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draft Transaction CPCS - Emergency Supply (GP) 2.16.840.1.113883.3.1937.777.28.4.225

Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft CPCS - Emergency Supply (GP) (2) 2.16.840.1.113883.3.1937.777.28.4.225
Version / effective date Expiration date
2021‑01‑26 13:22:53
Description
Name Details [‑]
folder draft Person demographics 1 … 1 Mandatory
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Cardinality 1 … 1 Mandatory
Description The person's details and contact information.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Person name 1 … 1 Mandatory
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Cardinality 1 … 1 Mandatory
Description Details of the person's name
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Person full name 1 … 1 Mandatory
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
Cardinality 1 … 1 Mandatory
Description The full name of the person in text representation.
Rationale Patient.name.text
Operationalization NHS data dictionary :- Patient full name
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date of birth 1 … 1 Mandatory
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
Cardinality 1 … 1 Mandatory
Description The date of birth of the person.

Properties

FHIR Patient.birthDate
Relationship
Rationale Patient.birthdate
Source NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=D&ID=186&Title=Date%20of%20Birth
Operationalization NHS data dictionary:- Person birth date
Value Domain
Property
Timestamp precision
day, month and year
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Sex 1 … 1 Mandatory
prsb03-dataelement-10877
Id prsb03-dataelement-10877 (2019‑03‑27 19:15:45) 1
Cardinality 1 … 1 Mandatory
notice There is an open issue with this item:
Description The person’s phenotypic sex. Determines how the person will be treated clinically.
Relationship
Operationalization NHS data dictionary:- person phenotypic sex classification
Value Domain
Property
max length
1
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft NHS number 0 … 1
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 1
Cardinality 0 … 1
Description The unique identifier for a person within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Relationship
Rationale Patient.identifier(nhsnumber)
Operationalization NHS data dictionary:- NHS number
Value Domain
Property
max length
10
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Other identifier 0 … *
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Cardinality 0 … *
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Relationship
Operationalization
Value Domain
Property
max length
20
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Person's address 1 … 1 Mandatory
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Cardinality 1 … 1 Mandatory
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

FHIR Patient.Address
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Address line 1 1 … 1 Mandatory
prsb03-dataelement-13082
Id prsb03-dataelement-13082 (2020‑05‑29 15:28:51)
Cardinality 1 … 1 Mandatory
Description Person's first line of address.
Rationale Patient.address.line
Operationalization
NHS data dictionary :-  Address line 1

Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Address line 2 0 … 1
prsb03-dataelement-13083
Id prsb03-dataelement-13083 (2020‑05‑29 15:32:41)
Cardinality 0 … 1
Description Person's second line of address.
Rationale Patient.address.city
Operationalization
NHS data dictionary :- Address line 2

Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Address line 3 0 … 1
prsb03-dataelement-13084
Id prsb03-dataelement-13084 (2020‑05‑29 15:35:34)
Cardinality 0 … 1
Description Person's third line of address.
Rationale Patient.address.district
Operationalization
NHS data dictionary : - Address line 3
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Address line 4 0 … 1
prsb03-dataelement-13085
Id prsb03-dataelement-13085 (2020‑06‑01 11:29:56)
Cardinality 0 … 1
Description Person's fourth line of address.
Rationale Patient.address.state
Operationalization
NHS data dictionary : - Address line 4

Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Address line 5 0 … 1
prsb03-dataelement-13086
Id prsb03-dataelement-13086 (2020‑06‑01 11:32:10)
Cardinality 0 … 1
Description Person's fifth line of address.
Rationale Patient.address.country
Operationalization NHS data dictionary : - Address line 5

Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Postcode 0 … 1
prsb03-dataelement-13087
Id prsb03-dataelement-13087 (2020‑06‑01 11:40:09)
Cardinality 0 … 1
Description The person's postcode.
Rationale Patient.address.postalcode
Operationalization NHS data dictionary :- Postcode of usual address

Value Domain
Property
max length
8
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Person's contact details 0 … *
prsb03-dataelement-13804
Id prsb03-dataelement-13804 (2020‑11‑25 18:32:36)
Cardinality 0 … *
Description Details of the person's contact information.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Person's telephone number details 0 … *
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Cardinality 0 … *
Description The person's telephone number details

Properties

FHIR Patient.telecom
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Person's telephone number 0 … 1
prsb03-dataelement-13808
Id prsb03-dataelement-13808 (2020‑11‑26 16:51:24)
Cardinality 0 … 1
Description The person's telephone number
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Person's telephone number type 0 … 1
prsb03-dataelement-13805
Id prsb03-dataelement-13805 (2020‑11‑25 18:37:54)
Cardinality 0 … 1
Description The contact type e.g. home, mobile
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Mobile
Example Temp
Example Old
Example Work
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Preference of telephone number 0 … 1
prsb03-dataelement-13809
Id prsb03-dataelement-13809 (2020‑11‑26 16:55:09)
Cardinality 0 … 1
Description The preferred order of use for the telephone number
Rationale Patient.telecom.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft GP practice 1 … 1 Mandatory
prsb03-dataelement-101
Id prsb03-dataelement-101 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Details of the person's GP practice.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft GP practice record entry 1 … * Mandatory
prsb03-dataelement-10643
Id prsb03-dataelement-10643 (2018‑11‑09 14:59:24)
Cardinality 1 … * Mandatory
Description This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft GP practice identifier 1 … 1 Mandatory
prsb03-dataelement-10001
Id prsb03-dataelement-10001 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The identifier of the registered GP practice.

Properties

FHIR Sliced into ODS and local identifier. PratitionerRole.organisation.identifier
Rationale PratitionerRole.organisation.identifier
Operationalization
Value Domain
Property
max length
6
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Legal information 0 … 1
prsb03-dataelement-520
Id prsb03-dataelement-520 (2018‑10‑31)
Cardinality 0 … 1
Description The legal information relating to the person.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Consent for treatment record 0 … 1
prsb03-dataelement-10420
Id prsb03-dataelement-10420 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's consent for treatment.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-13457
Id prsb03-dataelement-13457 (2020‑09‑02 12:31:32)
Cardinality 0 … 1
Description The date the consent was taken
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Location 0 … 1
prsb03-dataelement-13459
Id prsb03-dataelement-13459 (2020‑09‑02 12:33:42)
Cardinality 0 … 1
Description The location of where the consent was taken.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13460
Id prsb03-dataelement-13460 (2020‑09‑02 12:34:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13461
Id prsb03-dataelement-13461 (2020‑09‑02 12:34:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Consent for treatment record 0 … 1
prsb03-dataelement-13574
Id prsb03-dataelement-13574 (2020‑09‑07 16:40:51)
Cardinality 0 … 1
Description 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.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Location of document 0 … 1
prsb03-dataelement-13777
Id prsb03-dataelement-13777 (2020‑10‑16 16:32:46)
Cardinality 0 … 1
Description The location of the consent for treatment record.
Relationship
Operationalization Free text or URL
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Performing professional 0 … 1
prsb03-dataelement-13462
Id prsb03-dataelement-13462 (2020‑09‑02 12:35:54)
Cardinality 0 … 1
Description The professional who took the consent for treatment.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13463
Id prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Role 0 … 1
prsb03-dataelement-13464
Id prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11736 (2019‑05‑31 13:23:55)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Rationale Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobroletype
Value Domain
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Grade 0 … 1
prsb03-dataelement-13465
Id prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Speciality 0 … 1
prsb03-dataelement-13466
Id prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11738 (2019‑05‑31 13:23:55)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-13467
Id prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11739 (2019‑05‑31 13:23:55)
Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary : - Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 2 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-13468
Id prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
Description The name of the organisation the professional works for.
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Contact details 0 … 1
prsb03-dataelement-13469
Id prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11741 (2019‑05‑31 13:23:55)
Description Contact details of the professional
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary - UK phone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 2 times
 
folder draft Person completing record 0 … 1
prsb03-dataelement-13470
Id prsb03-dataelement-13470 (2020‑09‑02 12:40:15)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13471
Id prsb03-dataelement-13471 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-13472
Id prsb03-dataelement-13472 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
Description The organisational role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Relationship
Rationale Composition.author.Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobrole
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-13473
Id prsb03-dataelement-13473 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-13474
Id prsb03-dataelement-13474 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Relationship
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-13475
Id prsb03-dataelement-13475 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-13476
Id prsb03-dataelement-13476 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

Properties

FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
Relationship
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary :- Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-13477
Id prsb03-dataelement-13477 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
Description The date and time the record was completed.
Relationship
Rationale Composition.date
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-13478
Id prsb03-dataelement-13478 (2020‑09‑02 12:41:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
Description Contact details of the person completing the record.

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Consent for information sharing 0 … 1
prsb03-dataelement-10421
Id prsb03-dataelement-10421 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's consent for information sharing
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-11713
Id prsb03-dataelement-11713 (2019‑05‑31 13:15:18)
Cardinality 0 … 1
Description The date when the consent was given
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Location 0 … 1
prsb03-dataelement-11714
Id prsb03-dataelement-11714 (2019‑05‑31 13:15:54)
Cardinality 0 … 1
Description The location where the consent was taken.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13451
Id prsb03-dataelement-13451 (2020‑08‑27 16:51:03)
Cardinality 0 … 1
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13452
Id prsb03-dataelement-13452 (2020‑08‑27 16:52:16)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Consent for information sharing 0 … 1
prsb03-dataelement-13575
Id prsb03-dataelement-13575 (2020‑09‑07 16:47:31)
Cardinality 0 … 1
Description This is a record of consent for information sharing under the common law duty of confidentiality. Where consent has not been obtained or sought, the reason why should be provided. Include best interests decision where person lacks capacity. This is a placeholder until the national guidance is published.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Reason for consent not given 0 … 1
prsb03-dataelement-13778
Id prsb03-dataelement-13778 (2020‑10‑16 16:34:53)
Cardinality 0 … 1
Description Reason not given for consent
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Performing professional 0 … 1
prsb03-dataelement-11715
Id prsb03-dataelement-11715 (2019‑05‑31 13:16:35)
Cardinality 0 … 1
Description The professional who took the consent for information sharing
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-11716
Id prsb03-dataelement-11716 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-11717
Id prsb03-dataelement-11717 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Rationale Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobroletype
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-11718
Id prsb03-dataelement-11718 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Speciality 0 … 1
prsb03-dataelement-11719
Id prsb03-dataelement-11719 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-11720
Id prsb03-dataelement-11720 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary : - Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-11721
Id prsb03-dataelement-11721 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-11722
Id prsb03-dataelement-11722 (2019‑05‑31 13:17:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
Description Contact details of the professional
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary - UK phone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Person completing record 0 … 1
prsb03-dataelement-11723
Id prsb03-dataelement-11723 (2019‑05‑31 13:17:29)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-11724
Id prsb03-dataelement-11724 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-11725
Id prsb03-dataelement-11725 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
Description The organisational role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Relationship
Rationale Composition.author.Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobrole
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-11726
Id prsb03-dataelement-11726 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-11727
Id prsb03-dataelement-11727 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Relationship
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-11728
Id prsb03-dataelement-11728 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-11729
Id prsb03-dataelement-11729 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

Properties

FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
Relationship
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary :- Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-11730
Id prsb03-dataelement-11730 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
Description The date and time the record was completed.
Relationship
Rationale Composition.date
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-11731
Id prsb03-dataelement-11731 (2019‑05‑31 13:17:58)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
Description Contact details of the person completing the record.

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Consent relating to child 0 … 1
prsb03-dataelement-10422
Id prsb03-dataelement-10422 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's consent relating to child
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-11732
Id prsb03-dataelement-11732 (2019‑05‑31 13:21:58)
Cardinality 0 … 1
Description The date when the person with responsibility for the child was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Location 0 … 1
prsb03-dataelement-11733
Id prsb03-dataelement-11733 (2019‑05‑31 13:22:27)
Cardinality 0 … 1
Description The location where the person with responsibility for the child was identified.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13674
Id prsb03-dataelement-13674 (2020‑09‑08 23:44:15)
Cardinality 0 … 1
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13675
Id prsb03-dataelement-13675 (2020‑09‑08 23:45:35)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
Description Free text field to be used if no coded text available
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Consent relating to child 0 … 1
prsb03-dataelement-13576
Id prsb03-dataelement-13576 (2020‑09‑07 16:50:40)
Cardinality 0 … 1
Description The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Performing professional 0 … 1
prsb03-dataelement-11734
Id prsb03-dataelement-11734 (2019‑05‑31 13:23:06)
Cardinality 0 … 1
Description The professional who identified the person responsible for the child.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-11735
Id prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited once
 
draft Role 0 … 1
prsb03-dataelement-11736
Id prsb03-dataelement-11736 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Rationale Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobroletype
Value Domain
target Used by 14 transactions, 0 templates, inherited once
 
draft Grade 0 … 1
prsb03-dataelement-11737
Id prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited once
 
draft Speciality 0 … 1
prsb03-dataelement-11738
Id prsb03-dataelement-11738 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited once
 
draft Professional identifier 0 … 1
prsb03-dataelement-11739
Id prsb03-dataelement-11739 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary : - Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited once
 
folder draft Organisation 0 … 1
prsb03-dataelement-11740
Id prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
target Used by 14 transactions, 0 templates, inherited once
 
draft Contact details 0 … 1
prsb03-dataelement-11741
Id prsb03-dataelement-11741 (2019‑05‑31 13:23:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
Description Contact details of the professional
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary - UK phone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited once
 
folder draft Person completing record 0 … 1
prsb03-dataelement-11742
Id prsb03-dataelement-11742 (2019‑05‑31 13:23:59)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-11743
Id prsb03-dataelement-11743 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-11744
Id prsb03-dataelement-11744 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
Description The organisational role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Relationship
Rationale Composition.author.Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobrole
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-11745
Id prsb03-dataelement-11745 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-11746
Id prsb03-dataelement-11746 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Relationship
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-11747
Id prsb03-dataelement-11747 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-11748
Id prsb03-dataelement-11748 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

Properties

FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
Relationship
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary :- Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-11749
Id prsb03-dataelement-11749 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
Description The date and time the record was completed.
Relationship
Rationale Composition.date
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-11750
Id prsb03-dataelement-11750 (2019‑05‑31 13:24:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
Description Contact details of the person completing the record.

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Safeguarding 0 … 1
prsb03-dataelement-271
Id prsb03-dataelement-271 (2018‑10‑31)
Cardinality 0 … 1
Description The safeguarding details of the person.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Safeguarding concerns 0 … *
prsb03-dataelement-10821
Id prsb03-dataelement-10821 (2019‑03‑21 12:14:49)
Cardinality 0 … *
Description Details of safeguarding concerns
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Safeguarding indicator 0 … 1
prsb03-dataelement-13428
Id prsb03-dataelement-13428 (2020‑08‑12 15:01:11) 0.1
Cardinality 0 … 1
Description Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.
Operationalization Flag: No =N: Yes = Y
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Safeguarding concerns 0 … 1
prsb03-dataelement-10171
Id prsb03-dataelement-10171 (2018‑10‑31)
Cardinality 0 … 1
Description Identified safeguarding concerns.

Properties

FHIR Composition.text
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13756
Id prsb03-dataelement-13756 (2020‑09‑29 12:22:26)
Cardinality 0 … 1
Description The coded value for safeguarding concerns
Operationalization SNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13757
Id prsb03-dataelement-13757 (2020‑09‑29 12:23:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Comment 0 … 1
prsb03-dataelement-10175
Id prsb03-dataelement-10175 (2018‑10‑31)
Cardinality 0 … 1
Description Further details on safeguarding concerns.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Referral details 0 … 1
prsb03-dataelement-105
Id prsb03-dataelement-105 (2018‑10‑31)
Cardinality 0 … 1
Description The details of the referral.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Referral details record entry 0 … *
prsb03-dataelement-10917
Id prsb03-dataelement-10917 (2019‑04‑09 15:59:55)
Cardinality 0 … *
Description This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Reason for referral 0 … 1
prsb03-dataelement-10011
Id prsb03-dataelement-10011 (2018‑10‑31)
Cardinality 0 … 1
Description The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), or carer's concerns.
Operationalization Free text
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13455
Id prsb03-dataelement-13455 (2020‑08‑27 18:17:32)
Cardinality 0 … 1
Description The coded value for reason for referral
Operationalization SNOMED CT :- ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13456
Id prsb03-dataelement-13456 (2020‑08‑27 18:18:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Expectation of referral 0 … *
prsb03-dataelement-10699
Id prsb03-dataelement-10699 (2018‑12‑04 15:19:46)
Cardinality 0 … *
Description A clear statement of the expectations of the person or professional making the referral in regards to the management of the patient e.g. advice only, diagnosis, treatment, etc. To include any specific patient expectation.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Clinical urgency of referral 0 … 1
prsb03-dataelement-10010
Id prsb03-dataelement-10010 (2018‑10‑31)
Cardinality 0 … 1
Description The details of the clinical urgency of referral
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Reason for urgency of referral 0 … 1
prsb03-dataelement-10976
Id prsb03-dataelement-10976 (2019‑05‑22 17:54:38)
Cardinality 0 … 1
Description The reason for urgency of referral if not routine.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited once
 
folder draft Referral to 0 … 1
prsb03-dataelement-10008
Id prsb03-dataelement-10008 (2018‑10‑31)
Cardinality 0 … 1
Description Details of where the referral is to be sent.

If not an individual, this could be a service, e.g. GP surgery, department, specialty, subspecialty, educational institution, mental health etc.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10977
Id prsb03-dataelement-10977 (2019‑05‑22 17:56:22)
Cardinality 0 … 1
Description Name of person the referral is to be sent to.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10978
Id prsb03-dataelement-10978 (2019‑05‑22 17:56:39)
Cardinality 0 … 1
Description Role of person where the referral is to be sent to.
Operationalization FHIR value set : - sdsjobrole
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-10979
Id prsb03-dataelement-10979 (2019‑05‑22 17:56:51)
Cardinality 0 … 1
Description The grade of the person where the referral is sent to.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Team 0 … 1
prsb03-dataelement-10982
Id prsb03-dataelement-10982 (2019‑05‑22 17:59:49)
Cardinality 0 … 1
Description The team or department of the person where the referral is being sent to
Operationalization Free text.
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-10983
Id prsb03-dataelement-10983 (2019‑05‑22 18:00:28)
Cardinality 0 … 1
Description The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Service 0 … 1
prsb03-dataelement-12412
Id prsb03-dataelement-12412 (2019‑06‑05 18:20:52)
Cardinality 0 … 1
Description The service of where the referral is sent to.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13509
Id prsb03-dataelement-13509 (2020‑09‑03 17:50:24)
Cardinality 0 … 1
Description The coded value for service
Operationalization SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13510
Id prsb03-dataelement-13510 (2020‑09‑03 17:51:06)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-10980
Id prsb03-dataelement-10980 (2019‑05‑22 17:57:10)
Cardinality 0 … 1
Description The organisation of where the referral is to be sent.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13511
Id prsb03-dataelement-13511 (2020‑09‑03 17:54:29)
Cardinality 0 … 1
Description The coded value for organisation
Operationalization NHS data dictionary :- Organisation data service
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13512
Id prsb03-dataelement-13512 (2020‑09‑03 17:55:57)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-10981
Id prsb03-dataelement-10981 (2019‑05‑22 17:57:26)
Cardinality 0 … 1
Description The contact details of where the referral is to be sent.
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Contacts with professionals 1 … 1 Mandatory
prsb03-dataelement-169
Id prsb03-dataelement-169 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The details of the person’s contact with a professional.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Contacts with professionals record entry 1 … * Mandatory
prsb03-dataelement-10718
Id prsb03-dataelement-10718 (2019‑02‑08 13:49:22)
Cardinality 1 … * Mandatory
Description This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date of contact 1 … 1 Mandatory
prsb03-dataelement-10069
Id prsb03-dataelement-10069 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Date and time of the contact.

Properties

FHIR Encounter.period
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Location of contact 0 … 1
prsb03-dataelement-10075
Id prsb03-dataelement-10075 (2018‑10‑31)
Cardinality 0 … 1
Description The location where the contact took place.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13513
Id prsb03-dataelement-13513 (2020‑09‑03 18:01:56)
Cardinality 0 … 1
Description The coded value for location
Operationalization NHS data dictionary : - Organisation service code
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13514
Id prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited once
 
draft Reason for service 0 … 1
prsb03-dataelement-13751
Id prsb03-dataelement-13751 (2020‑09‑28 11:15:42)
Cardinality 0 … 1
Description The reason why the person has been offered the service
Operationalization Free text
Value Domain
Property
max length
150
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Consultation method 0 … 1
prsb03-dataelement-10071
Id prsb03-dataelement-10071 (2018‑10‑31)
Cardinality 0 … 1
Description Consultation method used e.g. face to face, telephone

Properties

FHIR Handled as text in the transfer of care
Operationalization NHS data dictionary - Consultation medium
Value Domain
Property
max length
2
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Service 0 … 1
prsb03-dataelement-10074
Id prsb03-dataelement-10074 (2018‑10‑31)
Cardinality 0 … 1
Description The service that was provided.

Properties

FHIR Encounter.Appointment.servicetype
Operationalization SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|



Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Person accompanying patient 0 … *
prsb03-dataelement-10079
Id prsb03-dataelement-10079 (2018‑10‑31)
Cardinality 0 … *
Description Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).

Properties

FHIR Encounter.participant
Operationalization NHS data dictionary : - Person full name
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation name 1 … 1 Mandatory
prsb03-dataelement-10706
Id prsb03-dataelement-10706 (2018‑12‑04 15:30:13)
Cardinality 1 … 1 Mandatory
Description The name, including the identifier, of the organisation providing the service
Operationalization NHS data dictionary : - Organisation name
Value Domain
Property
max length
255
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation address 0 … 1
prsb03-dataelement-10713
Id prsb03-dataelement-10713 (2018‑12‑04 15:37:02)
Cardinality 0 … 1
Description The name of the organisation, including the identifier.
Operationalization NHS data dictionary : - Organisation address
Value Domain
Property
max length
175
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation contact details 0 … *
prsb03-dataelement-10707
Id prsb03-dataelement-10707 (2018‑12‑04 15:31:05)
Cardinality 0 … *
Description The contact details of the organisation. For example a phone number, NHSmail address etc. Contact details are used to resolve queries about the record entry.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Reason for non-provision of service 0 … 1
prsb03-dataelement-10708
Id prsb03-dataelement-10708 (2018‑12‑04 15:31:26)
Cardinality 0 … 1
Description The reason why the patient was not provided with the service e.g. declined, did not attend etc.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Clinician name 1 … 1 Mandatory
prsb03-dataelement-10709
Id prsb03-dataelement-10709 (2018‑12‑04 15:31:49)
Cardinality 1 … 1 Mandatory
Description The name of the person providing the service.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10710
Id prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Cardinality 0 … 1
Description The role of the person providing the service.
Operationalization FHIR values set : - sdsjobrole
Value Domain
target Used by 13 transactions, 0 templates, inherited once
 
draft Chaperone 0 … *
prsb03-dataelement-10712
Id prsb03-dataelement-10712 (2018‑12‑04 15:33:12)
Cardinality 0 … *
Description The name of any chaperone(s).
Operationalization Free text
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Person collecting the medicine 0 … 1
prsb03-dataelement-13783
Id prsb03-dataelement-13783 (2020‑10‑22 15:43:21)
Cardinality 0 … 1
Description
Name, relationship, role (if formal role), contact details
Operationalization Free text
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-10711
Id prsb03-dataelement-10711 (2018‑12‑04 15:32:25)
Cardinality 0 … 1
Description Professional identifier of the person providing the service.
Operationalization NHS data dictionary : - professional identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Appliances 0 … 1
prsb03-dataelement-13762
Id prsb03-dataelement-13762 (2020‑09‑30 12:33:21)
Cardinality 0 … 1
Description Details of appliances
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Appliance records entry 0 … *
prsb03-dataelement-13763
Id prsb03-dataelement-13763 (2020‑09‑30 12:41:04)
Cardinality 0 … *
Description This is the appliance records entry.
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Appliance name 1 … 1 Mandatory
prsb03-dataelement-13764
Id prsb03-dataelement-13764 (2020‑09‑30 12:44:26)
Cardinality 1 … 1 Mandatory
Description May be generic name or brand name (as appropriate).
Operationalization As per dm+d (AMP)
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Product order number 0 … 1
prsb03-dataelement-13765
Id prsb03-dataelement-13765 (2020‑09‑30 12:59:10)
Cardinality 0 … 1
Description The product order number for the appliance.
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Manufacturer 0 … 1
prsb03-dataelement-13766
Id prsb03-dataelement-13766 (2020‑09‑30 13:01:00)
Cardinality 0 … 1
Description Name of appliance manufacturer
Operationalization Free text
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Batch number 0 … 1
prsb03-dataelement-13767
Id prsb03-dataelement-13767 (2020‑09‑30 13:03:53)
Cardinality 0 … 1
Description The batch number of the appliance.
Operationalization Free text
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Size 0 … 1
prsb03-dataelement-13768
Id prsb03-dataelement-13768 (2020‑09‑30 13:07:19)
Cardinality 0 … 1
Description The size of the appliance.
Operationalization UCUM
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Weight 0 … 1
prsb03-dataelement-13769
Id prsb03-dataelement-13769 (2020‑09‑30 13:09:16)
Cardinality 0 … 1
Description The weight of the appliance.
Operationalization UCUM
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Colour 0 … 1
prsb03-dataelement-13770
Id prsb03-dataelement-13770 (2020‑09‑30 13:11:53)
Cardinality 0 … 1
Description The colour of the appliance
Operationalization Free text
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Route 0 … 1
prsb03-dataelement-13771
Id prsb03-dataelement-13771 (2020‑09‑30 13:14:22)
Cardinality 0 … 1
Description Appliance administration description (IM, IV, etc.): may include method of administration, (e.g., by infusion).
Operationalization SNOMED CT: -  ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Coded Value 0 … 1
prsb03-dataelement-14268
Id prsb03-dataelement-14268 (2021‑03‑31 12:16:55)
Cardinality 0 … 1
Description Coded value for appliance route
Operationalization

SNOMED CT: -  ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14267
Id prsb03-dataelement-14267 (2021‑03‑31 12:16:40)
Cardinality 0 … 1
Description Free text field to be used if no coded text available
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
cancelled Coded value 0 … 1
prsb03-dataelement-13795
Id prsb03-dataelement-13795 (2020‑11‑04 12:10:01) 1
Cardinality 0 … 1
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
cancelled Free text 0 … 1
prsb03-dataelement-13794
Id prsb03-dataelement-13794 (2020‑11‑04 12:09:49) 1
Cardinality 0 … 1
Description Free text field to be used if no code available
Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Site 0 … 1
prsb03-dataelement-13772
Id prsb03-dataelement-13772 (2020‑09‑30 13:19:42) 1
Cardinality 0 … 1
Description The anatomical site at which the appliance is to be used, including laterality.
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Coded Value 0 … 1
prsb03-dataelement-14269
Id prsb03-dataelement-14269 (2021‑03‑31 12:46:03)
Cardinality 0 … 1
Description Coded value for site
Operationalization

SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14270
Id prsb03-dataelement-14270 (2021‑03‑31 12:48:09)
Cardinality 0 … 1
Description Free text where no coded value is available
Operationalization Free text
Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
cancelled Coded value 0 … 1
prsb03-dataelement-13797
Id prsb03-dataelement-13797 (2020‑11‑04 12:33:31) 1
Cardinality 0 … 1
Description Coded value for site
Operationalization
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
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
cancelled Free text 0 … 1
prsb03-dataelement-13796
Id prsb03-dataelement-13796 (2020‑11‑04 12:33:18) 1
Cardinality 0 … 1
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Quantity 0 … 1
prsb03-dataelement-13773
Id prsb03-dataelement-13773 (2020‑09‑30 14:00:10)
Cardinality 0 … 1
Description The quantity of the appliance (including the units).
Operationalization UCUM
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Indication 0 … 1
prsb03-dataelement-13774
Id prsb03-dataelement-13774 (2020‑09‑30 14:04:52)
Cardinality 0 … 1
Description Reason for appliance being prescribed, where known.
Operationalization Free text
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Matters identified during the discussion 1 … * Mandatory
prsb03-dataelement-13775
Id prsb03-dataelement-13775 (2020‑09‑30 14:06:42)
Cardinality 1 … * Mandatory
Description 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.
Operationalization Free text
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Date/time 1 … 1 Mandatory
prsb03-dataelement-13802
Id prsb03-dataelement-13802 (2020‑11‑12 20:45:55) 1
Cardinality 1 … 1 Mandatory
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft History 0 … 1
prsb03-dataelement-226
Id prsb03-dataelement-226 (2018‑10‑31)
Cardinality 0 … 1
Description History
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Relevant past medical, surgical and mental health history 0 … 1
prsb03-dataelement-10130
Id prsb03-dataelement-10130 (2018‑10‑31)
Cardinality 0 … 1
Description The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anesthesia issues, etc. (will include dental and obstetric history)

A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form or Information relating to past medical, surgical and mental health history may be provided by the referral document or during the consultation.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13787
Id prsb03-dataelement-13787 (2020‑10‑22 17:51:01)
Cardinality 0 … 1
notice There is an open issue with this item:
Description The coded value relevant past medical, surgical and mental health history
Operationalization SNOMED CT : -  ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13788
Id prsb03-dataelement-13788 (2020‑10‑22 17:53:28)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13450 (2020‑08‑27 16:43:57)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Clinical Summary 0 … 1
prsb03-dataelement-247
Id prsb03-dataelement-247 (2018‑10‑31)
Cardinality 0 … 1
Description Clinical Summary
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-13308
Id prsb03-dataelement-13308 (2020‑08‑06 13:53:22)
Cardinality 0 … 1
Description The date the clinical summary was written.
Operationalization Date
Value Domain
Property
Timestamp precision
day, month and year
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Location 0 … 1
prsb03-dataelement-13309
Id prsb03-dataelement-13309 (2020‑08‑06 13:56:22)
Cardinality 0 … 1
Description The location the clinical summary was written.
Relationship
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13310
Id prsb03-dataelement-13310 (2020‑08‑06 13:56:53)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13311
Id prsb03-dataelement-13311 (2020‑08‑06 13:56:53)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Clinical summary 0 … 1
prsb03-dataelement-10147
Id prsb03-dataelement-10147 (2018‑10‑31)
Cardinality 0 … 1
Description 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’.
Operationalization Free text
Value Domain
target Used by 5 transactions, 0 templates, inherited once
 
folder draft Performing professional 0 … 1
prsb03-dataelement-13312
Id prsb03-dataelement-13312 (2020‑08‑06 13:57:51)
Cardinality 0 … 1
Description The professional who wrote the clinical summary
Relationship
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13313
Id prsb03-dataelement-13313 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11505 (2019‑05‑30 14:35:29)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-13314
Id prsb03-dataelement-13314 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11506 (2019‑05‑30 14:35:29)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Rationale Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobroletype
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-13315
Id prsb03-dataelement-13315 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11507 (2019‑05‑30 14:35:29)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Speciality 0 … 1
prsb03-dataelement-13316
Id prsb03-dataelement-13316 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11508 (2019‑05‑30 14:35:29)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-13317
Id prsb03-dataelement-13317 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11509 (2019‑05‑30 14:35:29)
Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary : - Professional registration identifier
Value Domain
Property
max length
32
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-13318
Id prsb03-dataelement-13318 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11510 (2019‑05‑30 14:35:29)
Description The name of the organisation the professional works for.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-13319
Id prsb03-dataelement-13319 (2020‑08‑06 13:58:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11511 (2019‑05‑30 14:35:29)
Description Contact details of the professional
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary - UK phone number
Value Domain
Property
max length
35
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Person completing record 0 … 1
prsb03-dataelement-13320
Id prsb03-dataelement-13320 (2020‑08‑06 13:59:10)
Cardinality 0 … 1
Description A record of the details of the person that entered the clinical summary and the date on which is was entered.
Relationship
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13321
Id prsb03-dataelement-13321 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13036 (2020‑04‑28 19:33:40)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-13322
Id prsb03-dataelement-13322 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
Description The organisational role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Relationship
Rationale Composition.author.Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobrole
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-13323
Id prsb03-dataelement-13323 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13038 (2020‑04‑28 19:33:40)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-13324
Id prsb03-dataelement-13324 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13039 (2020‑04‑28 19:33:40)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Relationship
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-13325
Id prsb03-dataelement-13325 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
Description The organisation the person completing the record works for.
Relationship
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-13326
Id prsb03-dataelement-13326 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13041 (2020‑04‑28 19:33:40)
Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

Properties

FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
Relationship
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary :- Professional registration identifier
Value Domain
Property
max length
32
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-13327
Id prsb03-dataelement-13327 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13042 (2020‑04‑28 19:33:40)
Description The date and time the record was completed.
Relationship
Rationale Composition.date
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-13328
Id prsb03-dataelement-13328 (2020‑08‑06 13:59:45)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
Description Contact details of the person completing the record.

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

Organisation.telcom
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Formulation 0 … 1
prsb03-dataelement-10148
Id prsb03-dataelement-10148 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 3 times
 
draft Treatments and interventions and changes made to treatments. 0 … 1
prsb03-dataelement-10149
Id prsb03-dataelement-10149 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
Operationalization Free text
Value Domain
target Used by 5 transactions, 0 templates, inherited once
 
draft Clinical narrative 0 … 1
prsb03-dataelement-10150
Id prsb03-dataelement-10150 (2018‑10‑31)
Cardinality 0 … 1
Description A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Signpost details 0 … 1
prsb03-dataelement-13973
Id prsb03-dataelement-13973 (2021‑02‑11 12:24:29)
Cardinality 0 … 1
Description Details of signpost
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Signpost details record entry 0 … *
prsb03-dataelement-13974
Id prsb03-dataelement-13974 (2021‑02‑11 12:26:44)
Cardinality 0 … *
Description 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.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-13975
Id prsb03-dataelement-13975 (2021‑02‑11 12:28:32)
Cardinality 0 … 1
Description Date of signpost
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Signpost to 0 … 1
prsb03-dataelement-13976
Id prsb03-dataelement-13976 (2021‑02‑11 12:29:57)
Cardinality 0 … 1
Description Details of where the signpost is to.


If not an individual, this could be a service
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13977
Id prsb03-dataelement-13977 (2021‑02‑11 12:32:55)
Cardinality 0 … 1
Description Name of person signposted to
Operationalization Free Text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-13978
Id prsb03-dataelement-13978 (2021‑02‑11 12:34:34)
Cardinality 0 … 1
Description Role of person been signposted to.
Operationalization Free Text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-13979
Id prsb03-dataelement-13979 (2021‑02‑11 12:39:31)
Cardinality 0 … 1
Description The grade of the person been signposted to.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Team 0 … 1
prsb03-dataelement-13980
Id prsb03-dataelement-13980 (2021‑02‑11 12:40:50)
Cardinality 0 … 1
Description The team or department of the person been signposted to.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-13981
Id prsb03-dataelement-13981 (2021‑02‑11 12:41:59)
Cardinality 0 … 1
Description The specialty of where been signposted e.g. physiotherapy, oncology, mental health etc
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Service 0 … 1
prsb03-dataelement-13982
Id prsb03-dataelement-13982 (2021‑02‑11 12:43:49)
Cardinality 0 … 1
Description The service of where been signposted to.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13983
Id prsb03-dataelement-13983 (2021‑02‑11 12:45:12)
Cardinality 0 … 1
Description The coded value for service
Operationalization SNOMED CT : - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13984
Id prsb03-dataelement-13984 (2021‑02‑11 12:46:37)
Cardinality 0 … 1
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited once
 
folder draft Organisation 0 … 1
prsb03-dataelement-13985
Id prsb03-dataelement-13985 (2021‑02‑11 12:48:00)
Cardinality 0 … 1
Description Name of organisation been signposted to.
Operationalization

Free text
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-13987
Id prsb03-dataelement-13987 (2021‑02‑11 13:06:04)
Cardinality 0 … 1
Description The contact details of where been signposted to
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Reason for signpost 0 … 1
prsb03-dataelement-13988
Id prsb03-dataelement-13988 (2021‑02‑11 16:06:08)
Cardinality 0 … 1
Description Reason for signposting
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13990
Id prsb03-dataelement-13990 (2021‑02‑11 16:13:18)
Cardinality 0 … 1
Description Free text
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Clinical urgency for signpost 0 … 1
prsb03-dataelement-13991
Id prsb03-dataelement-13991 (2021‑02‑11 16:24:10)
Cardinality 0 … 1
Description The details of the clinical urgency of signpost
Operationalization

Free text
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions 0 … 1
prsb03-dataelement-282
Id prsb03-dataelement-282 (2018‑10‑31)
Cardinality 0 … 1
Description Allergies and adverse reactions
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions record entry 0 … *
prsb03-dataelement-10657
Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
Cardinality 0 … *
Description This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.

Each record entry is made up of a number of elements or data items.
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Type of reaction 0 … 1
prsb03-dataelement-10186
Id prsb03-dataelement-10186 (2018‑10‑31)
Cardinality 0 … 1
Description The type of reaction experienced by the person (allergic, adverse, intolerance)

Properties

FHIR AllergyIntolerance.type
Rationale AllergyIntolerance.type
Operationalization FHIR value set :- Allergy, Intolerance
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Causative agent 1 … 1 Mandatory
prsb03-dataelement-10182
Id prsb03-dataelement-10182 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”

Properties

FHIR AllergyIntolerance.code
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13441
Id prsb03-dataelement-13441 (2020‑08‑19 14:12:48)
Cardinality 0 … 1
Description The coded value for causative agent
Rationale Allergyintolerance.code
Operationalization SNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product| OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy| OR 196471000000108 |Transfer-degraded non-drug allergy)

Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13442
Id prsb03-dataelement-13442 (2020‑08‑19 15:33:40)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Reaction details cluster 0 … *
prsb03-dataelement-10658
Id prsb03-dataelement-10658 (2018‑11‑13 12:29:25)
Cardinality 0 … *
Description Details of the reaction.
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10190
Id prsb03-dataelement-10190 (2018‑10‑31)
Cardinality 0 … 1
Description The date that the reaction was identified.

Properties

FHIR dateAsserted
Rationale Allergyintolerance.asserteddate
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Description of reaction 0 … 1
prsb03-dataelement-10183
Id prsb03-dataelement-10183 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.

Properties

FHIR AllergyIntolerance.reaction.manifestation AllergyIntolerance.reaction.description
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13556
Id prsb03-dataelement-13556 (2020‑09‑04 16:48:37)
Cardinality 0 … 1
Description The coded value for description of reaction.
Rationale AllergyIntolerance.reaction.manifestation
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13557
Id prsb03-dataelement-13557 (2020‑09‑04 16:51:03)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Severity 0 … 1
prsb03-dataelement-10184
Id prsb03-dataelement-10184 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the severity of the reaction.

Properties

FHIR AllergyIntolerance.reaction.severity
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13558
Id prsb03-dataelement-13558 (2020‑09‑04 17:43:42)
Cardinality 0 … 1
Description The coded value for severity
Rationale AllergyIntolerance.reaction.severity
Operationalization FHIR value set : - Severity
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13559
Id prsb03-dataelement-13559 (2020‑09‑04 17:48:53)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Certainty 0 … 1
prsb03-dataelement-10185
Id prsb03-dataelement-10185 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the certainty that the stated causative agent caused the allergic or adverse reaction.

Properties

FHIR AllergyIntolerance.verificationStatus
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13560
Id prsb03-dataelement-13560 (2020‑09‑04 17:52:26)
Cardinality 0 … 1
Description The coded value for certainty.
Rationale AllergyIntolerance.verificationStatus
Operationalization FHIR value set : - Certainty
Value Domain
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13561
Id prsb03-dataelement-13561 (2020‑09‑04 17:55:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Comment 0 … 1
prsb03-dataelement-10189
Id prsb03-dataelement-10189 (2018‑10‑31)
Cardinality 0 … 1
Description Any additional comment or clarification about the adverse reaction.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Evidence 0 … 1
prsb03-dataelement-10187
Id prsb03-dataelement-10187 (2018‑10‑31)
Cardinality 0 … 1
Description Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests

Properties

FHIR AllergyIntolerance.extension.evidence
Rationale AllergyIntolerance.extension.evidence
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Date first experienced 0 … 1
prsb03-dataelement-10188
Id prsb03-dataelement-10188 (2018‑10‑31)
Cardinality 0 … 1
Description When the reaction was first experienced 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)

Properties

FHIR AllergyIntolerance.onset[x]
Rationale AllergyIntolerance.onset
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least year
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Allergy end date 0 … 1
prsb03-dataelement-14253
Id prsb03-dataelement-14253 (2021‑03‑04 13:29:34)
Cardinality 0 … 1
Description The date the allergy was diagnosed as ended
Operationalization Date and time 
Value Domain
Property
Timestamp precision
at least year
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Medications and medical devices 0 … 1
prsb03-dataelement-636
Id prsb03-dataelement-636 (2018‑10‑31)
Cardinality 0 … 1
Description Medications and medical devices
target Used by 9 transactions, 0 templates, inherited once
 
folder draft Medication item entry 0 … *
prsb03-dataelement-10663
Id prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
Cardinality 0 … *
Description All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
target Used by 9 transactions, 0 templates, inherited 2 times
 
folder draft Medication item cluster 0 … *
prsb03-dataelement-10664
Id prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
Cardinality 0 … *
Description Medication item cluster
target Used by 9 transactions, 0 templates, inherited 2 times
 
draft Date 0 … 1
prsb03-dataelement-10843
Id prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
Cardinality 0 … 1
Description The date on which the medication or medical device was prescribed.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 9 transactions, 0 templates, inherited 3 times
 
folder draft Medication name 1 … 1 Mandatory
prsb03-dataelement-10536
Id prsb03-dataelement-10536 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description May be generic name or brand name.

Properties

FHIR MedicationStatement.medication[x].medicationCodableConcept MedicationStatement.medication[x].medicationReference (see Medication) (Systems should send as much details as they can. dm+d code can be sent as a simple code/description pair using CodeableConcept, or as a detailed medication record)
target Used by 9 transactions, 0 templates, inherited 5 times
 
draft Coded value 0 … 1
prsb03-dataelement-13622
Id prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
Cardinality 0 … 1
Description The coded value for medication name
Operationalization SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set (foundation metadata concept)| OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set (foundation metadata concept)|
Value Domain
target Used by 9 transactions, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13623
Id prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited once
 
folder draft Form 0 … 1
prsb03-dataelement-10537
Id prsb03-dataelement-10537 (2018‑10‑31)
Cardinality 0 … 1
Description The form of the medication e.g. capsule, drops, tablet, lotion etc.

Properties

FHIR MedicationStatement.medication[x].medicationReference.medication.form (i.e. form is on the medication profile). Where VTM has form specified (coded) it goes here AMP & VMP don't need seperate Form (it is optional to populate) For VTM the form could be in MedicationStatement.dosage.text (as it would be part of a dosage string) i.e. not a seperately specified code
target Used by 9 transactions, 0 templates, inherited 4 times
 
draft Coded value 0 … 1
prsb03-dataelement-13624
Id prsb03-dataelement-13624 (2020‑09‑08 19:32:29)
Cardinality 0 … 1
Description The coded value for form.
Operationalization SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13625
Id prsb03-dataelement-13625 (2020‑09‑08 19:33:34)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited 0 times
 
folder draft Quantity supplied 1 … 1 Mandatory
prsb03-dataelement-10539
Id prsb03-dataelement-10539 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unit

Properties

FHIR MedicationStatement.quantityDispensed (Amount of medication to supply per dispense) quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
Operationalization Free text
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Value 0 … 1
prsb03-dataelement-14271
Id prsb03-dataelement-14271 (2021‑03‑31 16:58:30)
Cardinality 0 … 1
Description The value of the quantity supplied
Operationalization Enumerated value
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
draft Unit of measure 0 … 1
prsb03-dataelement-14272
Id prsb03-dataelement-14272 (2021‑03‑31 16:59:56)
Cardinality 0 … 1
Description Unit of measure of quantity supplied
Relationship
Operationalization UCUM code
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
folder draft Route 0 … *
prsb03-dataelement-10538
Id prsb03-dataelement-10538 (2018‑10‑31)
Cardinality 0 … *
Description The route by which the medication is administered e.g. oral, IM, IV

Properties

FHIR MedicationStatement.dosage.route
target Used by 9 transactions, 0 templates, inherited 5 times
 
draft Coded value 0 … 1
prsb03-dataelement-13655
Id prsb03-dataelement-13655 (2020‑09‑08 20:30:38)
Cardinality 0 … 1
Description The coded value for route
Operationalization SNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
Value Domain
target Used by 9 transactions, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13656
Id prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited once
 
folder draft Site 0 … 1
prsb03-dataelement-10540
Id prsb03-dataelement-10540 (2018‑10‑31)
Cardinality 0 … 1
Description The anatomical site at which the medication is to be administered.

Properties

FHIR MedicationStatement.dosage.site
target Used by 9 transactions, 0 templates, inherited 4 times
 
draft Coded value 0 … 1
prsb03-dataelement-13657
Id prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
Cardinality 0 … 1
Description The coded value for site
Operationalization

SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
Value Domain
target Used by 9 transactions, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-13658
Id prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13229 (2020‑07‑15 19:30:33)
Description Amount of vaccine administered.
Relationship
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited 2 times
 
draft Supply type 0 … 1
prsb03-dataelement-13754
Id prsb03-dataelement-13754 (2020‑09‑29 11:32:50)
Cardinality 0 … 1
Description A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
folder draft Batch number 0 … 1
prsb03-dataelement-13789
Id prsb03-dataelement-13789 (2020‑10‑22 18:25:26)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-10697 (2018‑12‑04 15:10:59)
Description The batch number of the product.
target Used by 9 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13790
Id prsb03-dataelement-13790 (2020‑10‑22 18:26:28)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13233 (2020‑07‑21 15:15:57)
Description The coded value for the batch number
Operationalization FMD code : - Derived from Falsified medicines directive
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13791
Id prsb03-dataelement-13791 (2020‑10‑22 18:26:28)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13234 (2020‑07‑21 15:17:14)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited 0 times
 
draft Dose directions description 0 … 1
prsb03-dataelement-10544
Id prsb03-dataelement-10544 (2018‑10‑31)
Cardinality 0 … 1
Description Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.

Properties

FHIR MedicationStatement.dosage.text
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited 4 times
 
folder draft Structured dose direction cluster 0 … 1
prsb03-dataelement-11639
Id prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
Cardinality 0 … 1
Description 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.
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Structured dose amount 0 … 1
prsb03-dataelement-10554
Id prsb03-dataelement-10554 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
Value Domain
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Structured dose timing 0 … 1
prsb03-dataelement-10555
Id prsb03-dataelement-10555 (2018‑10‑31)
Cardinality 0 … 1
Description 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.
Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
Value Domain
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Dose direction duration 0 … 1
prsb03-dataelement-10548
Id prsb03-dataelement-10548 (2018‑10‑31)
Cardinality 0 … 1
Description Recommendation of the time period for which the medication should be continued, including direction not to discontinue.

Properties

FHIR For coded information use MedicationStatement.dosage.additionalInstruction If no codes exist use MedicationStatement.dosage.additionalInstruction CodeableConcept.text Duration goes in MedicationStatement.effective[x].effectivePeriod 12/01/2018 MS.dosage.timing.bounds create another option "boundsCodeableConcept" to hold Continue Indef; Do not disconue; Stop When course complete MS.dosage.timing.bounds.duration to hold the duration For primary care always in dosage string
Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/

Value Domain
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Additional instructions 0 … *
prsb03-dataelement-10545
Id prsb03-dataelement-10545 (2018‑10‑31)
Cardinality 0 … *
Description Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.

Properties

FHIR Specific patient instruction use MedicationStatement.dosage.patientInstruction For narrative instructions (e.g. monitoring, pain, prevention) use MedicationStatement.note For dispensing instructions (EPS narrative) use MedicationRequest.note (intent "order" or "plan")
Operationalization FHIR value set : - Additional instruction
Value Domain
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Matters identified during discussion 1 … * Mandatory
prsb03-dataelement-13753
Id prsb03-dataelement-13753 (2020‑09‑29 11:01:13)
Cardinality 1 … * Mandatory
Description Matters identified during the service about the patient's experience of using the medication.
Operationalization
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
Value Domain
target Used by 9 transactions, 0 templates, inherited 0 times
 
folder draft Course details cluster 0 … 1
prsb03-dataelement-10561
Id prsb03-dataelement-10561 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the overall course of medication.
target Used by 9 transactions, 0 templates, inherited 3 times
 
draft Indication 0 … 1
prsb03-dataelement-10546
Id prsb03-dataelement-10546 (2018‑10‑31)
Cardinality 0 … 1
Description Reason for medication being prescribed, where known.

Properties

FHIR MedicationStatement.reasonCode
Operationalization Free text
Value Domain
Property
max length
150
target Used by 9 transactions, 0 templates, inherited 3 times
 
folder draft Information and advice given 0 … 1
prsb03-dataelement-315
Id prsb03-dataelement-315 (2018‑10‑31)
Cardinality 0 … 1
Description Information and advice given
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Information and advice given 0 … *
prsb03-dataelement-10215
Id prsb03-dataelement-10215 (2018‑10‑31)
Cardinality 0 … *
notice There is an open issue with this item:
Description

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.

Properties

FHIR Free text only
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Distribution list 0 … 1
prsb03-dataelement-330
Id prsb03-dataelement-330 (2018‑10‑31)
Cardinality 0 … 1
Description Distribution list
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Distribution list record entry 0 … *
prsb03-dataelement-10660
Id prsb03-dataelement-10660 (2018‑11‑13 13:21:33)
Cardinality 0 … *
Description This is a Distribution list record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10230
Id prsb03-dataelement-10230 (2018‑10‑31)
Cardinality 0 … 1
Description The name of the person the communication is to be sent to, this can be a person or professional.

Properties

FHIR Practitioner.name Patient ..... RelatedPerson.....
Operationalization Free text
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10231
Id prsb03-dataelement-10231 (2018‑10‑31)
Cardinality 0 … 1
Description If the communication is being sent to either a named individual, or to a non-named person with a specific role, then this is the role of the recipient.

Role may be entered as the communication is being created, or sourced from the hospital system. This may be a role defined in the National Workforce data set (see the NHS Data Dictionary Job Role Code).

Properties

FHIR PractitionerRole.code
Operationalization FHIR value set : - SDSjobrole
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-10232
Id prsb03-dataelement-10232 (2018‑10‑31)
Cardinality 0 … 1
Description The grade of the recipient, if known by the sending institution, otherwise omitted.

Properties

FHIR PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation name 0 … 1
prsb03-dataelement-10233
Id prsb03-dataelement-10233 (2018‑10‑31)
Cardinality 0 … 1
Description The name of the organisation the recipient is representing or the organisation named as the receiving organisation.

An identifier for the organisation will be sent alongside the name, but may not displayed on rendered document.

Properties

FHIR Organization.name Organization.identifier
Operationalization NHS data dictionary : - Organisation code
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Team 0 … 1
prsb03-dataelement-10234
Id prsb03-dataelement-10234 (2018‑10‑31)
Cardinality 0 … 1
Description Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.

Properties

FHIR Organization.name
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Relationship 0 … 1
prsb03-dataelement-13793
Id prsb03-dataelement-13793 (2020‑11‑02 15:35:45)
Cardinality 0 … 1
Description The relationship of the receiver to the person for example, carer or parent
Relationship
Operationalization FHIR value set : - Related person
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Plan and requested actions 0 … 1
prsb03-dataelement-535
Id prsb03-dataelement-535 (2018‑10‑31)
Cardinality 0 … 1
Description The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Plan and requested actions record entry 0 … *
prsb03-dataelement-10661
Id prsb03-dataelement-10661 (2018‑11‑13 13:38:58)
Cardinality 0 … *
Description This is a plan and requested actions record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Actions for professionals 0 … *
prsb03-dataelement-10436
Id prsb03-dataelement-10436 (2018‑10‑31)
Cardinality 0 … *
Description Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Actions for person or their carer 0 … *
prsb03-dataelement-10437
Id prsb03-dataelement-10437 (2018‑10‑31)
Cardinality 0 … *
Description For each action the following should be identified:outcome expectations, including person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times