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 … * |
prsb03-dataelement-13799 link
|
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
0 … 1 |
prsb03-dataelement-13800 link
|
|
The family name or surname of the personNHS data dictionary: - Person family 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.NHS data dictionary: - Person full name
|
|
0 … 1 |
prsb03-dataelement-13089 link
|
|
Person's titleNHS data dictionary: - Person title
|
|
0 … 1 |
prsb03-dataelement-13798 link
|
|
A textual suffix that may be added to the end of a PERSON's name, for example, OBE,
MBE, BSc, JP, GMNHS data dictionary: - Person suffix
|
|
0 … 1 |
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:- Person birth date
|
 |
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link
|
|
The person's stated gender.NHS data dictionary: - Person stated gender code
|
 |
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link
|
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
|
 |
|
Religion |
|
0 … 1 |
prsb03-dataelement-10876 link
|
|
The religious affiliation as specified by the person.SNOMED_CT: ^999000531000000100 |Religious or other belief system affiliation simple
reference set (foundation metadata concept)|
|
 |
|
Sex |
|
0 … 1 |
prsb03-dataelement-10877 link
|
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary:- person phenotypic sex classification
|
 |
|
NHS 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
|
 |
|
NHS number status indicator |
|
0 … 1 |
prsb03-dataelement-13297 link
|
|
Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
|
 |
|
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(extended), 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.
|
|
0 … 1 |
prsb03-dataelement-13082 link
|
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
0 … 1 |
prsb03-dataelement-13083 link
|
|
Person's second line of address.NHS data dictionary :- Address line 2
|
|
0 … 1 |
prsb03-dataelement-13084 link
|
|
Person's third line of address.NHS data dictionary :- Address line 3
|
|
0 … 1 |
prsb03-dataelement-13085 link
|
|
Person's fourth line of address.NHS data dictionary :- Address line 4
|
|
0 … 1 |
prsb03-dataelement-13086 link
|
|
Person's fifth line of address.NHS data dictionary:- Address line 5
|
|
0 … 1 |
prsb03-dataelement-13087 link
|
|
The person's postcode.
NHS data dictionary : - Postcode of usual address
|
 |
 |
Immigration status |
|
0 … 1 |
prsb03-dataelement-13293 link
|
|
Include details of the immigration status of the person, their permissions to live
and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain
in the UK. Include start date, end date and any comments.
|
|
0 … 1 |
prsb03-dataelement-13304 link
|
|
Details of the immigration status of the person, their permissions to live and receive
care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave
to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds
(NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled
status; 10: EU settled status
|
|
0 … 1 |
prsb03-dataelement-13294 link
|
|
Start date of immigration statusDate and time |
|
0 … 1 |
prsb03-dataelement-13295 link
|
|
End date of immigration statusDate and time |
|
0 … 1 |
prsb03-dataelement-13296 link
|
|
Relevant comments about the person's immigration statusFree text |
 |
GP practice |
|
1 … 1 Mandatory |
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 … 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: - General medical practise code (patient registration)
|
 |
About me |
|
0 … 1 |
prsb03-dataelement-466 link
|
|
About me |
 |
 |
About me |
|
0 … 1 |
prsb03-dataelement-10366 link
|
|
This is a record of the things that a person feels it is important to communicate
about their needs, strengths, values, concerns and preferences to others providing
support and care.
|
 |
 |
|
What is most important to me |
|
0 … 1 |
prsb03-dataelement-12964 link
|
|
A description of what is most important to you
Emergency Information : - Include any essential information that any professional in health and social care
should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals
and aspirations, Meaningful activities including leisure activities, visiting places,
sport and exercise, listening to music, employment, education, volunteeringFree text or multimedia file
|
 |
 |
|
People who are important to me |
|
0 … 1 |
prsb03-dataelement-13009 link
|
|
Details of who is important to you and why. They could be family members, carers,
friends, members of staff etc.
Include how you want the people important to you to be engaged and involved in your
care and support in both emergency and normal situations.
Who should not be contacted or consulted about your care and support and why, if you
wish to say
Free text or multimedia file
|
 |
 |
|
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-13006 link
|
|
A description of how you communicate normally including any communication aids you
use, for example a hearing aid.
- Include your preferred language of communication, if your first language is not English.
- Include how you would communicate when you are in pain or distress.
- Include how you communicate choices.
- Include how you give feedback or raise a concern.
Describe how you would like others to engage and communicate with you, including how
you would like to be addressed.
Free text or multimedia file
|
 |
 |
|
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-13008 link
|
|
A description of things you want someone supporting you to do or not to do.
For example, this might include: - Talk to me not to my carer, Remind me to take my
medication, Encourage me to wash my hands regularly, Explain to me what is happening
and why, Respond to my communication
A description of things you do not want someone supporting for you to do. For example,
this might include: - Asking questions about certain topics, Making assumptions about
something, Providing support when it is not wanted, Talking to you in a certain way
Free text or multimedia file
|
|
0 … 1 |
prsb03-dataelement-13005 link
|
|
A description covering what you are able to do, how you engage with others and how
you feel on a typical day through to on a day when you are unwell.
- Include any causes that might result in you becoming unwell and strategies for avoiding
or addressing the causes. For example, not drinking enough water could cause constipation.
- Include any signs that indicate you might be becoming unwell.
- On a bad day describe what is different about what you are able to do, how you engage
with others and how you feel.
- Include any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough,
pain that you are living with and that that affect your everyday life and how you
manage those conditions.
- Include past health issues or experiences that need to be considered
Free text or multimedia file
|
 |
 |
|
How and when to support me |
|
0 … 1 |
prsb03-dataelement-13007 link
|
|
A description of how and when you want someone caring for you to support you.
This could include support needs in an emergency situation (for example taking blood)
This could include support you need to maintain important routines or to carry out
particular activities, for example: - Personal care routines, Eating and drinking,
Bedtime routines, Taking medications, Moving and transitioning
This could also include support needed with:- wearing glasses/hearing aids/false teeth
etc, making informed choices or understanding dangers and risks, managing your emotions,
moods and behaviours, memory or confusion.
Include how your support needs change in different environments. Include any triggers
that might result in you needing further support and strategies for avoiding or addressing
the triggers. Include how you want the support to be provided.
Free text or multimedia file
|
 |
 |
|
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-13094 link
|
|
A description of what is also worth knowing about you for people caring or supporting
you.
This could include a short history of your life (where you have worked, where you
lived, important events in your life, important people in your past life).
This could include a short profile of your current life:- your work / study, your
aspirations, your skills, your networks, things you like e.g. particular foods, places,
a football team and things you like to talk about, things you dislike
This could also include any care and support preferences that have not been included
elsewhere.
Free text or multimedia file
|
|
0 … 1 |
prsb03-dataelement-10367 link
|
|
This is a record of the date that this information was last updated.Date and Time |
 |
 |
|
Supported to write this by |
|
0 … 1 |
prsb03-dataelement-10368 link
|
|
Where relevant, this is a record of name, relationship/role and contact details of
the individual who supported the person to write this section e.g. carer, family member,
advocate, professional.Free text
|
 |
Individual requirements |
|
0 … 1 |
prsb03-dataelement-160 link
|
|
The individual requirements of the person. |
 |
 |
Reasonable adjustment |
|
0 … 1 |
prsb03-dataelement-12991 link
|
|
A record of reasonable adjustments that must be provided by the service to comply
with the Equality Act 2010.
|
 |
 |
 |
Reasonable adjustment record entry |
|
0 … * |
prsb03-dataelement-13061 link
|
|
This is a reasonable adjustment record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items
|
|
0 … 1 |
prsb03-dataelement-13098 link
|
|
The location where the reasonable adjustment was identified. |
|
0 … 1 |
prsb03-dataelement-13357 link
|
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13358 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13017 link
|
|
The reasonable adjustment required e.g. requires specific contact method, requires
communication professional
|
|
0 … 1 |
prsb03-dataelement-13505 link
|
|
The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information
- communication support simple reference set (foundation metadata concept)|^999002151000000104
|Accessible information - requires communication professional simple reference set
(foundation metadata concept)|^999002131000000106 |Accessible information - requires
specific contact method simple reference set (foundation metadata concept)|^999002141000000102
|Accessible information - requires specific information format simple reference set
(foundation metadata concept)|Refsets for other categories in development
|
|
0 … 1 |
prsb03-dataelement-13506 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
|
Reasonable adjustment additional detail |
|
0 … 1 |
prsb03-dataelement-13018 link
|
|
Further detail about the support required and the consequence of not providing it.Free text |
|
0 … 1 |
prsb03-dataelement-13020 link
|
|
The date the reasonable adjustment was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-13027 link
|
|
The professional who confirmed the need for the reasonable adjustment. |
|
0 … 1 |
prsb03-dataelement-13028 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13029 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-13030 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13031 link
|
|
The specialty of the professional.NHS data dictionary - Main specialty code
|
|
0 … 1 |
prsb03-dataelement-13032 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13033 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13034 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13035 link
|
|
A record of the details of the person that entered the reasonable adjustment and the
date on which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13036 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13037 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13038 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13039 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13040 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13041 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13042 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13043 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Impairment |
|
0 … 1 |
prsb03-dataelement-13001 link
|
|
A record of any impairments for the person relating to reasonable adjustments. |
|
0 … * |
prsb03-dataelement-13062 link
|
|
This is a reasonable adjustment record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items
|
|
0 … 1 |
prsb03-dataelement-13099 link
|
|
The location where the impairment was identified. |
|
0 … 1 |
prsb03-dataelement-13429 link
|
|
The coded value for location.NHS data dictionary: - Organisation code service
|
|
0 … 1 |
prsb03-dataelement-13430 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13022 link
|
|
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory
disability - such as sight or hearing, Long-term condition
|
|
0 … 1 |
prsb03-dataelement-13507 link
|
|
The coded value for impairment.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-13508 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
|
Impairment additional detail |
|
0 … 1 |
prsb03-dataelement-13023 link
|
|
Description of what the person can do with the impairment, what they want to be able
to do and how they should be supported to do it and what the consequences are of not
providing the support.
Where there is a sensory disability include sensory processing difficulties (e.g.
affects to balance and movement, oversensitive, under-sensitive).
Free text
|
|
0 … 1 |
prsb03-dataelement-13024 link
|
|
The date the impairment was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-13044 link
|
|
The professional who confirmed the impairment. |
|
0 … 1 |
prsb03-dataelement-13045 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13046 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13047 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13048 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13049 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13050 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13051 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13052 link
|
|
A record of the details of the person that entered the impairment and the date on
which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13053 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13054 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13055 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13056 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13057 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13058 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13059 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13060 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Mobility |
|
0 … 1 |
prsb03-dataelement-10067 link
|
|
Details of the person's mobility needs. |
|
0 … 1 |
prsb03-dataelement-11707 link
|
|
The date when the mobility needs were identified.Date and time |
|
0 … 1 |
prsb03-dataelement-11710 link
|
|
The location where the mobility needs were identified. |
|
0 … 1 |
prsb03-dataelement-13433 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13434 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-13670 link
|
|
The mobility needs of the person that allows movement between two spaces and achieves
participation and a degree of independence.
|
|
0 … 1 |
prsb03-dataelement-13671 link
|
|
The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13672 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11487 link
|
|
The professional who identified the mobility needs. |
|
0 … 1 |
prsb03-dataelement-11488 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11489 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11490 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11491 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11492 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11493 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11494 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11495 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11496 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11497 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11498 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11499 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11500 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11501 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11502 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11503 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Other individual requirements |
|
0 … 1 |
prsb03-dataelement-10835 link
|
|
Details of any other individual requirements the person may have |
|
0 … 1 |
prsb03-dataelement-11711 link
|
|
The date when the other individual requirements were identified.Date and time |
|
0 … 1 |
prsb03-dataelement-11712 link
|
|
The location where the other individual requirements were identified. |
|
0 … 1 |
prsb03-dataelement-13435 link
|
|
The coded value for location.NHS data dictionary : - Organisation service code
|
|
0 … 1 |
prsb03-dataelement-13436 link
|
|
Free text field to be used if no coded text available |
 |
 |
|
Other individual requirement |
|
0 … 1 |
prsb03-dataelement-13673 link
|
|
Other individual requirements that a person may have.Free text |
|
0 … 1 |
prsb03-dataelement-11504 link
|
|
The professional who identified the other individual requirements. |
|
0 … 1 |
prsb03-dataelement-11505 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11506 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11507 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11508 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11509 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11510 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11511 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11512 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11513 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11514 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11515 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11516 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11517 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11518 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11519 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11520 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Alerts |
|
0 … * |
prsb03-dataelement-10741 link
|
|
Details of alerts. |
 |
 |
Alerts record entry |
|
0 … * |
prsb03-dataelement-10916 link
|
|
This is an alerts record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items
|
|
1 … 1 |
prsb03-dataelement-10742 link
|
|
Any significant information meriting a specific and highly visible warning to any
user (e.g. metallic implant, potential dangerous pet).Free text
|
|
0 … 1 |
prsb03-dataelement-12399 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12400 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12401 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12402 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12403 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12404 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12405 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12406 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12407 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Legal information |
|
0 … 1 |
prsb03-dataelement-520 link
|
|
The legal information relating to the person. |
 |
 |
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10420 link
|
|
Details of the person's consent for treatment. |
|
0 … 1 |
prsb03-dataelement-13457 link
|
|
The date the consent was takenDate |
|
0 … 1 |
prsb03-dataelement-13459 link
|
|
The location of where the consent was taken. |
|
0 … 1 |
prsb03-dataelement-13460 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13461 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-13574 link
|
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent. A statement about the patient's consent for treatment.Free text
|
|
0 … 1 |
prsb03-dataelement-13777 link
|
|
The location of the consent for treatment record.Free text or URL |
|
0 … 1 |
prsb03-dataelement-13462 link
|
|
The professional who took the consent for treatment. |
|
0 … 1 |
prsb03-dataelement-13463 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13464 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13465 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13466 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13467 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13468 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13469 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13470 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-13471 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13472 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13473 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13474 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13475 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13476 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13477 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13478 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10421 link
|
|
Details of the person's consent for information sharing |
|
0 … 1 |
prsb03-dataelement-11713 link
|
|
The date when the consent was givenDate and time |
|
0 … 1 |
prsb03-dataelement-11714 link
|
|
The location where the consent was taken. |
|
0 … 1 |
prsb03-dataelement-13451 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13452 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-13575 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. This is a placeholder
until the national guidance is published.Free text
|
 |
 |
|
Reason for consent not given |
|
0 … 1 |
prsb03-dataelement-13778 link
|
|
Reason not given for consentFree text |
|
0 … 1 |
prsb03-dataelement-11715 link
|
|
The professional who took the consent for information sharing |
|
0 … 1 |
prsb03-dataelement-11716 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11717 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11718 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11719 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11720 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11721 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11722 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11723 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11724 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11725 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11726 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11727 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11728 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11729 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11730 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11731 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Mental capacity assessment |
|
0 … * |
prsb03-dataelement-10424 link
|
|
Details of the persons mental capacity assessment |
|
0 … 1 |
prsb03-dataelement-11688 link
|
|
The date when the mental capacity assessment was made.Date and time |
|
0 … 1 |
prsb03-dataelement-11689 link
|
|
The location where the mental capacity assessment was made. |
|
0 … 1 |
prsb03-dataelement-13449 link
|
|
The coded value for location
NHS data dictionary : - Organisation code service
|
|
0 … 1 |
prsb03-dataelement-13450 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Mental capacity assessment |
|
0 … 1 |
prsb03-dataelement-13724 link
|
|
Whether an assessment of the mental capacity of the (adult) person has been undertaken,
if so, what capacity the decision relates to and the outcome of the assessment. Also
record best interests decision if person lacks capacity.Free text
|
|
0 … 1 |
prsb03-dataelement-13779 link
|
|
The location of the mental capacity assessment information.Free text or URL |
|
0 … 1 |
prsb03-dataelement-11281 link
|
|
The professional who made the mental capacity assessment. |
|
0 … 1 |
prsb03-dataelement-11282 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11283 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11288 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11284 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11285 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11286 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13521 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13522 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11287 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11289 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11290 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11291 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11292 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11293 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11294 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13523 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13524 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11295 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11296 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11297 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent) |
|
0 … 1 |
prsb03-dataelement-10425 link
|
|
Details of the person's LPA record or equivalent |
|
0 … 1 |
prsb03-dataelement-13630 link
|
|
The date the LPA was recordedDate and time |
|
0 … 1 |
prsb03-dataelement-13631 link
|
|
The location where the LPA was given |
|
0 … 1 |
prsb03-dataelement-13632 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13633 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Lasting power of attorney for personal welfare or court appointed deputy (or equivalent) |
|
0 … 1 |
prsb03-dataelement-13634 link
|
|
Record of one or more people who have been given power (LPA) by the person when they
had capacity to make decisions about their health and welfare should they lose capacity
to make those decisions. To be valid, an LPA must have been registered with the Court
of Protection. If life-sustaining treatment is being considered the LPA document must
state specifically that the attorney has been given power to consent to or refuse
life-sustaining treatment. Details of any person (deputy) appointed by the court to
make decisions about the person’s health and welfare. A deputy does not have the power
to refuse life-sustaining treatment.
|
|
0 … 1 |
prsb03-dataelement-13636 link
|
|
The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings
simple reference set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13776 link
|
|
The location of the LPA informationFree text or URL |
|
0 … 1 |
prsb03-dataelement-13635 link
|
|
The names of any appointed people or deputiesFree text |
|
0 … 1 |
prsb03-dataelement-13637 link
|
|
The contact details of the LPANHS data dictionary:- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-13638 link
|
|
The professional who took the details of the LPA or equivalent |
|
0 … 1 |
prsb03-dataelement-13639 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13640 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13641 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13642 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13643 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13644 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13645 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13646 link
|
|
Details of the person who recorded the ADRT. |
|
0 … 1 |
prsb03-dataelement-13647 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13648 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13649 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13650 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13651 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13652 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13653 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13654 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Deprivation of Liberty Safeguards or equivalent |
|
0 … 1 |
prsb03-dataelement-10426 link
|
|
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent |
|
0 … 1 |
prsb03-dataelement-13068 link
|
|
The date the application was madeDate and time |
|
0 … 1 |
prsb03-dataelement-13069 link
|
|
The status of the DOLs application.Free text : - Requested or authorised |
 |
 |
|
Deprivation of liberty safeguards or equivalent |
|
0 … 1 |
prsb03-dataelement-13626 link
|
|
Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason
for this.Free text
|
 |
 |
|
Start date of authorisation |
|
0 … 1 |
prsb03-dataelement-13071 link
|
|
The date the DOLs was authorised.Data and time |
 |
 |
|
Planned or actual end date of authorisation |
|
0 … 1 |
prsb03-dataelement-13072 link
|
|
The planned or actual end date of authorisation.Date and time |
|
0 … 1 |
prsb03-dataelement-13073 link
|
|
The professional who applied for the DOLs. |
|
0 … 1 |
prsb03-dataelement-13074 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13075 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13076 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13077 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13078 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13079 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13080 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Mental health act or equivalent status |
|
0 … * |
prsb03-dataelement-10427 link
|
|
Details of the persons mental health act record |
|
0 … 1 |
prsb03-dataelement-10920 link
|
|
The date the person was detained.Date and time |
|
0 … 1 |
prsb03-dataelement-10921 link
|
|
The date the person was no longer detained.Date and time |
|
0 … 1 |
prsb03-dataelement-11692 link
|
|
The location where the decision to detain the person was made under the mental health
act.
|
 |
 |
 |
Mental health act or equivalent status |
|
0 … 1 |
prsb03-dataelement-13627 link
|
|
Record where a person diagnosed with a mental disorder is formally detained under
the Mental health act or equivalent, including the section number. If person subject
to Community Treatment Order or Conditional Discharge (or equivalent) record here.
|
|
0 … 1 |
prsb03-dataelement-13628 link
|
|
The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
|
|
0 … 1 |
prsb03-dataelement-13629 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13755 link
|
|
If person subject to Community Treatment Order or Conditional Discharge (or equivalent)
record here.NHS data dictionary : - Community treatment order
|
|
0 … 1 |
prsb03-dataelement-11315 link
|
|
The professional who made the decision to detain the person under the mental health
act.
|
|
0 … 1 |
prsb03-dataelement-11316 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11317 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11318 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11319 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11320 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11321 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11322 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11323 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11324 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11325 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11326 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11327 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11328 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11329 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11330 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11331 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Advance decision to refuse treatment (ADRT) |
|
0 … 1 |
prsb03-dataelement-10428 link
|
|
Details of the person's ADRT status. |
|
0 … 1 |
prsb03-dataelement-13479 link
|
|
The date the ADRT was recorded.Date |
|
0 … 1 |
prsb03-dataelement-13480 link
|
|
The location where the ADRT was recorded. |
|
0 … 1 |
prsb03-dataelement-13481 link
|
|
The coded value of locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13482 link
|
|
Free text field to be used if no coded text available |
 |
 |
 |
Advance decision to refuse treatment |
|
0 … 1 |
prsb03-dataelement-13502 link
|
|
A record of an advance decision to refuse one or more specific types of future treatment,
made by a person who had capacity at the time of recording the decision. The decision
only applies when the person no longer has the capacity to consent to or refuse the
specific treatment being considered. An ADRT must be in writing, signed and witnessed.
If the ADRT is refusing life-sustaining treatment it must state specifically that
the treatment is refused even if the person’s life is at risk.
|
|
0 … 1 |
prsb03-dataelement-13503 link
|
|
The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings
simple reference set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13504 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13484 link
|
|
The professional who recorded the ADRT |
|
0 … 1 |
prsb03-dataelement-13485 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13486 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13487 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13488 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13489 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13490 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13491 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13492 link
|
|
Details of the person who recorded the ADRT. |
|
0 … 1 |
prsb03-dataelement-13493 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13494 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13495 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13496 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13497 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13498 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13499 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13500 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Safeguarding |
|
0 … 1 |
prsb03-dataelement-271 link
|
|
The safeguarding details of the person. |
 |
 |
Safeguarding concerns |
|
0 … * |
prsb03-dataelement-10821 link
|
|
Details of safeguarding concerns |
|
1 … 1 Mandatory |
prsb03-dataelement-13428 link
|
|
Indicates whether or not the hospital considers that there are safeguarding issues
associated with the patient.Flag: No =N: Yes = Y
|
 |
 |
|
Safeguarding concerns date |
|
0 … 1 |
prsb03-dataelement-10172 link
|
|
The date the safeguarding concerns were identified.Date and time |
 |
 |
|
Safeguarding concerns end date |
|
0 … 1 |
prsb03-dataelement-10766 link
|
|
The date safeguarding concerns ended.Date and time |
|
0 … 1 |
prsb03-dataelement-10173 link
|
|
The location where the safeguarding concerns were identified. |
|
0 … 1 |
prsb03-dataelement-13437 link
|
|
The coded value of locationNHS data dictionary :- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13438 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10171 link
|
|
Identified safeguarding concerns. |
|
0 … 1 |
prsb03-dataelement-13756 link
|
|
The coded value for safeguarding concernsSNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-13757 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11358 link
|
|
The professional who identified the safeguarding concerns. |
|
0 … 1 |
prsb03-dataelement-11359 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11360 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11361 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11362 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11363 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11364 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11365 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11366 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11367 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11368 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11369 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11370 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11371 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11372 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11373 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11374 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Local authority |
|
1 … 1 Mandatory |
prsb03-dataelement-13298 link
|
|
The details of the Local Authority that is responsible for providing care and support
to the person.
|
 |
|
Organisation code |
|
0 … * |
prsb03-dataelement-13299 link
|
|
The ODS (Organisation Data Service) code of the local authority that is responsible
for providing care and support to the person.NHS data dictionary :- Organisation data service
|
 |
|
Local authority name |
|
1 … 1 Mandatory |
prsb03-dataelement-13300 link
|
|
The name of the local authority that is responsible for providing care and support
to the person.Free text
|
 |
|
Social services team |
|
0 … * |
prsb03-dataelement-13301 link
|
|
The name of the local authority social services team or department that is responsible
for undertaking the care and support assessment for the person.Free text
|
 |
|
Local authority contact name |
|
1 … 1 Mandatory |
prsb03-dataelement-13302 link
|
|
The name of the person at the local authority who is responsible for liaising with
the hospital in relation to the person’s discharge.Free text
|
 |
|
Local authority contact details |
|
1 … 1 Mandatory |
prsb03-dataelement-13303 link
|
|
The contact details of the person at the local authority who is responsible for liaising
with the hospital in relation to the person’s discharge.Free text
|
 |
Professional contacts |
|
0 … 1 |
prsb03-dataelement-452 link
|
|
The details of the person’s professional contacts. |
 |
 |
Professional contacts record entry |
|
0 … * |
prsb03-dataelement-10767 link
|
|
This is a professional contacts record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10352 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-10353 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-10354 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-10355 link
|
|
The name of the team.Free text |
|
0 … 1 |
prsb03-dataelement-10356 link
|
|
The name of the organisation. |
|
0 … 1 |
prsb03-dataelement-13564 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13565 link
|
|
Free text field to be used if no code is availableFree text |
|
1 … 1 Mandatory |
prsb03-dataelement-10357 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
0 … 1 |
prsb03-dataelement-10358 link
|
|
The start date of the professional relationship with the person.Date and time |
|
0 … 1 |
prsb03-dataelement-10359 link
|
|
The end date of the professional relationship with the person.Date and time |
 |
Personal contacts |
|
0 … 1 |
prsb03-dataelement-445 link
|
|
The details of the individual's personal contacts. |
 |
 |
Personal contacts record entry |
|
0 … * |
prsb03-dataelement-10768 link
|
|
This is personal contacts record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
1 … 1 Mandatory |
prsb03-dataelement-10345 link
|
|
The name of the personal contact.Free text |
|
0 … 1 |
prsb03-dataelement-10346 link
|
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
0 … * |
prsb03-dataelement-12968 link
|
|
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin,
Emergency Contact, Dependent, etc.)Free text
|
|
1 … 1 Mandatory |
prsb03-dataelement-10350 link
|
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
0 … 1 |
prsb03-dataelement-10937 link
|
|
Notes on the significance of the personal contact to the person.Free text |
 |
Referral details |
|
1 … 1 Mandatory |
prsb03-dataelement-105 link
|
|
The details of the referral. |
 |
 |
Referral details record entry |
|
1 … 1 Mandatory |
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 |
|
1 … 1 Mandatory |
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.FHIR value set : - sdsjobrole
|
|
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 - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12411 link
|
|
The service of the referrer. |
|
0 … 1 |
prsb03-dataelement-13397 link
|
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services 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 codeNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13400 link
|
|
Free text field to be used if no code is availableFree text |
|
1 … 1 Mandatory |
prsb03-dataelement-10975 link
|
|
The contact details of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-12967 link
|
|
An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social
Care', 'GP Referral', etc.)
|
|
0 … 1 |
prsb03-dataelement-10007 link
|
|
The method in which a referral is sent and received. This may be a letter, email,
transcript of a telephone conversation, Choose and Book, in person (self-referral)
etc.Allow National Codes only
Fax
Phone
Secure Messaging
Secure Email
Letter
NHS E-Referral Service
Self referral
|
|
0 … 1 |
prsb03-dataelement-10011 link
|
|
The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation,
investigation, second opinion, management of the patient (e.g. palliative care), or
carer's concerns.Free text
|
|
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.FHIR value set : - sdsjobrole
|
|
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
etcNHS data dictionary - Activity treatment function code
|
|
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: - 1127531000000102 |Services 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 organisationNHS data dictionary :- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13512 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10981 link
|
|
The contact details of where the referral is to be sent.Free text. |
|
0 … 1 |
prsb03-dataelement-10015 link
|
|
Name of professional to be communicated with, if not the referrerFree text. |
 |
Admission details |
|
0 … 1 |
prsb03-dataelement-181 link
|
|
Admission details |
 |
 |
Admission details record entry |
|
0 … 1 |
prsb03-dataelement-10918 link
|
|
This is the admission details record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10085 link
|
|
Date and time the person was admitted to hospital.Date and time |
|
0 … 1 |
prsb03-dataelement-10090 link
|
|
The hospital the person was admitted to. |
|
0 … 1 |
prsb03-dataelement-13380 link
|
|
The coded value for admission toNHS data dictionary : - Organisations code of provider
|
|
0 … 1 |
prsb03-dataelement-13381 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Responsible care professional |
|
0 … 1 |
prsb03-dataelement-10087 link
|
|
The care professional who has overall responsibility for the person (may not actually
see the person)
|
|
0 … 1 |
prsb03-dataelement-10992 link
|
|
The name of the responsible care professional.Free text. |
|
0 … 1 |
prsb03-dataelement-10993 link
|
|
The role of the responsible consultant.FHIR value set: - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-10081 link
|
|
The health problems and issues experienced by the person that prompted the decision
to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific
procedure, intervention, investigation or treatment, non compliance with treatment.
|
|
0 … 1 |
prsb03-dataelement-13382 link
|
|
The coded value for reason for admissionSNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
0 … 1 |
prsb03-dataelement-13384 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10082 link
|
|
How the person was admitted to hospital e.g. elective, emergency, maternity, transfer
etc.
|
|
0 … 1 |
prsb03-dataelement-13385 link
|
|
The coded value for admission methodNHS data dictionary : - Admission method
|
|
0 … 1 |
prsb03-dataelement-13387 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10084 link
|
|
Where the person was immediately prior to admission, e.g. usual place of residence,
temporary place of residence, penal establishment.
|
|
0 … 1 |
prsb03-dataelement-13388 link
|
|
The coded value of source of admissionNHS data dictionary :- Source of admission
|
|
0 … 1 |
prsb03-dataelement-13389 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10086 link
|
|
This is the physical locations of the patient. For inpatient, e.g., hospital ward,
bed, theatre. For ambulatory care, e.g., health center, clinic, resources center,
patient’s home.Free text
|
 |
Discharge details |
|
0 … 1 |
prsb03-dataelement-191 link
|
|
Discharge details |
 |
 |
Discharge details record entry |
|
0 … 1 |
prsb03-dataelement-10919 link
|
|
This is the discharge details record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
 |
 |
|
Expected date of discharge |
|
0 … * |
prsb03-dataelement-13424 link
|
|
The expected/ proposed date the person will be discharged.SNOMED CT: - 861031000000101 |Expected date of discharge from service (observable
entity)|
|
|
0 … 1 |
prsb03-dataelement-10096 link
|
|
The date and time of dischargeDate and time |
|
0 … 1 |
prsb03-dataelement-10095 link
|
|
The hospital the person was discharged from.NHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-10093 link
|
|
The consultant responsible for the person at time of discharge. |
|
0 … 1 |
prsb03-dataelement-10994 link
|
|
The name of the discharging consultantFree text |
|
0 … 1 |
prsb03-dataelement-10995 link
|
|
The role of the discharging consultantFHIR value set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-10092 link
|
|
Patient status on discharge from emergency care.Sent as per the ECDS Emergency Care DischargeStatus code set (SNOMED CT): |
|
0 … 1 |
prsb03-dataelement-10098 link
|
|
The method of discharge from hospital e.g. person discharged on clinical advice or
with clinical consent; person discharged him/herself or was discharged by a relative
or advocate.
|
|
0 … 1 |
prsb03-dataelement-13393 link
|
|
The coded value for discharge methodNHS data dictionary : - Discharge method
|
|
0 … 1 |
prsb03-dataelement-13394 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10094 link
|
|
The specialty of the consultant responsible for the person at the time of discharge. |
|
0 … 1 |
prsb03-dataelement-13395 link
|
|
The coded value for discharge specialityNHS data dictionary : - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13396 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10987 link
|
|
The department from which the person is discharged.Free text |
|
0 … 1 |
prsb03-dataelement-10099 link
|
|
0 … 1 |
prsb03-dataelement-10100 link
|
|
The destination of the person on discharge from hospital e.g. usual place of residence,
NHS run care home.NHS data dictionary - Discharge destination.
|
|
0 … 1 |
prsb03-dataelement-10101 link
|
|
Address to which the person is discharged if not the usual place of residence.NHS data dictionary :- Address
|
 |
 |
Discharge date informed status |
|
1 … 1 Mandatory |
prsb03-dataelement-13383 link
|
|
A statement confirming that the person or carer has been informed of the date on which
it is proposed that the person be discharged
|
 |
 |
|
Discharge date person informed indicator |
|
1 … 1 Mandatory |
prsb03-dataelement-13423 link
|
|
Indicates whether or not the patient has been informed of the proposed discharge date.Flag;- yes or no |
 |
 |
|
Discharge date carer informed indicator |
|
1 … 1 Mandatory |
prsb03-dataelement-13422 link
|
|
Indicates whether or not the carer (where applicable) has been informed of the proposed
discharge date.
Flag : - N: No;Y: Yes; NKC: No Known Carer
|
 |
Problem list |
|
0 … 1 |
prsb03-dataelement-10927 link
|
|
A summary of the problems that require investigation or treatment. |
 |
 |
Problem list record entry |
|
0 … 1 |
prsb03-dataelement-10928 link
|
|
This is a problem list record entry.
There may be 0 to many record entries under problem list.
Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10929 link
|
|
The date the problem was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-12133 link
|
|
The professional who identified the problem. |
|
0 … 1 |
prsb03-dataelement-12134 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12135 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12136 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12137 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12138 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12139 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12140 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10931 link
|
|
The location the problem was identified. |
|
0 … 1 |
prsb03-dataelement-13242 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13243 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10932 link
|
|
A condition which needs addressing and so is important for every professional to know
about when seeing the person.
Problems may include diagnoses, symptoms, disabilities and social or behavioural issues,
and comprise the ‘Problem list’
|
|
0 … 1 |
prsb03-dataelement-13244 link
|
|
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-13245 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10933 link
|
|
A date or estimated date that the problem beganDate and time |
|
0 … 1 |
prsb03-dataelement-10934 link
|
|
The date or estimated date the problem was resolved.Date and time. |
|
0 … 1 |
prsb03-dataelement-10935 link
|
|
The stage of the disease where relevant.Free text |
|
0 … 1 |
prsb03-dataelement-12141 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12142 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12143 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12144 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12145 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12146 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12147 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12148 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12149 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10936 link
|
|
Supporting text may be given covering the problem.Free text |
 |
Procedures and therapies |
|
0 … 1 |
prsb03-dataelement-238 link
|
|
The details of any procedures performed. Includes both psychological and medical therapies
and procedures (e.g. cognitive behaviour therapy, hip replacement)
|
 |
 |
Procedure record entry |
|
0 … * |
prsb03-dataelement-10652 link
|
|
This is a procedure 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-10138 link
|
|
The date the procedure was performed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13246 link
|
|
The location the problem was identified. |
|
0 … 1 |
prsb03-dataelement-13247 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13248 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12150 link
|
|
The professional who performed the procedure. |
|
0 … 1 |
prsb03-dataelement-12151 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12152 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12153 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12154 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12155 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12156 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12157 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
1 … 1 Mandatory |
prsb03-dataelement-10141 link
|
|
The therapeutic or diagnostic procedure performed. Includes both psychological and
medical therapies and procedures (e.g. cognitive
behaviour therapy, or follow-up interventions as a result of physical health
checks). Complimentary or alternative procedures and therapies should be recorded
here.
|
|
1 … 1 Mandatory |
prsb03-dataelement-13249 link
|
|
The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context| |
|
0 … 1 |
prsb03-dataelement-13250 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10142 link
|
|
The body site of the procedure |
|
0 … 1 |
prsb03-dataelement-13251 link
|
|
The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)| |
|
0 … 1 |
prsb03-dataelement-13252 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10143 link
|
|
Laterality of the procedure |
|
0 … 1 |
prsb03-dataelement-13253 link
|
|
The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)| |
|
0 … 1 |
prsb03-dataelement-13254 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Complications related to procedure |
|
0 … 1 |
prsb03-dataelement-10144 link
|
|
Details of any intra-operative complications encountered during the procedure, arising
during the person’s stay in the recovery unit or directly attributable to the procedure.
|
|
0 … 1 |
prsb03-dataelement-13255 link
|
|
The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
|
|
0 … 1 |
prsb03-dataelement-13256 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Specific anesthesia issues |
|
0 … 1 |
prsb03-dataelement-10145 link
|
|
Details of any adverse reaction to any anesthetic agents including local anesthesia.
Problematic intubation, transfusion reaction, etc.
|
|
0 … 1 |
prsb03-dataelement-13257 link
|
|
The coded value for specific anesthesia issues.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-13258 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12158 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12159 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12160 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12161 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12162 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12163 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12164 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12165 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12166 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10146 link
|
|
Any further textual comment to clarify such as statement that information is partial
or incomplete. Also indicate the outcome of the procedure.Free text
|
 |
Clinical Summary |
|
0 … 1 |
prsb03-dataelement-247 link
|
|
Clinical Summary |
 |
|
Date |
|
0 … 1 |
prsb03-dataelement-13308 link
|
|
The date the clinical summary was written.Date |
 |
 |
Location |
|
1 … 1 |
prsb03-dataelement-13309 link
|
|
The location the clinical summary was written. |
|
1 … 1 |
prsb03-dataelement-13310 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
1 … 1 |
prsb03-dataelement-13311 link
|
|
Free text field to be used if no code is availableFree text |
 |
|
Clinical summary |
|
0 … 1 |
prsb03-dataelement-10147 link
|
|
Summary of the encounter. Where possible, very brief. This may include interpretation
of findings and results; differential diagnoses, opinion and specific action(s). Planned
actions will be recorded under ‘plan’.Free text
|
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-13312 link
|
|
The professional who wrote the clinical summary |
|
0 … 1 |
prsb03-dataelement-13313 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13314 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13315 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13316 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13317 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13318 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13319 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-13320 link
|
|
A record of the details of the person that entered the clinical summary and the date
on which is was entered.
|
|
0 … 1 |
prsb03-dataelement-13321 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13322 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13323 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13324 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13325 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13326 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13327 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13328 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Treatments and interventions |
|
0 … 1 |
prsb03-dataelement-12480 link
|
|
Treatments and interventions carried out |
 |
 |
Treatments and interventions and changes made to treatments. |
|
0 … 1 |
prsb03-dataelement-12481 link
|
|
The treatments and interventions carried out. Where appropriate record the rationale
for the decision to treat and the information sources reviewed e.g. end of life care
plan etc. All medications should be recorded under the medications heading.
|
|
0 … 1 |
prsb03-dataelement-13259 link
|
|
The coded value for treatment and interventions.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-13260 link
|
|
Free text field to be used if no code is availableFree text |
 |
Social context |
|
0 … 1 |
prsb03-dataelement-136 link
|
|
The social setting in which the person lives, such as their household, occupational
history, and lifestyle factors.
|
 |
 |
Household composition |
|
0 … 1 |
prsb03-dataelement-10036 link
|
|
Details of the person's household composition. |
|
0 … 1 |
prsb03-dataelement-11770 link
|
|
The date when the household composition was taken.Date and time. |
|
0 … 1 |
prsb03-dataelement-13271 link
|
|
The location where the household composition was taken. |
|
0 … 1 |
prsb03-dataelement-13272 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13273 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13261 link
|
|
Description of the household composition e.g. lives alone, lives with family, lives
with partner, etc.
|
|
0 … 1 |
prsb03-dataelement-13262 link
|
|
The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set
(foundation metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-13263 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11648 link
|
|
The professional who took the household composition. |
|
0 … 1 |
prsb03-dataelement-11649 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11650 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11651 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11652 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11653 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11654 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11655 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11521 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11522 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11523 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11524 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11525 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11526 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11527 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11528 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11529 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Lifestyle choices |
|
0 … 1 |
prsb03-dataelement-10039 link
|
|
The lifestyle choices made by the person which are pertinent to his or her health
and well-being, e.g. physical activity level, pets, hobbies and sexual habits
|
|
0 … 1 |
prsb03-dataelement-11784 link
|
|
The date when the lifestyle choices were taken.Date and time. |
|
0 … 1 |
prsb03-dataelement-11785 link
|
|
The location where the lifestyle choices were taken. |
|
0 … 1 |
prsb03-dataelement-13278 link
|
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13279 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13841 link
|
|
The lifestyle choices made by the person which are pertinent to his or her health
and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
|
|
0 … 1 |
prsb03-dataelement-11786 link
|
|
The professional who took the lifestyle choices. |
|
0 … 1 |
prsb03-dataelement-11787 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11788 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11789 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11790 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11791 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11792 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11793 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11548 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11549 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11550 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11551 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11552 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11553 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11554 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11555 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11556 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Smoking status |
|
0 … 1 |
prsb03-dataelement-10040 link
|
|
Details of the person's smoking status. |
|
0 … 1 |
prsb03-dataelement-11794 link
|
|
The date when the smoking status was taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11795 link
|
|
The location where the smoking status was taken. |
|
0 … 1 |
prsb03-dataelement-13281 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13282 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13283 link
|
|
Record of any drug/substance use by the person.
|
|
0 … 1 |
prsb03-dataelement-13284 link
|
|
The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13285 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11796 link
|
|
The professional who took the smoking status. |
|
0 … 1 |
prsb03-dataelement-11797 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11798 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11799 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11800 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11801 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11802 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11803 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11557 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11558 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11559 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11560 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11561 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11562 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11563 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11564 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11565 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Alcohol intake |
|
0 … 1 |
prsb03-dataelement-10041 link
|
|
Details of the person's alcohol intake |
|
0 … 1 |
prsb03-dataelement-11804 link
|
|
The date when the alcohol intake was noted.Date and time |
|
0 … 1 |
prsb03-dataelement-11805 link
|
|
The location where the alcohol intake was noted. |
|
0 … 1 |
prsb03-dataelement-13332 link
|
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13333 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13290 link
|
|
Latest or current alcohol consumption. |
|
0 … 1 |
prsb03-dataelement-13291 link
|
|
The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker
of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109
|Declined to provide information about alcohol use (situation)| OR 371434005 |History
of alcohol abuse (situation)|
|
|
0 … 1 |
prsb03-dataelement-13292 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13759 link
|
|
Detailed history of their alcohol use, amount/frequency, bingeing. Questionnaire/Assessment
used Audit C, FAST etcFree text
|
|
0 … 1 |
prsb03-dataelement-11806 link
|
|
The professional who noted the alcohol intake. |
|
0 … 1 |
prsb03-dataelement-11807 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11808 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11809 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11810 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11811 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11812 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11813 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11566 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11567 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11568 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11569 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11570 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11571 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11572 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11573 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11574 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Drug/substance use |
|
0 … 1 |
prsb03-dataelement-10042 link
|
|
Details of the person's drug and substance use. |
|
0 … 1 |
prsb03-dataelement-11814 link
|
|
The date when the drug/substance use was noted.Date and time |
|
0 … 1 |
prsb03-dataelement-11815 link
|
|
The location where the drug/substance use was noted. |
|
0 … 1 |
prsb03-dataelement-13334 link
|
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13335 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13336 link
|
|
Latest or current drug/substance use. |
|
0 … 1 |
prsb03-dataelement-13337 link
|
|
The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance
abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102
|Declined to give substance misuse history (finding)|
|
|
0 … 1 |
prsb03-dataelement-13338 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11816 link
|
|
The professional who noted the drug/substance use. |
|
0 … 1 |
prsb03-dataelement-11817 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11818 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11819 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11820 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11821 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11822 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11823 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11575 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11576 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11577 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11578 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11579 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11580 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11581 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11582 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11583 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Social circumstances |
|
0 … 1 |
prsb03-dataelement-10043 link
|
|
Details of the persons social circumstances |
|
0 … 1 |
prsb03-dataelement-11824 link
|
|
The date when the social circumstances were taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11825 link
|
|
The location where the social circumstances were taken. |
|
0 … 1 |
prsb03-dataelement-13339 link
|
|
The coded value for the location |
|
0 … 1 |
prsb03-dataelement-13340 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13341 link
|
|
A person’s social background, network and personal circumstances, e.g. housing. This
should include whether the person is a carer.Free text
|
|
0 … 1 |
prsb03-dataelement-11826 link
|
|
The professional who took the social circumstances. |
|
0 … 1 |
prsb03-dataelement-11827 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11828 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11829 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11830 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11831 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11832 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11833 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11584 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11585 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11586 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11587 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11588 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11589 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11590 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11591 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11592 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Access |
|
0 … 1 |
prsb03-dataelement-10045 link
|
|
Details of access for the person. |
|
0 … 1 |
prsb03-dataelement-11844 link
|
|
The date when the special access requirements were taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11845 link
|
|
The location where the special access requirements were taken. |
|
0 … 1 |
prsb03-dataelement-13343 link
|
|
The coded value for locationNHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13344 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-13342 link
|
|
Special access requirements e.g. key safe, coded lock, which door to use, stretcher
access, etc.Free text
|
|
0 … 1 |
prsb03-dataelement-11846 link
|
|
The professional who took the special access requirements. |
|
0 … 1 |
prsb03-dataelement-11847 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11848 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11849 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11850 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11851 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11852 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11853 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11602 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11603 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11604 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11605 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11606 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11607 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11608 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11609 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11610 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Dependants |
|
0 … 1 |
prsb03-dataelement-10046 link
|
|
Details of any responsibility the person has for dependants. |
|
0 … 1 |
prsb03-dataelement-11854 link
|
|
The date when the dependents details were taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11855 link
|
|
The location where the dependents details were taken. |
|
0 … 1 |
prsb03-dataelement-13346 link
|
|
The coded value for locationNHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13347 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13345 link
|
|
Provide details of any responsibility the person has for dependants. In the case of
children provide date of birth of the child.Free text
|
|
0 … 1 |
prsb03-dataelement-11856 link
|
|
The professional who took the dependents details. |
|
0 … 1 |
prsb03-dataelement-11857 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11858 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11859 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11860 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11861 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11862 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11863 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11611 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11612 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11613 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11614 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11615 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11616 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11617 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11618 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11619 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Accommodation status |
|
0 … 1 |
prsb03-dataelement-10047 link
|
|
Details of the type of accommodation where the person lives. |
|
0 … 1 |
prsb03-dataelement-11864 link
|
|
The date when the accommodation status was taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11865 link
|
|
The location where the accommodation was taken. |
|
0 … 1 |
prsb03-dataelement-13352 link
|
|
The coded value of locationNHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13353 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13348 link
|
|
An indication of the type of accommodation where the person lives.
This should be based on the main or permanent residence.
|
|
0 … 1 |
prsb03-dataelement-13349 link
|
|
The coded value for accommodation statusNHS data dictionary :- Accommodation status
|
|
0 … 1 |
prsb03-dataelement-13350 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11866 link
|
|
The professional who took the accommodation status. |
|
0 … 1 |
prsb03-dataelement-11867 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11868 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11869 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11870 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11871 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11872 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11873 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11874 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11875 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11876 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11877 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11878 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11879 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11880 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11881 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11882 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Household environment |
|
0 … 1 |
prsb03-dataelement-10051 link
|
|
Details of the person's household environment. |
|
0 … 1 |
prsb03-dataelement-11883 link
|
|
The date when the household environment details were taken.Date and time |
|
0 … 1 |
prsb03-dataelement-11884 link
|
|
The location where the household environment details were taken. |
|
0 … 1 |
prsb03-dataelement-13351 link
|
|
The coded value for locationNHS Data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13354 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13842 link
|
|
Factors in the household which impact the person's health and wellbeing, to include
smoking in the home, alcohol/substance use etc.Free text
|
|
0 … 1 |
prsb03-dataelement-11885 link
|
|
The professional who took the household environment details. |
|
0 … 1 |
prsb03-dataelement-11886 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11887 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11888 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11889 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11890 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11891 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11892 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11621 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11622 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11623 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11624 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11625 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11626 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11627 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11628 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11629 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Care needs summary |
|
1 … 1 Mandatory |
prsb03-dataelement-13063 link
|
|
A description of the person's current care needs. |
 |
|
Care needs summary |
|
1 … 1 Mandatory |
prsb03-dataelement-13064 link
|
|
A narrative summary of the person's nursing and care needs e.g. catheter/ continence/
stoma care, skin care (wounds, ulcers), tracteostomy, nutrition and fluids, behavioural
care and support.. Attach additional support plans as required.Free text
|
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-13174 link
|
|
The professional who completed the care needs summary. |
|
0 … 1 |
prsb03-dataelement-13182 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13183 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13184 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13185 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13186 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13187 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13188 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-13189 link
|
|
The location where the care needs summary was written. |
|
0 … 1 |
prsb03-dataelement-13729 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13730 link
|
|
Free text |
 |
|
Date |
|
0 … 1 |
prsb03-dataelement-13190 link
|
|
The date the care needs summary was written.Date and time. |
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-13191 link
|
|
A record of the details of the person that entered the care needs summary, and the
date on which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13192 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13193 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13194 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13195 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13196 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13197 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13198 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13199 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Assessed level of care |
|
0 … 1 |
prsb03-dataelement-13425 link
|
|
Record whether Enhanced care observation was required during the admission and details
of level of enhanced care observation needed and why.
|
 |
|
Level of enhanced care observation |
|
0 … 1 |
prsb03-dataelement-13427 link
|
|
Record the level of enhanced care observation the person required during the admission
and prior to discharge if different. Record why needed e.g. to reduce risk and protect the person because of high risk
of falling and sustaining injury or person very confused.Levels:A - General level i.e. needed usual inpatient observationB = Intermittent observation
i.e. every 30 to 60 minutes C = Continuous observation within eyesight i.e. in a cohort
bayD= High level multi professional continuous observation
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-13731 link
|
|
A record of the details of the person that entered the property or equipment the resident
is taking into hospital, and the date on which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13732 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13733 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13734 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13735 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13736 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13737 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13738 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13739 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Primary support reason |
|
0 … 1 |
prsb03-dataelement-12974 link
|
|
The primary support reason for social care. |
 |
 |
Primary support reason record entry |
|
0 … * |
prsb03-dataelement-12975 link
|
|
This is a primary support reason 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-12976 link
|
|
The Primary Support Reason used to classify a person for National Reporting on Short
and Long Term Services (SALT) e.g. Learning disability support, mental health support,
physical supportFree text
|
|
0 … 1 |
prsb03-dataelement-13305 link
|
|
Flag to indicate whether the primary support reason is currently activeFlag: - Yes or No |
|
0 … 1 |
prsb03-dataelement-13306 link
|
|
The date a primary support reason was authorised as active.Date and time |
|
0 … 1 |
prsb03-dataelement-13307 link
|
|
The end date of authorisation.Date and time |
 |
Assessments |
|
0 … * |
prsb03-dataelement-262 link
|
|
Assessment. |
 |
 |
Assessments record entry |
|
0 … * |
prsb03-dataelement-11664 link
|
|
This is the assessments record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10763 link
|
|
The date the assessment was done.Date and time. |
|
0 … 1 |
prsb03-dataelement-10764 link
|
|
The location where the assessment was done.ODS code or free text. |
|
0 … 1 |
prsb03-dataelement-13570 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13571 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10822 link
|
|
The type of the assessment e.g. social care needs assessment.Free text |
|
0 … 1 |
prsb03-dataelement-10754 link
|
|
The summary of the assessmentFree text |
|
0 … 1 |
prsb03-dataelement-10655 link
|
|
Details of the structured assessment. |
 |
 |
 |
|
Structured assessment name |
|
0 … 1 |
prsb03-dataelement-11751 link
|
|
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities
of Daily Living (ADL) etc.SNOMED CT
|
|
0 … 1 |
prsb03-dataelement-10162 link
|
|
The structured assessment score.Free text. |
|
0 … 1 |
prsb03-dataelement-10163 link
|
|
The structured assessment value.Numeric |
|
0 … 1 |
prsb03-dataelement-10166 link
|
|
The total global score from the assessment.Free text |
|
0 … 1 |
prsb03-dataelement-10169 link
|
|
The subscale score of the structured assessment.Free text. |
|
0 … 1 |
prsb03-dataelement-10170 link
|
|
The subscale value of the structured assessment.Numeric |
|
0 … 1 |
prsb03-dataelement-12382 link
|
|
The professional who did the assessment. |
|
0 … 1 |
prsb03-dataelement-12383 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12384 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12385 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12386 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12387 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12388 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12389 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11752 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11753 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11754 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11755 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11756 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11757 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11758 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11759 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11760 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10164 link
|
|
Supporting text may be given regarding the assessment.Free text |
 |
Risks |
|
0 … 1 |
prsb03-dataelement-276 link
|
|
Details of any risks related to the person. |
 |
 |
Risks to self |
|
0 … * |
prsb03-dataelement-10176 link
|
|
Details of the persons risk to self |
|
0 … 1 |
prsb03-dataelement-11893 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11894 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13579 link
|
|
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)| |
|
0 … 1 |
prsb03-dataelement-11895 link
|
|
The location where the risk was identified. |
|
0 … 1 |
prsb03-dataelement-13586 link
|
|
The coded value for locationNHS data dictionary : - Organisation service code
|
|
0 … 1 |
prsb03-dataelement-13587 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11896 link
|
|
The professional who identified the risk. |
|
0 … 1 |
prsb03-dataelement-11897 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11898 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11899 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11900 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11901 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11902 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11903 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11904 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11905 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11906 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11907 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11908 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11909 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11910 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11911 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11912 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Risks to others |
|
0 … * |
prsb03-dataelement-10177 link
|
|
Details of the person's risk to others |
|
0 … 1 |
prsb03-dataelement-11913 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11914 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13580 link
|
|
Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)| |
|
0 … 1 |
prsb03-dataelement-11915 link
|
|
The location where the risk to others was identified. |
|
0 … 1 |
prsb03-dataelement-13588 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13589 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11916 link
|
|
The professional who identifies the risk to others. |
|
0 … 1 |
prsb03-dataelement-11917 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11918 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11919 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11920 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11921 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11922 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11923 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11924 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11925 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11926 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11927 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11928 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11929 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11930 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11931 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11932 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Risk from others |
|
0 … * |
prsb03-dataelement-10178 link
|
|
Risks to the person from an identified individual e.g. family member etc.Free Text. |
|
0 … 1 |
prsb03-dataelement-11933 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11934 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13581 link
|
|
Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)| |
|
0 … 1 |
prsb03-dataelement-11935 link
|
|
The location where the risk from others was identified. |
|
0 … 1 |
prsb03-dataelement-13590 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13591 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11936 link
|
|
The professional who identified the risk from others. |
|
0 … 1 |
prsb03-dataelement-11937 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11938 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11939 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11940 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11941 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11942 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11943 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11944 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11945 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11946 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11947 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11948 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11949 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11950 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11951 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11952 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Risk of accidents |
|
0 … * |
prsb03-dataelement-10751 link
|
|
Details of the risks the person poses to themselves from accidents. |
|
0 … 1 |
prsb03-dataelement-11953 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11954 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13582 link
|
|
Risks the person poses to themselves from accidents.Free text |
|
0 … 1 |
prsb03-dataelement-11955 link
|
|
The location where the risk of accidents was identified. |
|
0 … 1 |
prsb03-dataelement-13592 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13593 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-11956 link
|
|
The professional who identified the risk of accidents. |
|
0 … 1 |
prsb03-dataelement-11957 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11958 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11959 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11960 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11961 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11962 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11963 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11964 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11965 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11966 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11967 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11968 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11969 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11970 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11971 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11972 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Other risks |
|
0 … * |
prsb03-dataelement-10802 link
|
|
Details of other risks, factors or behaviours relating to the person. |
|
0 … 1 |
prsb03-dataelement-11973 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11974 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13583 link
|
|
Other risks, factors or behaviours relating to the person.Free text |
|
0 … 1 |
prsb03-dataelement-11975 link
|
|
The location where the other risks were identified. |
|
0 … 1 |
prsb03-dataelement-13594 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13595 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11976 link
|
|
The professional who identified the other risks. |
|
0 … 1 |
prsb03-dataelement-11977 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11978 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11979 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11980 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11981 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11982 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11983 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11984 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11985 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11986 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11987 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11988 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11989 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11990 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11991 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11992 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Infection risk |
|
0 … * |
prsb03-dataelement-12479 link
|
|
Details of any known infection of the person for which special handling might be required |
|
0 … 1 |
prsb03-dataelement-10179 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-10801 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13596 link
|
|
Any known infection of the person for which special handling might be requiredFree text |
|
0 … 1 |
prsb03-dataelement-10180 link
|
|
The location where the risk was identified. |
|
0 … 1 |
prsb03-dataelement-13584 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13585 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13597 link
|
|
The professional who identified the risk of infections. |
|
0 … 1 |
prsb03-dataelement-13598 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13599 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13600 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13601 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13602 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13603 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13604 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13605 link
|
|
A record of the details of the person that entered the reasonable adjustment and the
date on which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13606 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13607 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13608 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13609 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13610 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13611 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13612 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13613 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Allergies and adverse reactions |
|
1 … 1 Mandatory |
prsb03-dataelement-282 link
|
|
Allergies and adverse reactions |
 |
 |
Allergies and adverse reactions record entry |
|
1 … * Mandatory |
prsb03-dataelement-10657 link
|
|
This is a allergies and adverse reactions record entry. There may be 1 to many record
entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10186 link
|
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
|
|
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.Date and time |
|
0 … 1 |
prsb03-dataelement-10846 link
|
|
Details of where the allergy was identified. Linked to the date of the diagnosis by
the professional.
|
|
0 … 1 |
prsb03-dataelement-13439 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13440 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11665 link
|
|
The substance, or a class of substances, that is considered to be responsible for
the adverse reaction.
|
|
0 … 1 |
prsb03-dataelement-13554 link
|
|
The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical
/ biologic product (product) |
|
|
0 … 1 |
prsb03-dataelement-13555 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10183 link
|
|
A description of the manifestation of the allergic or adverse reaction experienced
by the person. For example, skin rash.
|
|
0 … 1 |
prsb03-dataelement-13556 link
|
|
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
0 … 1 |
prsb03-dataelement-13557 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10184 link
|
|
A description of the severity of the reaction. |
|
0 … 1 |
prsb03-dataelement-13558 link
|
|
The coded value for severityFHIR value set : - Severity
|
|
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.FHIR value set : - Certainty
|
|
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-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 i.e this may not be the first this has happened.
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 |
|
0 … 1 |
prsb03-dataelement-12010 link
|
|
The professional who identified the reaction. |
|
0 … 1 |
prsb03-dataelement-12011 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12012 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12013 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12014 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12015 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12016 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12017 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12018 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12019 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12020 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12021 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12022 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12023 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12024 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12025 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12026 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
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 |
|
0 … 1 |
prsb03-dataelement-10843 link
|
|
The date on which the medication or medical device was prescribed.Date and time |
|
0 … 1 |
prsb03-dataelement-10844 link
|
|
The location where the medication or the medical device was prescribed. |
|
0 … 1 |
prsb03-dataelement-13620 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13621 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12002 link
|
|
The professional who prescribed the medication or medical device. |
|
0 … 1 |
prsb03-dataelement-12003 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12004 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12005 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12006 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12007 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12008 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12009 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
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 nameSNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines
and devices virtual therapeutic moiety simple reference set (foundation metadata concept)|
OR ^999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104
|National Health Service dictionary of medicines and devices virtual medicinal product
pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National
Health Service dictionary of medicines and devices actual medicinal product simple
reference set (foundation metadata concept)| OR ^999000551000001106 |National Health
Service dictionary of medicines and devices actual medicinal product pack simple reference
set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13623 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10537 link
|
|
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
|
0 … 1 |
prsb03-dataelement-13624 link
|
|
The coded value for form.SNOMED CT: - 421967003 | Drug dose form (qualifier value) | |
|
0 … 1 |
prsb03-dataelement-13625 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10538 link
|
|
The route by which the medication is administered e.g. oral, IM, IV |
|
0 … 1 |
prsb03-dataelement-13655 link
|
|
The coded value for routeSNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13656 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10540 link
|
|
The anatomical site at which the medication is to be administered. |
|
0 … 1 |
prsb03-dataelement-13657 link
|
|
The coded value for siteSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) | |
|
0 … 1 |
prsb03-dataelement-13658 link
|
|
Amount of vaccine administered.Free text |
|
0 … 1 |
prsb03-dataelement-10541 link
|
|
The technique or method by which the medication is to be administered. |
 |
 |
 |
|
Over the counter medication flag |
|
0 … 1 |
prsb03-dataelement-13379 link
|
|
Indicates if the medication or device is acquired without a prescription i.e. got
by the person over the counterFlag : - Yes or No
|
 |
 |
 |
|
Dose directions description |
|
0 … 1 |
prsb03-dataelement-10544 link
|
|
Describes the entire medication dosage and administration directions including dose
quantity and medication frequency and optionally duration e.g. “1 tablet at night"
or “2mg at 10pm”.Free text
|
 |
 |
 |
 |
Structured dose direction cluster |
|
0 … 1 |
prsb03-dataelement-11639 link
|
|
A structural representation of the elements carried by the dose syntax in 'parsable
dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum
dose.
|
|
0 … 1 |
prsb03-dataelement-10554 link
|
|
A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will
generally only be used when persisting data within systems with 'parsable dose directions'
being used to exchange the same information between systems.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
|
|
0 … 1 |
prsb03-dataelement-10555 link
|
|
A slot containing a structural, computable representation of dose timing and maximum
dose. This element will generally only be used when persisting data within systems
with 'parsable dose directions' being used to exchange the same information between
systems.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
|
|
0 … 1 |
prsb03-dataelement-10548 link
|
|
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.Free text
|
|
0 … 1 |
prsb03-dataelement-10545 link
|
|
Allows for: requirements for adherence support, e.g. compliance aids, prompts and
packaging requirements, additional information about specific medicines e.g. where
specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction
|
|
0 … 1 |
prsb03-dataelement-10561 link
|
|
Details of the overall course of medication. |
|
0 … 1 |
prsb03-dataelement-10666 link
|
|
The status of this prescription.FHIR value set : - Medication status
|
|
0 … 1 |
prsb03-dataelement-10546 link
|
|
Reason for medication being prescribed, where known.Free text |
|
0 … 1 |
prsb03-dataelement-10667 link
|
|
The date and/or time that the medication course should begin.Date and time |
|
0 … 1 |
prsb03-dataelement-10557 link
|
|
The date and/or time that the medication course should finish.Date and time |
 |
 |
 |
 |
|
Link to indication record |
|
0 … 1 |
prsb03-dataelement-10668 link
|
|
A link to the record which contains the indication for this medication order.Free text with URL |
|
0 … 1 |
prsb03-dataelement-10547 link
|
|
Suggestions about duration and/or review, ongoing monitoring requirements, advice
on starting, discontinuing or changing medication. Additional comment or recommendation
about the medication course e.g. 'Patient named supply', 'unlicensed medication',
'Foreign brand' or monitoring recommendationsFree text
|
 |
 |
 |
 |
Medication change summary cluster |
|
0 … 1 |
prsb03-dataelement-10568 link
|
|
Records the changes made to medication. |
|
0 … 1 |
prsb03-dataelement-10669 link
|
|
The nature of any change made to the medication.FHIR value set : Medication status
|
|
0 … 1 |
prsb03-dataelement-10670 link
|
|
Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.Free text |
|
0 … 1 |
prsb03-dataelement-10671 link
|
|
The date of the change - addition, or amendmentDate and time |
|
0 … 1 |
prsb03-dataelement-10672 link
|
|
Where a change is made to the medication i.e. one drug stopped and another started
or eg dose, frequency or route is changed.Free text
|
 |
 |
 |
|
Total dose daily quantity |
|
0 … 1 |
prsb03-dataelement-10665 link
|
|
The total daily dose of this medication. This is helpful for estimating optimal adherence
to dosing guidance. It may be computed from product/dose strength and frequency or
entered manually.Free text
|
|
0 … 1 |
prsb03-dataelement-11993 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11994 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11995 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11996 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11997 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11998 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11999 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12000 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12001 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10583 link
|
|
Medical devices |
|
1 … 1 Mandatory |
prsb03-dataelement-10673 link
|
|
Any medical device that isn't prescribed.Free text |
|
0 … 1 |
prsb03-dataelement-11280 link
|
|
Any information regarding the medical device.Free text |
 |
 |
 |
Medication discontinued entry |
|
0 … 1 |
prsb03-dataelement-10576 link
|
|
Medication discontinued entry |
 |
 |
 |
 |
Name of discontinued medication |
|
0 … 1 |
prsb03-dataelement-10577 link
|
|
The name of the medication or medical device being discontinued |
|
0 … 1 |
prsb03-dataelement-13659 link
|
|
The coded value for medication name
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-13660 link
|
|
Amount of vaccine administered.Free text |
|
0 … 1 |
prsb03-dataelement-12472 link
|
|
The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
|
|
0 … 1 |
prsb03-dataelement-10579 link
|
|
The clinical indication for any changes in medication statusFree text |
|
0 … 1 |
prsb03-dataelement-10580 link
|
|
The date of the discontinuationDate and time |
|
0 … 1 |
prsb03-dataelement-10582 link
|
|
Any additional comment about the discontinuation or amendment.Free text |
 |
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.
|
|
0 … * |
prsb03-dataelement-10445 link
|
|
The date on which the plan and requested actions were prepared.Date and time |
|
0 … 1 |
prsb03-dataelement-12167 link
|
|
The professional who prepared the plan and requested actions. |
|
0 … 1 |
prsb03-dataelement-12168 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12169 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12170 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12171 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12172 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12173 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12174 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10842 link
|
|
The location where the plan and requested actions were prepared. |
|
0 … 1 |
prsb03-dataelement-13684 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13685 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
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
|
 |
 |
|
Agreed with the person or their legitimate representative |
|
0 … * |
prsb03-dataelement-10438 link
|
|
Indicates whether the person or their legitimate representative has agreed the entire
plan or individual aspects of treatment, expected outcomes, risks and alternative
treatments. A record of the agreement of the decisions made.Free text
|
 |
 |
|
Outcome of plan and requested actions |
|
0 … * |
prsb03-dataelement-10950 link
|
|
The details of the outcome of the plan and requested actions.Free text. |
|
0 … 1 |
prsb03-dataelement-12175 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12176 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12177 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12178 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12179 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12180 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12181 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12182 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12183 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Person and carer concerns expectations and wishes |
|
0 … 1 |
prsb03-dataelement-292 link
|
|
Person and carer concerns, expectations and wishes |
 |
|
Date |
|
0 … 1 |
prsb03-dataelement-10193 link
|
|
The date on which the concerns, wishes or goals of the person were recorded |
 |
|
Location |
|
0 … 1 |
prsb03-dataelement-10856 link
|
|
The location where the concerns, expectations and wishes were recorded. |
 |
|
Patient and carer concerns, expectations and wishes |
|
0 … 1 |
prsb03-dataelement-10192 link
|
|
Description of the concerns, wishes or goals of the person in relation to their care,
as expressed by the person, their representative or carer. Record who has expressed
these (patient or carer/ representative on behalf of the patient).Where the person
lacks capacity this may include their representative's concerns, expectations or wishes.A record of statements expressed by the person or their carer or representative. Free
Text
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-13740 link
|
|
A record of the details of the person that entered the impairment and the date on
which it was entered.
|
|
0 … 1 |
prsb03-dataelement-13741 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13742 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13743 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13744 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13745 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13746 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13747 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13748 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Contingency plans |
|
0 … * |
prsb03-dataelement-469 link
|
|
Contingency plans. |
 |
|
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10369 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.Free text
|
 |
|
Anticipatory medicines/equipment |
|
0 … 1 |
prsb03-dataelement-10370 link
|
|
Medicines or equipment available that may be required in specific situations and their
location. A statement regarding the availability or location of the anticipatory medicines/equipment.Free text
|
 |
 |
Advance statement |
|
0 … 1 |
prsb03-dataelement-10777 link
|
|
Written requests and preferences made by a person with capacity conveying their wishes,
beliefs and values for their future care should they lose capacity.
|
|
0 … 1 |
prsb03-dataelement-12267 link
|
|
The date when the advanced statements was made.Date and time |
|
0 … 1 |
prsb03-dataelement-12268 link
|
|
The location where the advanced statement was made. |
|
0 … 1 |
prsb03-dataelement-13698 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13699 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13695 link
|
|
Does the person have an advance statement. |
|
0 … 1 |
prsb03-dataelement-13696 link
|
|
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13697 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13760 link
|
|
The location of where the advanced statement is held.Free text or URL |
|
0 … 1 |
prsb03-dataelement-12269 link
|
|
The professional who made the advance statement. |
|
0 … 1 |
prsb03-dataelement-12270 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12271 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12272 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12273 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12274 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12275 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12276 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12277 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12278 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12279 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12280 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12281 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12282 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12283 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12284 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12285 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
|
Contingency plan name |
|
0 … 1 |
prsb03-dataelement-10371 link
|
|
Name of the contingency plan – what condition or circumstances it is addressing.Free text |
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10372 link
|
|
The date that this contingency plan was last updated.Date and time |
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10373 link
|
|
This is the date/interval when this contingency plan will next be reviewed.Date and time |
 |
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10374 link
|
|
This is who has responsibility for arranging review of this information.
Should include their name, role and contact details.Free text.
|
 |
|
Trigger factors |
|
0 … 1 |
prsb03-dataelement-10375 link
|
|
Signs to watch out for that may indicate a significant change in health or other circumstances.
A statement of trigger factors.Free text
|
 |
|
What should happen |
|
0 … 1 |
prsb03-dataelement-10376 link
|
|
Guidance on specific actions or interventions that may be required or should be avoided
in specific situations. This may include circumstances where action needs to be taken
if a carer is unable to care for the person. A statement of suggested actions. Usually
expressed as: in the event of X do Y.Free text
|
 |
|
Who should be contacted |
|
0 … 1 |
prsb03-dataelement-10377 link
|
|
Who should be contacted in the event of significant problems or deterioration in health
or wellbeing. E.g. name, role and contact details.Free text
|
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12079 link
|
|
The location where the contingency plan was prepared. |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12045 link
|
|
The professional who prepared the contingency plans. |
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12053 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12054 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12055 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12056 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12057 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12058 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12059 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12060 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12061 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Additional support plans |
|
0 … * |
prsb03-dataelement-502 link
|
|
Additional support plans |
 |
|
Additional support plan name |
|
0 … 1 |
prsb03-dataelement-10402 link
|
|
The name of the particular additional supporting plan, e.g. dieticians plan, wound
management plan, discharge management plan and behaviour support plan.Free text
|
 |
|
Additional support plan content |
|
0 … 1 |
prsb03-dataelement-10403 link
|
|
This is the content of any additional care and support plan which the person and/or
care professional consider should be shared with others providing care and support.
May be structured in different ways, e.g. tables, diagrams, images. This is the content
of any additional care and support plan which the individual and/or care professional
consider should be shared with others providing care and support. It should be structured
as recommended for the care and support plan and if contains additional detail, it
may be referenced here.Free text
|
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10405 link
|
|
This is the date/interval when this information will next be reviewed.Date and time |
 |
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10406 link
|
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.Free text.
|
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10407 link
|
|
This is a record of the date that this information was last updated.Date and time |
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12080 link
|
|
The location where the additional support plan was prepared.ODS code or free text |
|
0 … 1 |
prsb03-dataelement-13722 link
|
|
The coded value for locationNHS data dictionary:- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13723 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12062 link
|
|
The professional who prepared the additional support plan. |
|
0 … 1 |
prsb03-dataelement-12063 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12064 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12065 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12066 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12067 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12068 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12069 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12070 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12071 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12072 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12073 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12074 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12075 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12076 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12077 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12078 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
End of life care |
|
0 … 1 |
prsb03-dataelement-10743 link
|
|
Information relating to end of life care.
N.B. This is not an end of life care plan but contains information that would be found
in an end of life care plan.
|
 |
 |
Cardio-pulmonary resuscitation (CPR) decision |
|
0 … 1 |
prsb03-dataelement-10771 link
|
|
Whether a decision has been made, the decision, who made the decision, the date of
decision, date for review and location of documentation. Where the person or their
family member/carer have not been informed of the clinical decision please state the
reason why.
|
|
0 … 1 |
prsb03-dataelement-12210 link
|
|
The date when the cardio-pulmonary resuscitation decision was made.Date and time. |
|
0 … 1 |
prsb03-dataelement-12211 link
|
|
The location where the cardio-pulmonary resuscitation decision was made. |
|
0 … 1 |
prsb03-dataelement-13689 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13690 link
|
|
Free text field to be used if no coded text available |
 |
 |
 |
Cardio-pulmonary resuscitation (CPR) decision |
|
0 … 1 |
prsb03-dataelement-13686 link
|
|
The cardio-pulmonary resuscitation (CPR) decision. |
|
0 … 1 |
prsb03-dataelement-13687 link
|
|
The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008
| Not for cardiopulmonary resuscitation (finding) |
|
|
0 … 1 |
prsb03-dataelement-13688 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13705 link
|
|
The date for review of CPR decision.Date and time |
|
0 … 1 |
prsb03-dataelement-13706 link
|
|
The location of the CPR decision documentFree text or URL |
|
0 … 1 |
prsb03-dataelement-12212 link
|
|
The professional who made the cardio-pulmonary resuscitation decision. |
|
0 … 1 |
prsb03-dataelement-12213 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12214 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12215 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12216 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12217 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12218 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12219 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12220 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12221 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12222 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12223 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12224 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12225 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12226 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12227 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12228 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Estimated prognosis |
|
0 … 1 |
prsb03-dataelement-10745 link
|
|
Details of the persons estimated prognosis |
|
0 … 1 |
prsb03-dataelement-12229 link
|
|
The date when the estimated prognosis was made.Date and time |
|
0 … 1 |
prsb03-dataelement-12230 link
|
|
The location where the estimated prognosis was made.ODS code or free text |
|
0 … 1 |
prsb03-dataelement-13703 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13704 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-13691 link
|
|
Where a person is terminally ill this is a clinical judgment indicating the anticipated
period of time until death e.g. last days, weeks, months or year of life.Free text
|
|
0 … 1 |
prsb03-dataelement-12231 link
|
|
The professional who made the estimated prognosis. |
|
0 … 1 |
prsb03-dataelement-12232 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12233 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12234 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12235 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12236 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12237 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12238 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12239 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12240 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12241 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12242 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12243 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12244 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12245 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12246 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12247 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Awareness of prognosis |
|
0 … 1 |
prsb03-dataelement-10775 link
|
|
Details of the persons awareness of prognosis |
|
0 … 1 |
prsb03-dataelement-12248 link
|
|
The date when the assessment of the level of awareness of the prognosis was made.Date and time |
|
0 … 1 |
prsb03-dataelement-12249 link
|
|
The location where the assessment of the level of awareness of the prognosis was made.ODS code and free text |
|
0 … 1 |
prsb03-dataelement-13693 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13694 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13692 link
|
|
Description of the level of awareness the person and or their carer/family has regarding
their estimated prognosis.Free text
|
|
0 … 1 |
prsb03-dataelement-12250 link
|
|
The professional who made the assessment of the level of awareness of the prognosis. |
|
0 … 1 |
prsb03-dataelement-12251 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12252 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12253 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12254 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12255 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12256 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12257 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12258 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12259 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12260 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12261 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12262 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12263 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12264 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12265 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12266 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Preferred place of death |
|
0 … 1 |
prsb03-dataelement-10780 link
|
|
Details of the person's preferred place of death |
|
0 … 1 |
prsb03-dataelement-12324 link
|
|
The date when the preferred place of death was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-12325 link
|
|
The location where the preferred place of death was identified. |
|
0 … 1 |
prsb03-dataelement-13713 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13714 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Preferred place of death 1st |
|
0 … 1 |
prsb03-dataelement-13710 link
|
|
The preferences that a person has identified as their preferred place to die. |
|
0 … 1 |
prsb03-dataelement-13711 link
|
|
The name of the preferred place of deathFree text |
|
0 … 1 |
prsb03-dataelement-13712 link
|
|
The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's
own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient
specialist palliative care)40: Care Home50: Other (free text eg secure and detained
settings)517111000000103, Preferred place of death: patient unable to express preference
517131000000106, Preferred place of death: discussion not appropriate766391000000108,
Preferred place of death: patient declined discussion517161000000101, Preferred place
of death: patient undecided
|
 |
 |
 |
Preferred place of death 2nd |
|
0 … 1 |
prsb03-dataelement-13716 link
|
|
The preferences that a person has identified as their preferred place to die. |
|
0 … 1 |
prsb03-dataelement-13717 link
|
|
The name of the preferred place of deathFree text |
|
0 … 1 |
prsb03-dataelement-13718 link
|
|
The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's
own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient
specialist palliative care)40: Care Home50: Other (free text eg secure and detained
settings)517111000000103, Preferred place of death: patient unable to express preference
517131000000106, Preferred place of death: discussion not appropriate766391000000108,
Preferred place of death: patient declined discussion517161000000101, Preferred place
of death: patient undecided
|
|
0 … 1 |
prsb03-dataelement-12326 link
|
|
The professional who identified the preferred place of death. |
|
0 … 1 |
prsb03-dataelement-12327 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12328 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12329 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12330 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12331 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12332 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12333 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12334 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12335 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12336 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12337 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12338 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12339 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12340 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12341 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12342 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
 |
Preferred place of care |
|
0 … 1 |
prsb03-dataelement-10781 link
|
|
Details of the persons preferred place of care |
|
0 … 1 |
prsb03-dataelement-12362 link
|
|
The date when the preferred place of care was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-12363 link
|
|
The location where the preferred place of care was identified. |
|
0 … 1 |
prsb03-dataelement-13720 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13721 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13719 link
|
|
The preferences that the person has identified as their preferred place to receive
care.Free text
|
|
0 … 1 |
prsb03-dataelement-12364 link
|
|
The professional who identified the preferred place of care. |
|
0 … 1 |
prsb03-dataelement-12365 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12366 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12367 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12368 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12369 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12370 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12371 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12372 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12373 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12374 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12375 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12376 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12377 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12378 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12379 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12380 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
 |
Documents (including correspondence and images) |
|
0 … 1 |
prsb03-dataelement-10820 link
|
|
Details about documents related to the person. |
 |
 |
Documents |
|
0 … * |
prsb03-dataelement-11259 link
|
|
This is the documents record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10943 link
|
|
The date and time the document was created.Date and time |
|
0 … 1 |
prsb03-dataelement-12422 link
|
|
The professional who authored the document.Free text. |
|
0 … 1 |
prsb03-dataelement-12423 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12424 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12425 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12426 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12427 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12428 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12429 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10946 link
|
|
The location of the documentFree text or URL |
|
0 … 1 |
prsb03-dataelement-10942 link
|
|
The code specifying the level of confidentiality of the document.
FHIR value set : - Confidentiality
|
|
0 … 1 |
prsb03-dataelement-10940 link
|
|
The document type e.g. report, summary, images, treatment plan, patient preferences,
workflowFree text.
|
|
0 … 1 |
prsb03-dataelement-10944 link
|
|
The title of the document.Free text |
|
0 … 1 |
prsb03-dataelement-10945 link
|
|
The name of the document. This should align to the PRSB document naming standard.
Where the document is a KOS document this field (designated typeCode) is used to carry
the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging
Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed
procedure with which the document is associated. Values may be found in a suitable
DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
|
|
0 … 1 |
prsb03-dataelement-10949 link
|
|
MIME type of the document e.g. application, pdf, audio, jpegFree text |
|
0 … 1 |
prsb03-dataelement-12430 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12431 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12432 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12433 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12434 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12435 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12436 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12437 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12438 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-11163 link
|
|
The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple
reference set (foundation metadata concept)|
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prsb03-dataelement-13749 link
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The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata
concept)|
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0 … 1 |
prsb03-dataelement-13750 link
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Free text field to be used if no code is availableFree text |
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prsb03-dataelement-10941 link
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Comments associated with the document.Free text |
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Assessment notice |
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prsb03-dataelement-13401 link
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Informs the social services team that an assessment will be required, with expected
discharge date if known.
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Issued date and time |
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prsb03-dataelement-13404 link
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The date and time on which the Assessment Notice was given. |
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Person consultation indicator |
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0 … 1 |
prsb03-dataelement-13408 link
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Indicates whether or not the patient has been consulted in relation to the Assessment
Notice.
Flag; N: No; Y: Yes
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Carer consultation indicator |
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0 … 1 |
prsb03-dataelement-13407 link
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Indicates whether or not the carer (where applicable) has been consulted in relation
to the Assessment Notice.
N: No; Y: Yes; NKC: No Known Carer
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Person consent indicator |
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prsb03-dataelement-13406 link
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Indicates whether or not the patient has consented to the Assessment Notice or lacks
the mental capacity to do so.
N: No; Y: Yes; L: Lacks Mental Capacity
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Third party person consent source |
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0 … 1 |
prsb03-dataelement-13405 link
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A coded value specifying the source of consent where the patient lacks mental capacity
and consent has been provided by a third party with the appropriate legal status.
C: Legal Representative (Carer); O: Legal Representative (Other); B: Best Interest
Decision; N/A: Not Applicable
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NHS CHC Assessment |
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prsb03-dataelement-13403 link
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NHS Continuing Healthcare Assessment (checklist) entry |
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Assessment considered indicator |
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0 … 1 |
prsb03-dataelement-13409 link
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Indicates whether or not the NHS body has considered providing the patient with NHS
Continuing Health Care.
Flag: - yes/ no; N: No; Y: Yes
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Assessment considered result |
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0 … * |
prsb03-dataelement-13410 link
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Used to record the result of a consideration to provide the patient with NHS Continuing
Care.Free text
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Discharge notice |
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prsb03-dataelement-13402 link
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Confirms discharge date to social services |
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Issued date and time |
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0 … 1 |
prsb03-dataelement-13411 link
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The date and time on which the discharge notice was given.
The date and time on which the discharge notice was given.
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Withdrawal notice |
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0 … * |
prsb03-dataelement-13412 link
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To withdraw either or both the assessment notice and/ or the discharge notice |
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Issued date and time |
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0 … 1 |
prsb03-dataelement-13413 link
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The date and time on which the Withdrawal Notice was issued. |
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Withdrawal type |
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0 … 1 |
prsb03-dataelement-13416 link
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The type of notice that has been withdrawn.
1: Assessment Notice; 2: Discharge Notice; 3: Assessment Notice and Discharge Notice
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Reason for withdrawal |
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0 … 1 |
prsb03-dataelement-13415 link
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The reason why the notice has been withdrawn.
01: Patient is safe to discharge without a needs assessment; 02: Patient is eligible
for NHS Continuing Health Care; 03: Proposed care package is inadequate;
04: Patient's proposed treatment has been cancelled or postponed; 05: Patient has
refused a needs assessment; 06: Patient is resident in another local authority;
07: Patient's condition has deteriorated; 08: Patient has died; 09: Patient has transferred
to intermediate care; 10: Patient has self- discharged; 11: Patient is making their
own arrangements; 12: Notice sent in error; 13: Other
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Reason for withdrawal - other |
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prsb03-dataelement-13414 link
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A free format description of the reason why the notice has been withdrawn. To be used
when 'Reason For Withdrawal = 'Other’.Free text
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Notice receipt |
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prsb03-dataelement-13417 link
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Notice receipt, from social services, entry. A receipt notice is issued and sent to
the referring organisation to acknowledge that a notice has been received e.g. assessment,
discharge, withdrawal.
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Issued date and time |
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prsb03-dataelement-13421 link
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The date and time on which the Notice Receipt was issued. |
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Notice type |
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prsb03-dataelement-13420 link
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The type of notice that the Notice Receipt relates to.
1: Assessment Notice; 2: Discharge Notice; 3: Withdrawal Notice (Assessment); 4: Withdrawal
Notice (Discharge); 5: Withdrawal Notice (Assessment and Discharge)
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Response type |
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0 … 1 |
prsb03-dataelement-13419 link
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The Notice Receipt response type.
1: Accept ;2: Reject
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Response details |
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prsb03-dataelement-13418 link
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Supporting information for the Notice Receipt, for example the reason why a notice
was rejectedFree text
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