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draft Transaction CPCS 2.16.840.1.113883.3.1937.777.28.4.203

Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft CPCS (1.1) 2.16.840.1.113883.3.1937.777.28.4.203
Version / effective date Expiration date
2020‑10‑19 16:48:49
Description
Name Details [‑]
folder draft Person demographics 1 … 1 Mandatory
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Cardinality 1 … 1 Mandatory
Description The person's details and contact information.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Person name 1 … 1 Mandatory
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Cardinality 1 … 1 Mandatory
Description Details of the person's name
Relationship
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Person full name 1 … 1 Mandatory
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
Cardinality 1 … 1 Mandatory
Description The full name of the person in text representation.
Rationale Patient.name.text
Operationalization NHS data dictionary :- Patient full name 
Value Domain
Property
max length
70
target Used by 7 transactions, 0 templates, inherited 0 times
 
draft Date of birth 1 … 1 Mandatory
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
Cardinality 1 … 1 Mandatory
Description The date of birth of the person.

Properties

FHIR Patient.birthDate
Relationship
Rationale NHS NSS : -  https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=D&ID=186&Title=Date%20of%20Birth

Source Patient.birthdate
Operationalization NHS data dictionary:-  Date of Birth 

Value Domain
Property
Timestamp precision default
day, month and year 10
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Sex 1 … 1 Mandatory
prsb03-dataelement-10877
Id prsb03-dataelement-10877 (2019‑03‑27 19:15:45) 1
Cardinality 1 … 1 Mandatory
notice There is an open issue with this item:
Description The person’s phenotypic sex. Determines how the person will be treated clinically.
Relationship
Operationalization NHS data dictionary:-  person phenotypic sex classification

Value Domain
Property
default
1
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft NHS number 0 … 1
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 1
Cardinality 0 … 1
Description The unique identifier for a person within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Relationship
Rationale Patient.identifier(nhsnumber)
Operationalization NHS data dictionary:- NHS number 

Value Domain
Property
max length
10
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Other identifier 0 … *
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Cardinality 0 … *
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. 
Relationship
Operationalization NHS data dictionary: - Local patient identifier,  HEALTH AND CARE NUMBER (NI only),  COMMUNITY HEALTH INDEX NUMBER (Scotland only)
Value Domain
Property
max length
10
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Person's address 1 … 1 Mandatory
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Cardinality 1 … 1 Mandatory
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

FHIR Patient.Address
Relationship
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Address line 1 1 … 1 Mandatory
prsb03-dataelement-13082
Id prsb03-dataelement-13082 (2020‑05‑29 15:28:51)
Cardinality 1 … 1 Mandatory
Description Person's first line of address.
Rationale Patient.address.line
Operationalization
NHS data dictionary :- Address line 1

Value Domain
Property
max length
35
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Address line 2 0 … 1
prsb03-dataelement-13083
Id prsb03-dataelement-13083 (2020‑05‑29 15:32:41)
Cardinality 0 … 1
Description Person's second line of address.
Rationale Patient.address.city
Operationalization NHS data dictionary :- Address line 2
Value Domain
Property
max length
35
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Address line 3 0 … 1
prsb03-dataelement-13084
Id prsb03-dataelement-13084 (2020‑05‑29 15:35:34)
Cardinality 0 … 1
Description Person's third line of address.  
Rationale Patient.address.district
Operationalization NHS data dictionary :- Address line 3
Value Domain
Property
max length
35
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Address line 4 0 … 1
prsb03-dataelement-13085
Id prsb03-dataelement-13085 (2020‑06‑01 11:29:56)
Cardinality 0 … 1
Description Person's fourth line of address.
Rationale Patient.address.state
Operationalization NHS data dictionary :- Address line 4
Value Domain
Property
max length
35
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Address line 5 0 … 1
prsb03-dataelement-13086
Id prsb03-dataelement-13086 (2020‑06‑01 11:32:10)
Cardinality 0 … 1
Description Person's fifth line of address.
Rationale Patient.address.country
Operationalization NHS data dictionary:- Address line 5
Value Domain
Property
max length
35
target Used by 8 transactions, 0 templates, inherited 0 times
 
draft Postcode 0 … 1
prsb03-dataelement-13087
Id prsb03-dataelement-13087 (2020‑06‑01 11:40:09)
Cardinality 0 … 1
Description The person's postcode.
Rationale Patient.address.postalcode
Operationalization
NHS data dictionary : - Postcode

Value Domain
Property
max length
8
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Person's telephone number 0 … *
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Cardinality 0 … *
Description Telephone contact details of the person. To include, e.g. mobile, work and home number if available.

Properties

FHIR Patient.telecom
Relationship
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary :- Person's telephone number
Value Domain
Property
max length
32
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft GP practice 1 … 1 Mandatory
prsb03-dataelement-101
Id prsb03-dataelement-101 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Details of the person's GP practice.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft GP practice record entry 1 … *
prsb03-dataelement-10643
Id prsb03-dataelement-10643 (2018‑11‑09 14:59:24)
Cardinality 1 … *
Description 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
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft GP practice identifier 1 … 1 Mandatory
prsb03-dataelement-10001
Id prsb03-dataelement-10001 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The identifier of the registered GP practice.

Properties

FHIR Sliced into ODS and local identifier. PratitionerRole.organisation.identifier
Rationale PratitionerRole.organisation.identifier
Operationalization NHS data dictionary: - Organisation data service
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Consent 0 … 1
prsb03-dataelement-10702
Id prsb03-dataelement-10702 (2018‑12‑04 15:27:12)
Cardinality 0 … 1
Description Legal information captured relating to patient care, such as consent.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Consent relating to child 0 … 1
prsb03-dataelement-10705
Id prsb03-dataelement-10705 (2018‑12‑04 15:28:03)
Cardinality 0 … 1
Description 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. 
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Consent for information sharing 0 … 1
prsb03-dataelement-10704
Id prsb03-dataelement-10704 (2018‑12‑04 15:27:48)
Cardinality 0 … 1
Description 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.
Operationalization Free text.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Consent for treatment record 0 … 1
prsb03-dataelement-10703
Id prsb03-dataelement-10703 (2018‑12‑04 15:27:26)
Cardinality 0 … 1
Description Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Referral details 0 … 1
prsb03-dataelement-105
Id prsb03-dataelement-105 (2018‑10‑31)
Cardinality 0 … 1
Description The details of the referral.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Referral details record entry 0 … *
prsb03-dataelement-10917
Id prsb03-dataelement-10917 (2019‑04‑09 15:59:55)
Cardinality 0 … *
Description 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.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Reason for referral 1 … 1 Mandatory
prsb03-dataelement-10011
Id prsb03-dataelement-10011 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description 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.
Operationalization Free text
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13455
Id prsb03-dataelement-13455 (2020‑08‑27 18:17:32)
Cardinality 0 … 1
Description The coded value for reason for referral
Operationalization SNOMED CT :- ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13456
Id prsb03-dataelement-13456 (2020‑08‑27 18:18:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Expectation of referral 0 … *
prsb03-dataelement-10699
Id prsb03-dataelement-10699 (2018‑12‑04 15:19:46)
Cardinality 0 … *
Description 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.
Operationalization Free text
Value Domain
target Used by 11 transactions, 0 templates, inherited 0 times
 
folder draft Clinical urgency of referral 0 … 1
prsb03-dataelement-10010
Id prsb03-dataelement-10010 (2018‑10‑31)
Cardinality 0 … 1
Description Referrer’s assessment of urgency (e.g. urgent, routine).
Operationalization NHS data dictionary : - PRIORITY TYPE
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Reason for urgency of referral 0 … 1
prsb03-dataelement-10976
Id prsb03-dataelement-10976 (2019‑05‑22 17:54:38)
Cardinality 0 … 1
Description The reason for urgency of referral if not routine.
Operationalization Free text
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Referral to 0 … 1
prsb03-dataelement-10008
Id prsb03-dataelement-10008 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10977
Id prsb03-dataelement-10977 (2019‑05‑22 17:56:22)
Cardinality 0 … 1
Description Name of person the referral is to be sent to.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10978
Id prsb03-dataelement-10978 (2019‑05‑22 17:56:39)
Cardinality 0 … 1
Description Role of person where the referral is to be sent to.
Operationalization NHS data dictionary : -  Care professional type
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-10979
Id prsb03-dataelement-10979 (2019‑05‑22 17:56:51)
Cardinality 0 … 1
Description The grade of the person where the referral is sent to.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Team 0 … 1
prsb03-dataelement-10982
Id prsb03-dataelement-10982 (2019‑05‑22 17:59:49)
Cardinality 0 … 1
Description The team or department of the person where the referral is being sent to
Operationalization Free text.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-10983
Id prsb03-dataelement-10983 (2019‑05‑22 18:00:28)
Cardinality 0 … 1
Description The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary - Main speciality

Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Service 0 … 1
prsb03-dataelement-12412
Id prsb03-dataelement-12412 (2019‑06‑05 18:20:52)
Cardinality 0 … 1
Description The service of where the referral is sent to.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13509
Id prsb03-dataelement-13509 (2020‑09‑03 17:50:24)
Cardinality 0 … 1
Description The coded value for service
Operationalization SNOMED CT:- ^999000191000000106 |Care planning patient outgoing referral simple reference set (foundation metadata concept)|
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13510
Id prsb03-dataelement-13510 (2020‑09‑03 17:51:06)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-10980
Id prsb03-dataelement-10980 (2019‑05‑22 17:57:10)
Cardinality 0 … 1
Description The organisation of where the referral is to be sent.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13511
Id prsb03-dataelement-13511 (2020‑09‑03 17:54:29)
Cardinality 0 … 1
Description The coded value for organisation 
Operationalization NHS data dictionary :- Organisation data service
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13512
Id prsb03-dataelement-13512 (2020‑09‑03 17:55:57)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-10981
Id prsb03-dataelement-10981 (2019‑05‑22 17:57:26)
Cardinality 0 … 1
Description The contact details of where the referral is to be sent.
Operationalization Free text.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Contacts with professionals 1 … 1 Mandatory
prsb03-dataelement-169
Id prsb03-dataelement-169 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The details of the person’s contact with a professional.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Contacts with professionals record entry 1 … * Mandatory
prsb03-dataelement-10718
Id prsb03-dataelement-10718 (2019‑02‑08 13:49:22)
Cardinality 1 … * Mandatory
Description 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.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Date of contact 1 … 1 Mandatory
prsb03-dataelement-10069
Id prsb03-dataelement-10069 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Date and time of the contact. 

Properties

FHIR Encounter.period
Operationalization Date and time.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Location of contact 0 … 1
prsb03-dataelement-10075
Id prsb03-dataelement-10075 (2018‑10‑31)
Cardinality 0 … 1
Description The location where the contact took place.
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13513
Id prsb03-dataelement-13513 (2020‑09‑03 18:01:56)
Cardinality 0 … 1
Description The coded value for location 
Operationalization NHS data dictionary : - Organisation service code
Value Domain
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13514
Id prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Consultation method 0 … 1
prsb03-dataelement-10071
Id prsb03-dataelement-10071 (2018‑10‑31)
Cardinality 0 … 1
Description Consultation method used e.g. face to face, telephone

Properties

FHIR Handled as text in the transfer of care
Operationalization NHS data dictionary - Consultation medium 

Value Domain
target Used by 10 transactions, 0 templates, inherited 0 times
 
draft Service 0 … 1
prsb03-dataelement-10074
Id prsb03-dataelement-10074 (2018‑10‑31)
Cardinality 0 … 1
Description The service that was provided.

Properties

FHIR Encounter.Appointment.servicetype
Operationalization SNOMED CT : - 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Person accompanying patient 0 … *
prsb03-dataelement-10079
Id prsb03-dataelement-10079 (2018‑10‑31)
Cardinality 0 … *
Description Identify, where clinically relevant, others accompanying the patient, eg parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).

Properties

FHIR Encounter.participant
Operationalization Information provided by patient or person accompanying patient.Text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Organisation name 1 … 1 Mandatory
prsb03-dataelement-10706
Id prsb03-dataelement-10706 (2018‑12‑04 15:30:13)
Cardinality 1 … 1 Mandatory
Description The name, including the identifier, of the organisation providing the service
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Organisation address 0 … 1
prsb03-dataelement-10713
Id prsb03-dataelement-10713 (2018‑12‑04 15:37:02)
Cardinality 0 … 1
Description The name of the organisation, including the identifier.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Organisation contact details 0 … *
prsb03-dataelement-10707
Id prsb03-dataelement-10707 (2018‑12‑04 15:31:05)
Cardinality 0 … *
Description 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.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Reason for non-provision of service 0 … 1
prsb03-dataelement-10708
Id prsb03-dataelement-10708 (2018‑12‑04 15:31:26)
Cardinality 0 … 1
Description The reason why the patient was not provided with the service e.g. declined, did not attend etc. 
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Clinician name 1 … 1 Mandatory
prsb03-dataelement-10709
Id prsb03-dataelement-10709 (2018‑12‑04 15:31:49)
Cardinality 1 … 1 Mandatory
Description The name of the person providing the service, preferably in a structured format.
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10710
Id prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Cardinality 0 … 1
Description The role of the person providing the service.
Value Domain
target Used by 12 transactions, 0 templates, inherited once
 
draft Person collecting the medicine 0 … 1
prsb03-dataelement-13783
Id prsb03-dataelement-13783 (2020‑10‑22 15:43:21)
Cardinality 0 … 1
Operationalization Free text
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-10711
Id prsb03-dataelement-10711 (2018‑12‑04 15:32:25)
Cardinality 0 … 1
Description Professional identifier of the person providing the service.
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Presenting complaints or issues 0 … 1
prsb03-dataelement-210
Id prsb03-dataelement-210 (2018‑10‑31)
Cardinality 0 … 1
Description Presenting complaints or issues
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Presenting complaint or issue 0 … *
prsb03-dataelement-13784
Id prsb03-dataelement-13784 (2020‑10‑22 17:40:08)
Cardinality 0 … *
Description 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.

Properties

FHIR Condition.code
Relationship
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13785
Id prsb03-dataelement-13785 (2020‑10‑22 17:41:38)
Cardinality 0 … 1
notice There is an open issue with this item:
Description The coded value for presenting complaint or issue
Operationalization SNOMED CT
Value Domain
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13786
Id prsb03-dataelement-13786 (2020‑10‑22 17:42:28)
Cardinality 0 … 1
Relationship
Operationalization Free text 
Value Domain
Property
max length
150
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft History 0 … 1
prsb03-dataelement-226
Id prsb03-dataelement-226 (2018‑10‑31)
Cardinality 0 … 1
Description History
target Used by 11 transactions, 0 templates, inherited 0 times
 
folder draft Relevant past medical, surgical and mental health history 0 … 1
prsb03-dataelement-10130
Id prsb03-dataelement-10130 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13787
Id prsb03-dataelement-13787 (2020‑10‑22 17:51:01)
Cardinality 0 … 1
notice There is an open issue with this item:
Description The coded value relevant past medical, surgical and mental health history
Operationalization SNOMED CT
Value Domain
target Used by 7 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13788
Id prsb03-dataelement-13788 (2020‑10‑22 17:53:28)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13450 (2020‑08‑27 16:43:57)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
target Used by 7 transactions, 0 templates, inherited 0 times
 
folder draft Clinical Summary 1 … 1 Mandatory
prsb03-dataelement-247
Id prsb03-dataelement-247 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Clinical Summary
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Clinical narrative 1 … 1 Mandatory
prsb03-dataelement-10150
Id prsb03-dataelement-10150 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.
Operationalization Free text
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions 0 … 1
prsb03-dataelement-282
Id prsb03-dataelement-282 (2018‑10‑31)
Cardinality 0 … 1
Description Allergies and adverse reactions
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions record entry 0 … *
prsb03-dataelement-10657
Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
Cardinality 0 … *
Description 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.
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Causative agent 1 … 1 Mandatory
prsb03-dataelement-10182
Id prsb03-dataelement-10182 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description 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”

Properties

FHIR AllergyIntolerance.code
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13441
Id prsb03-dataelement-13441 (2020‑08‑19 14:12:48)
Cardinality 0 … 1
Description The coded value for causative agent
Operationalization SNOMED 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)

Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13442
Id prsb03-dataelement-13442 (2020‑08‑19 15:33:40)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Reaction details cluster 0 … 1
prsb03-dataelement-10658
Id prsb03-dataelement-10658 (2018‑11‑13 12:29:25)
Cardinality 0 … 1
Description Details of the reaction.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10190
Id prsb03-dataelement-10190 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR dateAsserted
Operationalization Date and time 
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Description of reaction 0 … 1
prsb03-dataelement-10183
Id prsb03-dataelement-10183 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the manifestation of the allergic or adverse reaction experienced by the person.  For example, skin rash.

Properties

FHIR AllergyIntolerance.reaction.manifestation AllergyIntolerance.reaction.description
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13556
Id prsb03-dataelement-13556 (2020‑09‑04 16:48:37)
Cardinality 0 … 1
Description The coded value for description of reaction.
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13557
Id prsb03-dataelement-13557 (2020‑09‑04 16:51:03)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Severity 0 … 1
prsb03-dataelement-10184
Id prsb03-dataelement-10184 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the severity of the reaction.

Properties

FHIR AllergyIntolerance.reaction.severity
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13558
Id prsb03-dataelement-13558 (2020‑09‑04 17:43:42)
Cardinality 0 … 1
Description The coded value for severity 
Operationalization SNOMED CT: - ^999004521000000108 |Health issue severity simple reference set (foundation metadata concept) |
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13559
Id prsb03-dataelement-13559 (2020‑09‑04 17:48:53)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Certainty 0 … 1
prsb03-dataelement-10185
Id prsb03-dataelement-10185 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the certainty that the stated causative agent caused the allergic or adverse reaction.

Properties

FHIR AllergyIntolerance.verificationStatus
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13560
Id prsb03-dataelement-13560 (2020‑09‑04 17:52:26)
Cardinality 0 … 1
Description The coded value for certainty.
Operationalization SNOMED CT :- ^999004531000000105 |Health issue certainty simple reference set (foundation metadata concept) |
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13561
Id prsb03-dataelement-13561 (2020‑09‑04 17:55:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Comment 0 … 1
prsb03-dataelement-10189
Id prsb03-dataelement-10189 (2018‑10‑31)
Cardinality 0 … 1
Description Any additional comment or clarification about the adverse reaction.
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Type of reaction 0 … 1
prsb03-dataelement-10186
Id prsb03-dataelement-10186 (2018‑10‑31)
Cardinality 0 … 1
Description The type of reaction experienced by the person (allergic, adverse, intolerance)

Properties

FHIR AllergyIntolerance.type
Operationalization FHIR value set  :- Allergy, Intolerance, Not known
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Evidence 0 … 1
prsb03-dataelement-10187
Id prsb03-dataelement-10187 (2018‑10‑31)
Cardinality 0 … 1
Description Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests

Properties

FHIR AllergyIntolerance.extension.evidence
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Date first experienced 0 … 1
prsb03-dataelement-10188
Id prsb03-dataelement-10188 (2018‑10‑31)
Cardinality 0 … 1
Description When the reaction was first experienced. May be a date or partial date (e.g. year) or text (e.g. during childhood)

Properties

FHIR AllergyIntolerance.onset[x]
Operationalization Date and time 
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Probability of recurrence 0 … 1
prsb03-dataelement-10191
Id prsb03-dataelement-10191 (2018‑10‑31)
Cardinality 0 … 1
Description Probability of the reaction (allergic, adverse, intolerant) occurring.

Properties

FHIR AllergyIntolerance.extension.ProbabilityOfRecurrence
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Medications and medical devices 0 … 1
prsb03-dataelement-636
Id prsb03-dataelement-636 (2018‑10‑31)
Cardinality 0 … 1
Description Medications and medical devices
target Used by 8 transactions, 0 templates, inherited once
 
folder draft Medication item entry 0 … 1
prsb03-dataelement-10663
Id prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
Cardinality 0 … 1
Description 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.
target Used by 8 transactions, 0 templates, inherited 2 times
 
folder draft Medication item cluster 0 … 1
prsb03-dataelement-10664
Id prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
Cardinality 0 … 1
Description Medication item cluster
target Used by 8 transactions, 0 templates, inherited 2 times
 
folder draft Medication name 1 … 1 Mandatory
prsb03-dataelement-10536
Id prsb03-dataelement-10536 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description May be generic name or brand name.

Properties

FHIR MedicationStatement.medication[x].medicationCodableConcept MedicationStatement.medication[x].medicationReference (see Medication) (Systems should send as much details as they can. dm+d code can be sent as a simple code/description pair using CodeableConcept, or as a detailed medication record)
target Used by 6 transactions, 0 templates, inherited 5 times
 
draft Coded value 0 … 1
prsb03-dataelement-13622
Id prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
Cardinality 0 … 1
Description The coded value for medication name 
Operationalization 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)|
Value Domain
target Used by 6 transactions, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13623
Id prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 6 transactions, 0 templates, inherited once
 
folder draft Form 0 … 1
prsb03-dataelement-10537
Id prsb03-dataelement-10537 (2018‑10‑31)
Cardinality 0 … 1
Description The form of the medication e.g. capsule, drops, tablet, lotion etc.

Properties

FHIR MedicationStatement.medication[x].medicationReference.medication.form (i.e. form is on the medication profile). Where VTM has form specified (coded) it goes here AMP & VMP don't need seperate Form (it is optional to populate) For VTM the form could be in MedicationStatement.dosage.text (as it would be part of a dosage string) i.e. not a seperately specified code
target Used by 8 transactions, 0 templates, inherited 4 times
 
draft Coded value 0 … 1
prsb03-dataelement-13624
Id prsb03-dataelement-13624 (2020‑09‑08 19:32:29)
Cardinality 0 … 1
Description The coded value for form.
Operationalization SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
Value Domain
target Used by 8 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13625
Id prsb03-dataelement-13625 (2020‑09‑08 19:33:34)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
an150
target Used by 8 transactions, 0 templates, inherited 0 times
 
draft Quantity supplied 1 … 1 Mandatory
prsb03-dataelement-10539
Id prsb03-dataelement-10539 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description 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 unit

Properties

FHIR MedicationStatement.quantityDispensed (Amount of medication to supply per dispense) quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
Operationalization Free text.
Value Domain
target Used by 5 transactions, 0 templates, inherited 3 times
 
draft Date supplied 0 … 1
prsb03-dataelement-13792
Id prsb03-dataelement-13792 (2020‑10‑22 18:56:07)
Cardinality 0 … 1
Description The date/time the medication was supplied.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Site 0 … 1
prsb03-dataelement-10540
Id prsb03-dataelement-10540 (2018‑10‑31)
Cardinality 0 … 1
Description The anatomical site at which the medication is to be administered.

Properties

FHIR MedicationStatement.dosage.site
target Used by 5 transactions, 0 templates, inherited 3 times
 
draft Coded value 0 … 1
prsb03-dataelement-13657
Id prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
Cardinality 0 … 1
Description The coded value for site
Operationalization SNOMED CT: - 
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13658
Id prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13229 (2020‑07‑15 19:30:33)
Description Amount of vaccine administered.
Relationship
Operationalization Free text 
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Supply type 0 … 1
prsb03-dataelement-13754
Id prsb03-dataelement-13754 (2020‑09‑29 11:32:50)
Cardinality 0 … 1
Description A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Dose directions description 0 … 1
prsb03-dataelement-10544
Id prsb03-dataelement-10544 (2018‑10‑31)
Cardinality 0 … 1
Description 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”.

Properties

FHIR MedicationStatement.dosage.text
Operationalization Free text
Value Domain
target Used by 8 transactions, 0 templates, inherited 4 times
 
draft Additional instructions 0 … *
prsb03-dataelement-10545
Id prsb03-dataelement-10545 (2018‑10‑31)
Cardinality 0 … *
Description 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.

Properties

FHIR Specific patient instruction use MedicationStatement.dosage.patientInstruction For narrative instructions (e.g. monitoring, pain, prevention) use MedicationStatement.note For dispensing instructions (EPS narrative) use MedicationRequest.note (intent "order" or "plan")
Operationalization Free text
Value Domain
target Used by 5 transactions, 0 templates, inherited 3 times
 
folder draft Course details cluster 0 … 1
prsb03-dataelement-10561
Id prsb03-dataelement-10561 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the overall course of medication.
target Used by 8 transactions, 0 templates, inherited 3 times
 
draft Indication 0 … 1
prsb03-dataelement-10546
Id prsb03-dataelement-10546 (2018‑10‑31)
Cardinality 0 … 1
Description Reason for medication being prescribed, where known.

Properties

FHIR MedicationStatement.reasonCode
Operationalization Free text
Value Domain
target Used by 8 transactions, 0 templates, inherited 3 times
 
folder draft Information and advice given 0 … 1
prsb03-dataelement-315
Id prsb03-dataelement-315 (2018‑10‑31)
Cardinality 0 … 1
Description Information and advice given
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Information and advice given 0 … *
prsb03-dataelement-10215
Id prsb03-dataelement-10215 (2018‑10‑31)
Cardinality 0 … *
notice There is an open issue with this item:
Description 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

Properties

FHIR Free text only
Operationalization Free text 
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Distribution list 0 … 1
prsb03-dataelement-330
Id prsb03-dataelement-330 (2018‑10‑31)
Cardinality 0 … 1
Description Distribution list
target Used by 13 transactions, 0 templates, inherited 0 times
 
folder draft Distribution list record entry 0 … 1
prsb03-dataelement-10660
Id prsb03-dataelement-10660 (2018‑11‑13 13:21:33)
Cardinality 0 … 1
Description 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.
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10230
Id prsb03-dataelement-10230 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR Practitioner.name Patient ..... RelatedPerson.....
Operationalization Names may be entered as the communication is being created, or sourced from the hospital system.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10231
Id prsb03-dataelement-10231 (2018‑10‑31)
Cardinality 0 … 1
Description 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).

Properties

FHIR PractitionerRole.code
Operationalization NHS data dictionary : - Care professional
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-10232
Id prsb03-dataelement-10232 (2018‑10‑31)
Cardinality 0 … 1
Description The grade of the recipient, if known by the sending institution, otherwise omitted.

Properties

FHIR PractitionerRole.code
Operationalization Free text
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Organisation name 0 … 1
prsb03-dataelement-10233
Id prsb03-dataelement-10233 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR Organization.name Organization.identifier
Operationalization Organisation name, and identifier, taken from the Organisation Data Service (ODS).
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Team 0 … 1
prsb03-dataelement-10234
Id prsb03-dataelement-10234 (2018‑10‑31)
Cardinality 0 … 1
Description Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.

Properties

FHIR Organization.name
Operationalization There are no national codes for teams, so this value would have to be agreed locally, and entered as free text.
Value Domain
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Relationship 0 … 1
prsb03-dataelement-13793
Id prsb03-dataelement-13793 (2020‑11‑02 15:35:45)
Cardinality 0 … 1
Description The relationship of the receiver to the person for example, carer or parent
Relationship
Operationalization FHIR value set : - Related person

Value Domain
target Used by 7 transactions, 0 templates, inherited 0 times
 
folder draft Plan and requested actions 0 … 1
prsb03-dataelement-535
Id prsb03-dataelement-535 (2018‑10‑31)
Cardinality 0 … 1
Description The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
target Used by 11 transactions, 0 templates, inherited 0 times
 
folder draft Plan and requested actions record entry 0 … *
prsb03-dataelement-10661
Id prsb03-dataelement-10661 (2018‑11‑13 13:38:58)
Cardinality 0 … *
Description 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.
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Actions for professionals 0 … *
prsb03-dataelement-10436
Id prsb03-dataelement-10436 (2018‑10‑31)
Cardinality 0 … *
Description 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.
Operationalization Free text
Value Domain
target Used by 11 transactions, 0 templates, inherited 0 times
 
draft Actions for person or their carer 0 … *
prsb03-dataelement-10437
Id prsb03-dataelement-10437 (2018‑10‑31)
Cardinality 0 … *
Description 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.
Operationalization Free text
Value Domain
target Used by 11 transactions, 0 templates, inherited 0 times