| Name |
Details [‑] |
 Community Pharmacy Standard
prsb03-scenario-29
|
|
| Version / effective date |
1.1 - 2020‑09‑17 16:11:44 |
|
 Medication Review
prsb03-transaction-162 link
|
|
| Version / effective date |
1.1 - 2020‑09‑17 16:11:44 |
|
|
|
|
 |
  Medication Review (pharmacy record)
prsb03-transaction-163 link
|
|
| Version / effective date |
1 - 2020‑09‑17 16:11:44 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 |
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 |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 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 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 … * |
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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 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 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - 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 … * |
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 … * |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
1 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … 1 |
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 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … * |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-547 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anaesthesia issues, etc (with obstetric history).
|
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-12476 link |
|
The record of the person's significant medical, surgical and mental health history
(will include dental and obstetric history). Including relevant previous diagnoses,
problems and issues, procedures, investigations, specific anaesthesia issues, etc.
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form.
|
|
Allergies and adverse reactions |
|
0 … * |
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.
|
|
|
1 … 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-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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … * |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
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 … 1 |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
1 … 1 Mandatory |
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 … * |
prsb03-dataelement-10538 link |
|
The route by which the medication is administered e.g. oral, IM, IV |
|
|
|
|
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
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … * |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
 Medication Review (GP)
prsb03-transaction-164 link
|
|
| Version / effective date |
1.1 - 2020‑09‑17 16:11:44 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … 1 |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
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-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … * |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication item entry |
|
0 … * |
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 |
|
|
1 … 1 Mandatory |
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 … * |
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 |
|
|
|
|
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
|
|
|
|
|
Matters identified during discussion |
|
1 … * Mandatory |
prsb03-dataelement-13753 link |
|
Matters identified during the service about the patient's experience of using the
medication.
Coded text using the following descriptors:
a. patient reports using the medicine as prescribed
b. patient reports not using the medicine as prescribed
c. patient has not started using the medicine
d. prescriber has stopped new medicine
e. patient is not using the medicine in line with the directions of the prescriber
f. patient reports missing a dose in the past 7 days
g. patient reports need for more information about the medicine
h. patient reports side effects
i. patient reports negative feelings about the medicine
j. patient reports uncertainty on whether the medicine is working
k. patient reports concern about remembering to take the medicine
l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation
i. other - free text option
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … 1 |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
New Medicine Service
prsb03-transaction-165 link
|
|
| Version / effective date |
1.1 - 2020‑09‑17 16:14:21 |
|
|
|
|
 |
New Medicine Service (Pharmacy Record)
prsb03-transaction-166 link
|
|
| Version / effective date |
1 - 2020‑09‑17 16:14:21 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
|
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link |
|
The person's details and contact information.
|
|
|
Person name |
|
1 … 1 |
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 |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary: - Person gender code
|
|
|
Sex |
|
1 … 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 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 … * |
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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 |
prsb03-dataelement-13082 link |
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
|
1 … 1 |
prsb03-dataelement-13083 link |
|
Person's second line of address.NHS data dictionary :- Address line 2 |
|
|
1 … 1 |
prsb03-dataelement-13084 link |
|
Person's third line of address. NHS data dictionary :- Address line 3 |
|
|
1 … 1 |
prsb03-dataelement-13085 link |
|
Person's fourth line of address.NHS data dictionary :- Address line 4 |
|
|
1 … 1 |
prsb03-dataelement-13086 link |
|
Person's fifth line of address.NHS data dictionary:- Address line 5 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - Postcode
|
|
|
1 … 1 |
prsb03-dataelement-13221 link |
|
The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
|
|
|
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 … * |
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 … * |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
0 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … 1 |
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 … * |
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
|
|
|
1 … 1 |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Referrer Details |
|
0 … 1 |
prsb03-dataelement-10714 link |
|
|
Date and time of referral |
|
0 … 1 |
prsb03-dataelement-10717 link |
|
Date and time the patient was referred to the service. |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10716 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.
|
|
|
Referrer details |
|
0 … 1 |
prsb03-dataelement-10715 link |
|
Details of the source of the referral. Name, role, grade, organisation and contact
details of referrer, or details of the person making the contact for ambulance or
urgent care services. If not an individual, this could be e.g. GP surgery, department,
specialty, sub-specialty, educational institution, mental health team etc. Also needs
to include self-referral.Sent as per the ECDS Emergency Care Attendance Source code set (SNOMED CT).
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … * |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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. |
|
Reason for Referral |
|
0 … 1 |
prsb03-dataelement-460 link |
|
Reason for Referral |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10360 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.Free text
|
|
|
Clinical urgency of referral |
|
0 … 1 |
prsb03-dataelement-10361 link |
|
Referrer’s assessment of urgency (e.g. urgent/ soon/ routine). May include reason
if other than routine. E.g. two data items:
* level of urgency
* reason.PRIORITY TYPE (NHS Data Dictionary) free text reason https://www.datadictionary.nhs.uk/web_site_content/pages/search_pages/dosearch.asp
|
|
|
Expectation of referral |
|
0 … * |
prsb03-dataelement-10362 link |
|
A clear statement of the expectations of the person making the referral as to the
management of the patient e.g. advice only, diagnosis, treatment, etc.
To Include any specific patient expectation
In general text. Risk not put in a procedure not already receivedFree text
|
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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-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-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
1 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … 1 |
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.
|
|
|
1 … 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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
New Medicine Service (GP)
prsb03-transaction-167 link
|
|
| Version / effective date |
1.1 - 2020‑09‑17 16:14:21 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … 1 |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * |
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.
|
|
|
1 … 1 Mandatory |
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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
Free text
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication item entry |
|
0 … * |
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 … 1 |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
1 … 1 Mandatory |
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 … * |
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 |
|
|
|
|
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
|
|
|
|
|
Matters identified during discussion |
|
1 … * Mandatory |
prsb03-dataelement-13753 link |
|
Matters identified during the service about the patient's experience of using the
medication.
Coded text using the following descriptors:
a. patient reports using the medicine as prescribed
b. patient reports not using the medicine as prescribed
c. patient has not started using the medicine
d. prescriber has stopped new medicine
e. patient is not using the medicine in line with the directions of the prescriber
f. patient reports missing a dose in the past 7 days
g. patient reports need for more information about the medicine
h. patient reports side effects
i. patient reports negative feelings about the medicine
j. patient reports uncertainty on whether the medicine is working
k. patient reports concern about remembering to take the medicine
l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation
i. other - free text option
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
Appliance Use Review
prsb03-transaction-192 link
|
|
| Version / effective date |
1.1 - 2020‑10‑12 12:31:01 |
|
|
|
|
 |
Appliance Review (Pharmacy Record)
prsb03-transaction-193 link
|
|
| Version / effective date |
1 - 2020‑10‑12 12:31:01 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
|
Person demographics |
|
1 … 1 |
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 |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary: - Person gender code
|
|
|
Sex |
|
1 … 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 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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 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 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - 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 … * |
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 … * |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
0 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … 1 |
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 … * |
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
|
|
|
1 … 1 |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Referrer Details |
|
0 … 1 |
prsb03-dataelement-10714 link |
|
|
Date and time of referral |
|
0 … 1 |
prsb03-dataelement-10717 link |
|
Date and time the patient was referred to the service. |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10716 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.
|
|
|
Referrer details |
|
0 … 1 |
prsb03-dataelement-10715 link |
|
Details of the source of the referral. Name, role, grade, organisation and contact
details of referrer, or details of the person making the contact for ambulance or
urgent care services. If not an individual, this could be e.g. GP surgery, department,
specialty, sub-specialty, educational institution, mental health team etc. Also needs
to include self-referral.Sent as per the ECDS Emergency Care Attendance Source code set (SNOMED CT).
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
0 … 1 |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … * |
prsb03-dataelement-10712 link |
|
The name and designation of any chaperone(s). |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-547 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anaesthesia issues, etc (with obstetric history).
|
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-12476 link |
|
The record of the person's significant medical, surgical and mental health history
(will include dental and obstetric history). Including relevant previous diagnoses,
problems and issues, procedures, investigations, specific anaesthesia issues, etc.
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form.
|
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … 1 |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13765 link |
|
The product order number for the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13766 link |
|
|
0 … 1 |
prsb03-dataelement-13767 link |
|
The batch number of the appliance.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
|
|
Matters identified during the discussion |
|
1 … * |
prsb03-dataelement-13775 link |
|
Matters identified during the service about the patient's experience of using the
appliance. To include e.g, patient using/not using the appliance as prescribed, patient
reports negative feelings about the appliance etc. Also to include whether the information
was provided by the patient or somebody else (e.g. a relative, carer etc) e.g. patient
using/not using the appliance as prescribed, patient reports negative feelings about
the appliance etc.Free text
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … 1 |
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.
|
|
|
1 … 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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Information and advice given |
|
0 … * |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
Appliance Use Review (GP)
prsb03-transaction-194 link
|
|
| Version / effective date |
1.1 - 2020‑10‑12 12:31:01 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * Mandatory |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … * |
prsb03-dataelement-10712 link |
|
The name and designation of any chaperone(s). |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … * |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13765 link |
|
The product order number for the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13766 link |
|
|
0 … 1 |
prsb03-dataelement-13767 link |
|
The batch number of the appliance.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13795 link |
|
The following value set may be applicable, but would need validating for appliances:
• Coded text – constraint: NHS e-prescribing route of administration subset ID: 413001000001136
Original Id : 30201000001137 This is an extract from the SUBSET -BiAnnual-Drug-15.0.1-20130401:
SnomedCT_GB1000001_20130401/Subsets/EPrescribing/NHS e-Prescribing route of administration
subset. Constraint binding: [SNOMED-CT]subset=NHS e-Prescribing route of administration
subset
|
|
|
0 … 1 |
prsb03-dataelement-13794 link |
|
Free text field to be used if no code available
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13797 link |
|
Coded value for site
The following value set may be applicable, but would need validating for appliances:
• Coded text – constraint: SiteOfMedicationAdministration. Any valid site for the
administration of a medication. Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration
|
|
|
0 … 1 |
prsb03-dataelement-13796 link |
|
Free text field to be used if no code is available Free text |
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
|
|
Matters identified during the discussion |
|
1 … * Mandatory |
prsb03-dataelement-13775 link |
|
Matters identified during the service about the patient's experience of using the
appliance. To include e.g, patient using/not using the appliance as prescribed, patient
reports negative feelings about the appliance etc. Also to include whether the information
was provided by the patient or somebody else (e.g. a relative, carer etc) e.g. patient
using/not using the appliance as prescribed, patient reports negative feelings about
the appliance etc.Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
Vaccination Administration
prsb03-transaction-195 link
|
|
| Version / effective date |
1.1 - 2020‑10‑12 14:16:40 |
|
|
|
|
 |
Vaccination Administration (Pharmacy Records)
prsb03-transaction-196 link
|
|
| Version / effective date |
1 - 2020‑10‑12 14:16:40 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
|
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link |
|
The person's details and contact information.
|
|
|
Person name |
|
1 … 1 |
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
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary: - Person gender code
|
|
|
Sex |
|
1 … 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 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 … * |
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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 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 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - Postcode
|
|
|
Person's email address |
|
0 … 1 |
prsb03-dataelement-10882 link |
|
Email address of the person.NHS data dictionary :- Email address
|
|
|
Preferred contact method |
|
0 … * |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
0 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … 1 |
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 … * |
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
|
|
|
1 … 1 |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … * |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree 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. |
|
Reason for Referral |
|
0 … 1 |
prsb03-dataelement-460 link |
|
Reason for Referral |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10360 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.Free text
|
|
|
Clinical urgency of referral |
|
0 … 1 |
prsb03-dataelement-10361 link |
|
Referrer’s assessment of urgency (e.g. urgent/ soon/ routine). May include reason
if other than routine. E.g. two data items:
* level of urgency
* reason.PRIORITY TYPE (NHS Data Dictionary) free text reason https://www.datadictionary.nhs.uk/web_site_content/pages/search_pages/dosearch.asp
|
|
|
Expectation of referral |
|
0 … * |
prsb03-dataelement-10362 link |
|
A clear statement of the expectations of the person making the referral as to the
management of the patient e.g. advice only, diagnosis, treatment, etc.
To Include any specific patient expectation
In general text. Risk not put in a procedure not already receivedFree text
|
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 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-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
1 … 1 |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … * |
prsb03-dataelement-10712 link |
|
The name and designation of any chaperone(s). |
|
Vaccinations |
|
0 … * |
prsb03-dataelement-10685 link |
|
Details of vaccinations. |
|
|
Vaccinations record entry |
|
0 … 1 |
prsb03-dataelement-10686 link |
|
This is the vaccinations 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-10695 link |
|
The date on which the vaccination was administered or the reported/partial date on
which it was reported.Date and time
|
|
|
1 … 1 |
prsb03-dataelement-10687 link |
|
The vaccine product administered. |
|
|
0 … 1 |
prsb03-dataelement-13237 link |
|
The coded value for vaccine product.SNOMED CTAMP 999000541000001108 |National Health Service dictionary of medicines and
devices actual medicinal product simple reference set (foundation metadata concept)|
orVMP 999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| or
dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13238 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10698 link |
|
Name of vaccine manufacturer. |
|
|
0 … 1 |
prsb03-dataelement-13239 link |
|
The coded value of the manufacturer.Derived from GS1 code or dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13240 link |
|
Free text field to be used if no code is availableFree text |
|
|
1 … 1 |
prsb03-dataelement-10688 link |
|
The procedure which was used to administer the vaccine. |
|
|
0 … 1 |
prsb03-dataelement-13219 link |
|
The coded value for vaccine procedure SNOMED CT :- < 127785005 |Administration of substance to produce immunity, either
active or passive (procedure)|
|
|
|
0 … 1 |
prsb03-dataelement-13220 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10697 link |
|
The batch number of the product. |
|
|
0 … 1 |
prsb03-dataelement-13233 link |
|
The coded value for the batch numberDerived from FMD |
|
|
0 … 1 |
prsb03-dataelement-13234 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10696 link |
|
The date on which the vaccine will expire. Date/time |
|
|
0 … 1 |
prsb03-dataelement-10690 link |
|
A code that separately identifies two identical vaccines (i.e. same product, same
batch).
|
|
|
0 … 1 |
prsb03-dataelement-13235 link |
|
The coded value for serialisation code.Derived from FMD code |
|
|
0 … 1 |
prsb03-dataelement-13236 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10691 link |
|
Body site vaccine was administered. |
|
|
0 … 1 |
prsb03-dataelement-13222 link |
|
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13223 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10692 link |
|
How the vaccine entered the body. |
|
|
0 … 1 |
prsb03-dataelement-13224 link |
|
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13225 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10693 link |
|
The clinical indication or reason for administering the vaccine. |
|
|
0 … 1 |
prsb03-dataelement-13226 link |
|
The coded value for Indication.
SNOMED CT:-Routine mass immunisation 171279008|Immunization due (finding)|
Travel to endemic area 414448007|Identified as high risk for travel immunization
(finding)|Planned travel to high risk area 161096004|Going to travel abroad (finding)|Recent
travel to high risk area 506931000000109|Recent travel to disease affected area (finding)|
Subpopulation at special or unusual risk 78648007|At risk for infection (finding)|High
risk due to occupation 14679004 Occupation (occupation)High risk due to lifestyle
134436002|Lifestyle (finding)|High risk due to existing medical condition 398192003|Co-morbid
conditions (finding)|
Control of known sporadic outbreak 443684005|Disease outbreak (event)|
Patient request
183995001|Patient requested procedure (situation)|
Post-exposure prophyaxis 444107005|Exposure to communicable disease (event)|
Maternity record
<404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context
(situation)|
Other
723620004|Requires vaccination (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13227 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10694 link |
|
Amount of vaccine administered. |
|
|
0 … 1 |
prsb03-dataelement-13228 link |
|
Units of measure dm+d |
|
|
0 … 1 |
prsb03-dataelement-13229 link |
|
Amount of vaccine administered.
Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
Allergies and adverse reactions |
|
0 … * |
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.
|
|
|
1 … 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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Information and advice given |
|
0 … * |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Vaccination Administration (GP)
prsb03-transaction-197 link
|
|
| Version / effective date |
1.1 - 2020‑10‑12 14:16:40 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … * |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
0 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … * |
prsb03-dataelement-10712 link |
|
The name and designation of any chaperone(s). |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Vaccinations |
|
1 … 1 Mandatory |
prsb03-dataelement-10685 link |
|
Details of vaccinations. |
|
|
Vaccinations record entry |
|
1 … * Mandatory |
prsb03-dataelement-10686 link |
|
This is the vaccinations 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-10695 link |
|
The date on which the vaccination was administered or the reported/partial date on
which it was reported.Date and time
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10687 link |
|
The vaccine product administered. |
|
|
0 … 1 |
prsb03-dataelement-13237 link |
|
The coded value for vaccine product.SNOMED CTAMP 999000541000001108 |National Health Service dictionary of medicines and
devices actual medicinal product simple reference set (foundation metadata concept)|
orVMP 999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| or
dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13238 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10698 link |
|
Name of vaccine manufacturer. |
|
|
0 … 1 |
prsb03-dataelement-13239 link |
|
The coded value of the manufacturer.Derived from GS1 code or dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13240 link |
|
Free text field to be used if no code is availableFree text |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10688 link |
|
The procedure which was used to administer the vaccine. |
|
|
0 … 1 |
prsb03-dataelement-10690 link |
|
A code that separately identifies two identical vaccines (i.e. same product, same
batch).
|
|
|
0 … 1 |
prsb03-dataelement-13235 link |
|
The coded value for serialisation code.Derived from FMD code |
|
|
0 … 1 |
prsb03-dataelement-13236 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10691 link |
|
Body site vaccine was administered. |
|
|
0 … 1 |
prsb03-dataelement-13222 link |
|
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13223 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10692 link |
|
How the vaccine entered the body. |
|
|
0 … 1 |
prsb03-dataelement-13224 link |
|
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13225 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10693 link |
|
The clinical indication or reason for administering the vaccine. |
|
|
0 … 1 |
prsb03-dataelement-13226 link |
|
The coded value for Indication.
SNOMED CT:-Routine mass immunisation 171279008|Immunization due (finding)|
Travel to endemic area 414448007|Identified as high risk for travel immunization
(finding)|Planned travel to high risk area 161096004|Going to travel abroad (finding)|Recent
travel to high risk area 506931000000109|Recent travel to disease affected area (finding)|
Subpopulation at special or unusual risk 78648007|At risk for infection (finding)|High
risk due to occupation 14679004 Occupation (occupation)High risk due to lifestyle
134436002|Lifestyle (finding)|High risk due to existing medical condition 398192003|Co-morbid
conditions (finding)|
Control of known sporadic outbreak 443684005|Disease outbreak (event)|
Patient request
183995001|Patient requested procedure (situation)|
Post-exposure prophyaxis 444107005|Exposure to communicable disease (event)|
Maternity record
<404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context
(situation)|
Other
723620004|Requires vaccination (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13227 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10694 link |
|
Amount of vaccine administered. |
|
|
0 … 1 |
prsb03-dataelement-13228 link |
|
Units of measure dm+d |
|
|
0 … 1 |
prsb03-dataelement-13229 link |
|
Amount of vaccine administered.
Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Emergency Supply
prsb03-transaction-198 link
|
|
| Version / effective date |
1.1 - 2020‑10‑19 12:51:23 |
|
|
|
|
 |
Emergency Supply (Pharmacy Record)
prsb03-transaction-199 link
|
|
| Version / effective date |
1 - 2020‑10‑19 12:51:23 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
|
Person demographics |
|
1 … 1 |
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 |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 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 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 … * |
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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 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 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - 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 … * |
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
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
1 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … 1 |
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 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Referrer Details |
|
0 … 1 |
prsb03-dataelement-10714 link |
|
|
Date and time of referral |
|
0 … 1 |
prsb03-dataelement-10717 link |
|
Date and time the patient was referred to the service. |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10716 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.
|
|
|
Referrer details |
|
0 … 1 |
prsb03-dataelement-10715 link |
|
Details of the source of the referral. Name, role, grade, organisation and contact
details of referrer, or details of the person making the contact for ambulance or
urgent care services. If not an individual, this could be e.g. GP surgery, department,
specialty, sub-specialty, educational institution, mental health team etc. Also needs
to include self-referral.Sent as per the ECDS Emergency Care Attendance Source code set (SNOMED CT).
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10069 link |
|
Date and time of the contact. Date and time. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link |
|
Free text |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … 1 |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13765 link |
|
The product order number for the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13766 link |
|
|
0 … 1 |
prsb03-dataelement-13767 link |
|
The batch number of the appliance.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … * |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication administration record entry |
|
0 … * |
prsb03-dataelement-12483 link |
|
Each entry holds details of medications administered |
|
|
1 … 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 |
|
|
Medication item entry |
|
0 … * |
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-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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10539 link |
|
The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree 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-13754 link |
|
A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
|
|
|
0 … 1 |
prsb03-dataelement-13752 link |
|
The batch number of the medicine
Derived from FMD code/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
|
|
|
0 … * |
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-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … * |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
Emergency Supply (GP)
prsb03-transaction-200 link
|
|
| Version / effective date |
1.1 - 2020‑10‑19 12:51:23 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * Mandatory |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10069 link |
|
Date and time of the contact. Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link |
|
Free text |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … * |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13795 link |
|
The following value set may be applicable, but would need validating for appliances:
• Coded text – constraint: NHS e-prescribing route of administration subset ID: 413001000001136
Original Id : 30201000001137 This is an extract from the SUBSET -BiAnnual-Drug-15.0.1-20130401:
SnomedCT_GB1000001_20130401/Subsets/EPrescribing/NHS e-Prescribing route of administration
subset. Constraint binding: [SNOMED-CT]subset=NHS e-Prescribing route of administration
subset
|
|
|
0 … 1 |
prsb03-dataelement-13794 link |
|
Free text field to be used if no code available
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13797 link |
|
Coded value for site
The following value set may be applicable, but would need validating for appliances:
• Coded text – constraint: SiteOfMedicationAdministration. Any valid site for the
administration of a medication. Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration
|
|
|
0 … 1 |
prsb03-dataelement-13796 link |
|
Free text field to be used if no code is available Free text |
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13802 link |
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
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 … 1 |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
1 … 1 Mandatory |
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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10539 link |
|
The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree text.
|
|
|
0 … 1 |
prsb03-dataelement-13792 link |
|
The date/time the medication was supplied.Date and time |
|
|
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-13754 link |
|
A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
|
|
|
|
|
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
|
|
|
0 … * |
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-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
CPCS
prsb03-transaction-201 link
|
|
| Version / effective date |
1.1 - 2020‑10‑19 16:48:49 |
|
|
|
|
 |
DMIRS (Pharmacy Record)
prsb03-transaction-202 link
|
|
| Version / effective date |
1 - 2020‑10‑19 16:48:49 |
|
|
|
|
Actor |
stationary (organization) Pharmacy
|
|
Associations |
|
|
Contained concepts |
|
| Concept |
Card/Conf |
Id |
|
Person demographics |
|
1 … 1 |
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 |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 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 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 … * |
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 |
|
1 … 1 |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 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 |
|
|
1 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.
NHS data dictionary : - 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 … * |
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
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
1 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … 1 |
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 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Referrer Details |
|
0 … 1 |
prsb03-dataelement-10714 link |
|
|
Date and time of referral |
|
0 … 1 |
prsb03-dataelement-10717 link |
|
Date and time the patient was referred to the service. |
|
|
Reason for referral |
|
0 … 1 |
prsb03-dataelement-10716 link |
|
A clear statement of the purpose of the person making the referral e.g. diagnosis,
treatment, transfer of care due to relocation, investigation, second opinion, management
of the patient (e.g. palliative care), provide referrer with advice / guidance. This
may include referral because of carers' concerns.
|
|
|
Referrer details |
|
0 … 1 |
prsb03-dataelement-10715 link |
|
Details of the source of the referral. Name, role, grade, organisation and contact
details of referrer, or details of the person making the contact for ambulance or
urgent care services. If not an individual, this could be e.g. GP surgery, department,
specialty, sub-specialty, educational institution, mental health team etc. Also needs
to include self-referral.Sent as per the ECDS Emergency Care Attendance Source code set (SNOMED CT).
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … 1 |
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link |
|
Free text |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … 1 |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13765 link |
|
The product order number for the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13766 link |
|
|
0 … 1 |
prsb03-dataelement-13767 link |
|
The batch number of the appliance.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
Presenting complaints or issues |
|
0 … * |
prsb03-dataelement-210 link |
|
Presenting complaints or issues |
|
|
Presenting complaint or issue |
|
0 … 1 |
prsb03-dataelement-10110 link |
|
The health problem or issue experienced by the patient resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.Only ONE (chief complaint) sent as per the ECDS Emergency Care Chief Complaint code
set (SNOMED CT).
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
Clinical Summary |
|
1 … 1 |
prsb03-dataelement-247 link |
|
Clinical Summary |
|
|
Clinical narrative |
|
1 … 1 Mandatory |
prsb03-dataelement-10150 link |
|
A description detailing a patient’s reason for attendance, results from the diagnostic
and treatment process.Free text
|
|
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … 1 |
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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … * |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication administration record entry |
|
0 … * |
prsb03-dataelement-12483 link |
|
Each entry holds details of medications administered |
|
|
1 … 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 |
|
|
Medication item entry |
|
0 … * |
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-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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10539 link |
|
The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree 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-13754 link |
|
A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
|
|
|
0 … 1 |
prsb03-dataelement-13752 link |
|
The batch number of the medicine
Derived from FMD code/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
|
|
|
0 … * |
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-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … * |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-10235 link |
|
The relationship of the receiver to the person for example, carer or parent |
|
Plan and requested actions |
|
0 … * |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
CPCS
prsb03-transaction-203 link
|
|
| Version / effective date |
1.1 - 2020‑10‑19 16:48:49 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
Person's telephone number |
|
0 … * |
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
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.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.
|
|
|
1 … 1 Mandatory |
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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
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-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link |
|
Free text |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Presenting complaints or issues |
|
0 … 1 |
prsb03-dataelement-210 link |
|
Presenting complaints or issues |
|
|
Presenting complaint or issue |
|
0 … * |
prsb03-dataelement-13784 link |
|
The health problem or issue experienced by the patient resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.
|
|
|
0 … 1 |
prsb03-dataelement-13785 link |
|
The coded value for presenting complaint or issueSNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13786 link |
|
Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
Free text
|
|
Clinical Summary |
|
1 … 1 Mandatory |
prsb03-dataelement-247 link |
|
Clinical Summary |
|
|
Clinical narrative |
|
1 … 1 Mandatory |
prsb03-dataelement-10150 link |
|
A description detailing a patient’s reason for attendance, results from the diagnostic
and treatment process.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.
|
|
|
1 … 1 Mandatory |
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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
|
|
|
|
Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
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 … 1 |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
1 … 1 Mandatory |
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 |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10539 link |
|
The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree text.
|
|
|
0 … 1 |
prsb03-dataelement-13792 link |
|
The date/time the medication was supplied.Date and time |
|
|
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-13754 link |
|
A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
|
|
|
|
|
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
|
|
|
0 … * |
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-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … 1 |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
Single Community Pharmacy Standard
prsb03-transaction-189 link
|
|
| Version / effective date |
1.1 - 2020‑09‑24 12:45:56 |
|
|
|
|
 |
Pharmacy Record
prsb03-transaction-190 link
|
|
| Version / effective date |
1.1 - 2020‑09‑24 12:45:56 |
|
|
|
|
Actor |
stationary (organization) General practitioner
|
|
Associations |
|
|
Contained concepts |
|
| 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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Patient full name |
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Date of Birth
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary: - Person gender code
|
|
|
Sex |
|
1 … 1 Mandatory |
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 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 … * |
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 |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
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
|
|
|
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 … * |
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 … * |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.
NHS data dictionary :- Communication contact method
|
|
|
Relevant contacts |
|
0 … * |
prsb03-dataelement-10910 link |
|
Include the most important contacts including:
* Personal contacts e.g., next of kin, in case of emergency contact, lasting power
of attorney, dependents, informal carers etc.
* Health/care professional contacts e.g., social worker, hospital clinician, care
coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
Name, relationship, role (if formal role), contact details and availability, e.g.
out of hours.
Details of relevant contacts, such as carers or family members, as recorded on the
local system, or volunteered by the person. This will be a free text list of relevant
contacts.
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
1 … * Mandatory |
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
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.NHS data dictionary: - Organisation data service
|
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10705 link |
|
Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Record of person with parental responsibility or appointed guardian where child lacks
competency. Record if there is disagreement between patient and parent. Free text
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10703 link |
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent.Free text
|
|
Eligibility Criteria |
|
0 … 1 |
prsb03-dataelement-10700 link |
|
|
Eligibility criteria |
|
1 … * |
prsb03-dataelement-10701 link |
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.
|
|
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-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
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10699 link |
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.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. |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
1 … * Mandatory |
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.
|
|
|
1 … 1 Mandatory |
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-13751 link |
|
The reason why the person has been offered the serviceFree text |
|
|
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-10074 link |
|
The service that was provided.SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference
set (foundation metadata concept)|
|
|
|
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, eg parent, relative,
friend. Includes: Name, Relationship, role (e.g. informal carer).Information provided by patient or person accompanying patient.Text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link |
|
The name, including the identifier, of the organisation providing the serviceFree text |
|
|
0 … 1 |
prsb03-dataelement-10713 link |
|
The name of the organisation, including the identifier.Free text |
|
|
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link |
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
|
|
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link |
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link |
|
The name of the person providing the service, preferably in a structured format. |
|
|
0 … 1 |
prsb03-dataelement-10710 link |
|
The role of the person providing the service. |
|
|
0 … * |
prsb03-dataelement-10712 link |
|
The name and designation of any chaperone(s). |
|
|
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link |
|
Free text |
|
|
0 … 1 |
prsb03-dataelement-10711 link |
|
Professional identifier of the person providing the service. |
|
Vaccinations |
|
0 … 1 |
prsb03-dataelement-10685 link |
|
Details of vaccinations. |
|
|
Vaccinations record entry |
|
0 … * |
prsb03-dataelement-10686 link |
|
This is the vaccinations 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-10695 link |
|
The date on which the vaccination was administered or the reported/partial date on
which it was reported.Date and time
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10687 link |
|
The vaccine product administered. |
|
|
0 … 1 |
prsb03-dataelement-13237 link |
|
The coded value for vaccine product.SNOMED CTAMP 999000541000001108 |National Health Service dictionary of medicines and
devices actual medicinal product simple reference set (foundation metadata concept)|
orVMP 999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| or
dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13238 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10698 link |
|
Name of vaccine manufacturer. |
|
|
0 … 1 |
prsb03-dataelement-13239 link |
|
The coded value of the manufacturer.Derived from GS1 code or dm+d
|
|
|
0 … 1 |
prsb03-dataelement-13240 link |
|
Free text field to be used if no code is availableFree text |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10688 link |
|
The procedure which was used to administer the vaccine. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13219 link |
|
The coded value for vaccine procedure SNOMED CT :- < 127785005 |Administration of substance to produce immunity, either
active or passive (procedure)|
|
|
|
0 … 1 |
prsb03-dataelement-13220 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10697 link |
|
The batch number of the product. |
|
|
0 … 1 |
prsb03-dataelement-13233 link |
|
The coded value for the batch numberDerived from FMD |
|
|
0 … 1 |
prsb03-dataelement-13234 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10696 link |
|
The date on which the vaccine will expire. Date/time |
|
|
0 … 1 |
prsb03-dataelement-10690 link |
|
A code that separately identifies two identical vaccines (i.e. same product, same
batch).
|
|
|
0 … 1 |
prsb03-dataelement-13235 link |
|
The coded value for serialisation code.Derived from FMD code |
|
|
0 … 1 |
prsb03-dataelement-13236 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10691 link |
|
Body site vaccine was administered. |
|
|
0 … 1 |
prsb03-dataelement-13222 link |
|
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13223 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10692 link |
|
How the vaccine entered the body. |
|
|
0 … 1 |
prsb03-dataelement-13224 link |
|
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13225 link |
|
Free text field to be used if no coded text available
|
|
|
0 … 1 |
prsb03-dataelement-10693 link |
|
The clinical indication or reason for administering the vaccine. |
|
|
0 … 1 |
prsb03-dataelement-13226 link |
|
The coded value for Indication.
SNOMED CT:-Routine mass immunisation 171279008|Immunization due (finding)|
Travel to endemic area 414448007|Identified as high risk for travel immunization
(finding)|Planned travel to high risk area 161096004|Going to travel abroad (finding)|Recent
travel to high risk area 506931000000109|Recent travel to disease affected area (finding)|
Subpopulation at special or unusual risk 78648007|At risk for infection (finding)|High
risk due to occupation 14679004 Occupation (occupation)High risk due to lifestyle
134436002|Lifestyle (finding)|High risk due to existing medical condition 398192003|Co-morbid
conditions (finding)|
Control of known sporadic outbreak 443684005|Disease outbreak (event)|
Patient request
183995001|Patient requested procedure (situation)|
Post-exposure prophyaxis 444107005|Exposure to communicable disease (event)|
Maternity record
<404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context
(situation)|
Other
723620004|Requires vaccination (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13227 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10694 link |
|
Amount of vaccine administered. |
|
|
0 … 1 |
prsb03-dataelement-13228 link |
|
Units of measure dm+d |
|
|
0 … 1 |
prsb03-dataelement-13229 link |
|
Amount of vaccine administered.
Free text
|
|
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link |
|
Details of appliances |
|
|
Appliance records entry |
|
0 … * |
prsb03-dataelement-13763 link |
|
This is the appliance records entry. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link |
|
May be generic name or brand name (as appropriate).
As per dm+d (AMP)
|
|
|
0 … 1 |
prsb03-dataelement-13765 link |
|
The product order number for the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13766 link |
|
|
0 … 1 |
prsb03-dataelement-13767 link |
|
The batch number of the appliance.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13768 link |
|
The size of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13769 link |
|
The weight of the appliance.
|
|
|
0 … 1 |
prsb03-dataelement-13770 link |
|
|
0 … 1 |
prsb03-dataelement-13771 link |
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
|
|
|
0 … 1 |
prsb03-dataelement-13772 link |
|
The anatomical site at which the appliance is to be used, including laterality.
|
|
|
0 … 1 |
prsb03-dataelement-13773 link |
|
The quantity of the appliance (including the units).
Recorded in a structured format i.e. a unit and a value.
|
|
|
0 … 1 |
prsb03-dataelement-13774 link |
|
Reason for appliance being prescribed, where known.
Free text
|
|
|
|
Matters identified during the discussion |
|
1 … * |
prsb03-dataelement-13775 link |
|
Matters identified during the service about the patient's experience of using the
appliance. To include e.g, patient using/not using the appliance as prescribed, patient
reports negative feelings about the appliance etc. Also to include whether the information
was provided by the patient or somebody else (e.g. a relative, carer etc) e.g. patient
using/not using the appliance as prescribed, patient reports negative feelings about
the appliance etc.Free text
|
|
|
0 … 1 |
prsb03-dataelement-13802 link |
|
Presenting complaints or issues |
|
0 … 1 |
prsb03-dataelement-210 link |
|
Presenting complaints or issues |
|
|
Presenting complaint or issue |
|
0 … 1 |
prsb03-dataelement-13784 link |
|
The health problem or issue experienced by the patient resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.
|
|
|
0 … 1 |
prsb03-dataelement-13785 link |
|
The coded value for presenting complaint or issueSNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13786 link |
|
Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
History |
|
|
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … 1 |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is available
Free text
|
|
Clinical Summary |
|
1 … 1 Mandatory |
prsb03-dataelement-247 link |
|
Clinical Summary |
|
|
Clinical narrative |
|
1 … 1 Mandatory |
prsb03-dataelement-10150 link |
|
A description detailing a patient’s reason for attendance, results from the diagnostic
and treatment process.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.
|
|
|
1 … 1 Mandatory |
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”
|
|
|
1 … 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)
|
|
|
1 … 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-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-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance, Not known
|
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced. May be a date or partial date (e.g. year)
or text (e.g. during childhood)Date and time
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|
|
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Probability of recurrence |
|
0 … 1 |
prsb03-dataelement-10191 link |
|
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text |
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication item entry |
|
0 … * |
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 … 1 |
prsb03-dataelement-10664 link |
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Medication item cluster |
|
|
0 … 1 |
prsb03-dataelement-10843 link |
|
The date on which the medication or medical device was prescribed.Date and time |
|
|
1 … 1 Mandatory |
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-10539 link |
|
The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree text.
|
|
|
0 … 1 |
prsb03-dataelement-13792 link |
|
The date/time the medication was supplied.Date and time |
|
|
0 … * |
prsb03-dataelement-10538 link |
|
The route by which the medication is administered e.g. oral, IM, IV |
|
|
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-13754 link |
|
A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
|
|
|
0 … 1 |
prsb03-dataelement-13789 link |
|
The batch number of the product. |
|
|
0 … 1 |
prsb03-dataelement-13790 link |
|
The coded value for the batch numberDerived from FMD |
|
|
0 … 1 |
prsb03-dataelement-13791 link |
|
Free text field to be used if no code is availableFree 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 … * |
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
|
|
|
|
|
Matters identified during discussion |
|
1 … * |
prsb03-dataelement-13753 link |
|
Matters identified during the service about the patient's experience of using the
medication.
Coded text using the following descriptors:
a. patient reports using the medicine as prescribed
b. patient reports not using the medicine as prescribed
c. patient has not started using the medicine
d. prescriber has stopped new medicine
e. patient is not using the medicine in line with the directions of the prescriber
f. patient reports missing a dose in the past 7 days
g. patient reports need for more information about the medicine
h. patient reports side effects
i. patient reports negative feelings about the medicine
j. patient reports uncertainty on whether the medicine is working
k. patient reports concern about remembering to take the medicine
l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation
i. other - free text option
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … * |
prsb03-dataelement-10215 link |
|
This includes:
-what information
-to whom it was given.
-the oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
-description of information and advice given and patient/carer comprehension For this
use case this element also includes ECDS Emergency Care Discharge Information Given
code set (SNOMED CT): Copy of discharge letter NOT provided
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
This is a Distribution list 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-10230 link |
|
If the communication is being sent to a named individual, then this is the name of
the recipient, preferably in a structured format. An identifier for the individual,
for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient)
will be sent alongside the name, but may not displayed on rendered document.Names may be entered as the communication is being created, or sourced from the hospital
system.
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).
NHS data dictionary : - Care professional
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.Organisation name, and identifier, taken from the Organisation Data Service (ODS).
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.There are no national codes for teams, so this value would have to be agreed locally,
and entered as free text.
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parent
FHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions 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.
|
|
|
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.
Free text
|
|
|
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
GP Record
prsb03-transaction-191 link
|
|
| Version / effective date |
0.1 - 2020‑09‑24 12:45:56 |
|
|
|
|
Actor |
Sender (organization) Pharmacy
Receiver (organization) General practitioner
|
|
Associations |
|