The type of location where the contact took place e.g. person's homeNHS data dictionary - Location type
|
|
|
0 … 1 |
prsb03-dataelement-10070 link |
|
Type of contact e.g. GP consultation, outpatient attendance NHS data dictionary - Care contact type |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10073 link |
|
The specialty e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty codes
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-10078 link |
|
The name, role of the additional individuals or team members including consultant(s),
nurse consultant(s), allied health professional(s), social worker(s)
|
|
|
0 … 1 |
prsb03-dataelement-10990 link |
|
The name of the professional presentFree text |
|
|
0 … 1 |
prsb03-dataelement-10991 link |
|
The role of the professional present.NHS data dictionary : - Care professional |
|
|
0 … 1 |
prsb03-dataelement-10080 link |
|
This records the outcome of the contact.NHS data dictionary:- Attended or did not attend
|
|
Admission details |
|
0 … 1 |
prsb03-dataelement-181 link |
|
Admission details |
|
|
Admission details record entry |
|
0 … * |
prsb03-dataelement-10918 link |
|
This is the admission details record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10085 link |
|
Date and time the person was admitted to hospital.The date and time of admission as recorded on the Patient Administration System (PAS) |
|
|
0 … 1 |
prsb03-dataelement-10090 link |
|
The hospital the person was admitted to. |
|
|
0 … 1 |
prsb03-dataelement-13380 link |
|
The coded value for admission toNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13381 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10087 link |
|
The consultant who has overall responsibility for the person (may not actually see
the person)
|
|
|
0 … 1 |
prsb03-dataelement-10992 link |
|
The name of the responsible consultant.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10993 link |
|
The role of the responsible consultant.NHS data dictionary: - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10081 link |
|
The health problems and issues experienced by the person that prompted the decision
to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific
procedure, intervention, investigation or treatment, non compliance with treatment.
|
|
|
0 … 1 |
prsb03-dataelement-13382 link |
|
The coded value for reason for admission SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13384 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10082 link |
|
How the person was admitted to hospital e.g. elective, emergency, maternity, transfer
etc.
|
|
|
0 … 1 |
prsb03-dataelement-13385 link |
|
The coded value for admission methodNHS data dictionary : - Admission method
|
|
|
0 … 1 |
prsb03-dataelement-13387 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Legal status on admission |
|
0 … 1 |
prsb03-dataelement-10083 link |
|
Whether the person was admitted as informal or formal/detained.Free text |
|
|
0 … 1 |
prsb03-dataelement-10084 link |
|
Where the person was immediately prior to admission, e.g. usual place of residence,
temporary place of residence, penal establishment.
|
|
|
0 … 1 |
prsb03-dataelement-13388 link |
|
The coded value of source of admission NHS data dictionary :- Source of admission
|
|
|
0 … 1 |
prsb03-dataelement-13389 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Individual accompanying person |
|
0 … 1 |
prsb03-dataelement-10088 link |
|
Details of the accompanying individual and the extent to which they have provided
the information about the person.
|
|
|
0 … 1 |
prsb03-dataelement-10984 link |
|
Name of individual accompanying person.Free text |
|
|
0 … 1 |
prsb03-dataelement-10985 link |
|
Role of the individual accompanying the person. NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10986 link |
|
Relationship of individual accompanying the person. |
|
|
0 … 1 |
prsb03-dataelement-13517 link |
|
The coded value for relationship to person.FHIR value set: -
Relationship type
|
|
|
0 … 1 |
prsb03-dataelement-13518 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12447 link |
|
Information about the extent to which the accompanying individual provided information
about the person.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10089 link |
|
The specialty e.g. physiotherapy, oncology, mental health etc |
|
|
0 … 1 |
prsb03-dataelement-13390 link |
|
The coded value for specialty
NHS data dictionary: - Treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13391 link |
|
Free text field to be used if no code is availableFree text |
|
Discharge details |
|
0 … 1 |
prsb03-dataelement-191 link |
|
Discharge details |
|
|
Discharge details record entry |
|
0 … * |
prsb03-dataelement-10919 link |
|
This is the discharge details record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10096 link |
|
The date and time of dischargeDate and time |
|
|
0 … 1 |
prsb03-dataelement-10095 link |
|
The hospital the person was discharged from.NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-10093 link |
|
The consultant responsible for the person at time of discharge. |
|
|
0 … 1 |
prsb03-dataelement-10994 link |
|
The name of the discharging consultantFree text |
|
|
0 … 1 |
prsb03-dataelement-10995 link |
|
The role of the discharging consultantNHS data dictionary: - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10098 link |
|
The method of discharge from hospital e.g. person discharged on clinical advice or
with clinical consent; person discharged him/herself or was discharged by a relative
or advocate.
|
|
|
0 … 1 |
prsb03-dataelement-13393 link |
|
The coded value for discharge methodNHS data dictionary : - Discharge method
|
|
|
0 … 1 |
prsb03-dataelement-13394 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10094 link |
|
The specialty of the consultant responsible for the person at the time of discharge.
|
|
|
0 … 1 |
prsb03-dataelement-13395 link |
|
The coded value for discharge specialityNHS data dictionary code : - Discharge speciality |
|
|
0 … 1 |
prsb03-dataelement-13396 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10987 link |
|
The department from which the person is discharged.Free text |
|
|
|
Legal status on discharge |
|
0 … 1 |
prsb03-dataelement-10097 link |
|
Whether the person was discharged as informal or formal/detained.Free text |
|
|
0 … 1 |
prsb03-dataelement-10099 link |
|
|
0 … 1 |
prsb03-dataelement-10100 link |
|
The destination of the person on discharge from hospital e.g. usual place of residence,
NHS run care home.NHS data dictionary - Discharge destination.
|
|
|
0 … 1 |
prsb03-dataelement-10101 link |
|
Address to which the person is discharged if not the usual place of residence.Free text : - 5 lines or NHS data dictionary Organisation data service code if discharged
to another organisation.
|
|
Future appointments |
|
0 … 1 |
prsb03-dataelement-10720 link |
|
Details of future appointments. |
|
|
Future appointments record entry |
|
0 … * |
prsb03-dataelement-10721 link |
|
This is the future appointments record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10722 link |
|
Date and time of future appointment.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10723 link |
|
The status of the appointment e.g. proposed, booked, confirmed, rejected.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10724 link |
|
Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessmentFree text |
|
|
|
Location of future appointment |
|
0 … 1 |
prsb03-dataelement-10726 link |
|
The location of the appointment.
|
|
|
0 … 1 |
prsb03-dataelement-13519 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13520 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10727 link |
|
The specialty e.g. physiotherapy, oncology, mental health etc.NHS data dictionary - Main specialty codes
|
|
|
0 … 1 |
prsb03-dataelement-10728 link |
|
The service being provided.SNOMED CT :- 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Professional seeing the person |
|
0 … 1 |
prsb03-dataelement-10729 link |
|
The name and role of the professional e.g. consultant, care worker, nurse consultant. |
|
|
0 … 1 |
prsb03-dataelement-12413 link |
|
The name of the professional seeing the person.Free text
|
|
|
0 … 1 |
prsb03-dataelement-12414 link |
|
The role of the professional seeing the person.NHS data dictionary : - Care professional
|
|
Investigation results |
|
0 … 1 |
prsb03-dataelement-257 link |
|
Investigation results |
|
|
Investigation results record entry |
|
0 … * |
prsb03-dataelement-10654 link |
|
This is a investigation result record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10157 link |
|
The date and time when the investigation was performedDate and time |
|
|
0 … 1 |
prsb03-dataelement-12099 link |
|
The professional who performed the investigation. |
|
|
0 … 1 |
prsb03-dataelement-12100 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12101 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12102 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12103 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12104 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12105 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12106 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-10159 link |
|
The location where the investigation took place. |
|
|
0 … 1 |
prsb03-dataelement-13725 link |
|
The coded value for locationNHS data dictionary : Organisation data service |
|
|
0 … 1 |
prsb03-dataelement-13726 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10160 link |
|
The investigation performed. |
|
|
0 … 1 |
prsb03-dataelement-13525 link |
|
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
|
|
|
0 … 1 |
prsb03-dataelement-13526 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10161 link |
|
For each investigation, the result of the investigation. This can include a report
which may have results for multiple tests.
|
|
|
0 … 1 |
prsb03-dataelement-13527 link |
|
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with
explicit context (situation)|
|
|
|
0 … 1 |
prsb03-dataelement-13528 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Structured investigation result |
|
0 … 1 |
prsb03-dataelement-12415 link |
|
A structured set of information for each investigation result. |
|
|
0 … 1 |
prsb03-dataelement-12416 link |
|
The value of the investigation result.Free text |
|
|
0 … 1 |
prsb03-dataelement-12417 link |
|
The units of the investigation result.Free text |
|
|
0 … 1 |
prsb03-dataelement-12418 link |
|
The reference range for the investigation result.Free text |
|
|
0 … 1 |
prsb03-dataelement-12419 link |
|
Indicator if the investigation is abnormal. Abnormal or Normal |
|
|
0 … 1 |
prsb03-dataelement-12107 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12108 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12109 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12110 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12111 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12112 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12113 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12114 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12115 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Investigations requested |
|
0 … 1 |
prsb03-dataelement-10730 link |
|
Details of any investigations requested |
|
|
Investigations requested record entry |
|
0 … 1 |
prsb03-dataelement-10731 link |
|
This is an investigation requested record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10732 link |
|
The date the investigation was requested.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10736 link |
|
The location where the investigation was requested. |
|
|
0 … 1 |
prsb03-dataelement-13727 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13728 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-12081 link |
|
The professional who requested the investigation. |
|
|
0 … 1 |
prsb03-dataelement-12082 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12083 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12084 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12085 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12086 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12087 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12088 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-10733 link |
|
The investigation that is requested. The investigation may refer to an individual
test or a group of related tests or broader investigation required (so the investigator
can determine the appropriate tests)
|
|
|
0 … 1 |
prsb03-dataelement-13529 link |
|
The coded value for Investigation requested SNOMED CT: - <71388002 |Procedure (procedure)| |
|
|
0 … 1 |
prsb03-dataelement-13530 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10734 link |
|
The status of the investigation request.draft | active | suspended | completed | entered-in-error | cancelled |
|
|
0 … 1 |
prsb03-dataelement-10737 link |
|
An explanation or justification for why this investigation is being requested.
SNOMED CT or text.
|
|
|
0 … 1 |
prsb03-dataelement-10738 link |
|
The urgency of the investigation requested. routine | urgent | asap | stat |
|
|
0 … 1 |
prsb03-dataelement-12090 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12091 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12092 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12093 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12094 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12095 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12096 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12097 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12098 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Examination findings |
|
0 … 1 |
prsb03-dataelement-557 link |
|
Examination findings |
|
|
Examination findings record entry |
|
0 … * |
prsb03-dataelement-10662 link |
|
This is a examination findings record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10462 link |
|
The date the examination was performed.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12116 link |
|
The professional who performed the examiniation. |
|
|
0 … 1 |
prsb03-dataelement-12117 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12118 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12119 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12120 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12121 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12122 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12123 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-10461 link |
|
The location where the examination was performed. |
|
|
0 … 1 |
prsb03-dataelement-13445 link |
|
The coded value for location |
|
|
0 … 1 |
prsb03-dataelement-13446 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10458 link |
|
The record of findings from the examinations performed. |
|
|
0 … 1 |
prsb03-dataelement-13443 link |
|
The coded value for examination findingsSNOMED CT : - ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13444 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10464 link |
|
The record of essential physiological measurements, e.g., heart rate, blood pressure,
temperature, pulse, height, weight, respiratory rate, oxygen saturation.
|
|
|
0 … 1 |
prsb03-dataelement-13447 link |
|
The coded value for observationsSNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13448 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12124 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12125 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12126 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12127 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12128 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12129 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12130 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12131 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12132 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10476 link |
|
Any further textual comment to clarify such as the statement that information is partial
or incomplete.Free text
|
|
Assessments |
|
0 … 1 |
prsb03-dataelement-262 link |
|
Assessment. |
|
|
Assessments record entry |
|
0 … * |
prsb03-dataelement-11664 link |
|
This is the assessments record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10763 link |
|
The date the assessment was done.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-10764 link |
|
The location where the assessment was done.ODS code or free text. |
|
|
0 … 1 |
prsb03-dataelement-13570 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13571 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10822 link |
|
The type of the assessment e.g. social care needs assessment.Free text |
|
|
0 … 1 |
prsb03-dataelement-10754 link |
|
The summary of the assessment Free text |
|
|
0 … 1 |
prsb03-dataelement-10655 link |
|
Details of the structured assessment. |
|
|
|
|
Structured assessment name |
|
0 … 1 |
prsb03-dataelement-11751 link |
|
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities
of Daily Living (ADL) etc.SNOMED CT or free text
|
|
|
0 … 1 |
prsb03-dataelement-10162 link |
|
The structured assessment score.SNOMED CT or free text. |
|
|
0 … 1 |
prsb03-dataelement-10163 link |
|
The structured assessment value.Free text, alphanumeric or SNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-10166 link |
|
The total global score from the assessment.Free text |
|
|
0 … 1 |
prsb03-dataelement-10169 link |
|
The subscale score of the structured assessment.SNOMED CT or free text. |
|
|
0 … 1 |
prsb03-dataelement-10170 link |
|
The subscale value of the structured assessment.Free text, alphanumeric or SNOMED CT. |
|
|
0 … 1 |
prsb03-dataelement-12382 link |
|
The professional who did the assessment. |
|
|
0 … 1 |
prsb03-dataelement-12383 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12384 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12385 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12386 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12387 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12388 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12389 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11752 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11753 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11754 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11755 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11756 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11757 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11758 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11759 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11760 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10164 link |
|
Supporting text may be given regarding the assessment.Free text |
|
Risks |
|
0 … 1 |
prsb03-dataelement-276 link |
|
Details of any risks related to the person. |
|
|
Risks to self |
|
0 … 1 |
prsb03-dataelement-10176 link |
|
Details of the persons risk to self |
|
|
0 … 1 |
prsb03-dataelement-11893 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11894 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13579 link |
|
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11895 link |
|
The location where the risk was identified. |
|
|
0 … 1 |
prsb03-dataelement-13586 link |
|
The coded value for location NHS data dictionary : - Organisation service code
|
|
|
0 … 1 |
prsb03-dataelement-13587 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11896 link |
|
The professional who identified the risk. |
|
|
0 … 1 |
prsb03-dataelement-11897 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11898 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11899 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11900 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11901 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11902 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11903 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11904 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11905 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11906 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11907 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11908 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11909 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11910 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11911 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11912 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Risks to others |
|
0 … 1 |
prsb03-dataelement-10177 link |
|
Details of the person's risk to others |
|
|
0 … 1 |
prsb03-dataelement-11913 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11914 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13580 link |
|
Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11915 link |
|
The location where the risk to others was identified. |
|
|
0 … 1 |
prsb03-dataelement-13588 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13589 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11916 link |
|
The professional who identifies the risk to others. |
|
|
0 … 1 |
prsb03-dataelement-11917 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11918 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11919 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11920 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11921 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11922 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11923 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11924 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11925 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11926 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11927 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11928 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11929 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11930 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11931 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11932 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Risk from others |
|
0 … 1 |
prsb03-dataelement-10178 link |
|
Risks to the person from an identified individual e.g. family member etc.Free Text. |
|
|
0 … 1 |
prsb03-dataelement-11933 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11934 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13581 link |
|
Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11935 link |
|
The location where the risk from others was identified. |
|
|
0 … 1 |
prsb03-dataelement-13590 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13591 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11936 link |
|
The professional who identified the risk from others. |
|
|
0 … 1 |
prsb03-dataelement-11937 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11938 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11939 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11940 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11941 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11942 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11943 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11944 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11945 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11946 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11947 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11948 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11949 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11950 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11951 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11952 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Risk of accidents |
|
0 … 1 |
prsb03-dataelement-10751 link |
|
Details of the risks the person poses to themselves from accidents.
|
|
|
0 … 1 |
prsb03-dataelement-11953 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11954 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13582 link |
|
Risks the person poses to themselves from accidents.Free text |
|
|
0 … 1 |
prsb03-dataelement-11955 link |
|
The location where the risk of accidents was identified. |
|
|
0 … 1 |
prsb03-dataelement-13592 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13593 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-11956 link |
|
The professional who identified the risk of accidents. |
|
|
0 … 1 |
prsb03-dataelement-11957 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11958 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11959 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11960 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11961 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11962 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11963 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11964 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11965 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11966 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11967 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11968 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11969 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11970 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11971 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11972 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Other risks |
|
0 … 1 |
prsb03-dataelement-10802 link |
|
Details of other risks, factors or behaviours relating to the person. |
|
|
0 … 1 |
prsb03-dataelement-11973 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11974 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13583 link |
|
Other risks, factors or behaviours relating to the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-11975 link |
|
The location where the other risks were identified. |
|
|
0 … 1 |
prsb03-dataelement-13594 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13595 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11976 link |
|
The professional who identified the other risks. |
|
|
0 … 1 |
prsb03-dataelement-11977 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11978 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11979 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11980 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-11981 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11982 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11983 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11984 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11985 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11986 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11987 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11988 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11989 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11990 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11991 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11992 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … * |
prsb03-dataelement-10657 link |
|
This is a allergies and adverse reactions record entry. There may be 1 to many record
entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10182 link |
|
The agent such as food, drug or substances that has caused or may cause an allergy,
intolerance or adverse reaction in this person Or “No known drug allergies or adverse
reactions” Or “Information not available”
|
|
|
0 … 1 |
prsb03-dataelement-13441 link |
|
The coded value for causative agentSNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product|
OR <716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy|
OR 196471000000108 |Transfer-degraded non-drug allergy)
|
|
|
0 … 1 |
prsb03-dataelement-13442 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10658 link |
|
Details of the reaction. |
|
|
0 … 1 |
prsb03-dataelement-10190 link |
|
The date that the reaction was identified.
This will often equate to the date of onset of the reaction but this may not be wholly
clear from source data.Date and time
|
|
|
0 … 1 |
prsb03-dataelement-10846 link |
|
Details of where the allergy was identified. |
|
|
0 … 1 |
prsb03-dataelement-13439 link |
|
The coded value for location.NHS data dictionary : - Organisation data service |
|
|
0 … 1 |
prsb03-dataelement-13440 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11665 link |
|
The substance, or a class of substances, that is considered to be responsible for
the adverse reaction.
|
|
|
0 … 1 |
prsb03-dataelement-13554 link |
|
The coded value for substance
SNOMED CT: -
|
|
|
0 … 1 |
prsb03-dataelement-13555 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10183 link |
|
A description of the manifestation of the allergic or adverse reaction experienced
by the person. For example, skin rash.
|
|
|
0 … 1 |
prsb03-dataelement-13556 link |
|
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13557 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10184 link |
|
A description of the severity of the reaction. |
|
|
0 … 1 |
prsb03-dataelement-13558 link |
|
The coded value for severity SNOMED CT: - ^999004521000000108 |Health issue severity simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13559 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10185 link |
|
A description of the certainty that the stated causative agent caused the allergic
or adverse reaction.
|
|
|
0 … 1 |
prsb03-dataelement-13560 link |
|
The coded value for certainty.SNOMED CT :- ^999004531000000105 |Health issue certainty simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13561 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10189 link |
|
Any additional comment or clarification about the adverse reaction.Free text |
|
|
0 … 1 |
prsb03-dataelement-12010 link |
|
The professional who identified the reaction. |
|
|
0 … 1 |
prsb03-dataelement-12011 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12012 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12013 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12014 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12015 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12016 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12017 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12018 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12019 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12020 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12021 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12022 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12023 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12024 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12025 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12026 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication administration record entry |
|
0 … * |
prsb03-dataelement-12483 link |
|
Each entry holds details of medications administered |
|
|
0 … 1 |
prsb03-dataelement-12484 link |
|
May be generic name or brand name. |
|
|
0 … 1 |
prsb03-dataelement-13663 link |
|
The coded value for medication name SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines
and devices virtual therapeutic moiety simple reference set (foundation metadata concept)|
OR ^999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104
|National Health Service dictionary of medicines and devices virtual medicinal product
pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National
Health Service dictionary of medicines and devices actual medicinal product simple
reference set (foundation metadata concept)| OR ^999000551000001106 |National Health
Service dictionary of medicines and devices actual medicinal product pack simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13664 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12485 link |
|
The route by which the medication is administered e.g. oral, IM, IV |
|
|
0 … 1 |
prsb03-dataelement-13661 link |
|
The coded value for routeSNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13662 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12487 link |
|
The quantity and units of medication administeredFree text. The quantity and units administered |
|
|
|
Administration date and time |
|
0 … 1 |
prsb03-dataelement-12486 link |
|
The date and time when the medication was administered.Date and time |
|
|
Medication item entry |
|
0 … 1 |
prsb03-dataelement-10663 link |
|
All medications and devices that can be prescribed to be entered via this Medication
item entry. Handles details of continuation / addition / amendment of admission medications.
|
|
|
0 … * |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
0 … 1 |
prsb03-dataelement-10843 link |
|
The date on which the medication or medical device was prescribed.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10844 link |
|
The location where the medication or the medical device was prescribed. |
|
|
0 … 1 |
prsb03-dataelement-13620 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13621 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12002 link |
|
The professional who prescribed the medication or medical device. |
|
|
0 … 1 |
prsb03-dataelement-12003 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12004 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12005 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12006 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12007 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12008 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12009 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-10536 link |
|
May be generic name or brand name. |
|
|
0 … 1 |
prsb03-dataelement-13622 link |
|
The coded value for medication name SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines
and devices virtual therapeutic moiety simple reference set (foundation metadata concept)|
OR ^999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104
|National Health Service dictionary of medicines and devices virtual medicinal product
pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National
Health Service dictionary of medicines and devices actual medicinal product simple
reference set (foundation metadata concept)| OR ^999000551000001106 |National Health
Service dictionary of medicines and devices actual medicinal product pack simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13623 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10537 link |
|
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
|
|
0 … 1 |
prsb03-dataelement-13624 link |
|
The coded value for form.
SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
|
|
|
0 … 1 |
prsb03-dataelement-13625 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10538 link |
|
The route by which the medication is administered e.g. oral, IM, IV |
|
|
0 … 1 |
prsb03-dataelement-13655 link |
|
The coded value for routeSNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13656 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10540 link |
|
The anatomical site at which the medication is to be administered. |
|
|
0 … 1 |
prsb03-dataelement-13657 link |
|
The coded value for siteSNOMED CT: - |
|
|
0 … 1 |
prsb03-dataelement-13658 link |
|
Amount of vaccine administered.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-10541 link |
|
The technique or method by which the medication is to be administered.Free text |
|
|
|
|
Dose directions description |
|
0 … 1 |
prsb03-dataelement-10544 link |
|
Describes the entire medication dosage and administration directions including dose
quantity and medication frequency and optionally duration e.g. “1 tablet at night"
or “2mg at 10pm”.
Free text
|
|
|
|
|
Structured dose direction cluster |
|
0 … 1 |
prsb03-dataelement-11639 link |
|
A structural representation of the elements carried by the dose syntax in 'parsable
dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum
dose.
|
|
|
0 … 1 |
prsb03-dataelement-10554 link |
|
A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will
generally only be used when persisting data within systems with 'parsable dose directions'
being used to exchange the same information between systems.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
|
|
|
0 … 1 |
prsb03-dataelement-10555 link |
|
A slot containing a structural, computable representation of dose timing and maximum
dose. This element will generally only be used when persisting data within systems
with 'parsable dose directions' being used to exchange the same information between
systems.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
|
|
|
0 … 1 |
prsb03-dataelement-10548 link |
|
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10545 link |
|
Allows for: requirements for adherence support, e.g. compliance aids, prompts and
packaging requirements, additional information about specific medicines e.g. where
specific brand required, person requirements, e.g. unable to swallow tablets.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10666 link |
|
The status of this prescription.FHIR value set : - Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
|
0 … 1 |
prsb03-dataelement-10667 link |
|
The date and/or time that the medication course should begin.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10557 link |
|
The date and/or time that the medication course should finish.Date and time |
|
|
|
|
|
Link to indication record |
|
0 … 1 |
prsb03-dataelement-10668 link |
|
A link to the record which contains the indication for this medication order.Free text with URL |
|
|
0 … 1 |
prsb03-dataelement-10547 link |
|
Suggestions about duration and/or review, ongoing monitoring requirements, advice
on starting, discontinuing or changing medication. Additional comment or recommendation
about the medication course e.g. 'Patient named supply', 'unlicensed medication',
'Foreign brand' or monitoring recommendationsFree text
|
|
|
|
|
Medication change summary cluster |
|
0 … 1 |
prsb03-dataelement-10568 link |
|
Records the changes made to medication. |
|
|
0 … 1 |
prsb03-dataelement-10669 link |
|
The nature of any change made to the medication.FHIR value set : Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10670 link |
|
Reason for change in medication, e.g. sub-therapeutic dose, person intolerant. Free text |
|
|
0 … 1 |
prsb03-dataelement-10671 link |
|
The date of the change - addition, or amendmentDate and time |
|
|
0 … 1 |
prsb03-dataelement-10672 link |
|
Where a change is made to the medication i.e. one drug stopped and another started
or eg dose, frequency or route is changed.Free text
|
|
|
|
|
Total dose daily quantity |
|
0 … 1 |
prsb03-dataelement-10665 link |
|
The total daily dose of this medication. This is helpful for estimating optimal adherence
to dosing guidance. It may be computed from product/dose strength and frequency or
entered manually. Free text
|
|
|
0 … 1 |
prsb03-dataelement-11993 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11994 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11995 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-11996 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11997 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-11998 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11999 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12000 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12001 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
|
Medication discontinued entry |
|
0 … * |
prsb03-dataelement-10576 link |
|
Medication discontinued entry |
|
|
|
|
Name of discontinued medication |
|
0 … 1 |
prsb03-dataelement-10577 link |
|
The name of the medication or medical device being discontinued |
|
|
0 … 1 |
prsb03-dataelement-13659 link |
|
The coded value for medication name |
|
|
0 … 1 |
prsb03-dataelement-13660 link |
|
Amount of vaccine administered.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-12472 link |
|
The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10579 link |
|
The clinical indication for any changes in medication statusFree text |
|
|
0 … 1 |
prsb03-dataelement-10580 link |
|
The date of the discontinuationDate and time |
|
|
0 … 1 |
prsb03-dataelement-10582 link |
|
Any additional comment about the discontinuation.Free text |
|
|
0 … * |
prsb03-dataelement-10583 link |
|
Medical devices |
|
|
0 … 1 |
prsb03-dataelement-10673 link |
|
Any medical device that isn't prescribed.Free text |
|
|
0 … 1 |
prsb03-dataelement-11280 link |
|
Any information regarding the medical device.Free text |
|
Care and support plan |
|
0 … 1 |
prsb03-dataelement-508 link |
|
This records the decisions reached during conversation between the individual and
health and care professional about future plans and also records progress.
|
|
|
Strengths |
|
0 … 1 |
prsb03-dataelement-10419 link |
|
Any strengths and assets the person has relating to their goals and hopes about their
health and well-being.Free text
|
|
|
Needs, concerns or health problems |
|
0 … 1 |
prsb03-dataelement-10414 link |
|
Needs, concerns or health problems the person has that relating to their health and
well-being.Free text. May be linked to the problem list from the person’s record to avoid duplication.
|
|
|
Goals and hopes |
|
0 … 1 |
prsb03-dataelement-10413 link |
|
The overall goals, hopes, aims or targets that the person has.
Including anything that the person wants to achieve that relates to their future
health and wellbeing.
Each goal may include a description of why it is important to the person.
Goals may also be ranked in order of importance or priority to the person.Free text. May be SNOMED CT coded.
Coded status of goal: Achieved, partially achieved, not achieved, Not applicable
|
|
|
Actions and activities |
|
0 … 1 |
prsb03-dataelement-10408 link |
|
Actions or activities the person or others plan to take to achieve the person's goals
and the resources required to do this.
|
|
|
0 … 1 |
prsb03-dataelement-10674 link |
|
A specific sub-goal that is related to the overall goal as agreed by the person in
collaboration with a professional.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10675 link |
|
What the action is and how it is to be carried out?Free text. |
|
|
0 … 1 |
prsb03-dataelement-10676 link |
|
Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying
out the proposed action, and, if relevant where action should take place.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-10677 link |
|
Planned date, time, or interval, as relevantDate and time or free text. |
|
|
0 … 1 |
prsb03-dataelement-10678 link |
|
Suggested strategies for potential problems.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10679 link |
|
The status of the action or activity e.g. started, not started, completed, not applicable.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10680 link |
|
How confident the person feels to carry it outFree text. |
|
|
0 … 1 |
prsb03-dataelement-10681 link |
|
The outcome of the stage goalFree text. |
|
|
0 … 1 |
prsb03-dataelement-10682 link |
|
Date when action/activity record was last updatedDate and time |
|
|
0 … 1 |
prsb03-dataelement-10683 link |
|
When the stage goal and action need to be reviewed.Date and time. |
|
|
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10409 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.A record of the agreement of the decisions made.
|
|
|
Care funding source |
|
0 … 1 |
prsb03-dataelement-10410 link |
|
A reference to the funding source and any conditions or limitations associated.Free text |
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10412 link |
|
This is a record of the date that this care and support plan was last updated.Date and time |
|
|
Other care planning documents |
|
0 … 1 |
prsb03-dataelement-10415 link |
|
Reference other care planning documents, including the type, location and date.
This may include condition-specific plans, advance care plans, end of life care plan,
etc.Free text.
|
|
|
Outcomes |
|
0 … 1 |
prsb03-dataelement-10416 link |
|
Outcomes of each of the person’s goals, aims and targets.
Includes comments recorded by the person, date and status.Free text.May be SNOMED CT coded.
Coded text: fully achieved, partially achieved, not achieved, on-going, no longer
applicable.
|
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10417 link |
|
This is the date/interval when this information will next be reviewed.Date and time or free text. |
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10418 link |
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.Free text.
|
|
|
Location |
|
0 … 1 |
prsb03-dataelement-12044 link |
|
The location where the care and support plan was prepared. |
|
|
0 … 1 |
prsb03-dataelement-13665 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13666 link |
|
Free text field to be used if no coded text available
|
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12027 link |
|
The professional who prepared the care and support plan. |
|
|
0 … 1 |
prsb03-dataelement-12028 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12029 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12030 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12031 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12032 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12033 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12034 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-12035 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12036 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12037 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12038 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12039 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12040 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12041 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12042 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12043 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Contingency plans |
|
0 … 1 |
prsb03-dataelement-469 link |
|
Contingency plans. |
|
|
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10369 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.Free text
|
|
|
Anticipatory medicines/equipment |
|
0 … 1 |
prsb03-dataelement-10370 link |
|
Medicines or equipment available that may be required in specific situations and their
location.Free text. A statement regarding the availability or location of the anticipatory
medicines/equipment.
|
|
|
Contingency plan name |
|
0 … 1 |
prsb03-dataelement-10371 link |
|
Name of the contingency plan – what condition or circumstances it is addressing.SNOMED CT or free text. |
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10372 link |
|
The date that this contingency plan was last updated.Date and time |
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10373 link |
|
This is the date/interval when this contingency plan will next be reviewed.Date and time or free text. |
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10374 link |
|
This is who has responsibility for arranging review of this information.
Should include their name, role and contact details.Free text.
|
|
|
Trigger factors |
|
0 … 1 |
prsb03-dataelement-10375 link |
|
Signs to watch out for that may indicate a significant change in health or other circumstances.Free text.
A statement of trigger factors.
|
|
|
What should happen |
|
0 … 1 |
prsb03-dataelement-10376 link |
|
Guidance on specific actions or interventions that may be required or should be avoided
in specific situations.
This may include circumstances where action needs to be taken if a carer is unable
to care for the person.Free text.
A statement of suggested actions. Usually expressed as: in the event of X do Y.
|
|
|
Who should be contacted |
|
0 … 1 |
prsb03-dataelement-10377 link |
|
Who should be contacted in the event of significant problems or deterioration in health
or wellbeing. E.g. name, role and contact details.Free text. This may be obtained from the record of professional or personal contacts
elsewhere in the person’s record.
|
|
|
Location |
|
0 … 1 |
prsb03-dataelement-12079 link |
|
The location where the contingency plan was prepared. |
|
|
0 … 1 |
prsb03-dataelement-13667 link |
|
The coded value for location NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13668 link |
|
Free text field to be used if no code is availableFree text |
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12045 link |
|
The professional who prepared the contingency plans. |
|
|
0 … 1 |
prsb03-dataelement-12046 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12047 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12048 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12049 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12050 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12051 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12052 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-12053 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12054 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12055 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12056 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12057 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12058 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12059 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12060 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12061 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Additional support plans |
|
0 … 1 |
prsb03-dataelement-502 link |
|
Additional support plans |
|
|
Additional support plan name |
|
0 … 1 |
prsb03-dataelement-10402 link |
|
The name of the particular additional supporting plan, e.g. dieticians plan, wound
management plan, discharge management plan and behaviour support plan.Free text
|
|
|
Additional support plan content |
|
0 … 1 |
prsb03-dataelement-10403 link |
|
This is the content of any additional care and support plan which the person and/or
care professional consider should be shared with others providing care and support.Free text. May be structured in different ways, eg tables, diagrams, images. This
is the content of any additional care and support plan which the individual and/or
care professional consider should be shared with others providing care and support.
It should be structured as recommended for the care and support plan and if contains
additional detail, it may be referenced here.
|
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10405 link |
|
This is the date/interval when this information will next be reviewed.Date and time or free text. |
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10406 link |
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.Free text.
|
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10407 link |
|
This is a record of the date that this information was last updated.Date and time |
|
|
Location |
|
0 … 1 |
prsb03-dataelement-12080 link |
|
The location where the additional support plan was prepared.ODS code or free text |
|
|
0 … 1 |
prsb03-dataelement-13722 link |
|
The coded value for locationNHS data dictionary:- Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13723 link |
|
Free text field to be used if no code is availableFree text |
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12062 link |
|
The professional who prepared the additional support plan. |
|
|
0 … 1 |
prsb03-dataelement-12063 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12064 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12065 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12066 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12067 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12068 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12069 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-12070 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12071 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12072 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12073 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12074 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12075 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12076 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12077 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12078 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
End of life care |
|
0 … 1 |
prsb03-dataelement-10743 link |
|
Information relating to end of life care.
N.B. This is not an end of life care plan but contains information that would be found
in an end of life care plan.
|
|
|
Cardio-pulmonary resuscitation (CPR) decision |
|
0 … 1 |
prsb03-dataelement-10771 link |
|
Whether a decision has been made, the decision, who made the decision, the date of
decision, date for review and location of documentation. Where the person or their
family member/carer have not been informed of the clinical decision please state the
reason why.
|
|
|
0 … 1 |
prsb03-dataelement-12210 link |
|
The date when the cardio-pulmonary resuscitation decision was made.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12211 link |
|
The location where the cardio-pulmonary resuscitation decision was made. |
|
|
0 … 1 |
prsb03-dataelement-13689 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13690 link |
|
Free text field to be used if no coded text available
|
|
|
|
Cardio-pulmonary resuscitation (CPR) decision |
|
0 … 1 |
prsb03-dataelement-13686 link |
|
The cardio-pulmonary resuscitation (CPR) decision. |
|
|
0 … 1 |
prsb03-dataelement-13687 link |
|
The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008
| Not for cardiopulmonary resuscitation (finding) |
|
|
|
0 … 1 |
prsb03-dataelement-13688 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13705 link |
|
The date for review of CPR decision.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13706 link |
|
The location of the CPR decision documentFree text or URL |
|
|
0 … 1 |
prsb03-dataelement-12212 link |
|
The professional who made the cardio-pulmonary resuscitation decision. |
|
|
0 … 1 |
prsb03-dataelement-12213 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12214 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12215 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12216 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12217 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12218 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12219 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12220 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12221 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12222 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12223 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12224 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12225 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12226 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12227 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12228 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Estimated prognosis |
|
0 … 1 |
prsb03-dataelement-10745 link |
|
Details of the persons estimated prognosis
|
|
|
0 … 1 |
prsb03-dataelement-12229 link |
|
The date when the estimated prognosis was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12230 link |
|
The location where the estimated prognosis was made.ODS code or free text |
|
|
0 … 1 |
prsb03-dataelement-13703 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13704 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-13691 link |
|
Where a person is terminally ill this is a clinical judgment indicating the anticipated
period of time until death e.g. last days, weeks, months or year of life. Free text
|
|
|
0 … 1 |
prsb03-dataelement-12231 link |
|
The professional who made the estimated prognosis. |
|
|
0 … 1 |
prsb03-dataelement-12232 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12233 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12234 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12235 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12236 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12237 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12238 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12239 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12240 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12241 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12242 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12243 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12244 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12245 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12246 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12247 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Awareness of prognosis |
|
0 … 1 |
prsb03-dataelement-10775 link |
|
Details of the persons awareness of prognosis
|
|
|
0 … 1 |
prsb03-dataelement-12248 link |
|
The date when the assessment of the level of awareness of the prognosis was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12249 link |
|
The location where the assessment of the level of awareness of the prognosis was made.ODS code and free text |
|
|
0 … 1 |
prsb03-dataelement-13693 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13694 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13692 link |
|
Description of the level of awareness the person and or their carer/family has regarding
their estimated prognosis.Free text
|
|
|
0 … 1 |
prsb03-dataelement-12250 link |
|
The professional who made the assessment of the level of awareness of the prognosis. |
|
|
0 … 1 |
prsb03-dataelement-12251 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12252 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12253 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12254 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12255 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12256 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12257 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12258 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12259 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12260 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12261 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12262 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12263 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12264 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12265 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12266 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Advance statement |
|
0 … 1 |
prsb03-dataelement-10777 link |
|
Written requests and preferences made by a person with capacity conveying their wishes,
beliefs and values for their future care should they lose capacity.
|
|
|
|
0 … 1 |
prsb03-dataelement-12267 link |
|
The date when the advanced statements was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12268 link |
|
The location where the advanced statement was made. |
|
|
0 … 1 |
prsb03-dataelement-13698 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13699 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13695 link |
|
Does the person have an advance statement.
|
|
|
0 … 1 |
prsb03-dataelement-13696 link |
|
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding)
|
|
|
|
0 … 1 |
prsb03-dataelement-13697 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13760 link |
|
The location of where the advanced statement is held.Free text or URL |
|
|
0 … 1 |
prsb03-dataelement-12269 link |
|
The professional who made the advance statement. |
|
|
0 … 1 |
prsb03-dataelement-12270 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12271 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12272 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12273 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12274 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12275 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12276 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12277 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12278 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12279 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12280 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12281 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12282 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12283 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12284 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12285 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Anticipatory actions |
|
0 … * |
prsb03-dataelement-10786 link |
|
Details of the person's anticipatory actions
|
|
|
0 … 1 |
prsb03-dataelement-12286 link |
|
The date when the anticipatory actions were identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12287 link |
|
The location where the anticipatory actions were identified. |
|
|
0 … 1 |
prsb03-dataelement-13701 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13702 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-13700 link |
|
Guidance on specific interventions or actions that may be required or should be avoided
in specific situations. A statement of anticipatory actions. Usually expressed as:
in the event of X do Y.Free text
|
|
|
0 … 1 |
prsb03-dataelement-12288 link |
|
The professional who identified the anticipatory actions. |
|
|
0 … 1 |
prsb03-dataelement-12289 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12290 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12291 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12292 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12293 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12294 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12295 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12296 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12297 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12298 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12299 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12300 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12301 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12302 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12303 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12304 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Anticipatory medicines/equipment |
|
0 … * |
prsb03-dataelement-10785 link |
|
Details of the persons availability or location regarding their anticipatory medicines/equipment. |
|
|
0 … 1 |
prsb03-dataelement-12305 link |
|
The date when the statement regarding anticipatory medicines/equipment was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12306 link |
|
The location where the statement regarding anticipatory medicines/equipment was made. |
|
|
0 … 1 |
prsb03-dataelement-13708 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13709 link |
|
Free text field to be used if no coded text available
|
|
|
|
Anticipatory medicines/equipment |
|
0 … 1 |
prsb03-dataelement-13707 link |
|
A statement regarding the availability or location of the anticipatory medicines/equipment.Free text |
|
|
0 … 1 |
prsb03-dataelement-12307 link |
|
The professional who made the statement regarding anticipatory medicines/equipment
was made.
|
|
|
0 … 1 |
prsb03-dataelement-12308 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12309 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12310 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12311 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12312 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12313 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12314 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12315 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12316 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12317 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12318 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12319 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12320 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12321 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12322 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12323 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Preferred place of death |
|
0 … 1 |
prsb03-dataelement-10780 link |
|
Details of the person's preferred place of death
|
|
|
0 … 1 |
prsb03-dataelement-12324 link |
|
The date when the preferred place of death was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12325 link |
|
The location where the preferred place of death was identified. |
|
|
0 … 1 |
prsb03-dataelement-13713 link |
|
The coded value for location NHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13714 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Preferred place of death 1st |
|
0 … 1 |
prsb03-dataelement-13710 link |
|
The preferences that a person has identified as their preferred place to die. |
|
|
0 … 1 |
prsb03-dataelement-13711 link |
|
The name of the preferred place of deathFree text |
|
|
0 … 1 |
prsb03-dataelement-13712 link |
|
The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's
own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient
specialist palliative care)40: Care Home50: Other (free text eg secure and detained
settings)517111000000103, Preferred place of death: patient unable to express preference
517131000000106, Preferred place of death: discussion not appropriate766391000000108,
Preferred place of death: patient declined discussion517161000000101, Preferred place
of death: patient undecided
|
|
|
|
Preferred place of death 2nd |
|
0 … 1 |
prsb03-dataelement-13716 link |
|
The preferences that a person has identified as their preferred place to die. |
|
|
0 … 1 |
prsb03-dataelement-13717 link |
|
The name of the preferred place of deathFree text |
|
|
0 … 1 |
prsb03-dataelement-13718 link |
|
The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's
own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient
specialist palliative care)40: Care Home50: Other (free text eg secure and detained
settings)517111000000103, Preferred place of death: patient unable to express preference
517131000000106, Preferred place of death: discussion not appropriate766391000000108,
Preferred place of death: patient declined discussion517161000000101, Preferred place
of death: patient undecided
|
|
|
0 … 1 |
prsb03-dataelement-12326 link |
|
The professional who identified the preferred place of death. |
|
|
0 … 1 |
prsb03-dataelement-12327 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12328 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12329 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12330 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12331 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12332 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12333 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12334 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12335 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12336 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12337 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12338 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12339 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12340 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12341 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12342 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
Preferred place of care |
|
0 … 1 |
prsb03-dataelement-10781 link |
|
Details of the persons preferred place of care
|
|
|
0 … 1 |
prsb03-dataelement-12362 link |
|
The date when the preferred place of care was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12363 link |
|
The location where the preferred place of care was identified. |
|
|
0 … 1 |
prsb03-dataelement-13720 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13721 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13719 link |
|
The preferences that the person has identified as their preferred place to receive
care.Free text
|
|
|
0 … 1 |
prsb03-dataelement-12364 link |
|
The professional who identified the preferred place of care. |
|
|
0 … 1 |
prsb03-dataelement-12365 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12366 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12367 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12368 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12369 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12370 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12371 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-12372 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12373 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12374 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12375 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12376 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12377 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12378 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12379 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12380 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
Documents (including correspondence and images) |
|
0 … 1 |
prsb03-dataelement-10820 link |
|
Details about documents related to the person. |
|
|
Documents |
|
0 … * |
prsb03-dataelement-11259 link |
|
This is the documents record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10943 link |
|
The date and time the document was created.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12422 link |
|
The professional who authored the document.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12423 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12424 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12425 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12426 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12427 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12428 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12429 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-10946 link |
|
The URL for the document.Free text |
|
|
0 … 1 |
prsb03-dataelement-10942 link |
|
The code specifying the level of confidentiality of the document.
Free text, recommend the use of the FHIR values set.
https://www.hl7.org/fhir/v3/ConfidentialityClassification/vs.html
|
|
|
0 … 1 |
prsb03-dataelement-10940 link |
|
The document type e.g. report, summary, images, treatment plan, patient preferences,
workflowSNOMED CT or free text.
|
|
|
0 … 1 |
prsb03-dataelement-10944 link |
|
The title of the document.Free text |
|
|
0 … 1 |
prsb03-dataelement-10945 link |
|
The name of the document.
This should align to the PRSB document naming standard.
Where the document is a KOS document this field (designated typeCode) is used to carry
the DICOM Imaging procedure:
This attribute shall be populated by the XDS-I Imaging Document Source from a code
in the Procedure Code Sequence (0008,1032) of the performed procedure with which the
document is associated.
Values may be found in a suitable DICOM browser
Snomed CT code
As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
|
|
|
0 … 1 |
prsb03-dataelement-10949 link |
|
MIME type of the document e.g. application, pdfFree text |
|
|
0 … 1 |
prsb03-dataelement-12430 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12431 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12432 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12433 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12434 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12435 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12436 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12437 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12438 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
0 … 1 |
prsb03-dataelement-11163 link |
|
The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple
reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-10941 link |
|
Comments associated with the document.Free text |
|
|
|
Additional information required for images. |
|
0 … 1 |
prsb03-dataelement-12449 link |
|
Additional information required for images. |
|
|
0 … 1 |
prsb03-dataelement-12450 link |
|
The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
|
|
|
0 … 1 |
prsb03-dataelement-12451 link |
|
The date and time the image procedure was performed.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12452 link |
|
The professional who performed the image procedure. |
|
|
0 … 1 |
prsb03-dataelement-12453 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12454 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcNHS data dictionary:- Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12455 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12456 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-12457 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12458 link |
|
The name of the organisation the professional works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12459 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text. |
|
|
0 … 1 |
prsb03-dataelement-11158 link |
|
|
0 … 1 |
prsb03-dataelement-11159 link |
|
The date and time when the image was captured.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12460 link |
|
A unique image identifier generated by the system. Free text |
|
|
0 … 1 |
prsb03-dataelement-12461 link |
|
The URL for the imageFree text |
|
|
0 … 1 |
prsb03-dataelement-11161 link |
|
The format code of the document which provides information on how to display the document. Free text |
|
|
0 … 1 |
prsb03-dataelement-11160 link |
|
The type of image (acquisition modality) and the anatomical site imaged. DICOM code or free text. |
|
|
0 … 1 |
prsb03-dataelement-12462 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12463 link |
|
The name of the person completing the record.
Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12464 link |
|
The organisational role of the person completing record.NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-12465 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12466 link |
|
The main specialty of the person completing the record.NHS data dictionary - Main specialty
|
|
|
0 … 1 |
prsb03-dataelement-12467 link |
|
The organisation the person completing the record works for.
NHS data dictionary: -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12468 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12469 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12470 link |
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).Free text.
|
|
|
0 … 1 |
prsb03-dataelement-12471 link |
|
Comments associated with the imagingFree text |
Scenario Care home information 2.16.840.1.113883.3.1937.777.28.3.21
Care home information
Care home information
Response