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draft Scenario Community Pharmacy Standard 2.16.840.1.113883.3.1937.777.28.3.32

Name Details [‑]
draft Community Pharmacy Standard
prsb03-scenario-32
Version / effective date 2 - 2021‑01‑26 11:38:36
draft doublearrow Single Community Pharmacy Standard
prsb03-transaction-213link
Version / effective date 2 - 2021‑01‑26 11:38:36    
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draft rotate Pharmacy Record
prsb03-transaction-214link
Version / effective date 2 - 2021‑01‑26 11:38:36    
Actor
stationary (organization) Pharmacy
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
1 … 1 Mandatory
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
1 … 1 Mandatory
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 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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … 1
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree draft  Preferred contact method
0 … 1
prsb03-dataelement-10886link
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
treeblank treetree folder Person's email address details
0 … *
prsb03-dataelement-13807link
Details of the person's email address
treeblank treeblank treetree draft  Person's email address
0 … 1
prsb03-dataelement-10882link
Email address of the person.NHS data dictionary :- Contact email address
treeblank treeblank treetree draft  Person's email address type
0 … 1
prsb03-dataelement-13811link
The type of email address, home, workFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of email address
0 … 1
prsb03-dataelement-13810link
The preferred order of use of email addressPreference of use 1-5, 1 being the highest.
treetree draft  Place of birth
0 … 1
prsb03-dataelement-10884link
The country of birth of the person.NHS data dictionary :- Country code (birth)
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
1 … * Mandatory
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 practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Eligibility Criteria
0 … 1
prsb03-dataelement-10700link
treetree draft  Eligibility criteria
1 … *
prsb03-dataelement-10701link
Records which specific eligibility criteria have been met in order to administer the vaccine.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  Key worker
0 … 1
prsb03-dataelement-12973link
A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No
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
0 … 1
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
0 … 1
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 … 1
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  Parental Responsibility
0 … 1
prsb03-dataelement-10347link
Flag to indicate whether the personal contact has parental responsibilityFlag ; - Yes or No
treeblank treetree draft  Household member
0 … 1
prsb03-dataelement-10348link
Status identifying whether the personal contact is a member of the same householdFlag : - Yes or No
treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-10350link
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
treeblank treetree draft  NHS Number
0 … 1
prsb03-dataelement-10351link
The NHS number of the personal contactNHS data dictionary:- NHS NUMBER
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
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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
0 … 1
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
0 … 1
prsb03-dataelement-10975link
The contact details of the referrer.Free text
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Contact type
0 … 1
prsb03-dataelement-10070link
Type of contact e.g. GP consultation, outpatient attendanceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
1 … 1 Mandatory
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Person collecting the medicine
0 … 1
prsb03-dataelement-13783link

Name, relationship, role (if formal role), contact details
Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Vaccinations
0 … 1
prsb03-dataelement-10685link
Details of vaccinations.
treetree folder Vaccinations record entry
0 … *
prsb03-dataelement-10686link

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.

treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10695link
The date on which the vaccination was administered or the reported/partial date on which it was reported.Date and time
treeblank treetree folder Vaccine product
1 … 1 Mandatory
prsb03-dataelement-10687link
The vaccine product administered.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13237link
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
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13238link
Free text field to be used if no code is availableFree text
treeblank treetree folder Manufacturer
0 … 1
prsb03-dataelement-10698link
Name of vaccine manufacturer.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13239link
The coded value of the manufacturer.SNOMED CT: - DM+D or GS1
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13240link
Free text field to be used if no code is availableFree text
treeblank treetree folder Vaccine procedure
1 … 1 Mandatory
prsb03-dataelement-10688link
The procedure which was used to administer the vaccine.
treeblank treeblank treetree draft  Coded value
1 … 1 Mandatory
prsb03-dataelement-13219link
The coded value for vaccine procedureSNOMED CT :- < 127785005 |Administration of substance to produce immunity, either active or passive (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13220link
Free text field to be used if no code is availableFree text
treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-10697link
The batch number of the product.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13233link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13234link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expiry date
0 … 1
prsb03-dataelement-10696link
The date on which the vaccine will expire.Date/time
treeblank treetree folder Serialisation code
0 … 1
prsb03-dataelement-10690link
A code that separately identifies two identical vaccines (i.e. same product, same batch).
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13235link
The coded value for serialisation code.FMD code : - Derived from Falsified medicines directive
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13236link
Free text field to be used if no code is availableFree text
treeblank treetree folder Body site
0 … 1
prsb03-dataelement-10691link
Body site vaccine was administered.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13222link
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13223link
Free text field to be used if no coded text available
treeblank treetree folder Route
0 … 1
prsb03-dataelement-10692link
How the vaccine entered the body.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13224link
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13225link
Free text field to be used if no coded text available
treeblank treetree folder Indication
0 … 1
prsb03-dataelement-10693link
The clinical indication or reason for administering the vaccine.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13226link
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)
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13227link
Free text field to be used if no code is availableFree text
treeblank treetree folder Dose amount
0 … 1
prsb03-dataelement-10694link
Amount of vaccine administered.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13838link
The amount of vaccine administeredFree text
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13839link
The units of measure for the dose amountUCUM code
treeblank treetree draft  Dose sequence
0 … 1
prsb03-dataelement-10824link
Nominal position in a series of vaccines.Numeric value
folder Appliances
0 … 1
prsb03-dataelement-13762link
Details of appliances
treetree folder Appliance records entry
0 … *
prsb03-dataelement-13763link
This is the appliance records entry.
treeblank treetree draft  Appliance name
1 … 1 Mandatory
prsb03-dataelement-13764link
May be generic name or brand name (as appropriate).As per dm+d (AMP)
treeblank treetree draft  Product order number
0 … 1
prsb03-dataelement-13765link
The product order number for the appliance.
treeblank treetree draft  Manufacturer
0 … 1
prsb03-dataelement-13766link
Name of appliance manufacturerFree text
treeblank treetree draft  Batch number
0 … 1
prsb03-dataelement-13767link
The batch number of the appliance.Free text
treeblank treetree draft  Size
0 … 1
prsb03-dataelement-13768link
The size of the appliance.UCUM
treeblank treetree draft  Weight
0 … 1
prsb03-dataelement-13769link
The weight of the appliance.UCUM
treeblank treetree draft  Colour
0 … 1
prsb03-dataelement-13770link
The colour of the applianceFree text
treeblank treetree folder Route
0 … 1
prsb03-dataelement-13771link
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)|
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14268link
Coded value for appliance route SNOMED CT: -  ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14267link
Free text field to be used if no coded text available
treeblank treetree folder Site
0 … 1
prsb03-dataelement-13772link
The anatomical site at which the appliance is to be used, including laterality.
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14269link
Coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14270link
Free text where no coded value is availableFree text
treeblank treetree draft  Quantity
0 … 1
prsb03-dataelement-13773link
The quantity of the appliance (including the units).UCUM
treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-13774link
Reason for appliance being prescribed, where known.Free text
treeblank treetree draft  Matters identified during the discussion
1 … *
prsb03-dataelement-13775link
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
treeblank treetree draft  Date/time
0 … 1
prsb03-dataelement-13802link
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … 1
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
1 … 1 Mandatory
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
1 … 1 Mandatory
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free 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 Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
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 draft  Smoking status - details
0 … 1
prsb03-dataelement-13286link
Further details recorded about the smoking status of the personFree text
treeblank treetree folder Smoking record
0 … 1
prsb03-dataelement-13995link
Details of the person's smoking record
treeblank treeblank treetree draft  Nicotine Replacement Therapy used
0 … 1
prsb03-dataelement-14000link
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
treeblank treeblank treetree draft  Varenicline or other pharmacotherapy used
0 … 1
prsb03-dataelement-14001link
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
treeblank treeblank treetree draft  e-cigarettes used
0 … 1
prsb03-dataelement-14002link
Record of current use of e-cigarettes Coded - SNOMED CT: 722499006 |Electronic cigarette user (finding)|
treeblank treetree draft  Set quit date
0 … 1
prsb03-dataelement-14007link
Date set to quit smokingDate
treeblank treetree folder Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-13992link
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13993link
The coded value for treatment and interventions.SNOMED CT
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13994link
Free text field to be used if no code is availableFree text
treeblank treetree folder Date stopped smoking
0 … 1
prsb03-dataelement-13287link
The date the person stopped smoking (if known)
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13288link
The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13289link
The date the person stopped smoking.Date and time
folder Alcohol record
0 … 1
prsb03-dataelement-12498link
Details of a person's alcohol record
treetree folder Audit questionnaire
0 … 1
prsb03-dataelement-12499link
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]
treeblank treetree draft  Date
1 … 1 Mandatory
prsb03-dataelement-12524link

Date of person's AUDIT questionnaire.

Date and time
treeblank treetree folder AUDIT-C cluster
0 … 1
prsb03-dataelement-12500link


AUDIT-C questions: Frequency of consumption, Typical consumption, Binge drinking.
treeblank treeblank treetree draft  Frequency of consumption
1 … 1 Mandatory
prsb03-dataelement-12501link
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.]
treeblank treeblank treetree folder Typical consumption cluster
1 … 1 Mandatory
prsb03-dataelement-12502link
Details of the person's typical consumption
treeblank treeblank treeblank treetree draft  Absolute value
1 … 1 Mandatory
prsb03-dataelement-12503link

How many drinks did you have on a typical day when you were drinking in the past year?

Integer (0 to n)
treeblank treeblank treeblank treetree draft  Categorical value
1 … 1 Mandatory
prsb03-dataelement-12504link

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.]
treeblank treeblank treetree draft  Binge drinking
1 … 1 Mandatory
prsb03-dataelement-12505link

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.]
treeblank treeblank treetree draft  AUDIT-C total score
1 … 1 Mandatory
prsb03-dataelement-12525link
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)
treeblank treeblank treetree folder if AUDIT-C score >=5
0 … *
prsb03-dataelement-12507link
Populate this section if the AUDIT-C score is >=5.
treeblank treeblank treeblank treetree draft  Inability to stop
0 … 1
prsb03-dataelement-12511link

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.]
treeblank treeblank treeblank treetree draft  Failed expectations
0 … *
prsb03-dataelement-12512link

How often during the last year have you failed to do what was normally expected of you because of drinking?

treeblank treeblank treeblank treetree draft  Morning drinking
0 … 1
prsb03-dataelement-12513link

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.]
treeblank treeblank treeblank treetree draft  Guilt/remorse
0 … 1
prsb03-dataelement-12514link

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.]
treeblank treeblank treeblank treetree draft  Loss of memory
0 … 1
prsb03-dataelement-12515link

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.]
treeblank treeblank treeblank treetree draft  Injuries
0 … 1
prsb03-dataelement-12516link

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.]
treeblank treeblank treeblank treetree draft  External concern
0 … 1
prsb03-dataelement-12517link

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

treeblank treetree draft  AUDIT total score
0 … 1
prsb03-dataelement-12518link

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
folder Family history
0 … 1
prsb03-dataelement-251link
Family history
treetree folder Family history record entry
0 … 1
prsb03-dataelement-10653link
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.
treeblank treetree folder Family history
0 … 1
prsb03-dataelement-10151link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13678link
The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13679link
Free text field to be used if no coded text available
folder Investigation results
0 … 1
prsb03-dataelement-257link
Investigation results
treetree folder Investigation results record entry
0 … *
prsb03-dataelement-10654link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10157link
The date and time when the investigation was performedDate and time
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-12099link
The professional who performed the investigation.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-12100link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-12101link
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-12102link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-12103link
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-12104link
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-12105link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-12106link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Investigation
0 … 1
prsb03-dataelement-10160link
The investigation performed.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13525link
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13526link
Free text field to be used if no code is availableFree text
treeblank treetree folder Investigation result
0 … *
prsb03-dataelement-10161link
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13527link
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13528link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Investigation Method
0 … 1
prsb03-dataelement-14094link
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
treeblank treetree folder Structured investigation result
0 … 1
prsb03-dataelement-12415link
A structured set of information for each investigation result.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-12416link
The value of the investigation result.Numeric
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-12417link
The units of the investigation result.UCUM code
treeblank treeblank treetree draft  Reference ranges
0 … 1
prsb03-dataelement-12418link
The reference range for the investigation result.Free text
treeblank treeblank treetree draft  Abnormal indicator
0 … 1
prsb03-dataelement-12419link
Indicator if the investigation is abnormal.Abnormal or Normal
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Examination findings
0 … 1
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Height/length
0 … 1
prsb03-dataelement-13761link
The person's height and length measurement
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13812link
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13813link
The value of the observation.Numeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13817link
The units of measure for height/lengthUCUM code
treeblank treeblank treetree folder Weight
0 … 1
prsb03-dataelement-13814link
The person's weight in kgs
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13815link
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13816link
The value of the person's weightNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13818link
The units of measure for weightUCUM code
treeblank treeblank treetree folder BMI
0 … 1
prsb03-dataelement-13819link
The person's BMI calculation
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13820link
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13821link
The value of the person's BMINumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13822link
The units of measure for BMIUCUM code
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Heart rate
0 … 1
prsb03-dataelement-13859link
The beat of the heart as felt through the walls of a peripheral artery measured in bpm
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13970link
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13971link
The numeric value of heart rateNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13972link
The units of measure for heart rateUCUM code
treeblank treeblank treetree folder Temperature
0 … 1
prsb03-dataelement-14235link
The measurement of the person's temperature in Celsius (OC)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14236link
The coded value for tempretureSNOMED CT : -<<386725007 |Body temperature (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14237link
The value of the person tempretureNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14238link
The units of measure for the persons tempretureUCUM code
treeblank treeblank treetree folder Oxygen saturation
0 … 1
prsb03-dataelement-14239link
The measurement of oxygen within the blood (expressed as a percentage of 100)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14240link
The coded value for Oxygen saturationSNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14241link
The value for the persons oxygen saturationNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14242link
The units of measure for oxygen saturationUCUM code
treeblank treeblank treetree folder Pain score
0 … 1
prsb03-dataelement-14243link
The pain score for the person
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14244link
The coded value for pain scoreSNOMED CT : - 225908003 | Pain score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14245link
The value for the pain scoreNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14246link
The units of measure for pain scoreUCUM
treeblank treeblank treetree folder Level of conciousness
0 … 1
prsb03-dataelement-14247link
Person's level of arousal and awareness
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14249link

Coded value for level of consciousness

SNOMED CT : - 1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14251link
Value of the level of consciousnessNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14252link
Unit of measure for level of consciousnessUCUM
treeblank treeblank treetree folder Respiratory rate
0 … 1
prsb03-dataelement-14248link
Number of breaths you take per minute
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14254link
Coded value for respiratory rate SNOMED CT : - 86290005 | Respiratory rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14255link
Value for respiratory rateNumeric
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14256link
Unit of measure of respiratory rate UCUM code
treeblank treeblank treetree folder Air or Oxygen
0 … 1
prsb03-dataelement-14257link
If the person requires Air or Oxygen
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14258link
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) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14259link
The value for air or oxygenFree text
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14260link
The unit of measure for the air or oxygen valueUCUM
treeblank treeblank treetree folder National early warning score (NEWS 2)
0 … 1
prsb03-dataelement-13861link
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
treeblank treeblank treeblank treetree draft  Coded value total score
0 … 1
prsb03-dataelement-13862link
The coded value for NEWS 2 total scoreSNOMED CT : - 1104051000000101 | Royal College of Physicians National Early Warning Score 2 total score (observable entity) |
treeblank treeblank treeblank treetree draft  Value for total score
0 … 1
prsb03-dataelement-13863link
The actual NEWS 2 score.Numeric
treeblank treeblank treeblank treetree draft  Coded value subscore
0 … *
prsb03-dataelement-13864link
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) |
treeblank treeblank treeblank treetree draft  Subscore
0 … *
prsb03-dataelement-13865link
Subscore from each NEWS2 observationNumeric
folder Assessments
0 … 1
prsb03-dataelement-262link
Details of the person's assessments
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  Assessment scale
0 … 1
prsb03-dataelement-12962link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10763link
The date the assessment was done.Date and time.
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
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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
1 … 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
1 … 1
prsb03-dataelement-13442link
Free text field to be used if no code is availableFree text
treeblank treetree folder Reaction details cluster
0 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree draft  Date supplied
0 … 1
prsb03-dataelement-13792link
The date/time the medication was supplied.Date and time
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … *
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
treeblank treeblank treetree draft  Anticipatory medicines/equipment
0 … *
prsb03-dataelement-14023link
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
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … *
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Medication Review
prsb03-transaction-215link
Version / effective date 2 - 2021‑01‑26 12:11:03    
draft arrowleft Medication Review (GP)
prsb03-transaction-216link
Version / effective date 2 - 2021‑01‑26 12:11:03    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Eligibility Criteria
0 … 1
prsb03-dataelement-10700link
treetree draft  Eligibility criteria
0 … *
prsb03-dataelement-10701link
Records which specific eligibility criteria have been met in order to administer the vaccine.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … 1
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree folder Seen by
0 … 1
prsb03-dataelement-10077link
The professional that saw the person.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13515link
The name of the professional that saw the personFree text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13758link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Contact type
0 … 1
prsb03-dataelement-10070link
Type of contact e.g. GP consultation, outpatient attendanceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree draft  Presenting complaint or issue
0 … 1
prsb03-dataelement-10110link
The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.Only ONE (chief complaint) sent as per the ECDS Emergency Care Chief Complaint code set (SNOMED CT).
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … *
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree 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
0 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
0 … 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.
NHS data dictionary : - UK telephone number
treetree draft  Formulation
0 … 1
prsb03-dataelement-10148link
An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
treetree draft  Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-10149link
The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … *
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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 … 1
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  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
draft doublearrow New Medicine Service
prsb03-transaction-218link
Version / effective date 2 - 2021‑01‑26 12:14:39    
draft arrowleft New Medicine Service (GP)
prsb03-transaction-219link
Version / effective date 2 - 2021‑01‑26 12:14:39    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Eligibility Criteria
0 … 1
prsb03-dataelement-10700link
treetree draft  Eligibility criteria
0 … *
prsb03-dataelement-10701link
Records which specific eligibility criteria have been met in order to administer the vaccine.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … 1
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 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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree 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
0 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
0 … 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.
NHS data dictionary : - UK telephone number
treetree draft  Formulation
0 … 1
prsb03-dataelement-10148link
An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
treetree draft  Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-10149link
The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … 1
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Appliance Use Review
prsb03-transaction-220link
Version / effective date 2 - 2021‑01‑26 12:18:11    
draft arrowleft Appliance Use Review (GP)
prsb03-transaction-221link
Version / effective date 2 - 2021‑01‑26 12:18:11    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
1 … * Mandatory
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Appliances
0 … 1
prsb03-dataelement-13762link
Details of appliances
treetree folder Appliance records entry
0 … *
prsb03-dataelement-13763link
This is the appliance records entry.
treeblank treetree draft  Appliance name
1 … 1 Mandatory
prsb03-dataelement-13764link
May be generic name or brand name (as appropriate).As per dm+d (AMP)
treeblank treetree draft  Product order number
0 … 1
prsb03-dataelement-13765link
The product order number for the appliance.
treeblank treetree draft  Manufacturer
0 … 1
prsb03-dataelement-13766link
Name of appliance manufacturerFree text
treeblank treetree draft  Batch number
0 … 1
prsb03-dataelement-13767link
The batch number of the appliance.Free text
treeblank treetree draft  Size
0 … 1
prsb03-dataelement-13768link
The size of the appliance.UCUM
treeblank treetree draft  Weight
0 … 1
prsb03-dataelement-13769link
The weight of the appliance.UCUM
treeblank treetree draft  Colour
0 … 1
prsb03-dataelement-13770link
The colour of the applianceFree text
treeblank treetree folder Route
0 … 1
prsb03-dataelement-13771link
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)|
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14268link
Coded value for appliance route SNOMED CT: -  ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14267link
Free text field to be used if no coded text available
treeblank treetree folder Site
0 … 1
prsb03-dataelement-13772link
The anatomical site at which the appliance is to be used, including laterality.
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14269link
Coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14270link
Free text where no coded value is availableFree text
treeblank treetree draft  Quantity
0 … 1
prsb03-dataelement-13773link
The quantity of the appliance (including the units).UCUM
treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-13774link
Reason for appliance being prescribed, where known.Free text
treeblank treetree draft  Matters identified during the discussion
1 … * Mandatory
prsb03-dataelement-13775link
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
treeblank treetree draft  Date/time
1 … 1 Mandatory
prsb03-dataelement-13802link
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree 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
0 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
0 … 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.
NHS data dictionary : - UK telephone number
treetree draft  Formulation
0 … 1
prsb03-dataelement-10148link
An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
treetree draft  Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-10149link
The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … *
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
folder Plan and requested actions
0 … *
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  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
draft doublearrow Vaccination Administration
prsb03-transaction-222link
Version / effective date 2 - 2021‑01‑26 12:21:51    
draft arrowleft Vaccination Administration (GP)
prsb03-transaction-223link
Version / effective date 2 - 2021‑01‑26 12:21:51    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Eligibility Criteria
0 … *
prsb03-dataelement-10700link
treetree draft  Eligibility criteria
0 … *
prsb03-dataelement-10701link
Records which specific eligibility criteria have been met in order to administer the vaccine.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Vaccinations
1 … 1 Mandatory
prsb03-dataelement-10685link
Details of vaccinations.
treetree folder Vaccinations record entry
1 … * Mandatory
prsb03-dataelement-10686link

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.

treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10695link
The date on which the vaccination was administered or the reported/partial date on which it was reported.Date and time
treeblank treetree folder Vaccine product
1 … 1 Mandatory
prsb03-dataelement-10687link
The vaccine product administered.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13237link
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
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13238link
Free text field to be used if no code is availableFree text
treeblank treetree folder Manufacturer
0 … 1
prsb03-dataelement-10698link
Name of vaccine manufacturer.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13239link
The coded value of the manufacturer.SNOMED CT: - DM+D or GS1
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13240link
Free text field to be used if no code is availableFree text
treeblank treetree folder Vaccine procedure
1 … 1 Mandatory
prsb03-dataelement-10688link
The procedure which was used to administer the vaccine.
treeblank treetree folder Serialisation code
0 … 1
prsb03-dataelement-10690link
A code that separately identifies two identical vaccines (i.e. same product, same batch).
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13235link
The coded value for serialisation code.FMD code : - Derived from Falsified medicines directive
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13236link
Free text field to be used if no code is availableFree text
treeblank treetree folder Body site
0 … 1
prsb03-dataelement-10691link
Body site vaccine was administered.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13222link
The coded value for body siteSNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13223link
Free text field to be used if no coded text available
treeblank treetree folder Route
0 … 1
prsb03-dataelement-10692link
How the vaccine entered the body.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13224link
The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13225link
Free text field to be used if no coded text available
treeblank treetree folder Indication
0 … 1
prsb03-dataelement-10693link
The clinical indication or reason for administering the vaccine.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13226link
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)
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13227link
Free text field to be used if no code is availableFree text
treeblank treetree folder Dose amount
0 … 1
prsb03-dataelement-10694link
Amount of vaccine administered.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13228link
Amount of vaccine administered.SNOMED CT : - dm+d
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13229link
Amount of vaccine administered.Free text
treeblank treetree draft  Dose sequence
0 … 1
prsb03-dataelement-10824link
Nominal position in a series of vaccines.Numeric value
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree 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
0 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
0 … 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.
NHS data dictionary : - UK telephone number
treetree draft  Formulation
0 … 1
prsb03-dataelement-10148link
An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
treetree draft  Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-10149link
The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … *
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow CPCS - Emergency Supply
prsb03-transaction-224link
Version / effective date 2 - 2021‑01‑26 13:22:53    
draft arrowleft CPCS - Emergency Supply (GP)
prsb03-transaction-225link
Version / effective date 2 - 2021‑01‑26 13:22:53    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
1 … * Mandatory
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Person collecting the medicine
0 … 1
prsb03-dataelement-13783link

Name, relationship, role (if formal role), contact details
Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Appliances
0 … 1
prsb03-dataelement-13762link
Details of appliances
treetree folder Appliance records entry
0 … *
prsb03-dataelement-13763link
This is the appliance records entry.
treeblank treetree draft  Appliance name
1 … 1 Mandatory
prsb03-dataelement-13764link
May be generic name or brand name (as appropriate).As per dm+d (AMP)
treeblank treetree draft  Product order number
0 … 1
prsb03-dataelement-13765link
The product order number for the appliance.
treeblank treetree draft  Manufacturer
0 … 1
prsb03-dataelement-13766link
Name of appliance manufacturerFree text
treeblank treetree draft  Batch number
0 … 1
prsb03-dataelement-13767link
The batch number of the appliance.Free text
treeblank treetree draft  Size
0 … 1
prsb03-dataelement-13768link
The size of the appliance.UCUM
treeblank treetree draft  Weight
0 … 1
prsb03-dataelement-13769link
The weight of the appliance.UCUM
treeblank treetree draft  Colour
0 … 1
prsb03-dataelement-13770link
The colour of the applianceFree text
treeblank treetree folder Route
0 … 1
prsb03-dataelement-13771link
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)|
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14268link
Coded value for appliance route SNOMED CT: -  ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14267link
Free text field to be used if no coded text available
treeblank treeblank treetree cancelled  Coded value
0 … 1
prsb03-dataelement-13795link
treeblank treeblank treetree cancelled  Free text
0 … 1
prsb03-dataelement-13794link
Free text field to be used if no code availableFree text
treeblank treetree folder Site
0 … 1
prsb03-dataelement-13772link
The anatomical site at which the appliance is to be used, including laterality.
treeblank treeblank treetree draft  Coded Value
0 … 1
prsb03-dataelement-14269link
Coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-14270link
Free text where no coded value is availableFree text
treeblank treeblank treetree cancelled  Coded value
0 … 1
prsb03-dataelement-13797link
Coded value for site The following value set may be applicable, but would need validating for appliances: • Coded text – constraint: SiteOfMedicationAdministration. Any valid site for the administration of a medication. Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration
treeblank treeblank treetree cancelled  Free text
0 … 1
prsb03-dataelement-13796link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Quantity
0 … 1
prsb03-dataelement-13773link
The quantity of the appliance (including the units).UCUM
treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-13774link
Reason for appliance being prescribed, where known.Free text
treeblank treetree draft  Matters identified during the discussion
1 … * Mandatory
prsb03-dataelement-13775link
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
treeblank treetree draft  Date/time
1 … 1 Mandatory
prsb03-dataelement-13802link
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree 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
0 … 1
prsb03-dataelement-13309link
The location the clinical summary was written.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13310link
The coded value for location.NHS data dictionary : - Organisation data service code
treeblank treetree draft  Free text
0 … 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.
NHS data dictionary : - UK telephone number
treetree draft  Formulation
0 … 1
prsb03-dataelement-10148link
An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
treetree draft  Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-10149link
The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … *
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow CPCS - Minor Illness
prsb03-transaction-226link
Version / effective date 2 - 2021‑01‑26 13:24:56    
draft arrowleft CPCS - Minor Illness (GP)
prsb03-transaction-227link
Version / effective date 2 - 2021‑01‑26 13:24:56    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … * Mandatory
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Person collecting the medicine
0 … 1
prsb03-dataelement-13783link

Name, relationship, role (if formal role), contact details
Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … *
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
1 … 1 Mandatory
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
1 … 1 Mandatory
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Observations
0 … 1
prsb03-dataelement-12475link
The record of essential physiological observations
treetree draft  Observations
0 … *
prsb03-dataelement-12474link
The record of essential physiological observations e.g pulse, blood pressure, oxygen saturation/capnography, temperature, pain score, respiration rate, level of consciousness or new confusion. Use of National Early Warning Score (NEWS2) where appropriate.FHIR NEWS2 specification produced by NHS Digital and the associated observations. See implmentation guidance for restriction of the use of NEWS2 by age.
folder Examination findings
0 … *
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Height/length
0 … 1
prsb03-dataelement-13761link
The person's height and length measurement
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13812link
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13813link
The value of the observation.Numeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13817link
The units of measure for height/lengthUCUM code
treeblank treeblank treetree folder Weight
0 … 1
prsb03-dataelement-13814link
The person's weight in kgs
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13815link
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13816link
The value of the person's weightNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13818link
The units of measure for weightUCUM code
treeblank treeblank treetree folder BMI
0 … 1
prsb03-dataelement-13819link
The person's BMI calculation
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13820link
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13821link
The value of the person's BMINumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13822link
The units of measure for BMIUCUM code
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Heart rate
0 … 1
prsb03-dataelement-13859link
The beat of the heart as felt through the walls of a peripheral artery measured in bpm
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13970link
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13971link
The numeric value of heart rateNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13972link
The units of measure for heart rateUCUM code
treeblank treeblank treetree folder Temperature
0 … 1
prsb03-dataelement-14235link
The measurement of the person's temperature in Celsius (OC)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14236link
The coded value for tempretureSNOMED CT : -<<386725007 |Body temperature (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14237link
The value of the person tempretureNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14238link
The units of measure for the persons tempretureUCUM code
treeblank treeblank treetree folder Oxygen saturation
0 … 1
prsb03-dataelement-14239link
The measurement of oxygen within the blood (expressed as a percentage of 100)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14240link
The coded value for Oxygen saturationSNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14241link
The value for the persons oxygen saturationNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14242link
The units of measure for oxygen saturationUCUM code
treeblank treeblank treetree folder Pain score
0 … 1
prsb03-dataelement-14243link
The pain score for the person
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14244link
The coded value for pain scoreSNOMED CT : - 225908003 | Pain score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14245link
The value for the pain scoreNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14246link
The units of measure for pain scoreUCUM
treeblank treeblank treetree folder Level of conciousness
0 … 1
prsb03-dataelement-14247link
Person's level of arousal and awareness
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14249link

Coded value for level of consciousness

SNOMED CT : - 1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14251link
Value of the level of consciousnessNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14252link
Unit of measure for level of consciousnessUCUM
treeblank treeblank treetree folder Respiratory rate
0 … 1
prsb03-dataelement-14248link
Number of breaths you take per minute
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14254link
Coded value for respiratory rate SNOMED CT : - 86290005 | Respiratory rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14255link
Value for respiratory rateNumeric
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14256link
Unit of measure of respiratory rate UCUM code
treeblank treeblank treetree folder Air or Oxygen
0 … 1
prsb03-dataelement-14257link
If the person requires Air or Oxygen
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14258link
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) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14259link
The value for air or oxygenFree text
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14260link
The unit of measure for the air or oxygen valueUCUM
treeblank treeblank treetree folder National early warning score (NEWS 2)
0 … 1
prsb03-dataelement-13861link
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
treeblank treeblank treeblank treetree draft  Coded value total score
0 … 1
prsb03-dataelement-13862link
The coded value for NEWS 2 total scoreSNOMED CT : - 1104051000000101 | Royal College of Physicians National Early Warning Score 2 total score (observable entity) |
treeblank treeblank treeblank treetree draft  Value for total score
0 … 1
prsb03-dataelement-13863link
The actual NEWS 2 score.Numeric
treeblank treeblank treeblank treetree draft  Coded value subscore
0 … 1
prsb03-dataelement-13864link
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) |
treeblank treeblank treeblank treetree draft  Subscore
0 … 1
prsb03-dataelement-13865link
Subscore from each NEWS2 observationNumeric
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Smoking Cessation
prsb03-transaction-231link
Version / effective date 2 - 2021‑02‑08 11:02:21    
draft arrowleft Smoking Cessation (GP)
prsb03-transaction-233link
Version / effective date 2 - 2021‑02‑08 11:02:21    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … *
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
1 … 1 Mandatory
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
1 … 1 Mandatory
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free 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 Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
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 draft  Smoking status - details
0 … 1
prsb03-dataelement-13286link
Further details recorded about the smoking status of the personFree text
treeblank treetree folder Smoking record
0 … 1
prsb03-dataelement-13995link
Details of the person's smoking record
treeblank treeblank treetree draft  Nicotine Replacement Therapy used
0 … 1
prsb03-dataelement-14000link
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
treeblank treeblank treetree draft  Varenicline or other pharmacotherapy used
0 … 1
prsb03-dataelement-14001link
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
treeblank treeblank treetree draft  e-cigarettes used
0 … 1
prsb03-dataelement-14002link
Record of current use of e-cigarettes Coded - SNOMED CT: 722499006 |Electronic cigarette user (finding)|
treeblank treetree draft  Set quit date
0 … 1
prsb03-dataelement-14007link
Date set to quit smokingDate
treeblank treetree folder Treatments and interventions and changes made to treatments.
0 … 1
prsb03-dataelement-13992link
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13993link
The coded value for treatment and interventions.SNOMED CT
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13994link
Free text field to be used if no code is availableFree text
treeblank treetree folder Date stopped smoking
0 … 1
prsb03-dataelement-13287link
The date the person stopped smoking (if known)
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13288link
The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
treeblank treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13289link
The date the person stopped smoking.Date and time
folder Investigation results
0 … 1
prsb03-dataelement-257link
Investigation results
treetree folder Investigation results record entry
0 … *
prsb03-dataelement-10654link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10157link
The date and time when the investigation was performedDate and time
treeblank treetree folder Investigation
1 … 1 Mandatory
prsb03-dataelement-10160link
The investigation performed.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13525link
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13526link
Free text field to be used if no code is availableFree text
treeblank treetree folder Investigation result
0 … 1
prsb03-dataelement-10161link
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13527link
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13528link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Investigation Method
0 … 1
prsb03-dataelement-14094link
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
treeblank treetree folder Structured investigation result
0 … 1
prsb03-dataelement-12415link
A structured set of information for each investigation result.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-12416link
The value of the investigation result.Numeric
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-12417link
The units of the investigation result.UCUM code
treeblank treeblank treetree draft  Reference ranges
0 … 1
prsb03-dataelement-12418link
The reference range for the investigation result.Free text
treeblank treeblank treetree draft  Abnormal indicator
0 … 1
prsb03-dataelement-12419link
Indicator if the investigation is abnormal.Abnormal or Normal
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Hypertension Case Finding
prsb03-transaction-234link
Version / effective date 2 - 2021‑02‑08 11:30:24    
draft arrowleft Hypertension Case Finding (GP)
prsb03-transaction-236link
Version / effective date 2 - 2021‑02‑08 11:30:24    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Appliances
0 … 1
prsb03-dataelement-13762link
Details of appliances
treetree folder Appliance records entry
0 … *
prsb03-dataelement-13763link
This is the appliance records entry.
treeblank treetree draft  Appliance name
1 … 1 Mandatory
prsb03-dataelement-13764link
May be generic name or brand name (as appropriate).As per dm+d (AMP)
treeblank treetree draft  Product order number
0 … 1
prsb03-dataelement-13765link
The product order number for the appliance.
treeblank treetree draft  Manufacturer
0 … 1
prsb03-dataelement-13766link
Name of appliance manufacturerFree text
treeblank treetree draft  Quantity
0 … 1
prsb03-dataelement-13773link
The quantity of the appliance (including the units).UCUM
treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-13774link
Reason for appliance being prescribed, where known.Free text
treeblank treetree draft  Matters identified during the discussion
1 … * Mandatory
prsb03-dataelement-13775link
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
treeblank treetree draft  Date/time
1 … 1 Mandatory
prsb03-dataelement-13802link
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … *
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
0 … 1
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free 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 Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
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 draft  Smoking status - details
0 … 1
prsb03-dataelement-13286link
Further details recorded about the smoking status of the personFree text
folder Family history
0 … 1
prsb03-dataelement-251link
Family history
treetree folder Family history record entry
0 … *
prsb03-dataelement-10653link
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.
treeblank treetree folder Family history
0 … 1
prsb03-dataelement-10151link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13678link
The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13679link
Free text field to be used if no coded text available
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Examination findings
0 … 1
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Heart rate
0 … 1
prsb03-dataelement-13859link
The beat of the heart as felt through the walls of a peripheral artery measured in bpm
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13970link
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13971link
The numeric value of heart rateNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13972link
The units of measure for heart rateUCUM code
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Cardiovascular Disease
prsb03-transaction-237link
Version / effective date 2 - 2021‑02‑08 13:33:56    
draft arrowleft Cardiovascular Disease (GP)
prsb03-transaction-239link
Version / effective date 2 - 2021‑02‑08 13:33:56    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
1 … 1 Mandatory
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
1 … 1 Mandatory
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free 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 Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
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 draft  Smoking status - details
0 … 1
prsb03-dataelement-13286link
Further details recorded about the smoking status of the personFree text
folder Smoking record
1 … 1
prsb03-dataelement-12489link
Details of the person's smoking record
treetree draft  Overall smoking status
1 … 1 Mandatory
prsb03-dataelement-12490link

Statement about current smoking behaviour for smoking cigarettes (manufactured or roll up).

Defined by current smoking status and ever smoking status.

Coded text: Current Smoker Former Smoker Never Smoked ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
treetree draft  Date of quitting
0 … 1
prsb03-dataelement-12491link
Date when the individual stopped smoking (if a former smoker).Date and time
folder Alcohol record
0 … 1
prsb03-dataelement-12498link
Details of a person's alcohol record
treetree folder Audit questionnaire
0 … 1
prsb03-dataelement-12499link
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]
treeblank treetree draft  Date
1 … 1 Mandatory
prsb03-dataelement-12524link

Date of person's AUDIT questionnaire.

Date and time
treeblank treetree folder AUDIT-C cluster
0 … 1
prsb03-dataelement-12500link


AUDIT-C questions: Frequency of consumption, Typical consumption, Binge drinking.
treeblank treeblank treetree draft  Frequency of consumption
1 … 1 Mandatory
prsb03-dataelement-12501link
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.]
treeblank treeblank treetree folder Typical consumption cluster
1 … 1 Mandatory
prsb03-dataelement-12502link
Details of the person's typical consumption
treeblank treeblank treeblank treetree draft  Absolute value
1 … 1 Mandatory
prsb03-dataelement-12503link

How many drinks did you have on a typical day when you were drinking in the past year?

Integer (0 to n)
treeblank treeblank treeblank treetree draft  Categorical value
1 … 1 Mandatory
prsb03-dataelement-12504link

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.]
treeblank treeblank treetree draft  Binge drinking
1 … 1 Mandatory
prsb03-dataelement-12505link

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.]
treeblank treeblank treetree draft  AUDIT-C total score
1 … 1 Mandatory
prsb03-dataelement-12525link
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)
treeblank treeblank treetree folder if AUDIT-C score >=5
0 … *
prsb03-dataelement-12507link
Populate this section if the AUDIT-C score is >=5.
treeblank treeblank treeblank treetree draft  Inability to stop
0 … 1
prsb03-dataelement-12511link

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.]
treeblank treeblank treeblank treetree draft  Failed expectations
0 … *
prsb03-dataelement-12512link

How often during the last year have you failed to do what was normally expected of you because of drinking?

treeblank treeblank treeblank treetree draft  Morning drinking
0 … 1
prsb03-dataelement-12513link

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.]
treeblank treeblank treeblank treetree draft  Guilt/remorse
0 … 1
prsb03-dataelement-12514link

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.]
treeblank treeblank treeblank treetree draft  Loss of memory
0 … 1
prsb03-dataelement-12515link

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.]
treeblank treeblank treeblank treetree draft  Injuries
0 … 1
prsb03-dataelement-12516link

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.]
treeblank treeblank treeblank treetree draft  External concern
0 … 1
prsb03-dataelement-12517link

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

treeblank treetree draft  AUDIT total score
0 … 1
prsb03-dataelement-12518link

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
folder Family history
0 … 1
prsb03-dataelement-251link
Family history
treetree folder Family history record entry
0 … *
prsb03-dataelement-10653link
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.
treeblank treetree folder Family history
0 … 1
prsb03-dataelement-10151link
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.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13678link
The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13679link
Free text field to be used if no coded text available
folder Investigation results
0 … 1
prsb03-dataelement-257link
Investigation results
treetree folder Investigation results record entry
0 … *
prsb03-dataelement-10654link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10157link
The date and time when the investigation was performedDate and time
treeblank treetree folder Investigation
1 … 1 Mandatory
prsb03-dataelement-10160link
The investigation performed.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13525link
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13526link
Free text field to be used if no code is availableFree text
treeblank treetree folder Investigation result
0 … 1
prsb03-dataelement-10161link
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13527link
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13528link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Investigation Method
0 … 1
prsb03-dataelement-14094link
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
treeblank treetree folder Structured investigation result
0 … 1
prsb03-dataelement-12415link
A structured set of information for each investigation result.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-12416link
The value of the investigation result.Numeric
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-12417link
The units of the investigation result.UCUM code
treeblank treeblank treetree draft  Reference ranges
0 … 1
prsb03-dataelement-12418link
The reference range for the investigation result.Free text
treeblank treeblank treetree draft  Abnormal indicator
0 … 1
prsb03-dataelement-12419link
Indicator if the investigation is abnormal.Abnormal or Normal
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Examination findings
0 … 1
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Height/length
0 … 1
prsb03-dataelement-13761link
The person's height and length measurement
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13812link
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13813link
The value of the observation.Numeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13817link
The units of measure for height/lengthUCUM code
treeblank treeblank treetree folder Weight
0 … 1
prsb03-dataelement-13814link
The person's weight in kgs
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13815link
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13816link
The value of the person's weightNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13818link
The units of measure for weightUCUM code
treeblank treeblank treetree folder BMI
0 … 1
prsb03-dataelement-13819link
The person's BMI calculation
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13820link
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13821link
The value of the person's BMINumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13822link
The units of measure for BMIUCUM code
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Heart rate
0 … 1
prsb03-dataelement-13859link
The beat of the heart as felt through the walls of a peripheral artery measured in bpm
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13970link
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13971link
The numeric value of heart rateNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13972link
The units of measure for heart rateUCUM code
folder Assessments
0 … 1
prsb03-dataelement-262link
Details of the person's assessments
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  Assessment scale
0 … 1
prsb03-dataelement-12962link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10763link
The date the assessment was done.Date and time.
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 … *
prsb03-dataelement-10170link
The subscale value of the structured assessment.Numeric
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Contraception
prsb03-transaction-240link
Version / effective date 2 - 2021‑02‑08 14:03:54    
draft arrowleft Contraception (GP)
prsb03-transaction-242link
Version / effective date 2 - 2021‑02‑08 14:03:54    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
1 … 1 Mandatory
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
1 … 1 Mandatory
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free 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 Smoking status
0 … 1
prsb03-dataelement-10040link
Details of the person's smoking status.
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 draft  Smoking status - details
0 … 1
prsb03-dataelement-13286link
Further details recorded about the smoking status of the personFree text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Examination findings
0 … 1
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Height/length
0 … 1
prsb03-dataelement-13761link
The person's height and length measurement
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13812link
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13813link
The value of the observation.Numeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13817link
The units of measure for height/lengthUCUM code
treeblank treeblank treetree folder Weight
0 … 1
prsb03-dataelement-13814link
The person's weight in kgs
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13815link
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13816link
The value of the person's weightNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13818link
The units of measure for weightUCUM code
treeblank treeblank treetree folder BMI
0 … 1
prsb03-dataelement-13819link
The person's BMI calculation
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13820link
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13821link
The value of the person's BMINumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13822link
The units of measure for BMIUCUM code
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
folder Assessments
0 … 1
prsb03-dataelement-262link
Details of the person's assessments
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  Assessment scale
0 … 1
prsb03-dataelement-12962link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10763link
The date the assessment was done.Date and time.
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 … *
prsb03-dataelement-10170link
The subscale value of the structured assessment.Numeric
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Sore Throat Testing
prsb03-transaction-243link
Version / effective date 2 - 2021‑02‑08 14:19:12    
draft arrowleft Sore Throat Testing (GP)
prsb03-transaction-245link
Version / effective date 2 - 2021‑02‑08 14:19:12    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … *
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
0 … 1
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Investigation results
0 … 1
prsb03-dataelement-257link
Investigation results
treetree folder Investigation results record entry
0 … *
prsb03-dataelement-10654link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10157link
The date and time when the investigation was performedDate and time
treeblank treetree folder Investigation
1 … 1 Mandatory
prsb03-dataelement-10160link
The investigation performed.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13525link
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13526link
Free text field to be used if no code is availableFree text
treeblank treetree folder Investigation result
0 … 1
prsb03-dataelement-10161link
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13527link
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13528link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Investigation Method
0 … 1
prsb03-dataelement-14094link
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
treeblank treetree folder Structured investigation result
0 … 1
prsb03-dataelement-12415link
A structured set of information for each investigation result.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-12416link
The value of the investigation result.Numeric
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-12417link
The units of the investigation result.UCUM code
treeblank treeblank treetree draft  Reference ranges
0 … 1
prsb03-dataelement-12418link
The reference range for the investigation result.Free text
treeblank treeblank treetree draft  Abnormal indicator
0 … 1
prsb03-dataelement-12419link
Indicator if the investigation is abnormal.Abnormal or Normal
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Examination findings
0 … *
prsb03-dataelement-557link
Examination findings
treetree folder Examination findings record entry
0 … *
prsb03-dataelement-10662link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10462link
The date the examination was performed.Date and time
treeblank treetree folder Observations
0 … 1
prsb03-dataelement-10464link
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
treeblank treeblank treetree folder Observations record entry
0 … *
prsb03-dataelement-13866link
This is an observations 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 treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13447link
The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13832link
The measured value of the observationsEnumerated value e.g. numeric, natural numbers, mild, moderate
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13833link
The units of measure for the observation.UCUM code
treeblank treeblank treeblank treetree draft  Site
0 … 1
prsb03-dataelement-13848link
The anatomical site at which the observation is takenSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treetree draft  Interpretation
0 … 1
prsb03-dataelement-13843link
The assessment made based on the result of the observation e.g high, lowFHIR value set: - Interpretation
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13448link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Height/length
0 … 1
prsb03-dataelement-13761link
The person's height and length measurement
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13812link
The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13813link
The value of the observation.Numeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13817link
The units of measure for height/lengthUCUM code
treeblank treeblank treetree folder Weight
0 … 1
prsb03-dataelement-13814link
The person's weight in kgs
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13815link
The coded value of weightSNOMED CT : - 27113001 |Body weight (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13816link
The value of the person's weightNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13818link
The units of measure for weightUCUM code
treeblank treeblank treetree folder BMI
0 … 1
prsb03-dataelement-13819link
The person's BMI calculation
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13820link
The coded value of BMISNOMED CT: - 60621009 |Body mass index (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13821link
The value of the person's BMINumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13822link
The units of measure for BMIUCUM code
treeblank treeblank treetree folder Blood pressure
0 … 1
prsb03-dataelement-13823link
The person's blood pressure measurement
treeblank treeblank treeblank treetree folder Systolic blood pressure
0 … 1
prsb03-dataelement-13824link
Details of the person's systolic blood pressure
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13825link
The coded value for systolic blood pressureSNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13826link
The value of the systolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13827link
The units of measure for systolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13829link
The anatomical site at which the blood pressure is taken
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13830link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13831link
Amount of vaccine administered.Free text
treeblank treeblank treeblank treetree folder Diastolic blood pressure
0 … 1
prsb03-dataelement-13867link
treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13868link
The coded value for diastolic blood pressure.SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|
treeblank treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13869link
The value of the diastolic blood pressure readingNumeric
treeblank treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13870link
The units of measure for the diastolic blood pressureUCUM code
treeblank treeblank treeblank treeblank treetree folder Site
0 … 1
prsb03-dataelement-13871link
The anatomical site at which the medication is to be administered.
treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13872link
The coded value for site SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13873link
Amount of vaccine administered.Free text
treeblank treeblank treetree folder Heart rate
0 … 1
prsb03-dataelement-13859link
The beat of the heart as felt through the walls of a peripheral artery measured in bpm
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13970link
The coded value for heart rateSNOMED CT : - 364075005 | Heart rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-13971link
The numeric value of heart rateNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-13972link
The units of measure for heart rateUCUM code
treeblank treeblank treetree folder Temperature
0 … 1
prsb03-dataelement-14235link
The measurement of the person's temperature in Celsius (OC)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14236link
The coded value for tempretureSNOMED CT : -<<386725007 |Body temperature (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14237link
The value of the person tempretureNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14238link
The units of measure for the persons tempretureUCUM code
treeblank treeblank treetree folder Oxygen saturation
0 … 1
prsb03-dataelement-14239link
The measurement of oxygen within the blood (expressed as a percentage of 100)
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14240link
The coded value for Oxygen saturationSNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)|
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14241link
The value for the persons oxygen saturationNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14242link
The units of measure for oxygen saturationUCUM code
treeblank treeblank treetree folder Pain score
0 … 1
prsb03-dataelement-14243link
The pain score for the person
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14244link
The coded value for pain scoreSNOMED CT : - 225908003 | Pain score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14245link
The value for the pain scoreNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14246link
The units of measure for pain scoreUCUM
treeblank treeblank treetree folder Level of conciousness
0 … 1
prsb03-dataelement-14247link
Person's level of arousal and awareness
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14249link

Coded value for level of consciousness

SNOMED CT : - 1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14251link
Value of the level of consciousnessNumeric
treeblank treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-14252link
Unit of measure for level of consciousnessUCUM
treeblank treeblank treetree folder Respiratory rate
0 … 1
prsb03-dataelement-14248link
Number of breaths you take per minute
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-14254link
Coded value for respiratory rate SNOMED CT : - 86290005 | Respiratory rate (observable entity) |
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14255link
Value for respiratory rateNumeric
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14256link
Unit of measure of respiratory rate UCUM code
treeblank treeblank treetree folder National early warning score (NEWS 2)
0 … 1
prsb03-dataelement-13861link
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
treeblank treeblank treeblank treetree draft  Coded value total score
0 … 1
prsb03-dataelement-13862link
The coded value for NEWS 2 total scoreSNOMED CT : - 1104051000000101 | Royal College of Physicians National Early Warning Score 2 total score (observable entity) |
treeblank treeblank treeblank treetree draft  Value for total score
0 … 1
prsb03-dataelement-13863link
The actual NEWS 2 score.Numeric
treeblank treeblank treeblank treetree draft  Coded value subscore
0 … 1
prsb03-dataelement-13864link
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) |
treeblank treeblank treeblank treetree draft  Subscore
0 … 1
prsb03-dataelement-13865link
Subscore from each NEWS2 observationNumeric
folder Assessments
0 … 1
prsb03-dataelement-262link
Details of the person's assessments
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  Assessment scale
0 … 1
prsb03-dataelement-12962link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10763link
The date the assessment was done.Date and time.
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 … *
prsb03-dataelement-10170link
The subscale value of the structured assessment.Numeric
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Palliative Care
prsb03-transaction-246link
Version / effective date 2 - 2021‑02‑08 14:29:16    
draft arrowleft Palliative Care (GP)
prsb03-transaction-248link
Version / effective date 2 - 2021‑02‑08 14:29:16    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Person collecting the medicine
0 … 1
prsb03-dataelement-13783link

Name, relationship, role (if formal role), contact details
Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder Presenting complaints or issues
0 … 1
prsb03-dataelement-210link
Presenting complaints or issues
treetree folder Presenting complaint or issue
0 … *
prsb03-dataelement-13784link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13785link
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13786link
Free text
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
0 … 1
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Allergies and adverse reactions
0 … 1
prsb03-dataelement-282link
Allergies and adverse reactions
treetree folder Allergies and adverse reactions record entry
0 … *
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 … *
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 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 draft  Allergy end date
0 … 1
prsb03-dataelement-14253link
The date the allergy was diagnosed as endedDate and time 
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 … *
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 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 Quantity supplied
1 … 1 Mandatory
prsb03-dataelement-10539link
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
treeblank treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-14271link
The value of the quantity suppliedEnumerated value
treeblank treeblank treeblank treetree draft  Unit of measure
0 … 1
prsb03-dataelement-14272link
Unit of measure of quantity suppliedUCUM code
treeblank treeblank treetree folder Route
0 … *
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 site SNOMED 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 draft  Supply type
0 … 1
prsb03-dataelement-13754link
A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
treeblank treeblank treetree folder Batch number
0 … 1
prsb03-dataelement-13789link
The batch number of the product.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13790link
The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
treeblank treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13791link
Free text field to be used if no code is availableFree text
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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
treeblank treeblank treetree draft  Additional instructions
0 … *
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 draft  Matters identified during discussion
1 … * Mandatory
prsb03-dataelement-13753link
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
treeblank treeblank treetree folder Course details cluster
0 … 1
prsb03-dataelement-10561link
Details of the overall course of medication.
treeblank treeblank treeblank treetree draft  Indication
0 … 1
prsb03-dataelement-10546link
Reason for medication being prescribed, where known.Free text
treeblank treeblank treetree draft  Anticipatory medicines/equipment
0 … *
prsb03-dataelement-14023link
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
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
0 … 1
prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
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  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
draft doublearrow Hepatitis C
prsb03-transaction-249link
Version / effective date 2 - 2021‑02‑11 10:39:07    
draft arrowleft Hepatitis C (GP)
prsb03-transaction-251link
Version / effective date 2 - 2021‑02‑11 10:39:07    
Actor
Sender (organization) Pharmacy
Receiver (organization) General practitioner
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 full name
1 … 1 Mandatory
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  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Sex
1 … 1 Mandatory
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  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
1 … 1 Mandatory
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 Person's contact details
0 … *
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
treetree draft  Place of birth
0 … 1
prsb03-dataelement-10884link
The country of birth of the person.NHS data dictionary :- Country code (birth)
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
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 practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
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.
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.
NHS data dictionary : - UK telephone number
treetree folder Consent relating to child
0 … 1
prsb03-dataelement-10422link
Details of the person's consent relating to child
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-11732link
The date when the person with responsibility for the child was identified.Date and time
treeblank treetree folder Location
0 … 1
prsb03-dataelement-11733link
The location where the person with responsibility for the child was identified.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13674link
The coded value for locationNHS data dictionary : - Organisation data service
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13675link
Free text field to be used if no coded text available
treeblank treetree draft  Consent relating to child
0 … 1
prsb03-dataelement-13576link
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
treeblank treetree folder Performing professional
0 … 1
prsb03-dataelement-11734link
The professional who identified the person responsible for the child.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11735link
The name of the professional.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11736link
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-11737link
The grade of the professional.Free text
treeblank treeblank treetree draft  Speciality
0 … 1
prsb03-dataelement-11738link
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-11739link
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-11740link
The name of the organisation the professional works for.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11741link
Contact details of the professionalNHS data dictionary - UK phone number
treeblank treetree folder Person completing record
0 … 1
prsb03-dataelement-11742link
Details of the person completing the record.
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-11743link
The name of the person completing the record.Free text.
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-11744link
The organisational role of the person completing record.FHIR value set :- SDSjobrole
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-11745link
The grade of the person completing the record.Free text.
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-11746link
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-11747link
The organisation the person completing the record works for.
treeblank treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-11748link
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-11749link
The date and time the record was completed.Date and time.
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-11750link
Contact details of the person completing the record.
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
0 … 1
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 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 draft  Comment
0 … 1
prsb03-dataelement-10175link
Further details on safeguarding concerns.Free text
folder Referral details
0 … 1
prsb03-dataelement-105link
The details of the referral.
treetree folder Referral details record entry
0 … *
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 folder Reason for referral
1 … 1 Mandatory
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 treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13455link
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13456link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Expectation of referral
0 … *
prsb03-dataelement-10699link
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
treeblank treetree folder Clinical urgency of referral
0 … 1
prsb03-dataelement-10010link
The details of the clinical urgency of referral
treeblank treeblank treetree draft  Reason for urgency of referral
0 … 1
prsb03-dataelement-10976link
The reason for urgency of referral if not routine.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.
folder Contacts with professionals
1 … 1 Mandatory
prsb03-dataelement-169link
The details of the person’s contact with a professional.
treetree folder Contacts with professionals record entry
1 … *
prsb03-dataelement-10718link
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.
treeblank treetree draft  Date of contact
1 … 1 Mandatory
prsb03-dataelement-10069link
Date and time of the contact.Date and time.
treeblank treetree folder Location of contact
0 … 1
prsb03-dataelement-10075link
The location where the contact took place.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13513link
The coded value for locationNHS data dictionary : - Organisation service code
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13514link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Reason for service
0 … 1
prsb03-dataelement-13751link
The reason why the person has been offered the serviceFree text
treeblank treetree draft  Consultation method
0 … 1
prsb03-dataelement-10071link
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
treeblank treetree draft  Service
0 … 1
prsb03-dataelement-10074link
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
treeblank treetree draft  Person accompanying patient
0 … *
prsb03-dataelement-10079link
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
treeblank treetree draft  Organisation name
1 … 1 Mandatory
prsb03-dataelement-10706link
The name, including the identifier, of the organisation providing the serviceNHS data dictionary : - Organisation name
treeblank treetree draft  Organisation address
0 … 1
prsb03-dataelement-10713link
The name of the organisation, including the identifier.NHS data dictionary : - Organisation address
treeblank treetree draft  Organisation contact details
0 … *
prsb03-dataelement-10707link
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
treeblank treetree draft  Reason for non-provision of service
0 … 1
prsb03-dataelement-10708link
The reason why the patient was not provided with the service e.g. declined, did not attend etc.Free text
treeblank treetree draft  Clinician name
1 … 1 Mandatory
prsb03-dataelement-10709link
The name of the person providing the service.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10710link
The role of the person providing the service.FHIR values set : - sdsjobrole
treeblank treetree draft  Chaperone
0 … *
prsb03-dataelement-10712link
The name of any chaperone(s).Free text
treeblank treetree draft  Professional identifier
0 … 1
prsb03-dataelement-10711link
Professional identifier of the person providing the service.NHS data dictionary : - professional identifier
folder History
0 … 1
prsb03-dataelement-226link
History
treetree folder Relevant past medical, surgical and mental health history
0 … 1
prsb03-dataelement-10130link
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.
treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13787link
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13788link
Free text field to be used if no code is availableFree text
folder Clinical Summary
0 … 1
prsb03-dataelement-247link
Clinical Summary
treetree draft  Clinical narrative
0 … 1
prsb03-dataelement-10150link
A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.Free text
folder Investigation results
0 … 1
prsb03-dataelement-257link
Investigation results
treetree folder Investigation results record entry
0 … *
prsb03-dataelement-10654link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-10157link
The date and time when the investigation was performedDate and time
treeblank treetree folder Investigation
1 … 1 Mandatory
prsb03-dataelement-10160link
The investigation performed.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13525link
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13526link
Free text field to be used if no code is availableFree text
treeblank treetree folder Investigation result
0 … 1
prsb03-dataelement-10161link
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13527link
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
treeblank treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13528link
Free text field to be used if no code is availableFree text
treeblank treetree draft  Investigation Method
0 … 1
prsb03-dataelement-14094link
Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
treeblank treetree folder Structured investigation result
0 … 1
prsb03-dataelement-12415link
A structured set of information for each investigation result.
treeblank treeblank treetree draft  Value
0 … 1
prsb03-dataelement-12416link
The value of the investigation result.Numeric
treeblank treeblank treetree draft  Units of measure
0 … 1
prsb03-dataelement-12417link
The units of the investigation result.UCUM code
treeblank treeblank treetree draft  Reference ranges
0 … 1
prsb03-dataelement-12418link
The reference range for the investigation result.Free text
treeblank treeblank treetree draft  Abnormal indicator
0 … 1
prsb03-dataelement-12419link
Indicator if the investigation is abnormal.Abnormal or Normal
folder Signpost details
0 … 1
prsb03-dataelement-13973link
Details of signpost
treetree folder Signpost details record entry
0 … *
prsb03-dataelement-13974link
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.
treeblank treetree draft  Date
0 … 1
prsb03-dataelement-13975link
Date of signpost
treeblank treetree folder Signpost to
0 … 1
prsb03-dataelement-13976link
Details of where the signpost is to.


If not an individual, this could be a service
treeblank treeblank treetree draft  Name
0 … 1
prsb03-dataelement-13977link
Name of person signposted toFree Text
treeblank treeblank treetree draft  Role
0 … 1
prsb03-dataelement-13978link
Role of person been signposted to.Free Text
treeblank treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-13979link
The grade of the person been signposted to.Free text
treeblank treeblank treetree draft  Team
0 … 1
prsb03-dataelement-13980link
The team or department of the person been signposted to.Free text
treeblank treeblank treetree draft  Specialty
0 … 1
prsb03-dataelement-13981link
The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
treeblank treeblank treetree folder Service
0 … 1
prsb03-dataelement-13982link
The service of where been signposted to.
treeblank treeblank treeblank treetree draft  Coded value
0 … 1
prsb03-dataelement-13983link
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-13984link
Free text field to be used if no code is availableFree text
treeblank treeblank treetree folder Organisation
0 … 1
prsb03-dataelement-13985link
Name of organisation been signposted to. Free text
treeblank treeblank treetree draft  Contact details
0 … 1
prsb03-dataelement-13987link
The contact details of where been signposted toFree text
treetree folder Reason for signpost
0 … 1
prsb03-dataelement-13988link
Reason for signposting
treeblank treetree draft  Free text
0 … 1
prsb03-dataelement-13990link
Free textFree text
treetree folder Clinical urgency for signpost
0 … 1
prsb03-dataelement-13991link
The details of the clinical urgency of signpost Free text
folder Information and advice given
0 … 1
prsb03-dataelement-315link
Information and advice given
treetree draft  Information and advice given
0 … *
prsb03-dataelement-10215link

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
folder Distribution list
0 … 1
prsb03-dataelement-330link
Distribution list
treetree folder Distribution list record entry
0 … 1
prsb03-dataelement-10660link
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.
treeblank treetree draft  Name
0 … 1
prsb03-dataelement-10230link
The name of the person the communication is to be sent to, this can be a person or professional.Free text
treeblank treetree draft  Role
0 … 1
prsb03-dataelement-10231link
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
treeblank treetree draft  Grade
0 … 1
prsb03-dataelement-10232link
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text
treeblank treetree draft  Organisation name
0 … 1
prsb03-dataelement-10233link
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
treeblank treetree draft  Team
0 … 1
prsb03-dataelement-10234link
Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.Free text
treeblank treetree draft  Relationship
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prsb03-dataelement-13793link
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
folder Plan and requested actions
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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
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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  Actions for professionals
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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