Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link
|
|
The person's details and contact information. |
 |
 |
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link
|
|
Details of the person's name |
|
1 … 1 Mandatory |
prsb03-dataelement-13799 link
|
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
1 … 1 Mandatory |
prsb03-dataelement-13800 link
|
|
The family name or surname of the personNHS data dictionary : - Person family name
|
|
0 … 1 |
prsb03-dataelement-10870 link
|
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.NHS data dictionary: - Person full name
|
|
0 … 1 |
prsb03-dataelement-13089 link
|
|
Person's titleNHS data dictionary: - Person title
|
|
0 … 1 |
prsb03-dataelement-13801 link
|
|
The full name of the person in text representation.NHS data dictionary :- Patient full name
|
 |
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link
|
|
The date of birth of the person.NHS data dictionary:- Person birth date
|
 |
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link
|
|
The person's stated gender.NHS data dictionary :- Person stated gender code
|
 |
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link
|
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
|
 |
|
Sex |
|
1 … 1 Mandatory |
prsb03-dataelement-10877 link
|
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary:- person phenotypic sex classification
|
 |
|
NHS number |
|
0 … 1 |
prsb03-dataelement-10879 link
|
|
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
|
 |
|
Other identifier |
|
0 … * |
prsb03-dataelement-10880 link
|
|
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
NHS data dictionary: - Local patient identifier(extended), Health and care number
(NI only), Community health index number (Scotland only)
|
 |
 |
Person's address |
|
1 … 1 Mandatory |
prsb03-dataelement-10881 link
|
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
1 … 1 Mandatory |
prsb03-dataelement-13082 link
|
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
0 … 1 |
prsb03-dataelement-13083 link
|
|
Person's second line of address.
NHS data dictionary :- Address line 2
|
|
0 … 1 |
prsb03-dataelement-13084 link
|
|
Person's third line of address.
NHS data dictionary : - Address line 3
|
|
0 … 1 |
prsb03-dataelement-13085 link
|
|
Person's fourth line of address.
NHS data dictionary : - Address line 4
|
|
0 … 1 |
prsb03-dataelement-13086 link
|
|
Person's fifth line of address.NHS data dictionary : - Address line 5
|
|
0 … 1 |
prsb03-dataelement-13087 link
|
|
The person's postcode.NHS data dictionary :- Postcode of usual address
|
 |
 |
Person's contact details |
|
0 … 1 |
prsb03-dataelement-13804 link
|
|
Details of the person's contact information. |
|
0 … 1 |
prsb03-dataelement-10886 link
|
|
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
|
 |
 |
 |
Person's telephone number details |
|
0 … * |
prsb03-dataelement-10883 link
|
|
The person's telephone number details |
 |
 |
 |
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-13808 link
|
|
The person's telephone numberNHS data dictionary : - UK telephone number
|
 |
 |
 |
|
Person's telephone number type |
|
0 … 1 |
prsb03-dataelement-13805 link
|
|
The contact type e.g. home, mobileFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of telephone number |
|
0 … 1 |
prsb03-dataelement-13809 link
|
|
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest. |
 |
 |
 |
Person's email address details |
|
0 … * |
prsb03-dataelement-13807 link
|
|
Details of the person's email address |
|
0 … 1 |
prsb03-dataelement-10882 link
|
|
Email address of the person.NHS data dictionary :- Contact email address
|
 |
 |
 |
|
Person's email address type |
|
0 … 1 |
prsb03-dataelement-13811 link
|
|
The type of email address, home, workFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of email address |
|
0 … 1 |
prsb03-dataelement-13810 link
|
|
The preferred order of use of email addressPreference of use 1-5, 1 being the highest. |
 |
|
Place of birth |
|
0 … 1 |
prsb03-dataelement-10884 link
|
|
The country of birth of the person.NHS data dictionary :- Country code (birth)
|
 |
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link
|
|
Details of the person's GP practice. |
 |
 |
GP practice record entry |
|
1 … * Mandatory |
prsb03-dataelement-10643 link
|
|
This is an GP practice record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items
|
|
0 … 1 |
prsb03-dataelement-10003 link
|
|
The name of the person's GP. If the person is registered with a GP practice, their
usual GP name will be something volunteered by the person or their representative.Free text
|
|
0 … 1 |
prsb03-dataelement-10002 link
|
|
Name and address of the person's registered GP practice Registered GP practice details
are available from the Patient Demographics Service (PDS), or volunteered from the
person or their representative. Include details of the practice name and address.Free text
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link
|
|
The identifier of the registered GP practice.
NHS data dictionary : - General medical practice code (patient registration)
|
 |
Legal information |
|
0 … 1 |
prsb03-dataelement-520 link
|
|
The legal information relating to the person. |
 |
 |
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-10420 link
|
|
Details of the person's consent for treatment. |
|
0 … 1 |
prsb03-dataelement-13457 link
|
|
The date the consent was takenDate |
|
0 … 1 |
prsb03-dataelement-13459 link
|
|
The location of where the consent was taken. |
|
0 … 1 |
prsb03-dataelement-13460 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13461 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Consent for treatment record |
|
0 … 1 |
prsb03-dataelement-13574 link
|
|
Whether consent has been obtained for the treatment. May include where record of consent
is located or record of consent. A statement about the patient's consent for treatment.Free text
|
|
0 … 1 |
prsb03-dataelement-13777 link
|
|
The location of the consent for treatment record.Free text or URL |
|
0 … 1 |
prsb03-dataelement-13462 link
|
|
The professional who took the consent for treatment. |
|
0 … 1 |
prsb03-dataelement-13463 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13464 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-13465 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-13466 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13467 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13468 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13469 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-13470 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-13471 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13472 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-13473 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13474 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13475 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13476 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-13477 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13478 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10421 link
|
|
Details of the person's consent for information sharing |
|
0 … 1 |
prsb03-dataelement-11713 link
|
|
The date when the consent was givenDate and time |
|
0 … 1 |
prsb03-dataelement-11714 link
|
|
The location where the consent was taken. |
|
0 … 1 |
prsb03-dataelement-13451 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13452 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-13575 link
|
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity. This is a placeholder
until the national guidance is published.Free text
|
 |
 |
|
Reason for consent not given |
|
0 … 1 |
prsb03-dataelement-13778 link
|
|
Reason not given for consentFree text |
|
0 … 1 |
prsb03-dataelement-11715 link
|
|
The professional who took the consent for information sharing |
|
0 … 1 |
prsb03-dataelement-11716 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11717 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11718 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11719 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11720 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11721 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11722 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11723 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11724 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11725 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11726 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11727 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11728 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11729 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11730 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11731 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-10422 link
|
|
Details of the person's consent relating to child |
|
0 … 1 |
prsb03-dataelement-11732 link
|
|
The date when the person with responsibility for the child was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-11733 link
|
|
The location where the person with responsibility for the child was identified. |
|
0 … 1 |
prsb03-dataelement-13674 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13675 link
|
|
Free text field to be used if no coded text available |
 |
 |
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-13576 link
|
|
The person with parental responsibility or appointed guardian where a child lacks
competency. Consideration of age and competency, applying Gillick competency or Fraser
guidelines.Free text
|
|
0 … 1 |
prsb03-dataelement-11734 link
|
|
The professional who identified the person responsible for the child. |
|
0 … 1 |
prsb03-dataelement-11735 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11736 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11737 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11738 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11739 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11740 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11741 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11742 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11743 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11744 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11745 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11746 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11747 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11748 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11749 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11750 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Safeguarding |
|
0 … 1 |
prsb03-dataelement-271 link
|
|
The safeguarding details of the person. |
 |
 |
Safeguarding concerns |
|
0 … * |
prsb03-dataelement-10821 link
|
|
Details of safeguarding concerns |
|
0 … 1 |
prsb03-dataelement-13428 link
|
|
Indicates whether or not the hospital considers that there are safeguarding issues
associated with the patient.Flag: No =N: Yes = Y
|
|
0 … 1 |
prsb03-dataelement-10171 link
|
|
Identified safeguarding concerns. |
|
0 … 1 |
prsb03-dataelement-13756 link
|
|
The coded value for safeguarding concernsSNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-13757 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10175 link
|
|
Further details on safeguarding concerns.Free text |
 |
Eligibility Criteria |
|
0 … 1 |
prsb03-dataelement-10700 link
|
 |
|
Eligibility criteria |
|
1 … * |
prsb03-dataelement-10701 link
|
|
Records which specific eligibility criteria have been met in order to administer the
vaccine.Free text
|
 |
Professional contacts |
|
0 … 1 |
prsb03-dataelement-452 link
|
|
The details of the person’s professional contacts. |
 |
 |
Professional contacts record entry |
|
0 … * |
prsb03-dataelement-10767 link
|
|
This is a professional contacts record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10352 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-10353 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12973 link
|
|
A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No |
|
0 … 1 |
prsb03-dataelement-10354 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-10355 link
|
|
The name of the team.Free text |
|
0 … 1 |
prsb03-dataelement-10356 link
|
|
The name of the organisation. |
|
0 … 1 |
prsb03-dataelement-13564 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13565 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10357 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
0 … 1 |
prsb03-dataelement-10358 link
|
|
The start date of the professional relationship with the person.Date and time |
|
0 … 1 |
prsb03-dataelement-10359 link
|
|
The end date of the professional relationship with the person.Date and time |
 |
Personal contacts |
|
0 … 1 |
prsb03-dataelement-445 link
|
|
The details of the individual's personal contacts. |
 |
 |
Personal contacts record entry |
|
0 … * |
prsb03-dataelement-10768 link
|
|
This is personal contacts record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10345 link
|
|
The name of the personal contact.Free text |
|
0 … 1 |
prsb03-dataelement-10346 link
|
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
0 … 1 |
prsb03-dataelement-12968 link
|
|
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin,
Emergency Contact, Dependent, etc.)Free text
|
|
0 … 1 |
prsb03-dataelement-10347 link
|
|
Flag to indicate whether the personal contact has parental responsibilityFlag ; - Yes or No |
|
0 … 1 |
prsb03-dataelement-10348 link
|
|
Status identifying whether the personal contact is a member of the same householdFlag : - Yes or No |
|
0 … 1 |
prsb03-dataelement-10350 link
|
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
0 … 1 |
prsb03-dataelement-10351 link
|
|
The NHS number of the personal contactNHS data dictionary:- NHS NUMBER
|
|
0 … 1 |
prsb03-dataelement-10937 link
|
|
Notes on the significance of the personal contact to the person.Free text |
 |
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link
|
|
The details of the referral. |
 |
 |
Referral details record entry |
|
0 … * |
prsb03-dataelement-10917 link
|
|
This is the referral details record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10006 link
|
|
The date of referralDate and time |
|
0 … 1 |
prsb03-dataelement-10005 link
|
|
The details of the referrer.
This could be the person, GP surgery, department, specialty, sub-specialty, educational
institution, mental health team etc.
|
|
0 … 1 |
prsb03-dataelement-10971 link
|
|
The name of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-10972 link
|
|
Role of the referrer.FHIR value set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-10973 link
|
|
The grade of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-12409 link
|
|
The team or department of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-12410 link
|
|
The specialty of the referrer.NHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12411 link
|
|
The service of the referrer. |
|
0 … 1 |
prsb03-dataelement-13397 link
|
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13398 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10974 link
|
|
The organisation of the referrer. |
|
0 … 1 |
prsb03-dataelement-13399 link
|
|
The coded value for organisation codeNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13400 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10975 link
|
|
The contact details of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-10011 link
|
|
The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation,
investigation, second opinion, management of the patient (e.g. palliative care), or
carer's concerns.Free text
|
|
0 … 1 |
prsb03-dataelement-13455 link
|
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
0 … 1 |
prsb03-dataelement-13456 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-10699 link
|
|
A clear statement of the expectations of the person or professional making the referral
in regards to the management of the patient e.g. advice only, diagnosis, treatment,
etc. To include any specific patient expectation.Free text
|
 |
 |
 |
Clinical urgency of referral |
|
0 … 1 |
prsb03-dataelement-10010 link
|
|
The details of the clinical urgency of referral |
 |
 |
 |
|
Reason for urgency of referral |
|
0 … 1 |
prsb03-dataelement-10976 link
|
|
The reason for urgency of referral if not routine.Free text |
|
0 … 1 |
prsb03-dataelement-10008 link
|
|
Details of where the referral is to be sent.
If not an individual, this could be a service, e.g. GP surgery, department, specialty,
subspecialty, educational institution, mental health etc.
|
|
0 … 1 |
prsb03-dataelement-10977 link
|
|
Name of person the referral is to be sent to.Free text |
|
0 … 1 |
prsb03-dataelement-10978 link
|
|
Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-10979 link
|
|
The grade of the person where the referral is sent to.Free text |
|
0 … 1 |
prsb03-dataelement-10982 link
|
|
The team or department of the person where the referral is being sent toFree text. |
|
0 … 1 |
prsb03-dataelement-10983 link
|
|
The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health
etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12412 link
|
|
The service of where the referral is sent to. |
|
0 … 1 |
prsb03-dataelement-13509 link
|
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13510 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10980 link
|
|
The organisation of where the referral is to be sent. |
|
0 … 1 |
prsb03-dataelement-13511 link
|
|
The coded value for organisationNHS data dictionary :- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13512 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10981 link
|
|
The contact details of where the referral is to be sent.Free text. |
 |
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link
|
|
The details of the person’s contact with a professional. |
 |
 |
Contacts with professionals record entry |
|
1 … * Mandatory |
prsb03-dataelement-10718 link
|
|
This is a contacts record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
1 … 1 Mandatory |
prsb03-dataelement-10069 link
|
|
Date and time of the contact.Date and time. |
|
0 … 1 |
prsb03-dataelement-10075 link
|
|
The location where the contact took place. |
|
0 … 1 |
prsb03-dataelement-13513 link
|
|
The coded value for locationNHS data dictionary : - Organisation service code
|
|
0 … 1 |
prsb03-dataelement-13514 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13751 link
|
|
The reason why the person has been offered the serviceFree text |
|
0 … 1 |
prsb03-dataelement-10070 link
|
|
Type of contact e.g. GP consultation, outpatient attendanceFree text |
|
0 … 1 |
prsb03-dataelement-10071 link
|
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
1 … 1 Mandatory |
prsb03-dataelement-10074 link
|
|
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
 |
 |
|
Person accompanying patient |
|
0 … * |
prsb03-dataelement-10079 link
|
|
Identify, where clinically relevant, others accompanying the patient, e.g. parent,
relative, friend. Includes: Name, Relationship, role (e.g. informal carer).NHS data dictionary : - Person full name
|
|
1 … 1 Mandatory |
prsb03-dataelement-10706 link
|
|
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
|
|
0 … 1 |
prsb03-dataelement-10713 link
|
|
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
|
 |
 |
|
Organisation contact details |
|
0 … * |
prsb03-dataelement-10707 link
|
|
The contact details of the organisation. For example a phone number, NHSmail address
etc. Contact details are used to resolve queries about the record entry.Free text
|
 |
 |
|
Reason for non-provision of service |
|
0 … 1 |
prsb03-dataelement-10708 link
|
|
The reason why the patient was not provided with the service e.g. declined, did not
attend etc.Free text
|
|
1 … 1 Mandatory |
prsb03-dataelement-10709 link
|
|
The name of the person providing the service.Free text |
|
0 … 1 |
prsb03-dataelement-10710 link
|
|
The role of the person providing the service.FHIR values set : - sdsjobrole
|
|
0 … * |
prsb03-dataelement-10712 link
|
|
The name of any chaperone(s).Free text |
 |
 |
|
Person collecting the medicine |
|
0 … 1 |
prsb03-dataelement-13783 link
|
|
Name, relationship, role (if formal role), contact details
Free text
|
|
0 … 1 |
prsb03-dataelement-10711 link
|
|
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
|
 |
Vaccinations |
|
0 … 1 |
prsb03-dataelement-10685 link
|
|
Details of vaccinations. |
 |
 |
Vaccinations record entry |
|
0 … * |
prsb03-dataelement-10686 link
|
|
This is the vaccinations record entry.
There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10695 link
|
|
The date on which the vaccination was administered or the reported/partial date on
which it was reported.Date and time
|
|
1 … 1 Mandatory |
prsb03-dataelement-10687 link
|
|
The vaccine product administered. |
|
0 … 1 |
prsb03-dataelement-13237 link
|
|
The coded value for vaccine product.SNOMED CTAMP 999000541000001108 |National Health Service dictionary of medicines and
devices actual medicinal product simple reference set (foundation metadata concept)|
orVMP 999000561000001109 |National Health Service dictionary of medicines and devices
virtual medicinal product simple reference set (foundation metadata concept)| or
dm+d
|
|
0 … 1 |
prsb03-dataelement-13238 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10698 link
|
|
Name of vaccine manufacturer. |
|
0 … 1 |
prsb03-dataelement-13239 link
|
|
The coded value of the manufacturer.SNOMED CT: - DM+D or GS1 |
|
0 … 1 |
prsb03-dataelement-13240 link
|
|
Free text field to be used if no code is availableFree text |
|
1 … 1 Mandatory |
prsb03-dataelement-10688 link
|
|
The procedure which was used to administer the vaccine. |
|
1 … 1 Mandatory |
prsb03-dataelement-13219 link
|
|
The coded value for vaccine procedureSNOMED CT :- < 127785005 |Administration of substance to produce immunity, either
active or passive (procedure)|
|
|
0 … 1 |
prsb03-dataelement-13220 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10697 link
|
|
The batch number of the product. |
|
0 … 1 |
prsb03-dataelement-13233 link
|
|
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive |
|
0 … 1 |
prsb03-dataelement-13234 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10696 link
|
|
The date on which the vaccine will expire.Date/time |
|
0 … 1 |
prsb03-dataelement-10690 link
|
|
A code that separately identifies two identical vaccines (i.e. same product, same
batch).
|
|
0 … 1 |
prsb03-dataelement-13235 link
|
|
The coded value for serialisation code.FMD code : - Derived from Falsified medicines directive |
|
0 … 1 |
prsb03-dataelement-13236 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10691 link
|
|
Body site vaccine was administered. |
|
0 … 1 |
prsb03-dataelement-13222 link
|
|
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference
set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13223 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-10692 link
|
|
How the vaccine entered the body. |
|
0 … 1 |
prsb03-dataelement-13224 link
|
|
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13225 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-10693 link
|
|
The clinical indication or reason for administering the vaccine. |
|
0 … 1 |
prsb03-dataelement-13226 link
|
|
The coded value for Indication.
SNOMED CT:-Routine mass immunisation
171279008|Immunization due (finding)|
Travel to endemic area
414448007|Identified as high risk for travel immunization (finding)|Planned travel
to high risk area 161096004|Going to travel abroad (finding)|Recent travel to high
risk area 506931000000109|Recent travel to disease affected area (finding)|
Subpopulation at special or unusual risk
78648007|At risk for infection (finding)|High risk due to occupation 14679004 Occupation
(occupation)High risk due to lifestyle 134436002|Lifestyle (finding)|High risk due
to existing medical condition 398192003|Co-morbid conditions (finding)|
Control of known sporadic outbreak
443684005|Disease outbreak (event)|
Patient request
183995001|Patient requested procedure (situation)|
Post-exposure prophyaxis
444107005|Exposure to communicable disease (event)|
Maternity record
<404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context
(situation)|
Other
723620004|Requires vaccination (finding)
|
|
0 … 1 |
prsb03-dataelement-13227 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10694 link
|
|
Amount of vaccine administered. |
|
0 … 1 |
prsb03-dataelement-13838 link
|
|
The amount of vaccine administeredFree text |
|
0 … 1 |
prsb03-dataelement-13839 link
|
|
The units of measure for the dose amountUCUM code |
|
0 … 1 |
prsb03-dataelement-10824 link
|
|
Nominal position in a series of vaccines.Numeric value |
 |
Appliances |
|
0 … 1 |
prsb03-dataelement-13762 link
|
|
Details of appliances |
 |
 |
Appliance records entry |
|
0 … * |
prsb03-dataelement-13763 link
|
|
This is the appliance records entry. |
|
1 … 1 Mandatory |
prsb03-dataelement-13764 link
|
|
May be generic name or brand name (as appropriate).As per dm+d (AMP) |
|
0 … 1 |
prsb03-dataelement-13765 link
|
|
The product order number for the appliance. |
|
0 … 1 |
prsb03-dataelement-13766 link
|
|
Name of appliance manufacturerFree text |
|
0 … 1 |
prsb03-dataelement-13767 link
|
|
The batch number of the appliance.Free text |
|
0 … 1 |
prsb03-dataelement-13768 link
|
|
The size of the appliance.UCUM |
|
0 … 1 |
prsb03-dataelement-13769 link
|
|
The weight of the appliance.UCUM |
|
0 … 1 |
prsb03-dataelement-13770 link
|
|
The colour of the applianceFree text |
|
0 … 1 |
prsb03-dataelement-13771 link
|
|
Appliance administration description (IM, IV, etc.): may include method of administration,
(e.g., by infusion).
SNOMED CT: -
^999000051000001100 |ePrescribing route of administration simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14268 link
|
|
Coded value for appliance route
SNOMED CT: -
^999000051000001100 |ePrescribing route of administration simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14267 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-13772 link
|
|
The anatomical site at which the appliance is to be used, including laterality. |
|
0 … 1 |
prsb03-dataelement-14269 link
|
|
Coded value for site
SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
|
|
0 … 1 |
prsb03-dataelement-14270 link
|
|
Free text where no coded value is availableFree text |
|
0 … 1 |
prsb03-dataelement-13773 link
|
|
The quantity of the appliance (including the units).UCUM |
|
0 … 1 |
prsb03-dataelement-13774 link
|
|
Reason for appliance being prescribed, where known.Free text |
 |
 |
|
Matters identified during the discussion |
|
1 … * |
prsb03-dataelement-13775 link
|
|
Matters identified during the service about the patient's experience of using the
appliance. To include e.g, patient using/not using the appliance as prescribed, patient
reports negative feelings about the appliance etc. Also to include whether the information
was provided by the patient or somebody else (e.g. a relative, carer etc) e.g. patient
using/not using the appliance as prescribed, patient reports negative feelings about
the appliance etc.Free text
|
|
0 … 1 |
prsb03-dataelement-13802 link
|
 |
Presenting complaints or issues |
|
0 … 1 |
prsb03-dataelement-210 link
|
|
Presenting complaints or issues |
 |
 |
Presenting complaint or issue |
|
0 … 1 |
prsb03-dataelement-13784 link
|
|
The health problem or issue experienced by the patient resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.
|
|
0 … 1 |
prsb03-dataelement-13785 link
|
|
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-13786 link
|
|
Free text |
 |
History |
|
0 … 1 |
prsb03-dataelement-226 link
|
|
History |
 |
 |
Relevant past medical, surgical and mental health history |
|
0 … 1 |
prsb03-dataelement-10130 link
|
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
0 … 1 |
prsb03-dataelement-13787 link
|
|
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-13788 link
|
|
Free text field to be used if no code is availableFree text |
 |
Clinical Summary |
|
1 … 1 Mandatory |
prsb03-dataelement-247 link
|
|
Clinical Summary |
 |
|
Clinical narrative |
|
1 … 1 Mandatory |
prsb03-dataelement-10150 link
|
|
A description detailing a patient’s reason for attendance, results from the diagnostic
and treatment process.Free text
|
 |
Social context |
|
0 … 1 |
prsb03-dataelement-136 link
|
|
The social setting in which the person lives, such as their household, occupational
history, and lifestyle factors.
|
 |
 |
Smoking status |
|
0 … 1 |
prsb03-dataelement-10040 link
|
|
Details of the person's smoking status. |
|
0 … 1 |
prsb03-dataelement-13283 link
|
|
Record of any drug/substance use by the person.
|
|
0 … 1 |
prsb03-dataelement-13284 link
|
|
The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13285 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13286 link
|
|
Further details recorded about the smoking status of the personFree text |
|
0 … 1 |
prsb03-dataelement-13995 link
|
|
Details of the person's smoking record |
 |
 |
 |
|
Nicotine Replacement Therapy used |
|
0 … 1 |
prsb03-dataelement-14000 link
|
|
A record of whether nicotine replacement therapy (NRT) is currently used or prescribed
in this appointment
NRT not currently used
NRT currently used
NRT prescribed at this appointment
|
 |
 |
 |
|
Varenicline or other pharmacotherapy used |
|
0 … 1 |
prsb03-dataelement-14001 link
|
|
Record of whether varenicline or other smoking cessation pharmacotherapy (other than
nicotine replacement therapy) is currently used or prescribed in this appointment.
Varenicline/other pharmacotherapy not used
Varenicline/other pharmacotherapy currently used
Varenicline/other pharmacotherapy prescribed in this appointment
|
|
0 … 1 |
prsb03-dataelement-14002 link
|
|
Record of current use of e-cigarettes
Coded - SNOMED CT:
722499006 |Electronic cigarette user (finding)|
|
|
0 … 1 |
prsb03-dataelement-14007 link
|
|
Date set to quit smokingDate |
 |
 |
 |
Treatments and interventions and changes made to treatments. |
|
0 … 1 |
prsb03-dataelement-13992 link
|
|
The treatments and interventions carried out. Where appropriate record the rationale
for the decision to treat and the information sources reviewed e.g. end of life care
plan etc. All medications should be recorded under the medications heading.
|
|
0 … 1 |
prsb03-dataelement-13993 link
|
|
The coded value for treatment and interventions.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-13994 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13287 link
|
|
The date the person stopped smoking (if known) |
|
0 … 1 |
prsb03-dataelement-13288 link
|
|
The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)| |
|
0 … 1 |
prsb03-dataelement-13289 link
|
|
The date the person stopped smoking.Date and time |
 |
Alcohol record |
|
0 … 1 |
prsb03-dataelement-12498 link
|
|
Details of a person's alcohol record |
 |
 |
Audit questionnaire |
|
0 … 1 |
prsb03-dataelement-12499 link
|
|
Alcohol use disorder identification test (AUDIT) questionnaire
SNOMED-CT coded.
Please note the codes in this section are still under review by NHS Digital and may
change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract
changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
Assessment using Alcohol Use Disorders Identification Test Consumption [SNOMED-CT::1084571000000109]
Alcohol use disorder identification test consumption questionnaire [SNOMED-CT::335811000000106]
Alcohol consumption screening test declined [SNOMED-CT::428073005]
Alcohol assessment declined [SNOMED-CT::361731000000101]
|
|
1 … 1 Mandatory |
prsb03-dataelement-12524 link
|
|
Date of person's AUDIT questionnaire.
Date and time
|
|
0 … 1 |
prsb03-dataelement-12500 link
|
|
AUDIT-C questions: Frequency of consumption, Typical consumption, Binge drinking.
|
|
1 … 1 Mandatory |
prsb03-dataelement-12501 link
|
|
How often did you have a drink containing alcohol in the past year?
0: Never [No drinking of alcohol in the past year.]
1: Monthly or Less [Drinking alcohol monthly or less frequently during the past year.]
2: 2 to 4 Times a Month [Drinking alcohol two to four times a month during the past
year.]
3: 2 to 3 Times a Week [Drinking alcohol two to three times a week during the past
year.]
4: 4 or More Times a Week [Drinking alcohol four or more times a week during the past
year.]
|
 |
 |
 |
 |
Typical consumption cluster |
|
1 … 1 Mandatory |
prsb03-dataelement-12502 link
|
|
Details of the person's typical consumption |
|
1 … 1 Mandatory |
prsb03-dataelement-12503 link
|
|
How many drinks did you have on a typical day when you were drinking in the past year?
Integer (0 to n)
|
|
1 … 1 Mandatory |
prsb03-dataelement-12504 link
|
|
How many drinks did you have on a typical day when you were drinking in the past year?
This item is generated from Typical consumption (absolute value).
0: 0 to 2 [Zero to two drinks of alcohol on a typical day in the past year.]
1: 3 or 4 [Three or four drinks of alcohol on a typical day in the past year.]
2: 5 or 6 [Five or six drinks of alcohol on a typical day in the past year.]
3: 7 to 9 [Seven, eight or nine drinks of alcohol on a typical day in the past year.]
4: 10 or More [Ten or more drinks of alcohol on a typical day in the past year.]
|
|
1 … 1 Mandatory |
prsb03-dataelement-12505 link
|
|
How often did you have six or more drinks on one occasion in the past year?
0:Never [Never, in the past year.]
1: Less than Monthly [Less than monthly, during the past year.]
2: Monthly [Monthly, during the past year.]
3: Weekly [Weekly, during the past year.]
4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
|
|
1 … 1 Mandatory |
prsb03-dataelement-12525 link
|
|
AUDIT-C total score calculated from the 3 questions only: Frequency of consumption, Typical
consumption (categorical value), Binge drinking.
SNOMED-CT coded with associated value calculated from the first 3 questions only.
Please note the codes in this section are still under review by NHS Digital and may
change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract
changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
[SNOMED-CT::1084581000000106] (Alcohol Use Disorders Identification Test - Consumption
score)
And add a value to a field associated with the code to record the score. The score
are as follows:
Current non-drinker (AUDIT-C score = 0)
Low risk of alcohol misuse (AUDIT-C score 1-4)
High risk of alcohol misuse (AUDIT-C score >=5)
|
|
0 … * |
prsb03-dataelement-12507 link
|
|
Populate this section if the AUDIT-C score is >=5. |
|
0 … 1 |
prsb03-dataelement-12511 link
|
|
How often during the last year have you found that you were not able to stop drinking
once you had started?
0: Never [Never, in the past year.]
1: Less than Monthly [Less than monthly, during the past year.]
2: Monthly [Monthly, during the past year.]
3: Weekly [Weekly, during the past year.]
4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
|
|
0 … * |
prsb03-dataelement-12512 link
|
|
How often during the last year have you failed to do what was normally expected of
you because of drinking?
|
|
0 … 1 |
prsb03-dataelement-12513 link
|
|
How often during the last year have you needed a first drink in the morning to get
yourself going after a heavy drinking session?
0: Never [Never, in the past year.]
1: Less than Monthly [Less than monthly, during the past year.]
2: Monthly [Monthly, during the past year.]
3: Weekly [Weekly, during the past year.]
4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
|
|
0 … 1 |
prsb03-dataelement-12514 link
|
|
How often during the last year have you had a feeling of guilt or remorse after drinking?
0: Never [Never, in the past year.]
1: Less than Monthly [Less than monthly, during the past year.]
2: Monthly [Monthly, during the past year.]
3: Weekly [Weekly, during the past year.]
4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
|
|
0 … 1 |
prsb03-dataelement-12515 link
|
|
How often during the last year have you been unable to remember what happened the
night before because of your drinking?
0: Never [Never, in the past year.]
1: Less than Monthly [Less than monthly, during the past year.]
2: Monthly [Monthly, during the past year.]
3: Weekly [Weekly, during the past year.]
4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
|
|
0 … 1 |
prsb03-dataelement-12516 link
|
|
Have you or someone else been injured because of your drinking?
0: No [No occurrence.]
2: Yes, but not in the last year. [Yes, this has occurred, but not in the last year.]
4: Yes, during the last year. [Yes this has occurred during the last year.]
|
|
0 … 1 |
prsb03-dataelement-12517 link
|
|
Has a relative, friend, doctor, or other health care worker been concerned about your
drinking or suggested you cut down?
|
|
0 … 1 |
prsb03-dataelement-12518 link
|
|
AUDIT total score calculated from the 10 AUDIT questions.
SNOMED-CT coded with associated value calculated from the 10 AUDIT questions.
Please note the codes in this section are still under review by NHS Digital and may
change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract
changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
Alcohol use disorders identification test score [SNOMED-CT::443280005]
And add a value to a field associated with the code to record the score. The score
are as follows:
• 0–7 indicates sensible or lower risk drinking
• 8–15 indicates increasing risk drinking
• 16–19 indicates higher risk drinking
• 20 and over indicates possible alcohol dependence
|
 |
Family history |
|
0 … 1 |
prsb03-dataelement-251 link
|
|
Family history |
 |
 |
Family history record entry |
|
0 … 1 |
prsb03-dataelement-10653 link
|
|
This is a family history record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10151 link
|
|
The record of relevant illness in family relations deemed to be significant to the
care or health of the person, including mental illness and suicide, genetic information
etc.
|
|
0 … 1 |
prsb03-dataelement-13678 link
|
|
The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with
explicit context (situation)|
|
|
0 … 1 |
prsb03-dataelement-13679 link
|
|
Free text field to be used if no coded text available |
 |
Investigation results |
|
0 … 1 |
prsb03-dataelement-257 link
|
|
Investigation results |
 |
 |
Investigation results record entry |
|
0 … * |
prsb03-dataelement-10654 link
|
|
This is a investigation result record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10157 link
|
|
The date and time when the investigation was performedDate and time |
|
0 … 1 |
prsb03-dataelement-12099 link
|
|
The professional who performed the investigation. |
|
0 … 1 |
prsb03-dataelement-12100 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12101 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12102 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12103 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12104 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12105 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12106 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10160 link
|
|
The investigation performed. |
|
0 … 1 |
prsb03-dataelement-13525 link
|
|
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
|
|
0 … 1 |
prsb03-dataelement-13526 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-10161 link
|
|
For each investigation, the result of the investigation. This can include a report
which may have results for multiple tests.
|
|
0 … 1 |
prsb03-dataelement-13527 link
|
|
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with
explicit context (situation)|
|
|
0 … 1 |
prsb03-dataelement-13528 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-14094 link
|
|
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test |
 |
 |
 |
Structured investigation result |
|
0 … 1 |
prsb03-dataelement-12415 link
|
|
A structured set of information for each investigation result. |
|
0 … 1 |
prsb03-dataelement-12416 link
|
|
The value of the investigation result.Numeric |
|
0 … 1 |
prsb03-dataelement-12417 link
|
|
The units of the investigation result.UCUM code |
|
0 … 1 |
prsb03-dataelement-12418 link
|
|
The reference range for the investigation result.Free text |
|
0 … 1 |
prsb03-dataelement-12419 link
|
|
Indicator if the investigation is abnormal.Abnormal or Normal |
 |
Signpost details |
|
0 … 1 |
prsb03-dataelement-13973 link
|
|
Details of signpost |
 |
 |
Signpost details record entry |
|
0 … * |
prsb03-dataelement-13974 link
|
|
This is the signpost details record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-13975 link
|
|
Date of signpost |
|
0 … 1 |
prsb03-dataelement-13976 link
|
|
Details of where the signpost is to.
If not an individual, this could be a service
|
|
0 … 1 |
prsb03-dataelement-13977 link
|
|
Name of person signposted toFree Text |
|
0 … 1 |
prsb03-dataelement-13978 link
|
|
Role of person been signposted to.Free Text |
|
0 … 1 |
prsb03-dataelement-13979 link
|
|
The grade of the person been signposted to.Free text |
|
0 … 1 |
prsb03-dataelement-13980 link
|
|
The team or department of the person been signposted to.Free text |
|
0 … 1 |
prsb03-dataelement-13981 link
|
|
The specialty of where been signposted e.g. physiotherapy, oncology, mental health
etc
|
|
0 … 1 |
prsb03-dataelement-13982 link
|
|
The service of where been signposted to. |
|
0 … 1 |
prsb03-dataelement-13983 link
|
|
The coded value for serviceSNOMED CT : - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13984 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13985 link
|
|
Name of organisation been signposted to.
Free text
|
|
0 … 1 |
prsb03-dataelement-13987 link
|
|
The contact details of where been signposted toFree text |
 |
 |
Reason for signpost |
|
0 … 1 |
prsb03-dataelement-13988 link
|
|
Reason for signposting |
|
0 … 1 |
prsb03-dataelement-13990 link
|
|
Free textFree text |
 |
 |
Clinical urgency for signpost |
|
0 … 1 |
prsb03-dataelement-13991 link
|
|
The details of the clinical urgency of signpost
Free text
|
 |
Examination findings |
|
0 … 1 |
prsb03-dataelement-557 link
|
|
Examination findings |
 |
 |
Examination findings record entry |
|
0 … * |
prsb03-dataelement-10662 link
|
|
This is a examination findings record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10462 link
|
|
The date the examination was performed.Date and time |
|
0 … 1 |
prsb03-dataelement-10464 link
|
|
The record of essential physiological measurements, e.g., heart rate, blood pressure,
temperature, pulse, height, weight, respiratory rate, oxygen saturation.
|
|
0 … 1 |
prsb03-dataelement-13761 link
|
|
The person's height and length measurement |
|
0 … 1 |
prsb03-dataelement-13812 link
|
|
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length
of body (observable entity)|
|
|
0 … 1 |
prsb03-dataelement-13813 link
|
|
The value of the observation.Numeric |
|
0 … 1 |
prsb03-dataelement-13817 link
|
|
The units of measure for height/lengthUCUM code |
|
0 … 1 |
prsb03-dataelement-13814 link
|
|
The person's weight in kgs |
|
0 … 1 |
prsb03-dataelement-13815 link
|
|
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)| |
|
0 … 1 |
prsb03-dataelement-13816 link
|
|
The value of the person's weightNumeric |
|
0 … 1 |
prsb03-dataelement-13818 link
|
|
The units of measure for weightUCUM code |
|
0 … 1 |
prsb03-dataelement-13819 link
|
|
The person's BMI calculation |
|
0 … 1 |
prsb03-dataelement-13820 link
|
|
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)| |
|
0 … 1 |
prsb03-dataelement-13821 link
|
|
The value of the person's BMINumeric |
|
0 … 1 |
prsb03-dataelement-13822 link
|
|
The units of measure for BMIUCUM code |
|
0 … 1 |
prsb03-dataelement-13823 link
|
|
The person's blood pressure measurement |
|
0 … 1 |
prsb03-dataelement-13824 link
|
|
Details of the person's systolic blood pressure |
|
0 … 1 |
prsb03-dataelement-13825 link
|
|
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
|
|
0 … 1 |
prsb03-dataelement-13826 link
|
|
The value of the systolic blood pressure readingNumeric |
|
0 … 1 |
prsb03-dataelement-13827 link
|
|
The units of measure for systolic blood pressureUCUM code |
|
0 … 1 |
prsb03-dataelement-13829 link
|
|
The anatomical site at which the blood pressure is taken |
|
0 … 1 |
prsb03-dataelement-13830 link
|
|
The coded value for site
SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
|
|
0 … 1 |
prsb03-dataelement-13831 link
|
|
Amount of vaccine administered.Free text |
|
0 … 1 |
prsb03-dataelement-13867 link
|
|
0 … 1 |
prsb03-dataelement-13868 link
|
|
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
|
|
0 … 1 |
prsb03-dataelement-13869 link
|
|
The value of the diastolic blood pressure readingNumeric |
|
0 … 1 |
prsb03-dataelement-13870 link
|
|
The units of measure for the diastolic blood pressureUCUM code |
|
0 … 1 |
prsb03-dataelement-13871 link
|
|
The anatomical site at which the medication is to be administered. |
|
0 … 1 |
prsb03-dataelement-13872 link
|
|
The coded value for site
SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
|
|
0 … 1 |
prsb03-dataelement-13873 link
|
|
Amount of vaccine administered.Free text |
|
0 … 1 |
prsb03-dataelement-13859 link
|
|
The beat of the heart as felt through the walls of a peripheral artery measured in
bpm
|
|
0 … 1 |
prsb03-dataelement-13970 link
|
|
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) | |
|
0 … 1 |
prsb03-dataelement-13971 link
|
|
The numeric value of heart rateNumeric |
|
0 … 1 |
prsb03-dataelement-13972 link
|
|
The units of measure for heart rateUCUM code |
|
0 … 1 |
prsb03-dataelement-14235 link
|
|
The measurement of the person's temperature in Celsius (OC)
|
|
0 … 1 |
prsb03-dataelement-14236 link
|
|
The coded value for tempretureSNOMED CT : -<<386725007 |Body temperature (observable entity)|
|
|
0 … 1 |
prsb03-dataelement-14237 link
|
|
The value of the person tempretureNumeric |
|
0 … 1 |
prsb03-dataelement-14238 link
|
|
The units of measure for the persons tempretureUCUM code |
|
0 … 1 |
prsb03-dataelement-14239 link
|
|
The measurement of oxygen within the blood (expressed as a percentage of 100) |
|
0 … 1 |
prsb03-dataelement-14240 link
|
|
The coded value for Oxygen saturationSNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)| |
|
0 … 1 |
prsb03-dataelement-14241 link
|
|
The value for the persons oxygen saturationNumeric |
|
0 … 1 |
prsb03-dataelement-14242 link
|
|
The units of measure for oxygen saturationUCUM code |
|
0 … 1 |
prsb03-dataelement-14243 link
|
|
The pain score for the person |
|
0 … 1 |
prsb03-dataelement-14244 link
|
|
The coded value for pain scoreSNOMED CT : - 225908003 | Pain score (observable entity) | |
|
0 … 1 |
prsb03-dataelement-14245 link
|
|
The value for the pain scoreNumeric |
|
0 … 1 |
prsb03-dataelement-14246 link
|
|
The units of measure for pain scoreUCUM |
|
0 … 1 |
prsb03-dataelement-14247 link
|
|
Person's level of arousal and awareness |
|
0 … 1 |
prsb03-dataelement-14249 link
|
|
Coded value for level of consciousness
SNOMED CT : - 1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score
(observable entity) |
|
|
0 … 1 |
prsb03-dataelement-14251 link
|
|
Value of the level of consciousnessNumeric |
|
0 … 1 |
prsb03-dataelement-14252 link
|
|
Unit of measure for level of consciousnessUCUM |
|
0 … 1 |
prsb03-dataelement-14248 link
|
|
Number of breaths you take per minute
|
|
0 … 1 |
prsb03-dataelement-14254 link
|
|
Coded value for respiratory rate
SNOMED CT : - 86290005 | Respiratory rate (observable entity) |
|
|
0 … 1 |
prsb03-dataelement-14255 link
|
|
Value for respiratory rateNumeric |
|
0 … 1 |
prsb03-dataelement-14256 link
|
|
Unit of measure of respiratory rate
UCUM code
|
|
0 … 1 |
prsb03-dataelement-14257 link
|
|
If the person requires Air or Oxygen |
|
0 … 1 |
prsb03-dataelement-14258 link
|
|
The coded value for Air or OxygenSNOMED CT: - 722742002 |Breathing room air| OR 371825009 |Patient on oxygen| OR 315041000
| High concentration oxygen therapy (procedure) | OR 9999016 | High flow oxygen therapy
(procedure) |
|
|
0 … 1 |
prsb03-dataelement-14259 link
|
|
The value for air or oxygenFree text |
|
0 … 1 |
prsb03-dataelement-14260 link
|
|
The unit of measure for the air or oxygen valueUCUM |
 |
 |
 |
 |
National early warning score (NEWS 2) |
|
0 … 1 |
prsb03-dataelement-13861 link
|
|
The NEWS is based on a simple aggregate scoring system in which a score is allocated
to physiological measurements, already recorded in routine practice, when patients
present to, or are being monitored in hospital
-
|
|
0 … 1 |
prsb03-dataelement-13862 link
|
|
The coded value for NEWS 2 total scoreSNOMED CT : - 1104051000000101 | Royal College of Physicians National Early Warning
Score 2 total score (observable entity) |
|
|
0 … 1 |
prsb03-dataelement-13863 link
|
|
The actual NEWS 2 score.Numeric |
|
0 … * |
prsb03-dataelement-13864 link
|
|
Coded value for the subscoreSNOMED CT : - 1104301000000104 | Royal College of Physicians National Early Warning
Score 2 - respiration rate score (observable entity) | 1104351000000103
| Royal College of Physicians National Early Warning Score 2 - pulse score (observable
entity) | 1104311000000102 | Royal College of Physicians
National Early Warning Score 2 - oxygen saturation scale 1 score (observable entity)
| 1104331000000105 | Royal College of Physicians National
Early Warning Score 2 - air or oxygen score (observable entity) |
1104371000000107 | Royal College of Physicians National Early Warning Score
2 - temperature score (observable entity) | 1104341000000101
| Royal College of Physicians National Early Warning Score 2 - systolic blood pressure
score (observable entity) | 1104361000000100 | Royal College
of Physicians National Early Warning Score 2 - consciousness score (observable entity)
|
|
|
0 … * |
prsb03-dataelement-13865 link
|
|
Subscore from each NEWS2 observationNumeric |
 |
Assessments |
|
0 … 1 |
prsb03-dataelement-262 link
|
|
Details of the person's assessments |
 |
 |
Assessments record entry |
|
0 … * |
prsb03-dataelement-11664 link
|
|
This is the assessments record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-12962 link
|
|
Assessment scale used, e.g. New York Heart Failure, Activities of Daily Living (ADL)Free Text. Content could include scale name, date and time of assessment and values
recorded, including overall score. Format of assessment would be determined locally
and may be tabular.
|
|
0 … 1 |
prsb03-dataelement-10763 link
|
|
The date the assessment was done.Date and time. |
|
0 … 1 |
prsb03-dataelement-10822 link
|
|
The type of the assessment e.g. social care needs assessment.Free text |
|
0 … 1 |
prsb03-dataelement-10754 link
|
|
The summary of the assessmentFree text |
|
0 … 1 |
prsb03-dataelement-10655 link
|
|
Details of the structured assessment. |
 |
 |
 |
|
Structured assessment name |
|
0 … 1 |
prsb03-dataelement-11751 link
|
|
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities
of Daily Living (ADL) etc.SNOMED CT
|
|
0 … 1 |
prsb03-dataelement-10162 link
|
|
The structured assessment score.Free text. |
|
0 … 1 |
prsb03-dataelement-10163 link
|
|
The structured assessment value.Numeric |
|
0 … 1 |
prsb03-dataelement-10166 link
|
|
The total global score from the assessment.Free text |
|
0 … 1 |
prsb03-dataelement-10169 link
|
|
The subscale score of the structured assessment.Free text. |
|
0 … 1 |
prsb03-dataelement-10170 link
|
|
The subscale value of the structured assessment.Numeric |
 |
Allergies and adverse reactions |
|
0 … 1 |
prsb03-dataelement-282 link
|
|
Allergies and adverse reactions |
 |
 |
Allergies and adverse reactions record entry |
|
0 … * |
prsb03-dataelement-10657 link
|
|
This is a allergies and adverse reactions record entry. There may be 1 to many record
entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10186 link
|
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
|
|
1 … 1 Mandatory |
prsb03-dataelement-10182 link
|
|
The agent such as food, drug or substances that has caused or may cause an allergy,
intolerance or adverse reaction in this person Or “No known drug allergies or adverse
reactions” Or “Information not available”
|
|
1 … 1 |
prsb03-dataelement-13441 link
|
|
The coded value for causative agentSNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product|
OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy|
OR 196471000000108 |Transfer-degraded non-drug allergy)
|
|
1 … 1 |
prsb03-dataelement-13442 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-10658 link
|
|
Details of the reaction. |
|
0 … 1 |
prsb03-dataelement-10190 link
|
|
The date that the reaction was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-10183 link
|
|
A description of the manifestation of the allergic or adverse reaction experienced
by the person. For example, skin rash.
|
|
0 … 1 |
prsb03-dataelement-13556 link
|
|
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
0 … 1 |
prsb03-dataelement-13557 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10184 link
|
|
A description of the severity of the reaction. |
|
0 … 1 |
prsb03-dataelement-13558 link
|
|
The coded value for severityFHIR value set : - Severity
|
|
0 … 1 |
prsb03-dataelement-13559 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10185 link
|
|
A description of the certainty that the stated causative agent caused the allergic
or adverse reaction.
|
|
0 … 1 |
prsb03-dataelement-13560 link
|
|
The coded value for certainty.FHIR value set : - Certainty
|
|
0 … 1 |
prsb03-dataelement-13561 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10189 link
|
|
Any additional comment or clarification about the adverse reaction.Free text |
|
0 … 1 |
prsb03-dataelement-10187 link
|
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
0 … 1 |
prsb03-dataelement-10188 link
|
|
When the reaction was first experienced i.e this may not be the first this has happened.
May be a date or partial date (e.g. year) or text (e.g. during childhood)Date and time
|
|
0 … 1 |
prsb03-dataelement-14253 link
|
|
The date the allergy was diagnosed as endedDate and time |
 |
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link
|
|
Medications and medical devices |
 |
 |
Medication item entry |
|
0 … * |
prsb03-dataelement-10663 link
|
|
All medications and devices that can be prescribed to be entered via this Medication
item entry. Handles details of continuation / addition / amendment of admission medications.
|
|
0 … 1 |
prsb03-dataelement-10664 link
|
|
Medication item cluster |
|
0 … 1 |
prsb03-dataelement-10843 link
|
|
The date on which the medication or medical device was prescribed.Date and time |
|
1 … 1 Mandatory |
prsb03-dataelement-10536 link
|
|
May be generic name or brand name. |
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0 … 1 |
prsb03-dataelement-13622 link
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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)|
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0 … 1 |
prsb03-dataelement-13623 link
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Free text field to be used if no code is availableFree text |
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0 … 1 |
prsb03-dataelement-10537 link
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The form of the medication e.g. capsule, drops, tablet, lotion etc. |
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0 … 1 |
prsb03-dataelement-13624 link
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The coded value for form.SNOMED CT: - 421967003 | Drug dose form (qualifier value) | |
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0 … 1 |
prsb03-dataelement-13625 link
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Free text field to be used if no code is availableFree text |
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1 … 1 Mandatory |
prsb03-dataelement-10539 link
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The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person.
This may be dispensed by the pharmacy or on the ward. Record in a structured format
i.e. value and a unitFree text
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0 … 1 |
prsb03-dataelement-14271 link
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The value of the quantity suppliedEnumerated value |
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0 … 1 |
prsb03-dataelement-14272 link
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Unit of measure of quantity suppliedUCUM code |
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0 … 1 |
prsb03-dataelement-13792 link
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The date/time the medication was supplied.Date and time |
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0 … * |
prsb03-dataelement-10538 link
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The route by which the medication is administered e.g. oral, IM, IV |
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0 … 1 |
prsb03-dataelement-13655 link
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The coded value for routeSNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
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0 … 1 |
prsb03-dataelement-13656 link
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Free text field to be used if no code is availableFree text |
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0 … 1 |
prsb03-dataelement-10540 link
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The anatomical site at which the medication is to be administered. |
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0 … 1 |
prsb03-dataelement-13657 link
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The coded value for site
SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
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0 … 1 |
prsb03-dataelement-13658 link
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Amount of vaccine administered.Free text |
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0 … 1 |
prsb03-dataelement-13754 link
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A description of the type of supply (e.g. emergency supply, over the counter medication,
patient group direction etc)
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0 … 1 |
prsb03-dataelement-13789 link
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The batch number of the product. |
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0 … 1 |
prsb03-dataelement-13790 link
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The coded value for the batch numberFMD code : - Derived from Falsified medicines directive |
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0 … 1 |
prsb03-dataelement-13791 link
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Free text field to be used if no code is availableFree text |
 |
 |
 |
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Dose directions description |
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0 … 1 |
prsb03-dataelement-10544 link
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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
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 |
 |
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Structured dose direction cluster |
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0 … 1 |
prsb03-dataelement-11639 link
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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.
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0 … 1 |
prsb03-dataelement-10554 link
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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/
|
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0 … 1 |
prsb03-dataelement-10555 link
|
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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/
|
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0 … 1 |
prsb03-dataelement-10548 link
|
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Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
|
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0 … * |
prsb03-dataelement-10545 link
|
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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
|
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 |
 |
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Matters identified during discussion |
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1 … * |
prsb03-dataelement-13753 link
|
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Matters identified during the service about the patient's experience of using the
medication.
Coded text using the following descriptors:
a. patient reports using the medicine as prescribed
b. patient reports not using the medicine as prescribed
c. patient has not started using the medicine
d. prescriber has stopped new medicine
e. patient is not using the medicine in line with the directions of the prescriber
f. patient reports missing a dose in the past 7 days
g. patient reports need for more information about the medicine
h. patient reports side effects
i. patient reports negative feelings about the medicine
j. patient reports uncertainty on whether the medicine is working
k. patient reports concern about remembering to take the medicine
l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation
i. other - free text option
|
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0 … 1 |
prsb03-dataelement-10561 link
|
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Details of the overall course of medication. |
|
0 … 1 |
prsb03-dataelement-10546 link
|
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Reason for medication being prescribed, where known.Free text |
 |
 |
 |
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Anticipatory medicines/equipment |
|
0 … * |
prsb03-dataelement-14023 link
|
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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
|
 |
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link
|
|
Information and advice given |
 |
|
Information and advice given |
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0 … * |
prsb03-dataelement-10215 link
|
|
The oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
Free text
|
 |
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link
|
|
Distribution list |
 |
 |
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link
|
|
This is a Distribution list record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10230 link
|
|
The name of the person the communication is to be sent to, this can be a person or
professional.Free text
|
|
0 … 1 |
prsb03-dataelement-10231 link
|
|
If the communication is being sent to either a named individual, or to a non-named
person with a specific role, then this is the role of the recipient.
Role may be entered as the communication is being created, or sourced from the hospital
system. This may be a role defined in the National Workforce data set (see the NHS
Data Dictionary Job Role Code).FHIR value set : - SDSjobrole
|
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0 … 1 |
prsb03-dataelement-10232 link
|
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
0 … 1 |
prsb03-dataelement-10233 link
|
|
The name of the organisation the recipient is representing or the organisation named
as the receiving organisation.
An identifier for the organisation will be sent alongside the name, but may not displayed
on rendered document.
NHS data dictionary : - Organisation code
|
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0 … 1 |
prsb03-dataelement-10234 link
|
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.Free text
|
|
0 … 1 |
prsb03-dataelement-13793 link
|
|
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
|
 |
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link
|
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
 |
 |
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link
|
|
This is a plan and requested actions record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
 |
 |
|
Actions for professionals |
|
0 … * |
prsb03-dataelement-10436 link
|
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.Free text
|
 |
 |
|
Actions for person or their carer |
|
0 … * |
prsb03-dataelement-10437 link
|
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|