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draft Scenario Hospital referral for assessment for community care and support 2.16.840.1.113883.3.1937.777.28.3.24

Name Details [‑]
draft Hospital referral for assessment for community care and support
prsb03-scenario-24
Version / effective date 1 - 2020‑06‑04 16:52:10
Description The person'r referral from hospital to local authority for extra care and support
draft doublearrow Hospital referral for assessment for community care and support
prsb03-transaction-147link
Version / effective date 1 - 2020‑06‑04 16:52:10    
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draft arrowright Hospital referral for assessment for community care and support
prsb03-transaction-148link
Version / effective date 1 - 2020‑06‑04 16:52:10    
Actor
Sender (organization) Hospital
Receiver (organization) Local authority
Associations
Contained concepts
Concept Card/Conf Id
folder Person demographics
1 … 1 Mandatory
prsb03-dataelement-10868link
The person's details and contact information.
treetree folder Person name
1 … 1 Mandatory
prsb03-dataelement-10869link
Details of the person's name
treeblank treetree draft  Person first name
0 … *
prsb03-dataelement-13799link
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
treeblank treetree draft  Person family name
0 … 1
prsb03-dataelement-13800link
The family name or surname of the personNHS data dictionary: - Person family name
treeblank treetree draft  Person preferred name
0 … 1
prsb03-dataelement-10870link
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
treeblank treetree draft  Title
0 … 1
prsb03-dataelement-13089link
Person's titleNHS data dictionary: - Person title
treeblank treetree draft  Person name suffix
0 … 1
prsb03-dataelement-13798link
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
treeblank treetree draft  Person full name
0 … 1
prsb03-dataelement-13801link
The full name of the person in text representation.NHS data dictionary :- Patient full name
treetree draft  Date of birth
1 … 1 Mandatory
prsb03-dataelement-10871link
The date of birth of the person.NHS data dictionary:- Person birth date
treetree draft  Gender
0 … 1
prsb03-dataelement-10872link
The person's stated gender.NHS data dictionary: - Person stated gender code
treetree draft  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Religion
0 … 1
prsb03-dataelement-10876link
The religious affiliation as specified by the person.SNOMED_CT: ^999000531000000100 |Religious or other belief system affiliation simple reference set (foundation metadata concept)|
treetree draft  Sex
0 … 1
prsb03-dataelement-10877link
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary:- person phenotypic sex classification
treetree draft  NHS number
0 … 1
prsb03-dataelement-10879link
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
treetree draft  NHS number status indicator
0 … 1
prsb03-dataelement-13297link
Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
treetree draft  Other identifier
0 … *
prsb03-dataelement-10880link
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)
treetree folder Person's address
1 … 1 Mandatory
prsb03-dataelement-10881link
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
treeblank treetree draft  Address line 1
0 … 1
prsb03-dataelement-13082link
Person's first line of address. NHS data dictionary :- Address line 1
treeblank treetree draft  Address line 2
0 … 1
prsb03-dataelement-13083link
Person's second line of address.NHS data dictionary :- Address line 2
treeblank treetree draft  Address line 3
0 … 1
prsb03-dataelement-13084link
Person's third line of address.NHS data dictionary :- Address line 3
treeblank treetree draft  Address line 4
0 … 1
prsb03-dataelement-13085link
Person's fourth line of address.NHS data dictionary :- Address line 4
treeblank treetree draft  Address line 5
0 … 1
prsb03-dataelement-13086link
Person's fifth line of address.NHS data dictionary:- Address line 5
treeblank treetree draft  Postcode
0 … 1
prsb03-dataelement-13087link
The person's postcode. NHS data dictionary : - Postcode of usual address
treetree folder Immigration status
0 … 1
prsb03-dataelement-13293link
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.
treeblank treetree draft  Immigration status
0 … 1
prsb03-dataelement-13304link
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
treeblank treetree draft  Start date
0 … 1
prsb03-dataelement-13294link
Start date of immigration statusDate and time
treeblank treetree draft  End date
0 … 1
prsb03-dataelement-13295link
End date of immigration statusDate and time
treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-13296link
Relevant comments about the person's immigration statusFree text
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
0 … 1
prsb03-dataelement-10643link
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
treeblank treetree draft  GP name
0 … 1
prsb03-dataelement-10003link
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
treeblank treetree draft  GP practice details
0 … 1
prsb03-dataelement-10002link
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
treeblank treetree draft  GP practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice.NHS data dictionary: - General medical practise code (patient registration)
folder About me
0 … 1
prsb03-dataelement-466link
About me
treetree folder About me
0 … 1
prsb03-dataelement-10366link
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.
treeblank treetree draft  What is most important to me
0 … 1
prsb03-dataelement-12964link
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
treeblank treetree draft  People who are important to me
0 … 1
prsb03-dataelement-13009link
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
treeblank treetree draft  How I communicate and how to communicate with me
0 … 1
prsb03-dataelement-13006link

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
treeblank treetree draft  Please do and please don't
0 … 1
prsb03-dataelement-13008link

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
treeblank treetree draft  My wellness
0 … 1
prsb03-dataelement-13005link

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
treeblank treetree draft  How and when to support me
0 … 1
prsb03-dataelement-13007link

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
treeblank treetree draft  Also worth knowing about me
0 … 1
prsb03-dataelement-13094link

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
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10367link
This is a record of the date that this information was last updated.Date and Time
treeblank treetree draft  Supported to write this by
0 … 1
prsb03-dataelement-10368link
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
folder Individual requirements
0 … 1
prsb03-dataelement-160link
The individual requirements of the person.
treetree folder Reasonable adjustment
0 … 1
prsb03-dataelement-12991link
A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
treeblank treetree folder Reasonable adjustment record entry
0 … *
prsb03-dataelement-13061link
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
treeblank treeblank treetree folder Location
0 … 1
prsb03-dataelement-13098link
The location where the reasonable adjustment was identified.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13357link
The coded value for location.NHS Data dictionary : - Organisation data service code
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13358link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Reasonable adjustment
0 … 1
prsb03-dataelement-13017link
The reasonable adjustment required e.g. requires specific contact method, requires communication professional
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13505link
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
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13506link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Reasonable adjustment additional detail
0 … 1
prsb03-dataelement-13018link
Further detail about the support required and the consequence of not providing it.Free text
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13020link
The date the reasonable adjustment was identified.Date and time
treeblank treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13027link
The professional who confirmed the need for the reasonable adjustment.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13028link
The name of the professional.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13029link
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13030link
The grade of the professional.Free text
treeblank treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13031link
The specialty of the professional.NHS data dictionary - Main specialty code
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13032link
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
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13033link
The name of the organisation the professional works for.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13034link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13035link
A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13036link
The name of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13037link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13038link
The grade of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13039link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13040link
The organisation the person completing the record works for.
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13041link
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
treeblank treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13042link
The date and time the record was completed.Date and time.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13043link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Impairment
0 … 1
prsb03-dataelement-13001link
A record of any impairments for the person relating to reasonable adjustments.
treeblank treetree folder Impairment record entry
0 … *
prsb03-dataelement-13062link
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
treeblank treeblank treetree folder Location
0 … 1
prsb03-dataelement-13099link
The location where the impairment was identified.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13429link
The coded value for location.NHS data dictionary: - Organisation code service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13430link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Impairment category
0 … 1
prsb03-dataelement-13022link
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13507link
The coded value for impairment.SNOMED CT
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13508link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Impairment additional detail
0 … 1
prsb03-dataelement-13023link

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
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13024link
The date the impairment was identified.Date and time
treeblank treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13044link
The professional who confirmed the impairment.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13045link
The name of the professional.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13046link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13047link
The grade of the professional.Free text
treeblank treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13048link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13049link
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
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13050link
The name of the organisation the professional works for.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13051link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13052link

A record of the details of the person that entered the impairment and the date on which it was entered.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13053link
The name of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13054link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13055link
The grade of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13056link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13057link
The organisation the person completing the record works for.
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13058link
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
treeblank treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13059link
The date and time the record was completed.Date and time.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13060link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Mobility
0 … 1
prsb03-dataelement-10067link
Details of the person's mobility needs.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11707link
The date when the mobility needs were identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11710link
The location where the mobility needs were identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13433link
The coded value for location.NHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13434link
Free text field to be used if no coded text available
treeblank treetree folder Mobility needs
0 … 1
prsb03-dataelement-13670link
The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13671link
The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13672link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11487link
The professional who identified the mobility needs.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11488link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11489link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11490link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11491link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11492link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11493link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11494link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11495link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11496link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11497link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11498link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11499link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11500link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11501link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11502link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11503link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Other individual requirements
0 … 1
prsb03-dataelement-10835link
Details of any other individual requirements the person may have
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11711link
The date when the other individual requirements were identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11712link
The location where the other individual requirements were identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13435link
The coded value for location.NHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13436link
Free text field to be used if no coded text available
treeblank treetree draft  Other individual requirement
0 … 1
prsb03-dataelement-13673link
Other individual requirements that a person may have.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11504link
The professional who identified the other individual requirements.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11505link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11506link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11507link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11508link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11509link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11510link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11511link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11512link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11513link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11514link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11515link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11516link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11517link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11518link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11519link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11520link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Alerts
0 … *
prsb03-dataelement-10741link
Details of alerts.
treetree folder Alerts record entry
0 … *
prsb03-dataelement-10916link
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
treeblank treetree draft  Alert
1 … 1
prsb03-dataelement-10742link
Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).Free text
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12399link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12400link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12401link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12402link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12403link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12404link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12405link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12406link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12407link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Legal information
0 … 1
prsb03-dataelement-520link
The legal information relating to the person.
treetree folder Consent for treatment record
0 … 1
prsb03-dataelement-10420link
Details of the person's consent for treatment.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13457link
The date the consent was takenDate
treeblank treetree folder Location
0 … 1
prsb03-dataelement-13459link
The location of where the consent was taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13460link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13461link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Consent for treatment record
0 … 1
prsb03-dataelement-13574link
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
treeblank treetree draft  Location of document
0 … 1
prsb03-dataelement-13777link
The location of the consent for treatment record.Free text or URL
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13462link
The professional who took the consent for treatment.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13463link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13464link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13465link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13466link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13467link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13468link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13469link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13470link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13471link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13472link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13473link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13474link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13475link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13476link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13477link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13478link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Consent for information sharing
0 … 1
prsb03-dataelement-10421link
Details of the person's consent for information sharing
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11713link
The date when the consent was givenDate and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11714link
The location where the consent was taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13451link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13452link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Consent for information sharing
0 … 1
prsb03-dataelement-13575link
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
treeblank treetree draft  Reason for consent not given
0 … 1
prsb03-dataelement-13778link
Reason not given for consentFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11715link
The professional who took the consent for information sharing
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11716link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11717link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11718link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11719link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11720link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11721link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11722link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11723link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11724link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11725link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11726link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11727link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11728link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11729link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11730link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11731link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Mental capacity assessment
0 … *
prsb03-dataelement-10424link
Details of the persons mental capacity assessment
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11688link
The date when the mental capacity assessment was made.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11689link
The location where the mental capacity assessment was made.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13449link
The coded value for location NHS data dictionary : - Organisation code service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13450link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Mental capacity assessment
0 … 1
prsb03-dataelement-13724link
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
treeblank treetree draft  Location of document
0 … 1
prsb03-dataelement-13779link
The location of the mental capacity assessment information.Free text or URL
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11281link
The professional who made the mental capacity assessment.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11282link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11283link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11288link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11284link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11285link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11286link
The name of the organisation the professional works for.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13521link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13522link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11287link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11289link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11290link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11291link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11292link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11293link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11294link
The organisation the person completing the record works for.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13523link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13524link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11295link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11296link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11297link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
0 … 1
prsb03-dataelement-10425link
Details of the person's LPA record or equivalent
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13630link
The date the LPA was recordedDate and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-13631link
The location where the LPA was given
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13632link
The coded value for locationNHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13633link
Free text field to be used if no code is availableFree text
treeblank treetree folder Lasting power of attorney for personal welfare or court appointed deputy (or equivalent)
0 … 1
prsb03-dataelement-13634link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13636link
The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Location of document
0 … 1
prsb03-dataelement-13776link
The location of the LPA informationFree text or URL
treeblank treeblank treetree draft  Name of LPA
0 … 1
prsb03-dataelement-13635link
The names of any appointed people or deputiesFree text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13637link
The contact details of the LPANHS data dictionary:- UK telephone number
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13638link
The professional who took the details of the LPA or equivalent
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13639link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13640link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13641link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13642link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13643link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13644link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13645link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13646link
Details of the person who recorded the ADRT.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13647link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13648link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13649link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13650link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13651link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13652link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13653link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13654link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Deprivation of Liberty Safeguards or equivalent
0 … 1
prsb03-dataelement-10426link
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
treeblank treetree draft  Application date
0 … 1
prsb03-dataelement-13068link
The date the application was madeDate and time
treeblank treetree draft  Application status
0 … 1
prsb03-dataelement-13069link
The status of the DOLs application.Free text : - Requested or authorised
treeblank treetree draft  Deprivation of liberty safeguards or equivalent
0 … 1
prsb03-dataelement-13626link
Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.Free text
treeblank treetree draft  Start date of authorisation
0 … 1
prsb03-dataelement-13071link
The date the DOLs was authorised.Data and time
treeblank treetree draft  Planned or actual end date of authorisation
0 … 1
prsb03-dataelement-13072link
The planned or actual end date of authorisation.Date and time
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13073link
The professional who applied for the DOLs.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13074link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13075link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13076link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13077link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13078link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13079link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13080link
Contact details of the professionalNHS data dictionary - UK phone number
treetree folder Mental health act or equivalent status
0 … *
prsb03-dataelement-10427link
Details of the persons mental health act record
treeblank treetree draft  Section start date
0 … 1
prsb03-dataelement-10920link
The date the person was detained.Date and time
treeblank treetree draft  Section end date
0 … 1
prsb03-dataelement-10921link
The date the person was no longer detained.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11692link
The location where the decision to detain the person was made under the mental health act.
treeblank treetree folder Mental health act or equivalent status
0 … 1
prsb03-dataelement-13627link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13628link
The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13629link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Supporting information
0 … 1
prsb03-dataelement-13755link
If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.NHS data dictionary : - Community treatment order
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11315link
The professional who made the decision to detain the person under the mental health act.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11316link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11317link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11318link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11319link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11320link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11321link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11322link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11323link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11324link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11325link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11326link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11327link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11328link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11329link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11330link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11331link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Advance decision to refuse treatment (ADRT)
0 … 1
prsb03-dataelement-10428link
Details of the person's ADRT status.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13479link
The date the ADRT was recorded.Date
treeblank treetree folder Location
0 … 1
prsb03-dataelement-13480link
The location where the ADRT was recorded.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13481link
The coded value of locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13482link
Free text field to be used if no coded text available
treeblank treetree folder Advance decision to refuse treatment
0 … 1
prsb03-dataelement-13502link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13503link
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)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13504link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13484link
The professional who recorded the ADRT
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13485link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13486link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13487link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13488link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13489link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13490link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13491link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13492link
Details of the person who recorded the ADRT.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13493link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13494link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13495link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13496link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13497link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13498link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13499link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13500link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Safeguarding
0 … 1
prsb03-dataelement-271link
The safeguarding details of the person.
treetree folder Safeguarding concerns
0 … *
prsb03-dataelement-10821link
Details of safeguarding concerns
treeblank treetree draft  Safeguarding indicator
1 … 1 Mandatory
prsb03-dataelement-13428link
Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.Flag: No =N: Yes = Y
treeblank treetree draft  Safeguarding concerns date
0 … 1
prsb03-dataelement-10172link
The date the safeguarding concerns were identified.Date and time
treeblank treetree draft  Safeguarding concerns end date
0 … 1
prsb03-dataelement-10766link
The date safeguarding concerns ended.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-10173link
The location where the safeguarding concerns were identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13437link
The coded value of locationNHS data dictionary :- Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13438link
Free text field to be used if no code is availableFree text
treeblank treetree folder Safeguarding concerns
0 … 1
prsb03-dataelement-10171link
Identified safeguarding concerns.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13756link
The coded value for safeguarding concernsSNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13757link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11358link
The professional who identified the safeguarding concerns.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11359link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11360link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11361link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11362link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11363link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11364link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11365link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11366link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11367link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11368link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11369link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11370link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11371link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11372link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11373link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11374link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Local authority
1 … 1 Mandatory
prsb03-dataelement-13298link
The details of the Local Authority that is responsible for providing care and support to the person.
treetree draft  Organisation code
0 … *
prsb03-dataelement-13299link
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
treetree draft  Local authority name
1 … 1 Mandatory
prsb03-dataelement-13300link
The name of the local authority that is responsible for providing care and support to the person.Free text
treetree draft  Social services team
0 … *
prsb03-dataelement-13301link
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
treetree draft  Local authority contact name
1 … 1 Mandatory
prsb03-dataelement-13302link
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
treetree draft  Local authority contact details
1 … 1 Mandatory
prsb03-dataelement-13303link
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
folder Professional contacts
0 … 1
prsb03-dataelement-452link
The details of the person’s professional contacts.
treetree folder Professional contacts record entry
0 … *
prsb03-dataelement-10767link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10352link
The name of the professional with responsibility for the care of the person.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10353link
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
treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-10354link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10355link
The name of the team.Free text
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-10356link
The name of the organisation.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13564link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13565link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Contact details
1 … 1 Mandatory
prsb03-dataelement-10357link
Contact details of the professional (e.g. telephone number, email address etc.).Free text
treeblank treetree draft  Start date
0 … 1
prsb03-dataelement-10358link
The start date of the professional relationship with the person.Date and time
treeblank treetree draft  End date
0 … 1
prsb03-dataelement-10359link
The end date of the professional relationship with the person.Date and time
folder Personal contacts
0 … 1
prsb03-dataelement-445link
The details of the individual's personal contacts.
treetree folder Personal contacts record entry
0 … *
prsb03-dataelement-10768link
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.
treeblank treetree draft  Name
1 … 1 Mandatory
prsb03-dataelement-10345link
The name of the personal contact.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-10346link
The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.FHIR value set : - Related person
treeblank treetree draft  Relationship type
0 … *
prsb03-dataelement-12968link
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)Free text
treeblank treetree draft  Contact details
1 … 1 Mandatory
prsb03-dataelement-10350link
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
treeblank treetree draft  Comments
0 … 1
prsb03-dataelement-10937link
Notes on the significance of the personal contact to the person.Free text
folder Referral details
1 … 1 Mandatory
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
1 … 1 Mandatory
prsb03-dataelement-10917link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10006link
The date of referralDate and time
treeblank treetree folder Referrer details
1 … 1 Mandatory
prsb03-dataelement-10005link
The details of the referrer.

This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team etc.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10971link
The name of the referrer.Free text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10972link
Role of the referrer.FHIR value set : - sdsjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10973link
The grade of the referrer.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-12409link
The team or department of the referrer.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12410link
The specialty of the referrer.NHS data dictionary - Activity treatment function code
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-12411link
The service of the referrer.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13397link
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13398link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-10974link
The organisation of the referrer.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13399link
The coded value for organisation codeNHS data dictionary : - Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13400link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Contact details
1 … 1 Mandatory
prsb03-dataelement-10975link
The contact details of the referrer.Free text
treeblank treetree draft  Referral type
0 … 1
prsb03-dataelement-12967link
An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)
treeblank treetree draft  Referral method
0 … 1
prsb03-dataelement-10007link
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
treeblank treetree folder Reason for referral
0 … 1
prsb03-dataelement-10011link
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
treeblank treetree folder Referral to
0 … 1
prsb03-dataelement-10008link
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.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10977link
Name of person the referral is to be sent to.Free text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10978link
Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10979link
The grade of the person where the referral is sent to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10982link
The team or department of the person where the referral is being sent toFree text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-10983link
The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-12412link
The service of where the referral is sent to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13509link
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13510link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-10980link
The organisation of where the referral is to be sent.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13511link
The coded value for organisationNHS data dictionary :- Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13512link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-10981link
The contact details of where the referral is to be sent.Free text.
treeblank treetree draft  Return response to
0 … 1
prsb03-dataelement-10015link
Name of professional to be communicated with, if not the referrerFree text.
folder Admission details
0 … 1
prsb03-dataelement-181link
Admission details
treetree folder Admission details record entry
0 … 1
prsb03-dataelement-10918link
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.
treeblank treetree draft  Date of admission
0 … 1
prsb03-dataelement-10085link
Date and time the person was admitted to hospital.Date and time
treeblank treetree folder Admitted to
0 … 1
prsb03-dataelement-10090link
The hospital the person was admitted to.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13380link
The coded value for admission toNHS data dictionary : - Organisations code of provider
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13381link
Free text field to be used if no code is availableFree text
treeblank treetree folder Responsible care professional
0 … 1
prsb03-dataelement-10087link
The care professional who has overall responsibility for the person (may not actually see the person)
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10992link
The name of the responsible care professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10993link
The role of the responsible consultant.FHIR value set: - sdsjobrole
treeblank treetree folder Reason for admission
0 … 1
prsb03-dataelement-10081link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13382link
The coded value for reason for admissionSNOMED CT: - ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13384link
Free text field to be used if no code is availableFree text
treeblank treetree folder Admission method
0 … 1
prsb03-dataelement-10082link
How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13385link
The coded value for admission methodNHS data dictionary : - Admission method
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13387link
Free text field to be used if no code is availableFree text
treeblank treetree folder Source of admission
0 … 1
prsb03-dataelement-10084link
Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13388link
The coded value of source of admissionNHS data dictionary :- Source of admission
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13389link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Patient location
0 … 1
prsb03-dataelement-10086link
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
folder Discharge details
0 … 1
prsb03-dataelement-191link
Discharge details
treetree folder Discharge details record entry
0 … 1
prsb03-dataelement-10919link
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.
treeblank treetree draft  Expected date of discharge
0 … *
prsb03-dataelement-13424link
The expected/ proposed date the person will be discharged.SNOMED CT: - 861031000000101 |Expected date of discharge from service (observable entity)|
treeblank treetree draft  Date of discharge
0 … 1
prsb03-dataelement-10096link
The date and time of dischargeDate and time
treeblank treetree draft  Discharge location
0 … 1
prsb03-dataelement-10095link
The hospital the person was discharged from.NHS data dictionary : - Organisation data service
treeblank treetree folder Discharging consultant
0 … 1
prsb03-dataelement-10093link
The consultant responsible for the person at time of discharge.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10994link
The name of the discharging consultantFree text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10995link
The role of the discharging consultantFHIR value set : - sdsjobrole
treeblank treetree draft  Discharge status
0 … 1
prsb03-dataelement-10092link
Patient status on discharge from emergency care.Sent as per the ECDS Emergency Care DischargeStatus code set (SNOMED CT):
treeblank treetree folder Discharge method
0 … 1
prsb03-dataelement-10098link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13393link
The coded value for discharge methodNHS data dictionary : - Discharge method
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13394link
Free text field to be used if no code is availableFree text
treeblank treetree folder Discharging specialty
0 … 1
prsb03-dataelement-10094link
The specialty of the consultant responsible for the person at the time of discharge.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13395link
The coded value for discharge specialityNHS data dictionary : - Activity treatment function code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13396link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Discharging department
0 … 1
prsb03-dataelement-10987link
The department from which the person is discharged.Free text
treeblank treetree folder Discharge destination
0 … 1
prsb03-dataelement-10099link
treeblank treeblank treetree draft  Discharge destination
0 … 1
prsb03-dataelement-10100link
The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.NHS data dictionary - Discharge destination.
treeblank treeblank treetree draft  Discharge address
0 … 1
prsb03-dataelement-10101link
Address to which the person is discharged if not the usual place of residence.NHS data dictionary :- Address
treetree folder Discharge date informed status
1 … 1 Mandatory
prsb03-dataelement-13383link
A statement confirming that the person or carer has been informed of the date on which it is proposed that the person be discharged
treeblank treetree draft  Discharge date person informed indicator
1 … 1 Mandatory
prsb03-dataelement-13423link
Indicates whether or not the patient has been informed of the proposed discharge date.Flag;- yes or no
treeblank treetree draft  Discharge date carer informed indicator
1 … 1 Mandatory
prsb03-dataelement-13422link
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
folder Problem list
0 … 1
prsb03-dataelement-10927link
A summary of the problems that require investigation or treatment.
treetree folder Problem list record entry
0 … 1
prsb03-dataelement-10928link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10929link
The date the problem was identified.Date and time
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12133link
The professional who identified the problem.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12134link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12135link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12136link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12137link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12138link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12139link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12140link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Location
0 … 1
prsb03-dataelement-10931link
The location the problem was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13242link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13243link
Free text field to be used if no code is availableFree text
treeblank treetree folder Problem
0 … 1
prsb03-dataelement-10932link
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’
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13244link
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13245link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Onset date
0 … 1
prsb03-dataelement-10933link
A date or estimated date that the problem beganDate and time
treeblank treetree draft  End Date
0 … 1
prsb03-dataelement-10934link
The date or estimated date the problem was resolved.Date and time.
treeblank treetree draft  Stage of disease
0 … 1
prsb03-dataelement-10935link
The stage of the disease where relevant.Free text
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12141link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12142link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12143link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12144link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12145link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12146link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12147link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12148link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12149link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-10936link
Supporting text may be given covering the problem.Free text
folder Procedures and therapies
0 … 1
prsb03-dataelement-238link
The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
treetree folder Procedure record entry
0 … *
prsb03-dataelement-10652link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10138link
The date the procedure was performed.Date and time.
treeblank treetree folder Location
0 … 1
prsb03-dataelement-13246link
The location the problem was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13247link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13248link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12150link
The professional who performed the procedure.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12151link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12152link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12153link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12154link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12155link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12156link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12157link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Procedure
1 … 1 Mandatory
prsb03-dataelement-10141link
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.
treeblank treeblank treetree draft  Coded value
1 … 1 Mandatory
prsb03-dataelement-13249link
The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13250link
Free text field to be used if no code is availableFree text
treeblank treetree folder Anatomical site
0 … 1
prsb03-dataelement-10142link
The body site of the procedure
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13251link
The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13252link
Free text field to be used if no code is availableFree text
treeblank treetree folder Laterality
0 … 1
prsb03-dataelement-10143link
Laterality of the procedure
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13253link
The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13254link
Free text field to be used if no code is availableFree text
treeblank treetree folder Complications related to procedure
0 … 1
prsb03-dataelement-10144link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13255link
The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13256link
Free text field to be used if no code is availableFree text
treeblank treetree folder Specific anesthesia issues
0 … 1
prsb03-dataelement-10145link
Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13257link
The coded value for specific anesthesia issues.SNOMED CT
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13258link
Free text field to be used if no code is availableFree text
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12158link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12159link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12160link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12161link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12162link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12163link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12164link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12165link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12166link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-10146link
Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.Free text
folder Clinical Summary
0 … 1
prsb03-dataelement-247link
Clinical Summary
treetree draft  Date
0 … 1
prsb03-dataelement-13308link
The date the clinical summary was written.Date
treetree folder Location
1 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
1 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
1 … 1
prsb03-dataelement-13311link
Free text field to be used if no code is availableFree text
treetree draft  Clinical summary
0 … 1
prsb03-dataelement-10147link
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
treetree folder Performing professional
0 … 1
prsb03-dataelement-13312link
The professional who wrote the clinical summary
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13313link
The name of the professional.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13314link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13315link
The grade of the professional.Free text
treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13316link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13317link
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
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13318link
The name of the organisation the professional works for.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13319link
Contact details of the professionalNHS data dictionary - UK phone number
treetree folder Person completing record
0 … 1
prsb03-dataelement-13320link
A record of the details of the person that entered the clinical summary and the date on which is was entered.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13321link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13322link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13323link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13324link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13325link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13326link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13327link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13328link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Treatments and interventions
0 … 1
prsb03-dataelement-12480link
Treatments and interventions carried out
treetree folder Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-12481link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13259link
The coded value for treatment and interventions.SNOMED CT
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13260link
Free text field to be used if no code is availableFree text
folder Social context
0 … 1
prsb03-dataelement-136link
The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
treetree folder Household composition
0 … 1
prsb03-dataelement-10036link
Details of the person's household composition.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11770link
The date when the household composition was taken.Date and time.
treeblank treetree folder Location
0 … 1
prsb03-dataelement-13271link
The location where the household composition was taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13272link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13273link
Free text field to be used if no code is availableFree text
treeblank treetree folder Household composition
0 … 1
prsb03-dataelement-13261link
Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13262link
The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13263link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11648link
The professional who took the household composition.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11649link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11650link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11651link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11652link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11653link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11654link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11655link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11521link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11522link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11523link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11524link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11525link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11526link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11527link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11528link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11529link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Lifestyle choices
0 … 1
prsb03-dataelement-10039link
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
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11784link
The date when the lifestyle choices were taken.Date and time.
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11785link
The location where the lifestyle choices were taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13278link
The coded value for location.NHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13279link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Lifestyle choices
0 … 1
prsb03-dataelement-13841link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11786link
The professional who took the lifestyle choices.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11787link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11788link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11789link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11790link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11791link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11792link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11793link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11548link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11549link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11550link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11551link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11552link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11553link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11554link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11555link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11556link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11794link
The date when the smoking status was taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11795link
The location where the smoking status was taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13281link
The coded value for locationNHS data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13282link
Free text field to be used if no code is availableFree text
treeblank treetree folder Smoking status
0 … 1
prsb03-dataelement-13283link
Record of any drug/substance use by the person.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13284link
The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13285link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11796link
The professional who took the smoking status.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11797link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11798link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11799link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11800link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11801link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11802link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11803link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11557link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11558link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11559link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11560link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11561link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11562link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11563link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11564link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11565link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Alcohol intake
0 … 1
prsb03-dataelement-10041link
Details of the person's alcohol intake
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11804link
The date when the alcohol intake was noted.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11805link
The location where the alcohol intake was noted.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13332link
The coded value for location.NHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13333link
Free text field to be used if no code is availableFree text
treeblank treetree folder Alcohol intake
0 … 1
prsb03-dataelement-13290link
Latest or current alcohol consumption.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13291link
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)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13292link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Alcohol use details
0 … 1
prsb03-dataelement-13759link
Detailed history of their alcohol use, amount/frequency, bingeing. Questionnaire/Assessment used Audit C, FAST etcFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11806link
The professional who noted the alcohol intake.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11807link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11808link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11809link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11810link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11811link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11812link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11813link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11566link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11567link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11568link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11569link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11570link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11571link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11572link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11573link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11574link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Drug/substance use
0 … 1
prsb03-dataelement-10042link
Details of the person's drug and substance use.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11814link
The date when the drug/substance use was noted.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11815link
The location where the drug/substance use was noted.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13334link
The coded value for location.NHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13335link
Free text field to be used if no code is availableFree text
treeblank treetree folder Drug/substance use
0 … 1
prsb03-dataelement-13336link
Latest or current drug/substance use.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13337link
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)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13338link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11816link
The professional who noted the drug/substance use.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11817link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11818link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11819link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11820link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11821link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11822link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11823link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11575link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11576link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11577link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11578link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11579link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11580link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11581link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11582link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11583link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Social circumstances
0 … 1
prsb03-dataelement-10043link
Details of the persons social circumstances
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11824link
The date when the social circumstances were taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11825link
The location where the social circumstances were taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13339link
The coded value for the location
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13340link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Social circumstances
0 … 1
prsb03-dataelement-13341link
A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11826link
The professional who took the social circumstances.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11827link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11828link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11829link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11830link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11831link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11832link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11833link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11584link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11585link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11586link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11587link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11588link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11589link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11590link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11591link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11592link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Access
0 … 1
prsb03-dataelement-10045link
Details of access for the person.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11844link
The date when the special access requirements were taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11845link
The location where the special access requirements were taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13343link
The coded value for locationNHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13344link
Free text field to be used if no coded text available
treeblank treetree draft  Access
0 … 1
prsb03-dataelement-13342link
Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11846link
The professional who took the special access requirements.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11847link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11848link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11849link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11850link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11851link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11852link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11853link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11602link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11603link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11604link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11605link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11606link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11607link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11608link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11609link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11610link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Dependants
0 … 1
prsb03-dataelement-10046link
Details of any responsibility the person has for dependants.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11854link
The date when the dependents details were taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11855link
The location where the dependents details were taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13346link
The coded value for locationNHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13347link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Dependants
0 … 1
prsb03-dataelement-13345link
Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11856link
The professional who took the dependents details.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11857link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11858link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11859link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11860link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11861link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11862link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11863link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11611link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11612link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11613link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11614link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11615link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11616link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11617link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11618link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11619link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Accommodation status
0 … 1
prsb03-dataelement-10047link
Details of the type of accommodation where the person lives.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11864link
The date when the accommodation status was taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11865link
The location where the accommodation was taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13352link
The coded value of locationNHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13353link
Free text field to be used if no code is availableFree text
treeblank treetree folder Accommodation status
0 … 1
prsb03-dataelement-13348link
An indication of the type of accommodation where the person lives.

This should be based on the main or permanent residence.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13349link
The coded value for accommodation statusNHS data dictionary :- Accommodation status
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13350link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11866link
The professional who took the accommodation status.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11867link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11868link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11869link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11870link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11871link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11872link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11873link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11874link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11875link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11876link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11877link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11878link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11879link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11880link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11881link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11882link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Household environment
0 … 1
prsb03-dataelement-10051link
Details of the person's household environment.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11883link
The date when the household environment details were taken.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11884link
The location where the household environment details were taken.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13351link
The coded value for locationNHS Data dictionary : - Organisation data service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13354link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Household environment
0 … 1
prsb03-dataelement-13842link
Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11885link
The professional who took the household environment details.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11886link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11887link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11888link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11889link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11890link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11891link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11892link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11621link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11622link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11623link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11624link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11625link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11626link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11627link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11628link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11629link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Care needs summary
1 … 1 Mandatory
prsb03-dataelement-13063link
A description of the person's current care needs.
treetree draft  Care needs summary
1 … 1 Mandatory
prsb03-dataelement-13064link
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
treetree folder Performing professional
0 … 1
prsb03-dataelement-13174link
The professional who completed the care needs summary.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13182link
The name of the professional.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13183link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13184link
The grade of the professional.Free text
treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13185link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13186link
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
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13187link
The name of the organisation the professional works for.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13188link
Contact details of the professionalNHS data dictionary - UK phone number
treetree folder Location
0 … 1
prsb03-dataelement-13189link
The location where the care needs summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13729link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13730link
Free text
treetree draft  Date
0 … 1
prsb03-dataelement-13190link
The date the care needs summary was written.Date and time.
treetree folder Person completing record
0 … 1
prsb03-dataelement-13191link
A record of the details of the person that entered the care needs summary, and the date on which it was entered.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13192link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13193link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13194link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13195link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13196link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13197link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13198link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13199link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Assessed level of care
0 … 1
prsb03-dataelement-13425link
Record whether Enhanced care observation was required during the admission and details of level of enhanced care observation needed and why.
treetree draft  Level of enhanced care observation
0 … 1
prsb03-dataelement-13427link
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
treetree folder Person completing record
0 … 1
prsb03-dataelement-13731link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13732link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13733link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13734link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13735link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13736link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13737link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13738link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13739link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Primary support reason
0 … 1
prsb03-dataelement-12974link
The primary support reason for social care.
treetree folder Primary support reason record entry
0 … *
prsb03-dataelement-12975link
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.
treeblank treetree draft  Primary support reason
0 … 1
prsb03-dataelement-12976link
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
treeblank treetree draft  Active
0 … 1
prsb03-dataelement-13305link
Flag to indicate whether the primary support reason is currently activeFlag: - Yes or No
treeblank treetree draft  Start date
0 … 1
prsb03-dataelement-13306link
The date a primary support reason was authorised as active.Date and time
treeblank treetree draft  End date
0 … 1
prsb03-dataelement-13307link
The end date of authorisation.Date and time
folder Assessments
0 … *
prsb03-dataelement-262link
Assessment.
treetree folder Assessments record entry
0 … *
prsb03-dataelement-11664link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10763link
The date the assessment was done.Date and time.
treeblank treetree folder Location
0 … 1
prsb03-dataelement-10764link
The location where the assessment was done.ODS code or free text.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13570link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13571link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Assessment type
0 … 1
prsb03-dataelement-10822link
The type of the assessment e.g. social care needs assessment.Free text
treeblank treetree draft  Assessment summary
0 … 1
prsb03-dataelement-10754link
The summary of the assessmentFree text
treeblank treetree folder Structured assessment
0 … 1
prsb03-dataelement-10655link
Details of the structured assessment.
treeblank treeblank treetree draft  Structured assessment name
0 … 1
prsb03-dataelement-11751link
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.SNOMED CT
treeblank treeblank treetree draft  Assessment score
0 … 1
prsb03-dataelement-10162link
The structured assessment score.Free text.
treeblank treeblank treetree draft  Assessment value
0 … 1
prsb03-dataelement-10163link
The structured assessment value.Numeric
treeblank treeblank treetree draft  Global score
0 … 1
prsb03-dataelement-10166link
The total global score from the assessment.Free text
treeblank treeblank treetree draft  Subscale score
0 … 1
prsb03-dataelement-10169link
The subscale score of the structured assessment.Free text.
treeblank treeblank treetree draft  Subscale value
0 … 1
prsb03-dataelement-10170link
The subscale value of the structured assessment.Numeric
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12382link
The professional who did the assessment.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12383link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12384link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12385link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12386link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12387link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12388link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12389link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11752link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11753link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11754link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11755link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11756link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11757link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11758link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11759link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11760link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-10164link
Supporting text may be given regarding the assessment.Free text
folder Risks
0 … 1
prsb03-dataelement-276link
Details of any risks related to the person.
treetree folder Risks to self
0 … *
prsb03-dataelement-10176link
Details of the persons risk to self
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-11893link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-11894link
The date the risk ended.Date and time
treeblank treetree draft  Risk to self
0 … 1
prsb03-dataelement-13579link
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11895link
The location where the risk was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13586link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13587link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11896link
The professional who identified the risk.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11897link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11898link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11899link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11900link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11901link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11902link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11903link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11904link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11905link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11906link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11907link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11908link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11909link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11910link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11911link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11912link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Risks to others
0 … *
prsb03-dataelement-10177link
Details of the person's risk to others
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-11913link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-11914link
The date the risk ended.Date and time
treeblank treetree draft  Risks to others
0 … 1
prsb03-dataelement-13580link
Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11915link
The location where the risk to others was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13588link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13589link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11916link
The professional who identifies the risk to others.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11917link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11918link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11919link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11920link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11921link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11922link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11923link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11924link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11925link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11926link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11927link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11928link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11929link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11930link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11931link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11932link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Risk from others
0 … *
prsb03-dataelement-10178link
Risks to the person from an identified individual e.g. family member etc.Free Text.
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-11933link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-11934link
The date the risk ended.Date and time
treeblank treetree draft  Risk from others
0 … 1
prsb03-dataelement-13581link
Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11935link
The location where the risk from others was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13590link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13591link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11936link
The professional who identified the risk from others.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11937link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11938link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11939link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11940link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11941link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11942link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11943link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11944link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11945link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11946link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11947link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11948link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11949link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11950link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11951link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11952link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Risk of accidents
0 … *
prsb03-dataelement-10751link
Details of the risks the person poses to themselves from accidents.
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-11953link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-11954link
The date the risk ended.Date and time
treeblank treetree draft  Risk of accidents
0 … 1
prsb03-dataelement-13582link
Risks the person poses to themselves from accidents.Free text
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11955link
The location where the risk of accidents was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13592link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13593link
Free text field to be used if no coded text available
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11956link
The professional who identified the risk of accidents.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11957link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11958link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11959link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11960link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11961link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11962link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11963link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11964link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11965link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11966link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11967link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11968link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11969link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11970link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11971link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11972link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Other risks
0 … *
prsb03-dataelement-10802link
Details of other risks, factors or behaviours relating to the person.
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-11973link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-11974link
The date the risk ended.Date and time
treeblank treetree draft  Other risks
0 … 1
prsb03-dataelement-13583link
Other risks, factors or behaviours relating to the person.Free text
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11975link
The location where the other risks were identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13594link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13595link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11976link
The professional who identified the other risks.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11977link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11978link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11979link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11980link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11981link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11982link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11983link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11984link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11985link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11986link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11987link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11988link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11989link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11990link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-11991link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11992link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Infection risk
0 … *
prsb03-dataelement-12479link
Details of any known infection of the person for which special handling might be required
treeblank treetree draft  Start date of risk
0 … 1
prsb03-dataelement-10179link
The start date of the risk.Date and time
treeblank treetree draft  End date of risk
0 … 1
prsb03-dataelement-10801link
The date the risk ended.Date and time
treeblank treetree draft  Infection risk
0 … 1
prsb03-dataelement-13596link
Any known infection of the person for which special handling might be requiredFree text
treeblank treetree folder Location
0 … 1
prsb03-dataelement-10180link
The location where the risk was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13584link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13585link
Free text field to be used if no code is availableFree text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-13597link
The professional who identified the risk of infections.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13598link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13599link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13600link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-13601link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13602link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13603link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13604link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-13605link
A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13606link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13607link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13608link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13609link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13610link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13611link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13612link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13613link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Allergies and adverse reactions
1 … 1 Mandatory
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
1 … * Mandatory
prsb03-dataelement-10657link
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.
treeblank treetree draft  Type of reaction
0 … 1
prsb03-dataelement-10186link
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
treeblank treetree folder Causative agent
1 … 1 Mandatory
prsb03-dataelement-10182link
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”
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13441link
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)
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13442link
Free text field to be used if no code is availableFree text
treeblank treetree folder Reaction details cluster
0 … 1
prsb03-dataelement-10658link
Details of the reaction.
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10190link
The date that the reaction was identified.Date and time
treeblank treeblank treetree folder Location
0 … 1
prsb03-dataelement-10846link
Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13439link
The coded value for location.NHS data dictionary : - Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13440link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Substance
0 … 1
prsb03-dataelement-11665link
The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13554link
The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13555link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Description of reaction
0 … 1
prsb03-dataelement-10183link
A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13556link
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13557link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Severity
0 … 1
prsb03-dataelement-10184link
A description of the severity of the reaction.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13558link
The coded value for severityFHIR value set : - Severity
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13559link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Certainty
0 … 1
prsb03-dataelement-10185link
A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13560link
The coded value for certainty.FHIR value set : - Certainty
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13561link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-10189link
Any additional comment or clarification about the adverse reaction.Free text
treeblank treetree draft  Evidence
0 … 1
prsb03-dataelement-10187link
Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text
treeblank treetree draft  Date first experienced
0 … 1
prsb03-dataelement-10188link
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
treeblank treetree cancelled  Probability of recurrence
0 … 1
prsb03-dataelement-10191link
Probability of the reaction (allergic, adverse, intolerant) occurring.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12010link
The professional who identified the reaction.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12011link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12012link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12013link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12014link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12015link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12016link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12017link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12018link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12019link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12020link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12021link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12022link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12023link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12024link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12025link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12026link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Medications and medical devices
0 … 1
prsb03-dataelement-636link
Medications and medical devices
treetree folder Medication item entry
0 … *
prsb03-dataelement-10663link
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.
treeblank treetree folder Medication item cluster
0 … 1
prsb03-dataelement-10664link
Medication item cluster
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10843link
The date on which the medication or medical device was prescribed.Date and time
treeblank treeblank treetree folder Location
0 … 1
prsb03-dataelement-10844link
The location where the medication or the medical device was prescribed.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13620link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13621link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12002link
The professional who prescribed the medication or medical device.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12003link
The name of the professional.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12004link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12005link
The grade of the professional.Free text
treeblank treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12006link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12007link
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
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12008link
The name of the organisation the professional works for.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12009link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treeblank treetree folder Medication name
1 … 1 Mandatory
prsb03-dataelement-10536link
May be generic name or brand name.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13622link
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)|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13623link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Form
0 … 1
prsb03-dataelement-10537link
The form of the medication e.g. capsule, drops, tablet, lotion etc.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13624link
The coded value for form.SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13625link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Route
0 … 1
prsb03-dataelement-10538link
The route by which the medication is administered e.g. oral, IM, IV
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13655link
The coded value for routeSNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13656link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-10540link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13657link
The coded value for siteSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13658link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Method
0 … 1
prsb03-dataelement-10541link
The technique or method by which the medication is to be administered.
treeblank treeblank treetree draft  Over the counter medication flag
0 … 1
prsb03-dataelement-13379link
Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counterFlag : - Yes or No
treeblank treeblank treetree draft  Dose directions description
0 … 1
prsb03-dataelement-10544link
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
treeblank treeblank treetree folder Structured dose direction cluster
0 … 1
prsb03-dataelement-11639link
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.
treeblank treeblank treeblank treetree draft  Structured dose amount
0 … 1
prsb03-dataelement-10554link
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/
treeblank treeblank treeblank treetree draft  Structured dose timing
0 … 1
prsb03-dataelement-10555link
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/
treeblank treeblank treeblank treetree draft  Dose direction duration
0 … 1
prsb03-dataelement-10548link
Recommendation of the time period for which the medication should be continued, including direction not to discontinue.Free text
treeblank treeblank treetree draft  Additional instructions
0 … 1
prsb03-dataelement-10545link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Course status
0 … 1
prsb03-dataelement-10666link
The status of this prescription.FHIR value set : - Medication status
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
treeblank treeblank treeblank treetree draft  Start date/time
0 … 1
prsb03-dataelement-10667link
The date and/or time that the medication course should begin.Date and time
treeblank treeblank treeblank treetree draft  End date/time
0 … 1
prsb03-dataelement-10557link
The date and/or time that the medication course should finish.Date and time
treeblank treeblank treeblank treetree draft  Link to indication record
0 … 1
prsb03-dataelement-10668link
A link to the record which contains the indication for this medication order.Free text with URL
treeblank treeblank treeblank treetree draft  Comment/recommendation
0 … 1
prsb03-dataelement-10547link
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
treeblank treeblank treetree folder Medication change summary cluster
0 … 1
prsb03-dataelement-10568link
Records the changes made to medication.
treeblank treeblank treeblank treetree draft  Status
0 … 1
prsb03-dataelement-10669link
The nature of any change made to the medication.FHIR value set : Medication status
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10670link
Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.Free text
treeblank treeblank treeblank treetree draft  Date of change
0 … 1
prsb03-dataelement-10671link
The date of the change - addition, or amendmentDate and time
treeblank treeblank treeblank treetree draft  Description of amendment
0 … 1
prsb03-dataelement-10672link
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
treeblank treeblank treetree draft  Total dose daily quantity
0 … 1
prsb03-dataelement-10665link
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
treeblank treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11993link
Details of the person completing the record.
treeblank treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11994link
The name of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11995link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11996link
The grade of the person completing the record.Free text.
treeblank treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11997link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-11998link
The organisation the person completing the record works for.
treeblank treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11999link
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
treeblank treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12000link
The date and time the record was completed.Date and time.
treeblank treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12001link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treeblank treetree folder Medical devices entry
0 … 1
prsb03-dataelement-10583link
Medical devices
treeblank treeblank treetree draft  Medical device
1 … 1 Mandatory
prsb03-dataelement-10673link
Any medical device that isn't prescribed.Free text
treeblank treeblank treetree draft  Comments
0 … 1
prsb03-dataelement-11280link
Any information regarding the medical device.Free text
treeblank treetree folder Medication discontinued entry
0 … 1
prsb03-dataelement-10576link
Medication discontinued entry
treeblank treeblank treetree folder Name of discontinued medication
0 … 1
prsb03-dataelement-10577link
The name of the medication or medical device being discontinued
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13659link
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)|
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13660link
Amount of vaccine administered.Free text
treeblank treeblank treetree draft  Status
0 … 1
prsb03-dataelement-12472link
The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10579link
The clinical indication for any changes in medication statusFree text
treeblank treeblank treetree draft  Date of change
0 … 1
prsb03-dataelement-10580link
The date of the discontinuationDate and time
treeblank treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-10582link
Any additional comment about the discontinuation or amendment.Free text
folder Plan and requested actions
0 … 1
prsb03-dataelement-535link
The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
treetree folder Plan and requested actions record entry
0 … *
prsb03-dataelement-10661link
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.
treeblank treetree draft  Date
0 … *
prsb03-dataelement-10445link
The date on which the plan and requested actions were prepared.Date and time
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12167link
The professional who prepared the plan and requested actions.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12168link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12169link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12170link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12171link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12172link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12173link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12174link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Location
0 … 1
prsb03-dataelement-10842link
The location where the plan and requested actions were prepared.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13684link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13685link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Actions for professionals
0 … *
prsb03-dataelement-10436link
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
treeblank treetree draft  Actions for person or their carer
0 … *
prsb03-dataelement-10437link
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
treeblank treetree draft  Agreed with the person or their legitimate representative
0 … *
prsb03-dataelement-10438link
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
treeblank treetree draft  Outcome of plan and requested actions
0 … *
prsb03-dataelement-10950link
The details of the outcome of the plan and requested actions.Free text.
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12175link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12176link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12177link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12178link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12179link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12180link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12181link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12182link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12183link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Person and carer concerns expectations and wishes
0 … 1
prsb03-dataelement-292link
Person and carer concerns, expectations and wishes
treetree draft  Date
0 … 1
prsb03-dataelement-10193link
The date on which the concerns, wishes or goals of the person were recorded
treetree draft  Location
0 … 1
prsb03-dataelement-10856link
The location where the concerns, expectations and wishes were recorded.
treetree draft  Patient and carer concerns, expectations and wishes
0 … 1
prsb03-dataelement-10192link
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
treetree folder Person completing record
0 … 1
prsb03-dataelement-13740link

A record of the details of the person that entered the impairment and the date on which it was entered.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13741link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13742link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13743link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13744link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13745link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-13746link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-13747link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13748link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Contingency plans
0 … *
prsb03-dataelement-469link
Contingency plans.
treetree draft  Agreed with person or legitimate representative
0 … 1
prsb03-dataelement-10369link
Indicates whether the plan was discussed and agreed with the person or legitimate representative.Free text
treetree draft  Anticipatory medicines/equipment
0 … 1
prsb03-dataelement-10370link
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
treetree folder Advance statement
0 … 1
prsb03-dataelement-10777link
Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12267link
The date when the advanced statements was made.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12268link
The location where the advanced statement was made.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13698link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13699link
Free text field to be used if no code is availableFree text
treeblank treetree folder Advance statement
0 … 1
prsb03-dataelement-13695link
Does the person have an advance statement.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13696link
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13697link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Location of document
0 … 1
prsb03-dataelement-13760link
The location of where the advanced statement is held.Free text or URL
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12269link
The professional who made the advance statement.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12270link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12271link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12272link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12273link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12274link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12275link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12276link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12277link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12278link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12279link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12280link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12281link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12282link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12283link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12284link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12285link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree draft  Contingency plan name
0 … 1
prsb03-dataelement-10371link
Name of the contingency plan – what condition or circumstances it is addressing.Free text
treetree draft  Date this plan was last updated
0 … 1
prsb03-dataelement-10372link
The date that this contingency plan was last updated.Date and time
treetree draft  Planned review date/interval
0 … 1
prsb03-dataelement-10373link
This is the date/interval when this contingency plan will next be reviewed.Date and time
treetree draft  Responsibility for review
0 … 1
prsb03-dataelement-10374link
This is who has responsibility for arranging review of this information.

Should include their name, role and contact details.Free text.
treetree draft  Trigger factors
0 … 1
prsb03-dataelement-10375link
Signs to watch out for that may indicate a significant change in health or other circumstances. A statement of trigger factors.Free text
treetree draft  What should happen
0 … 1
prsb03-dataelement-10376link
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
treetree draft  Who should be contacted
0 … 1
prsb03-dataelement-10377link
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
treetree folder Location
0 … 1
prsb03-dataelement-12079link
The location where the contingency plan was prepared.
treetree folder Performing professional
0 … 1
prsb03-dataelement-12045link
The professional who prepared the contingency plans.
treetree folder Person completing record
0 … 1
prsb03-dataelement-12053link
Details of the person completing the record.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12054link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12055link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12056link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12057link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12058link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12059link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12060link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12061link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Additional support plans
0 … *
prsb03-dataelement-502link
Additional support plans
treetree draft  Additional support plan name
0 … 1
prsb03-dataelement-10402link
The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.Free text
treetree draft  Additional support plan content
0 … 1
prsb03-dataelement-10403link
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
treetree draft  Planned review date/interval
0 … 1
prsb03-dataelement-10405link
This is the date/interval when this information will next be reviewed.Date and time
treetree draft  Responsibility for review
0 … 1
prsb03-dataelement-10406link
This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.Free text.
treetree draft  Date this plan was last updated
0 … 1
prsb03-dataelement-10407link
This is a record of the date that this information was last updated.Date and time
treetree folder Location
0 … 1
prsb03-dataelement-12080link
The location where the additional support plan was prepared.ODS code or free text
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13722link
The coded value for locationNHS data dictionary:- Organisation data service
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13723link
Free text field to be used if no code is availableFree text
treetree folder Performing professional
0 … 1
prsb03-dataelement-12062link
The professional who prepared the additional support plan.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12063link
The name of the professional.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12064link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12065link
The grade of the professional.Free text
treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12066link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12067link
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
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12068link
The name of the organisation the professional works for.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12069link
Contact details of the professionalNHS data dictionary - UK phone number
treetree folder Person completing record
0 … 1
prsb03-dataelement-12070link
Details of the person completing the record.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12071link
The name of the person completing the record.Free text.
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12072link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12073link
The grade of the person completing the record.Free text.
treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12074link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12075link
The organisation the person completing the record works for.
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12076link
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
treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12077link
The date and time the record was completed.Date and time.
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12078link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder End of life care
0 … 1
prsb03-dataelement-10743link
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.
treetree folder Cardio-pulmonary resuscitation (CPR) decision
0 … 1
prsb03-dataelement-10771link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12210link
The date when the cardio-pulmonary resuscitation decision was made.Date and time.
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12211link
The location where the cardio-pulmonary resuscitation decision was made.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13689link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13690link
Free text field to be used if no coded text available
treeblank treetree folder Cardio-pulmonary resuscitation (CPR) decision
0 … 1
prsb03-dataelement-13686link
The cardio-pulmonary resuscitation (CPR) decision.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13687link
The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13688link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Date for review
0 … 1
prsb03-dataelement-13705link
The date for review of CPR decision.Date and time
treeblank treetree draft  Location of document
0 … 1
prsb03-dataelement-13706link
The location of the CPR decision documentFree text or URL
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12212link
The professional who made the cardio-pulmonary resuscitation decision.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12213link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12214link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12215link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12216link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12217link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12218link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12219link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12220link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12221link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12222link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12223link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12224link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12225link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12226link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12227link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12228link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Estimated prognosis
0 … 1
prsb03-dataelement-10745link
Details of the persons estimated prognosis
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12229link
The date when the estimated prognosis was made.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12230link
The location where the estimated prognosis was made.ODS code or free text
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13703link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13704link
Free text field to be used if no coded text available
treeblank treetree draft  Estimated prognosis
0 … 1
prsb03-dataelement-13691link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12231link
The professional who made the estimated prognosis.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12232link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12233link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12234link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12235link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12236link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12237link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12238link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12239link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12240link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12241link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12242link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12243link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12244link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12245link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12246link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12247link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Awareness of prognosis
0 … 1
prsb03-dataelement-10775link
Details of the persons awareness of prognosis
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12248link
The date when the assessment of the level of awareness of the prognosis was made.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12249link
The location where the assessment of the level of awareness of the prognosis was made.ODS code and free text
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13693link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13694link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Awareness of prognosis
0 … 1
prsb03-dataelement-13692link
Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12250link
The professional who made the assessment of the level of awareness of the prognosis.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12251link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12252link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12253link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12254link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12255link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12256link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12257link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12258link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12259link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12260link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12261link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12262link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12263link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12264link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12265link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12266link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Preferred place of death
0 … 1
prsb03-dataelement-10780link
Details of the person's preferred place of death
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12324link
The date when the preferred place of death was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12325link
The location where the preferred place of death was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13713link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13714link
Free text field to be used if no code is availableFree text
treeblank treetree folder Preferred place of death 1st
0 … 1
prsb03-dataelement-13710link
The preferences that a person has identified as their preferred place to die.
treeblank treeblank treetree draft  Name of the place
0 … 1
prsb03-dataelement-13711link
The name of the preferred place of deathFree text
treeblank treeblank treetree draft  Type of place
0 … 1
prsb03-dataelement-13712link
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
treeblank treetree folder Preferred place of death 2nd
0 … 1
prsb03-dataelement-13716link
The preferences that a person has identified as their preferred place to die.
treeblank treeblank treetree draft  Name of the place
0 … 1
prsb03-dataelement-13717link
The name of the preferred place of deathFree text
treeblank treeblank treetree draft  Type of place
0 … 1
prsb03-dataelement-13718link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12326link
The professional who identified the preferred place of death.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12327link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12328link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12329link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12330link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12331link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12332link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12333link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12334link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12335link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12336link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12337link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12338link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12339link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12340link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12341link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12342link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treetree folder Preferred place of care
0 … 1
prsb03-dataelement-10781link
Details of the persons preferred place of care
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-12362link
The date when the preferred place of care was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-12363link
The location where the preferred place of care was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13720link
The coded value for locationNHS data dictionary: - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13721link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Preferred place of care
0 … 1
prsb03-dataelement-13719link
The preferences that the person has identified as their preferred place to receive care.Free text
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12364link
The professional who identified the preferred place of care.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12365link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12366link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12367link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12368link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12369link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12370link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12371link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12372link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12373link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12374link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12375link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12376link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12377link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12378link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12379link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12380link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
folder Documents (including correspondence and images)
0 … 1
prsb03-dataelement-10820link
Details about documents related to the person.
treetree folder Documents
0 … *
prsb03-dataelement-11259link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10943link
The date and time the document was created.Date and time
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12422link
The professional who authored the document.Free text.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12423link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12424link
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12425link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12426link
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12427link
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
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12428link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12429link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree draft  Documentation location
0 … 1
prsb03-dataelement-10946link
The location of the documentFree text or URL
treeblank treetree draft  Confidentiality
0 … 1
prsb03-dataelement-10942link
The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
treeblank treetree draft  Class
0 … 1
prsb03-dataelement-10940link
The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
treeblank treetree draft  Document title
0 … 1
prsb03-dataelement-10944link
The title of the document.Free text
treeblank treetree draft  Document name
0 … 1
prsb03-dataelement-10945link
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
treeblank treetree draft  Document MIME type
0 … 1
prsb03-dataelement-10949link
MIME type of the document e.g. application, pdf, audio, jpegFree text
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-12430link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12431link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12432link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-12433link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-12434link
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-12435link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-12436link
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
treeblank treeblank treetree draft  Date completed
0 … 1
prsb03-dataelement-12437link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12438link
Contact details of the person completing the record (e.g. telephone number, email address etc.).NHS data dictionary : - UK telephone number
treeblank treetree folder Service
0 … 1
prsb03-dataelement-11163link
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)|
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13749link
The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13750link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Comments
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prsb03-dataelement-10941link
Comments associated with the document.Free text
folder Assessment notice
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prsb03-dataelement-13401link
Informs the social services team that an assessment will be required, with expected discharge date if known.
treetree draft  Issued date and time
0 … 1
prsb03-dataelement-13404link
The date and time on which the Assessment Notice was given.
treetree draft  Person consultation indicator
0 … 1
prsb03-dataelement-13408link
Indicates whether or not the patient has been consulted in relation to the Assessment Notice. Flag; N: No; Y: Yes
treetree draft  Carer consultation indicator
0 … 1
prsb03-dataelement-13407link
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
treetree draft  Person consent indicator
0 … 1
prsb03-dataelement-13406link
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
treetree draft  Third party person consent source
0 … 1
prsb03-dataelement-13405link
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
folder NHS CHC Assessment
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prsb03-dataelement-13403link
NHS Continuing Healthcare Assessment (checklist) entry
treetree draft  Assessment considered indicator
0 … 1
prsb03-dataelement-13409link
Indicates whether or not the NHS body has considered providing the patient with NHS Continuing Health Care. Flag: - yes/ no; N: No; Y: Yes
treetree draft  Assessment considered result
0 … *
prsb03-dataelement-13410link
Used to record the result of a consideration to provide the patient with NHS Continuing Care.Free text
folder Discharge notice
0 … *
prsb03-dataelement-13402link
Confirms discharge date to social services
treetree draft  Issued date and time
0 … 1
prsb03-dataelement-13411link
The date and time on which the discharge notice was given. The date and time on which the discharge notice was given.
folder Withdrawal notice
0 … *
prsb03-dataelement-13412link
To withdraw either or both the assessment notice and/ or the discharge notice
treetree draft  Issued date and time
0 … 1
prsb03-dataelement-13413link
The date and time on which the Withdrawal Notice was issued.
treetree draft  Withdrawal type
0 … 1
prsb03-dataelement-13416link
The type of notice that has been withdrawn. 1: Assessment Notice; 2: Discharge Notice; 3: Assessment Notice and Discharge Notice
treetree draft  Reason for withdrawal
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prsb03-dataelement-13415link
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
treetree draft  Reason for withdrawal - other
0 … *
prsb03-dataelement-13414link
A free format description of the reason why the notice has been withdrawn. To be used when 'Reason For Withdrawal = 'Other’.Free text
folder Notice receipt
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prsb03-dataelement-13417link
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.
treetree draft  Issued date and time
0 … 1
prsb03-dataelement-13421link
The date and time on which the Notice Receipt was issued.
treetree draft  Notice type
0 … 1
prsb03-dataelement-13420link
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)
treetree draft  Response type
0 … 1
prsb03-dataelement-13419link
The Notice Receipt response type. 1: Accept ;2: Reject
treetree draft  Response details
0 … *
prsb03-dataelement-13418link
Supporting information for the Notice Receipt, for example the reason why a notice was rejectedFree text
cancelled arrowleft Response
prsb03-transaction-149link
Version / effective date 0.2 - 2020‑06‑04 16:52:10    
Actor
Sender (organization) General practitioner
Receiver (organization) General practitioner
Associations