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draft Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft PRSB Record structure and content (1) 2.16.840.1.113883.3.1937.777.28.1.1
Version / effective date Expiration date
2018‑10‑31
Description
PRSB Record structure and content
Name Details [‑]
cancelled test
prsb03-dataelement-10684
Id prsb03-dataelement-10684 (2018‑11‑28 12:58:48)
Value Domain
folder draft Patient demographics
prsb03-dataelement-116
Id prsb03-dataelement-116 (2018‑10‑31)
Description Patient Demographics
draft Patient name
prsb03-dataelement-10016
Id prsb03-dataelement-10016 (2018‑10‑31)
Description The full name of the person.

Properties

FHIR Patient.name
Operationalization The legal name of the patient from the Patient Demographics Service (PDS), or the name volunteered by the patient.
Value Domain
draft Patient preferred name
prsb03-dataelement-10017
Id prsb03-dataelement-10017 (2018‑10‑31)
Description The name by which a patient wishes to be addressed.

Properties

FHIR Patient.name
Operationalization The preferred name volunteered by the patient and recorded on the Patient Administration System (PAS), or a preferred name given by PDS that the patient has asked to be called by.
Value Domain
draft Date of birth
prsb03-dataelement-10018
Id prsb03-dataelement-10018 (2018‑10‑31)
Description The date of birth of the patient.

Properties

FHIR Patient.birthDate
Operationalization The date of birth of the patient taken from PDS, or the date of birth volunteered by the patient (as recorded on the PAS (Patient Administration System). The date of birth will be as precise as possible, but should at least contain a year
Value Domain
draft Gender
prsb03-dataelement-10019
Id prsb03-dataelement-10019 (2018‑10‑31)
notice There is an open issue with this item:
Description The person's stated gender.

Properties

FHIR Patient.gender
Operationalization PERSON STATED GENDER CODE is self-declared or inferred by observation for those unable to declare their PERSON STATED GENDER.1 Male2 Female9 Indeterminate (unable to be classified as either male or female)X not known (not recorded)

or

Sent as per the ECDS Person Stated Gender code set:

1 Male

2 Female

9 Indeterminate

X Unknown

Value Domain
draft Person alias
prsb03-dataelement-10020
Id prsb03-dataelement-10020 (2018‑10‑31)
Description Record details where a person is known to use assumed identities to access health and care services.
Operationalization Other name(s) associated with the person which may be recorded on the local PAS.
Value Domain
draft Ethnicity
prsb03-dataelement-10021
Id prsb03-dataelement-10021 (2018‑10‑31)
Description The ethnicity of a person as specified by the person.
Operationalization The ethnic cateogory codes defined in the 2001 national census or the Office for National Statistics (ONS) ethnic category codes should be used.
Value Domain
draft Religion
prsb03-dataelement-10022
Id prsb03-dataelement-10022 (2018‑10‑31)
Description The religious affiliation as specified by the person.
Operationalization The religious affiliation as volunteered by the person. Use SNOMED CT subset 10791000000130 or free text.
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
cancelled Religion
prsb03-dataelement-10875
Id prsb03-dataelement-10875 (2019‑03‑27 19:12:11)
Concept inherits from draft prsb03-dataelement-10022 (2018‑10‑31)
Description The religious affiliation as specified by the person.
Operationalization The religious affiliation as volunteered by the person. Use SNOMED CT subset 10791000000130 or free text.
Value Domain
draft Sex
prsb03-dataelement-10023
Id prsb03-dataelement-10023 (2018‑10‑31)
Description The person’s phenotypic sex. Determines how the person will be treated clinically.
Operationalization Sent as per the NHS Data Dictionary: person phenotypic sex classification
Value Domain
draft NHS number
prsb03-dataelement-10024
Id prsb03-dataelement-10024 (2018‑10‑31)
Description The unique identifier for a patient within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Operationalization Sent as per the NHS Data Dictionary NHS number. Traced and verified NHS Numbers only should be used i.e. NHS

number status indicator code:

value 01. If there is no NHS number then this data item should be reported as null and other unique identifiers will need to flow.
Value Domain
draft Other identifier
prsb03-dataelement-10025
Id prsb03-dataelement-10025 (2018‑10‑31)
Description Country specific or local identifier, e.g., Community Health Index (CHI) in Scotland.
Operationalization Recorded as per NHS Data Dictionary: - Local patient identifier, -Local patient identified (extended), -Health and Care number, -Community Health Index number
Value Domain
draft Patient address
prsb03-dataelement-10026
Id prsb03-dataelement-10026 (2018‑10‑31)
Description Patient’s usual place of residence.

Properties

FHIR Patient.Address
Operationalization Sent in accordance with the NHS Data Dictionary: patient usual address. May be auto generated from PDS, GP referral record, or from the local PAS.
Value Domain
draft Patient email address
prsb03-dataelement-10027
Id prsb03-dataelement-10027 (2018‑10‑31)
Description Email address of the patient

Properties

FHIR Patient.telecom
Operationalization Set in accordance with the NHS Data Dictionary: contact email address (patient or lead contact). May be auto generated from PDS, GP referral record, or from the local PAS.
Value Domain
draft Patient telephone number
prsb03-dataelement-10028
Id prsb03-dataelement-10028 (2018‑10‑31)
Description Telephone contact details of the patient. To include, e.g., mobile, work and home number if available.

Properties

FHIR Patient.telecom
Operationalization Contact details may come from PDS, or those recorded on the local PAS. Both the actual contact number and its use (work number, home number, mobile number etc).
Value Domain
draft Relevant contacts
prsb03-dataelement-10029
Id prsb03-dataelement-10029 (2018‑10‑31)
Description Include the most important contacts including:

* Personal contacts e.g., next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc.

* Health/care professional contacts e.g., social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.

Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.

Properties

FHIR Patient.contact
Operationalization Details of relevant contacts, such as carers or family members, as recorded on the local system, or volunteered by the patient. This will be a free text list of relevant contacts.
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Communication preferences
prsb03-dataelement-10030
Id prsb03-dataelement-10030 (2018‑10‑31)
Description Preferred contact method, e.g., sign language, letter, phone, etc. Also preferred written communication format, e.g., large print, braille.
Operationalization Derived from the PDS - communication preferences
Value Domain
draft Place of birth
prsb03-dataelement-10031
Id prsb03-dataelement-10031 (2018‑10‑31)
Description The town and country of birth of the patient
Value Domain
draft Marital status
prsb03-dataelement-10032
Id prsb03-dataelement-10032 (2018‑10‑31)
Description An indicator to identify the legal marital status of the patient
Value Domain
draft Date of death
prsb03-dataelement-10033
Id prsb03-dataelement-10033 (2018‑10‑31)
Description The date of death of the patient (if applicable)
Value Domain
draft Time of death
prsb03-dataelement-10034
Id prsb03-dataelement-10034 (2018‑10‑31)
Description The time of death of the patient (if applicable)
Value Domain
draft Educational establishment
prsb03-dataelement-10035
Id prsb03-dataelement-10035 (2018‑10‑31)
Description If the person is a child, name and address of where the child attends, eg play group, nursery, school.
Operationalization Free text or ODS code where available.
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder cancelled Test
prsb03-dataelement-13091
Id prsb03-dataelement-13091 (2020‑06‑11 12:26:59) 1
Description Test
folder cancelled test record entry
prsb03-dataelement-13092
Id prsb03-dataelement-13092 (2020‑06‑11 12:27:47) 1
folder cancelled medications heading
prsb03-dataelement-13093
Id prsb03-dataelement-13093 (2020‑06‑11 12:28:17) 1
folder draft Person demographics
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Description The person's details and contact information.
folder draft Person name
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Description Details of the person's name
Relationship
draft Person first name
prsb03-dataelement-13799
Id prsb03-dataelement-13799 (2020‑11‑09 16:09:39)
Description The first name(s) of the person. This includes middle names.
Rationale Patient.name.given
Operationalization NHS data dictionary :- Person given name
Value Domain
Property
max length
35
draft Person family name
prsb03-dataelement-13800
Id prsb03-dataelement-13800 (2020‑11‑09 16:43:41)
Description The family name or surname of the person
Rationale Patient.name.family
Operationalization NHS data dictionary : - Person family name

Value Domain
Property
max length
35
draft Person preferred name
prsb03-dataelement-10870
Id prsb03-dataelement-10870 (2019‑03‑27 19:06:43)
Description The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.
Relationship
Rationale Patient.name
Operationalization NHS data dictionary: - Person full name
Value Domain
Property
max length
70
draft Title
prsb03-dataelement-13089
Id prsb03-dataelement-13089 (2020‑06‑04 17:22:32) 0.1
Description Person's title
Rationale Patient.name.prefix
Operationalization NHS data dictionary: - Person title
Value Domain
Property
max length
35
draft Person name suffix
prsb03-dataelement-13798
Id prsb03-dataelement-13798 (2020‑11‑08 22:52:48)
Description A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM
Rationale Patient.name.suffix
Operationalization NHS data dictionary: - Person suffix
Value Domain
Property
max length
35
draft Person full name
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
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
draft Date of birth
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
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
draft Time of birth
prsb03-dataelement-13803
Id prsb03-dataelement-13803 (2020‑11‑20 17:04:14)
Description The time of birth of the person
Rationale Patient.extension(patient-birthTime)
Operationalization NHS data dictionary :- Person birth time
Value Domain
draft Gender
prsb03-dataelement-10872
Id prsb03-dataelement-10872 (2019‑03‑27 19:08:52) 1
Description The person's stated gender.

Properties

FHIR Patient.gender
Relationship
Rationale Patient.gender
Source NHS Wales : - https://fhir.standards.wales/CodeSystem/GenderIdentity
Operationalization NHS data dictionary :- Person stated gender code

Value Domain
Property
max length
1
draft Person alias
prsb03-dataelement-10873
Id prsb03-dataelement-10873 (2019‑03‑27 19:10:48) 1
Description Other name(s) associated with the person.
Relationship
Operationalization Free text
Value Domain
Property
max length
70
draft Ethnicity
prsb03-dataelement-10874
Id prsb03-dataelement-10874 (2019‑03‑27 19:11:37) 1
Description The ethnicity of the person as specified by the person.
Relationship
Rationale Patient.extension(ethnicCategory)
Source NHS_Wales: https://fhir.standards.wales/CodeSystem/DataStandardsWales-Ethnicity

NHS_NSS: https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnic%20Group
Operationalization NHS data dictionary :- Ethnic category
Value Domain
Property
max length
2
draft Religion
prsb03-dataelement-10876
Id prsb03-dataelement-10876 (2019‑03‑27 19:15:05) 1
Description The religious affiliation as specified by the person.
Relationship
Rationale Patient.extension(religiousAffiliation)
Source NHS NSS: - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=R&ID=795&Title=Religion
Operationalization SNOMED_CT: ^999000531000000100 |Religious or other belief system affiliation simple reference set (foundation metadata concept)|
Value Domain
draft Sex
prsb03-dataelement-10877
Id prsb03-dataelement-10877 (2019‑03‑27 19:15:45) 1
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
draft NHS number
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 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
draft NHS number status indicator
prsb03-dataelement-13297
Id prsb03-dataelement-13297 (2020‑08‑06 12:08:33)
Description Provides an indication of the reliability of an NHS Number.
Rationale Patient.identifier(nhsnumber).extension(nhsverificationstatus)
Operationalization NHS data dictionary :- NHS number status indicator
Value Domain
Property
max length
2
draft Other identifier
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Relationship
Operationalization
Value Domain
Property
max length
20
folder draft Person's address
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

FHIR Patient.Address
Relationship
draft Address line 1
prsb03-dataelement-13082
Id prsb03-dataelement-13082 (2020‑05‑29 15:28:51)
Description Person's first line of address.
Rationale Patient.address.line
Operationalization
NHS data dictionary :-  Address line 1

Value Domain
Property
max length
35
draft Address line 2
prsb03-dataelement-13083
Id prsb03-dataelement-13083 (2020‑05‑29 15:32:41)
Description Person's second line of address.
Rationale Patient.address.city
Operationalization
NHS data dictionary :- Address line 2

Value Domain
Property
max length
35
draft Address line 3
prsb03-dataelement-13084
Id prsb03-dataelement-13084 (2020‑05‑29 15:35:34)
Description Person's third line of address.
Rationale Patient.address.district
Operationalization
NHS data dictionary : - Address line 3
Value Domain
Property
max length
35
draft Address line 4
prsb03-dataelement-13085
Id prsb03-dataelement-13085 (2020‑06‑01 11:29:56)
Description Person's fourth line of address.
Rationale Patient.address.state
Operationalization
NHS data dictionary : - Address line 4

Value Domain
Property
max length
35
draft Address line 5
prsb03-dataelement-13086
Id prsb03-dataelement-13086 (2020‑06‑01 11:32:10)
Description Person's fifth line of address.
Rationale Patient.address.country
Operationalization NHS data dictionary : - Address line 5

Value Domain
Property
max length
35
draft Postcode
prsb03-dataelement-13087
Id prsb03-dataelement-13087 (2020‑06‑01 11:40:09)
Description The person's postcode.
Rationale Patient.address.postalcode
Operationalization NHS data dictionary :- Postcode of usual address

Value Domain
Property
max length
8
draft Address type
prsb03-dataelement-13221
Id prsb03-dataelement-13221 (2020‑07‑08 15:58:39)
Description The type of address e.g. Main address, Temp address
Rationale Patient.address.use
Operationalization NHS data dictionary : - Address association type
Value Domain
Property
max length
1
folder draft Person's contact details
prsb03-dataelement-13804
Id prsb03-dataelement-13804 (2020‑11‑25 18:32:36)
Description Details of the person's contact information.
draft Preferred contact method
prsb03-dataelement-10886
Id prsb03-dataelement-10886 (2019‑03‑27 19:29:17)
Description Preferred contact method, e.g. email, letter, phone, text message etc.
Relationship
Operationalization NHS data dictionary :- Communication contact method
Value Domain
Property
max length
1
folder draft Person's telephone number details
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Description The person's telephone number details

Properties

FHIR Patient.telecom
Relationship
draft Person's telephone number
prsb03-dataelement-13808
Id prsb03-dataelement-13808 (2020‑11‑26 16:51:24)
Description The person's telephone number
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
draft Person's telephone number type
prsb03-dataelement-13805
Id prsb03-dataelement-13805 (2020‑11‑25 18:37:54)
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
draft Preference of telephone number
prsb03-dataelement-13809
Id prsb03-dataelement-13809 (2020‑11‑26 16:55:09)
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
folder draft Person's email address details
prsb03-dataelement-13807
Id prsb03-dataelement-13807 (2020‑11‑26 16:29:22)
Description Details of the person's email address
draft Person's email address
prsb03-dataelement-10882
Id prsb03-dataelement-10882 (2019‑03‑27 19:20:19)
Description Email address of the person.

Properties

FHIR Patient.telecom
Relationship
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary :- Contact email address
Value Domain
Property
max length
255
draft Person's email address type
prsb03-dataelement-13811
Id prsb03-dataelement-13811 (2020‑11‑26 17:30:54)
Description The type of email address, home, work
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Work
Example old
draft Preference of email address
prsb03-dataelement-13810
Id prsb03-dataelement-13810 (2020‑11‑26 17:07:11)
Description The preferred order of use of email address
Rationale Patient.telecon.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
draft Other contact information
prsb03-dataelement-13806
Id prsb03-dataelement-13806 (2020‑11‑26 16:07:06)
Description Contact details via fax, sms, url
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary:- Communication contact string
Value Domain
Property
max length
255
draft Photograph
prsb03-dataelement-13065
Id prsb03-dataelement-13065 (2020‑05‑15 16:50:49)
Description A photograph of the person for identification and to show what the person looks like normally.
Rationale Patient.photo
Operationalization Mulitmedia file
Value Domain
cancelled Location of birth
prsb03-dataelement-13081
Id prsb03-dataelement-13081 (2020‑05‑28 16:18:56) 0.1
Description The place the person was born.
Operationalization NHS data dictionary:- Location of birth
Value Domain
Property
min length max length
5an 9an
draft Place of birth
prsb03-dataelement-10884
Id prsb03-dataelement-10884 (2019‑03‑27 19:25:07)
Description The country of birth of the person.
Relationship
Rationale Patient.extension(Birthplace)
Operationalization NHS data dictionary :- Country code (birth)
Value Domain
Property
max length
3
draft Marital status
prsb03-dataelement-10885
Id prsb03-dataelement-10885 (2019‑03‑27 19:25:57)
Description An indicator to identify the legal marital status of the person.
Relationship
Rationale Patient.maritalstatus
Operationalization NHS data dictionary :- Person marital status
Value Domain
Property
max length
1
folder draft Immigration status
prsb03-dataelement-13293
Id prsb03-dataelement-13293 (2020‑08‑06 12:01:14)
Description Include details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK. Include start date, end date and any comments.
draft Immigration status
prsb03-dataelement-13304
Id prsb03-dataelement-13304 (2020‑08‑06 13:06:19) 0.1
Description Details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.
Operationalization Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds (NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled status; 10: EU settled status
Value Domain
draft Start date
prsb03-dataelement-13294
Id prsb03-dataelement-13294 (2020‑08‑06 12:02:54)
Description Start date of immigration status
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft End date
prsb03-dataelement-13295
Id prsb03-dataelement-13295 (2020‑08‑06 12:04:03)
Description End date of immigration status
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Comment
prsb03-dataelement-13296
Id prsb03-dataelement-13296 (2020‑08‑06 12:05:00)
Description Relevant comments about the person's immigration status
Operationalization Free text
Value Domain
Property
max length
150
folder cancelled Organ and tissue donation
prsb03-dataelement-10430
Id prsb03-dataelement-10430 (2018‑10‑31) 0.1
Description Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.
Rationale Patient.extension(patient-cadavericDonor)
Operationalization Flag
cancelled Date
prsb03-dataelement-11695
Id prsb03-dataelement-11695 (2019‑05‑31 12:56:56)
Concept inherits from draft prsb03-dataelement-11688 (2019‑05‑31 11:50:22)
Description The date when the mental capacity assessment was made.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Location
prsb03-dataelement-11696
Id prsb03-dataelement-11696 (2019‑05‑31 12:58:01)
Concept inherits from draft prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
Description The location where the mental capacity assessment was made.
folder cancelled Person completing record
prsb03-dataelement-11349
Id prsb03-dataelement-11349 (2019‑05‑30 13:37:15)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
cancelled Name
prsb03-dataelement-11350
Id prsb03-dataelement-11350 (2019‑05‑30 13:37:40)
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
cancelled Role
prsb03-dataelement-11351
Id prsb03-dataelement-11351 (2019‑05‑30 13:37:40)
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
cancelled Grade
prsb03-dataelement-11352
Id prsb03-dataelement-11352 (2019‑05‑30 13:37:40)
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
cancelled Specialty
prsb03-dataelement-11353
Id prsb03-dataelement-11353 (2019‑05‑30 13:37:40)
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
folder cancelled Organisation
prsb03-dataelement-11354
Id prsb03-dataelement-11354 (2019‑05‑30 13:37:40)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
cancelled Professional identifier
prsb03-dataelement-11355
Id prsb03-dataelement-11355 (2019‑05‑30 13:37:40)
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
cancelled Date completed
prsb03-dataelement-11356
Id prsb03-dataelement-11356 (2019‑05‑30 13:37:40)
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
cancelled Contact details
prsb03-dataelement-11357
Id prsb03-dataelement-11357 (2019‑05‑30 13:37:40)
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
draft Organ and tissue donation
prsb03-dataelement-13847
Id prsb03-dataelement-13847 (2020‑12‑30 11:45:54)
Description Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.
Operationalization Flag: - Yes or No
Value Domain
draft Overseas visitor status
prsb03-dataelement-10908
Id prsb03-dataelement-10908 (2019‑04‑02 13:22:04)
Description The charging category relating to an overseas visitor.
Rationale Patient.(extension(treatmentCategory)
Operationalization NHS data dictionary :- Overseas visitor charging catergory
Value Domain
Property
max length
1
cancelled Accommodation status
prsb03-dataelement-10909
Id prsb03-dataelement-10909 (2019‑04‑02 13:25:31) 0.1
Description An indication of the type of accommodation where the person lives. This should be based on the main or temporary residence.
Relationship
Operationalization Free text
Value Domain
draft Accommodation status
prsb03-dataelement-12473
Id prsb03-dataelement-12473 (2019‑06‑25 17:28:11)
Description An indication of the type of accommodation where the person lives. This should be based on the main or temporary residence.
Relationship
Operationalization NHS data dictionary - Accommodation status ECDS
Value Domain
Property
min length max length
6 18
draft Relevant contacts
prsb03-dataelement-10910
Id prsb03-dataelement-10910 (2019‑04‑02 13:27:59)
Description Include the most important contacts including:

* Personal contacts e.g., next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc.

* Health/care professional contacts e.g., social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.

Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.

Properties

FHIR Patient.contact
Relationship
Operationalization Details of relevant contacts, such as carers or family members, as recorded on the local system, or volunteered by the person. This will be a free text list of relevant contacts.
Value Domain
draft Educational establishment
prsb03-dataelement-10911
Id prsb03-dataelement-10911 (2019‑04‑02 13:30:05)
Concept inherits from draft prsb03-dataelement-10035 (2018‑10‑31)
Description If the person is a child, name and address of where the child attends, eg play group, nursery, school.
Operationalization Free text or ODS code where available.
Value Domain
draft Date of death
prsb03-dataelement-12963
Id prsb03-dataelement-12963 (2020‑03‑25 16:55:17)
Description The date of death of the person.
Relationship
Operationalization NHS data dictionary :- Person death date
Value Domain
Property
Timestamp precision default
day, month and year 10
draft Time of death
prsb03-dataelement-13088
Id prsb03-dataelement-13088 (2020‑06‑01 15:48:50)
Description The time on which the person died.
Operationalization NHS data dictionary :- Time of death
Value Domain
cancelled NHS Number
prsb03-dataelement-10878
Id prsb03-dataelement-10878 (2019‑03‑27 19:16:26)
Concept inherits from draft prsb03-dataelement-10351 (2018‑10‑31)
Description The NHS number of the personal contact
Operationalization NHS data dictionary:- NHS NUMBER
Value Domain
Property
max length
10
folder draft GP practice
prsb03-dataelement-101
Id prsb03-dataelement-101 (2018‑10‑31)
Description Details of the person's GP practice.
folder draft GP practice record entry
prsb03-dataelement-10643
Id prsb03-dataelement-10643 (2018‑11‑09 14:59:24)
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
draft GP name
prsb03-dataelement-10003
Id prsb03-dataelement-10003 (2018‑10‑31)
Description The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.

Properties

FHIR Practitioner.name, where PractitionerRole.code=GP
Rationale Practitioner.name
Operationalization Free text
Value Domain
Property
max length
70
draft GP practice details
prsb03-dataelement-10002
Id prsb03-dataelement-10002 (2018‑10‑31)
Description Name and address of the person's registered GP practice Registered GP practice details are available from the Patient Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.

Properties

FHIR PractitionerRole.organisation.Name (0..1) PractitionerRole.organisation.telcom (0..*) PractitionerRole.organisation.Address (0..*)
Rationale PractitionerRole.organisation.Name (0..1)

PractitionerRole.organisation.telcom (0..*)

PractitionerRole.organisation.Address (0..*)
Operationalization Free text
Value Domain
Property
max length
150
draft GP practice identifier
prsb03-dataelement-10001
Id prsb03-dataelement-10001 (2018‑10‑31)
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
draft GP opt out indicator
prsb03-dataelement-10004
Id prsb03-dataelement-10004 (2018‑10‑31)
Description Indication that the person has opted out of registering with a GP.
Operationalization SNOMED CT : - 1092961000000104 |Does not wish to register with an NHS general practitioner (finding)| OR 1092941000000100 |Family using private general practitioner (finding)|
Value Domain
folder draft About me
prsb03-dataelement-466
Id prsb03-dataelement-466 (2018‑10‑31)
Description About me
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft About me
prsb03-dataelement-10366
Id prsb03-dataelement-10366 (2018‑10‑31)
Description This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
target Used by one transaction, 0 templates, inherited 0 times
 
draft What is most important to me
prsb03-dataelement-12964
Id prsb03-dataelement-12964 (2020‑03‑30 10:50:29) 0.3
Description A description of what is most important to you
Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering
Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft People who are important to me
prsb03-dataelement-13009
Id prsb03-dataelement-13009 (2020‑04‑27 11:23:17) 0.3
Description  Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say
Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft How I communicate and how to communicate with me
prsb03-dataelement-13006
Id prsb03-dataelement-13006 (2020‑04‑24 11:48:24) 0.3
Description

A description of how you communicate normally including any communication aids you use, for example a hearing aid.

  • Include your preferred language of communication, if your first language is not English.
  • Include how you would communicate when you are in pain or distress.
  • Include how you communicate choices.
  • Include how you give feedback or raise a concern.
  • Include how you like to receive information

Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft My wellness
prsb03-dataelement-13005
Id prsb03-dataelement-13005 (2020‑04‑24 11:45:53)
Synonym
0.3
Description

A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.

  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations
Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Please do and please don't
prsb03-dataelement-13008
Id prsb03-dataelement-13008 (2020‑04‑27 10:34:59) 0.3
Description

A description of things you want someone supporting you to do or not to do.

For example, this might include: - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.

A description of things you do not want someone supporting for you to do. For example, this might include: - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way.

Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft How and when to support me
prsb03-dataelement-13007
Id prsb03-dataelement-13007 (2020‑04‑27 10:29:54) 0.3
Description

A description of how and when you want someone caring for you to support you.

This could include support needs in an emergency situation (for example taking blood)

This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning

This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.

Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Also worth knowing about me
prsb03-dataelement-13094
Id prsb03-dataelement-13094 (2020‑06‑22 11:30:09) 0.2
Description

A description of what is also worth knowing about you for people caring or supporting you.

This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).

This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike

This could also include any care and support preferences that have not been included elsewhere.

Operationalization Free text or multimedia file
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date
prsb03-dataelement-10367
Id prsb03-dataelement-10367 (2018‑10‑31)
Description This is a record of the date that this information was last updated.
Operationalization Date and Time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by one transaction, 0 templates, inherited 0 times
 
draft Supported to write this by
prsb03-dataelement-10368
Id prsb03-dataelement-10368 (2018‑10‑31)
Description Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
cancelled My sleep
prsb03-dataelement-13010
Id prsb03-dataelement-13010 (2020‑04‑27 11:24:58) 0.1
Description Quality of sleep, disturbed sleep patterns, early wakening, or daytime sleepiness and support for good quality sleep.
Operationalization Free text
Value Domain
cancelled My medications and treatment
prsb03-dataelement-13011
Id prsb03-dataelement-13011 (2020‑04‑27 11:26:35) 0.1
Description How medication is taken and support required with taking medicines.
Operationalization Free text
Value Domain
cancelled My mobility and movement
prsb03-dataelement-13012
Id prsb03-dataelement-13012 (2020‑04‑27 11:27:46) 0.1
Description Mobility and movement both inside and outside and support needed to achieve a degree of independence.
Operationalization Free text
Value Domain
cancelled My memory and thoughts
prsb03-dataelement-13013
Id prsb03-dataelement-13013 (2020‑04‑27 11:28:58) 0.1
Description What helps the person with memory and confusion.
Operationalization Free text
Value Domain
cancelled My emotions, mood and behaviour
prsb03-dataelement-13014
Id prsb03-dataelement-13014 (2020‑04‑27 11:30:36) 0.1
Description
Managing different emotions.
- what emotions are experienced (depression, anxiety, stress, frustration, worry).
- what makes the person feel happy and relaxed.
- what stops the person feeling happy and relaxed.
Operationalization Free text
Value Domain
cancelled My work and learning
prsb03-dataelement-13015
Id prsb03-dataelement-13015 (2020‑04‑27 11:32:00) 0.1
Description Current and historic jobs or study and any support requirements at school or work.
Operationalization Free text
Value Domain
cancelled Symptoms or conditions that affect my daily living
prsb03-dataelement-13016
Id prsb03-dataelement-13016 (2020‑04‑27 11:54:40) 0.1
Description Important or significant symptoms that affect daily life e.g., itchiness, cough, pain and associated support requirements.
Operationalization Free text
Value Domain
folder draft Individual requirements
prsb03-dataelement-160
Id prsb03-dataelement-160 (2018‑10‑31)
Description The individual requirements of the person.
folder cancelled Individual requirements record entry
prsb03-dataelement-12984
Id prsb03-dataelement-12984 (2020‑04‑23 18:51:14) 0.1
Description This is an individual requirements 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.
cancelled Additional communications support
prsb03-dataelement-12985
Id prsb03-dataelement-12985 (2020‑04‑23 19:07:17) 0.1
Description Identifies other communications support (outside the accessible information areas) e.g. requires carer at encounter or uses apps on mobile device to support communication or has difficulty analysing information).
Operationalization Free text
Value Domain
cancelled Community language support
prsb03-dataelement-12986
Id prsb03-dataelement-12986 (2020‑04‑23 19:08:31) 0.1
Description Identifies that an interpreter would be needed and the language spoken at home.
Operationalization Free text
Value Domain
cancelled Additional support
prsb03-dataelement-12987
Id prsb03-dataelement-12987 (2020‑04‑23 19:12:02) 0.1
Description Additional support requirements, e.g. needs assistance with medication regimen adherence or has appointed person with personal welfare lasting power of attorney (Mental Capacity Act 2005)
Operationalization Free text
Value Domain
cancelled Individual care requirements
prsb03-dataelement-12988
Id prsb03-dataelement-12988 (2020‑04‑23 19:13:47) 0.1
Description Requirements related to care e.g. has anticipatory care plan or preference for male healthcare professional.
Operationalization Free text
Value Domain
cancelled Adjustments to the environment
prsb03-dataelement-12989
Id prsb03-dataelement-12989 (2020‑04‑23 19:14:53) 0.1
Description Any adjustments needed to the environment e.g. related to noise intolerance, photophobia or requires wheelchair access
Operationalization Free text
Value Domain
cancelled Other reasonable adjustments
prsb03-dataelement-12990
Id prsb03-dataelement-12990 (2020‑04‑23 19:16:06) 0.1
Description Any other reasonable adjustments not covered by a code.
Operationalization Free text
Value Domain
cancelled Date reasonable adjustments record was created
prsb03-dataelement-13002
Id prsb03-dataelement-13002 (2020‑04‑23 20:19:28) 0.1
Description The date on which the reasonable adjustment record was created
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
cancelled Consent provided by
prsb03-dataelement-13003
Id prsb03-dataelement-13003 (2020‑04‑23 20:21:28) 0.1
Description
The details of the person that provided consent for the reasonable adjustments record.
Operationalization Free text
Value Domain
cancelled Person completing record
prsb03-dataelement-13004
Id prsb03-dataelement-13004 (2020‑04‑23 20:23:11) 0.1
Concept inherits from cancelled prsb03-dataelement-10954 (2019‑05‑18 21:07:16)
Description This is the person completing the record.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Accessible information standard
prsb03-dataelement-13241
Id prsb03-dataelement-13241 (2020‑07‑27 13:27:30)
Description From 1st August 2016 onwards, all organisations that provide NHS care and / or publicly-funded adult social care are legally required to follow the Accessible Information Standard. The Standard sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss.
folder draft Accessible information - requires specific information format
prsb03-dataelement-11032
Id prsb03-dataelement-11032 (2019‑05‑24 11:06:51)
Description The specific format the person requires in order for information to be accessible.
draft Date
prsb03-dataelement-11697
Id prsb03-dataelement-11697 (2019‑05‑31 12:59:21)
Description The date the accessible information requirement was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11698
Id prsb03-dataelement-11698 (2019‑05‑31 12:59:49)
Description The location where the accessible information requirement was identified.
Relationship
draft Coded value
prsb03-dataelement-13371
Id prsb03-dataelement-13371 (2020‑08‑06 19:02:35)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13372
Id prsb03-dataelement-13372 (2020‑08‑06 19:03:11)
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
folder draft Requires specific information format
prsb03-dataelement-13359
Id prsb03-dataelement-13359 (2020‑08‑06 17:47:48)
Description The specific format the person requires in order for information to be accessible.
draft Coded value
prsb03-dataelement-13360
Id prsb03-dataelement-13360 (2020‑08‑06 17:50:15)
Description The coded value. https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/658
Operationalization SNOMED CT: - : ^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13361
Id prsb03-dataelement-13361 (2020‑08‑06 17:53:11)
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
folder draft Performing professional
prsb03-dataelement-11402
Id prsb03-dataelement-11402 (2019‑05‑30 14:04:34)
Description The professional who identified the accessible information requirement.
Relationship
draft Name
prsb03-dataelement-11403
Id prsb03-dataelement-11403 (2019‑05‑30 14:04:54)
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
draft Role
prsb03-dataelement-11404
Id prsb03-dataelement-11404 (2019‑05‑30 14:04:54)
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
draft Grade
prsb03-dataelement-11405
Id prsb03-dataelement-11405 (2019‑05‑30 14:04:54)
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
draft Speciality
prsb03-dataelement-11406
Id prsb03-dataelement-11406 (2019‑05‑30 14:04:54)
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
draft Professional identifier
prsb03-dataelement-11407
Id prsb03-dataelement-11407 (2019‑05‑30 14:04:54)
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
folder draft Organisation
prsb03-dataelement-11408
Id prsb03-dataelement-11408 (2019‑05‑30 14:04:54)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11409
Id prsb03-dataelement-11409 (2019‑05‑30 14:04:54)
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
folder draft Person completing record
prsb03-dataelement-11410
Id prsb03-dataelement-11410 (2019‑05‑30 14:05:15)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11411
Id prsb03-dataelement-11411 (2019‑05‑30 14:06:19)
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
draft Role
prsb03-dataelement-11412
Id prsb03-dataelement-11412 (2019‑05‑30 14:06:19)
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
draft Grade
prsb03-dataelement-11413
Id prsb03-dataelement-11413 (2019‑05‑30 14:06:19)
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
draft Specialty
prsb03-dataelement-11414
Id prsb03-dataelement-11414 (2019‑05‑30 14:06:19)
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
folder draft Organisation
prsb03-dataelement-11415
Id prsb03-dataelement-11415 (2019‑05‑30 14:06:19)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11416
Id prsb03-dataelement-11416 (2019‑05‑30 14:06:19)
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
draft Date completed
prsb03-dataelement-11417
Id prsb03-dataelement-11417 (2019‑05‑30 14:06:19)
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
draft Contact details
prsb03-dataelement-11418
Id prsb03-dataelement-11418 (2019‑05‑30 14:06:19)
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
folder cancelled Performing professional
prsb03-dataelement-11178
Id prsb03-dataelement-11178 (2019‑05‑28 17:55:07)
Concept inherits from cancelled prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
cancelled Name
prsb03-dataelement-11179
Id prsb03-dataelement-11179 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11180
Id prsb03-dataelement-11180 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11181
Id prsb03-dataelement-11181 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11182
Id prsb03-dataelement-11182 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11183
Id prsb03-dataelement-11183 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11184
Id prsb03-dataelement-11184 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Professional identifier
prsb03-dataelement-11185
Id prsb03-dataelement-11185 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
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)
Value Domain
cancelled Start date
prsb03-dataelement-11186
Id prsb03-dataelement-11186 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11187
Id prsb03-dataelement-11187 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11188
Id prsb03-dataelement-11188 (2019‑05‑28 17:55:37)
Concept inherits from cancelled prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
folder cancelled Person completing record
prsb03-dataelement-11189
Id prsb03-dataelement-11189 (2019‑05‑28 17:57:32)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11190
Id prsb03-dataelement-11190 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11191
Id prsb03-dataelement-11191 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11192
Id prsb03-dataelement-11192 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11193
Id prsb03-dataelement-11193 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11194
Id prsb03-dataelement-11194 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11195
Id prsb03-dataelement-11195 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11196
Id prsb03-dataelement-11196 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11197
Id prsb03-dataelement-11197 (2019‑05‑28 17:58:01)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
folder cancelled Performing professional
prsb03-dataelement-11043
Id prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Name
prsb03-dataelement-11045
Id prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled Role
prsb03-dataelement-11046
Id prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled Speciality
prsb03-dataelement-11047
Id prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10354 (2018‑10‑31)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled Team
prsb03-dataelement-11048
Id prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10355 (2018‑10‑31)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 6 times
 
folder cancelled Organisation
prsb03-dataelement-11049
Id prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10356 (2018‑10‑31)
Description The name of the organisation.
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled Contact details
prsb03-dataelement-11050
Id prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled Start date
prsb03-dataelement-11051
Id prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10358 (2018‑10‑31)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 6 times
 
cancelled End date
prsb03-dataelement-11052
Id prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10359 (2018‑10‑31)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 6 times
 
folder cancelled Professional contacts record entry
prsb03-dataelement-11044
Id prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Concept inherits from draft prsb03-dataelement-10767 (2019‑03‑18 18:07:16)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 0 transactions, 0 templates, inherited 5 times
 
folder cancelled Performing professional
prsb03-dataelement-11033
Id prsb03-dataelement-11033 (2019‑05‑24 11:12:34)
Description The performing professional identifying the accessible information.
Relationship
folder cancelled Professional contacts record entry
prsb03-dataelement-11034
Id prsb03-dataelement-11034 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10767 (2019‑03‑18 18:07:16)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
cancelled Name
prsb03-dataelement-11035
Id prsb03-dataelement-11035 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11036
Id prsb03-dataelement-11036 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11037
Id prsb03-dataelement-11037 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10354 (2018‑10‑31)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11038
Id prsb03-dataelement-11038 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10355 (2018‑10‑31)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11039
Id prsb03-dataelement-11039 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10356 (2018‑10‑31)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11040
Id prsb03-dataelement-11040 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11041
Id prsb03-dataelement-11041 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10358 (2018‑10‑31)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11042
Id prsb03-dataelement-11042 (2019‑05‑24 11:13:32)
Concept inherits from draft prsb03-dataelement-10359 (2018‑10‑31)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Person completing record
prsb03-dataelement-11023
Id prsb03-dataelement-11023 (2019‑05‑24 11:01:31)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11024
Id prsb03-dataelement-11024 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11025
Id prsb03-dataelement-11025 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11026
Id prsb03-dataelement-11026 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11027
Id prsb03-dataelement-11027 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11028
Id prsb03-dataelement-11028 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11029
Id prsb03-dataelement-11029 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11030
Id prsb03-dataelement-11030 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11031
Id prsb03-dataelement-11031 (2019‑05‑24 11:02:03)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Accessible information - requires specific contact method
prsb03-dataelement-10063
Id prsb03-dataelement-10063 (2018‑10‑31)
Description The contact method the person requires in order for information to be accessible.
draft Date
prsb03-dataelement-11699
Id prsb03-dataelement-11699 (2019‑05‑31 13:00:44)
Description The date the accessible information requirement was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11700
Id prsb03-dataelement-11700 (2019‑05‑31 13:01:11)
Description The location where the accessible information requirement was identified.
Relationship
draft Coded value
prsb03-dataelement-13373
Id prsb03-dataelement-13373 (2020‑08‑06 19:04:27)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13374
Id prsb03-dataelement-13374 (2020‑08‑06 19:05:13)
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
folder draft Requires specific contact method
prsb03-dataelement-13362
Id prsb03-dataelement-13362 (2020‑08‑06 18:39:01)
Description The contact method the person requires in order for information to be accessible.
draft Coded value
prsb03-dataelement-13363
Id prsb03-dataelement-13363 (2020‑08‑06 18:41:53)
Description The coded value for contact method. https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/658
Operationalization SNOMED CT :- ^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13364
Id prsb03-dataelement-13364 (2020‑08‑06 18:44:22)
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
folder draft Performing professional
prsb03-dataelement-11419
Id prsb03-dataelement-11419 (2019‑05‑30 14:08:28)
Description The professional who identified the accessible information requirement.
Relationship
draft Name
prsb03-dataelement-11420
Id prsb03-dataelement-11420 (2019‑05‑30 14:08:48)
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
draft Role
prsb03-dataelement-11421
Id prsb03-dataelement-11421 (2019‑05‑30 14:08:48)
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
draft Grade
prsb03-dataelement-11422
Id prsb03-dataelement-11422 (2019‑05‑30 14:08:48)
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
draft Speciality
prsb03-dataelement-11423
Id prsb03-dataelement-11423 (2019‑05‑30 14:08:48)
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
draft Professional identifier
prsb03-dataelement-11424
Id prsb03-dataelement-11424 (2019‑05‑30 14:08:48)
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
folder draft Organisation
prsb03-dataelement-11425
Id prsb03-dataelement-11425 (2019‑05‑30 14:08:48)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11426
Id prsb03-dataelement-11426 (2019‑05‑30 14:08:48)
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
folder draft Person completing record
prsb03-dataelement-11427
Id prsb03-dataelement-11427 (2019‑05‑30 14:09:00)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11428
Id prsb03-dataelement-11428 (2019‑05‑30 14:09:25)
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
draft Role
prsb03-dataelement-11429
Id prsb03-dataelement-11429 (2019‑05‑30 14:09:25)
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
draft Grade
prsb03-dataelement-11430
Id prsb03-dataelement-11430 (2019‑05‑30 14:09:25)
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
draft Specialty
prsb03-dataelement-11431
Id prsb03-dataelement-11431 (2019‑05‑30 14:09:25)
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
folder draft Organisation
prsb03-dataelement-11432
Id prsb03-dataelement-11432 (2019‑05‑30 14:09:25)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11433
Id prsb03-dataelement-11433 (2019‑05‑30 14:09:25)
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
draft Date completed
prsb03-dataelement-11434
Id prsb03-dataelement-11434 (2019‑05‑30 14:09:25)
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
draft Contact details
prsb03-dataelement-11435
Id prsb03-dataelement-11435 (2019‑05‑30 14:09:25)
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
folder cancelled Performing professional
prsb03-dataelement-11198
Id prsb03-dataelement-11198 (2019‑05‑28 18:01:11)
Concept inherits from cancelled prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
cancelled Name
prsb03-dataelement-11199
Id prsb03-dataelement-11199 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11200
Id prsb03-dataelement-11200 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11201
Id prsb03-dataelement-11201 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11202
Id prsb03-dataelement-11202 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11203
Id prsb03-dataelement-11203 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11204
Id prsb03-dataelement-11204 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Professional identifier
prsb03-dataelement-11205
Id prsb03-dataelement-11205 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
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)
Value Domain
cancelled Start date
prsb03-dataelement-11206
Id prsb03-dataelement-11206 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11207
Id prsb03-dataelement-11207 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11208
Id prsb03-dataelement-11208 (2019‑05‑28 18:02:55)
Concept inherits from cancelled prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
folder cancelled Person completing record
prsb03-dataelement-11209
Id prsb03-dataelement-11209 (2019‑05‑28 18:04:59)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11210
Id prsb03-dataelement-11210 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11211
Id prsb03-dataelement-11211 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11212
Id prsb03-dataelement-11212 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11213
Id prsb03-dataelement-11213 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11214
Id prsb03-dataelement-11214 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11215
Id prsb03-dataelement-11215 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11216
Id prsb03-dataelement-11216 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11217
Id prsb03-dataelement-11217 (2019‑05‑28 18:05:50)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
folder cancelled Performing professional
prsb03-dataelement-11053
Id prsb03-dataelement-11053 (2019‑05‑24 11:27:22)
Concept inherits from cancelled prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
cancelled Name
prsb03-dataelement-11054
Id prsb03-dataelement-11054 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11055
Id prsb03-dataelement-11055 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11056
Id prsb03-dataelement-11056 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11057
Id prsb03-dataelement-11057 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11058
Id prsb03-dataelement-11058 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11059
Id prsb03-dataelement-11059 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11060
Id prsb03-dataelement-11060 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11061
Id prsb03-dataelement-11061 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11062
Id prsb03-dataelement-11062 (2019‑05‑24 11:28:02)
Concept inherits from cancelled prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
folder cancelled Person completing record
prsb03-dataelement-11063
Id prsb03-dataelement-11063 (2019‑05‑24 11:28:14)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11064
Id prsb03-dataelement-11064 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11065
Id prsb03-dataelement-11065 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11066
Id prsb03-dataelement-11066 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11067
Id prsb03-dataelement-11067 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11068
Id prsb03-dataelement-11068 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11069
Id prsb03-dataelement-11069 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11070
Id prsb03-dataelement-11070 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11071
Id prsb03-dataelement-11071 (2019‑05‑24 11:28:43)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Accessible information - requires communication support
prsb03-dataelement-10062
Id prsb03-dataelement-10062 (2018‑10‑31)
Description The communication support the person requires in order for information to be accessible.
draft Date
prsb03-dataelement-11701
Id prsb03-dataelement-11701 (2019‑05‑31 13:03:10)
Description The date the accessible information requirement was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Location
prsb03-dataelement-11702
Id prsb03-dataelement-11702 (2019‑05‑31 13:03:39)
Description The location where the accessible information requirement was identified.
Relationship
draft Coded value
prsb03-dataelement-13375
Id prsb03-dataelement-13375 (2020‑08‑06 19:07:03)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13376
Id prsb03-dataelement-13376 (2020‑08‑06 19:08:01)
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
folder draft Requires communication support
prsb03-dataelement-13365
Id prsb03-dataelement-13365 (2020‑08‑06 18:45:45)
Description The communication support the person requires in order for information to be accessible.
draft Coded value
prsb03-dataelement-13366
Id prsb03-dataelement-13366 (2020‑08‑06 18:47:48)
Description The coded value for communication support. https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/658
Operationalization SNOMED CT :- ^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)
Value Domain
draft Free text
prsb03-dataelement-13367
Id prsb03-dataelement-13367 (2020‑08‑06 18:48:50)
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
folder draft Performing professional
prsb03-dataelement-11436
Id prsb03-dataelement-11436 (2019‑05‑30 14:13:49)
Description The professional who identified the accessible information requirement.
Relationship
draft Name
prsb03-dataelement-11437
Id prsb03-dataelement-11437 (2019‑05‑30 14:18:52)
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
draft Role
prsb03-dataelement-11438
Id prsb03-dataelement-11438 (2019‑05‑30 14:18:52)
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
draft Grade
prsb03-dataelement-11439
Id prsb03-dataelement-11439 (2019‑05‑30 14:18:52)
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
draft Speciality
prsb03-dataelement-11440
Id prsb03-dataelement-11440 (2019‑05‑30 14:18:52)
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
draft Professional identifier
prsb03-dataelement-11441
Id prsb03-dataelement-11441 (2019‑05‑30 14:18:52)
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
folder draft Organisation
prsb03-dataelement-11442
Id prsb03-dataelement-11442 (2019‑05‑30 14:18:52)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11443
Id prsb03-dataelement-11443 (2019‑05‑30 14:18:52)
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
folder draft Person completing record
prsb03-dataelement-11444
Id prsb03-dataelement-11444 (2019‑05‑30 14:19:18)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11445
Id prsb03-dataelement-11445 (2019‑05‑30 14:19:57)
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
draft Role
prsb03-dataelement-11446
Id prsb03-dataelement-11446 (2019‑05‑30 14:19:57)
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
draft Grade
prsb03-dataelement-11447
Id prsb03-dataelement-11447 (2019‑05‑30 14:19:57)
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
draft Specialty
prsb03-dataelement-11448
Id prsb03-dataelement-11448 (2019‑05‑30 14:19:57)
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
folder draft Organisation
prsb03-dataelement-11449
Id prsb03-dataelement-11449 (2019‑05‑30 14:19:57)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11450
Id prsb03-dataelement-11450 (2019‑05‑30 14:19:57)
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
draft Date completed
prsb03-dataelement-11451
Id prsb03-dataelement-11451 (2019‑05‑30 14:19:57)
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
draft Contact details
prsb03-dataelement-11452
Id prsb03-dataelement-11452 (2019‑05‑30 14:19:57)
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
folder cancelled Performing professional
prsb03-dataelement-11218
Id prsb03-dataelement-11218 (2019‑05‑28 18:10:22)
Concept inherits from cancelled prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
cancelled Name
prsb03-dataelement-11219
Id prsb03-dataelement-11219 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11220
Id prsb03-dataelement-11220 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11221
Id prsb03-dataelement-11221 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11222
Id prsb03-dataelement-11222 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11223
Id prsb03-dataelement-11223 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11224
Id prsb03-dataelement-11224 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Professional identifier
prsb03-dataelement-11225
Id prsb03-dataelement-11225 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
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)
Value Domain
cancelled Start date
prsb03-dataelement-11226
Id prsb03-dataelement-11226 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11227
Id prsb03-dataelement-11227 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11228
Id prsb03-dataelement-11228 (2019‑05‑28 18:11:38)
Concept inherits from cancelled prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
folder cancelled Person completing record
prsb03-dataelement-11229
Id prsb03-dataelement-11229 (2019‑05‑28 18:13:20)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11230
Id prsb03-dataelement-11230 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11231
Id prsb03-dataelement-11231 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11232
Id prsb03-dataelement-11232 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11233
Id prsb03-dataelement-11233 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11234
Id prsb03-dataelement-11234 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11235
Id prsb03-dataelement-11235 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11236
Id prsb03-dataelement-11236 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11237
Id prsb03-dataelement-11237 (2019‑05‑28 18:13:47)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
folder cancelled Performing professional
prsb03-dataelement-11072
Id prsb03-dataelement-11072 (2019‑05‑24 11:29:36)
Concept inherits from cancelled prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
cancelled Name
prsb03-dataelement-11073
Id prsb03-dataelement-11073 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11074
Id prsb03-dataelement-11074 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11075
Id prsb03-dataelement-11075 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11076
Id prsb03-dataelement-11076 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11077
Id prsb03-dataelement-11077 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11078
Id prsb03-dataelement-11078 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11079
Id prsb03-dataelement-11079 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11080
Id prsb03-dataelement-11080 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11081
Id prsb03-dataelement-11081 (2019‑05‑24 11:31:26)
Concept inherits from cancelled prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
folder cancelled Person completing record
prsb03-dataelement-11082
Id prsb03-dataelement-11082 (2019‑05‑24 11:31:31)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11083
Id prsb03-dataelement-11083 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11084
Id prsb03-dataelement-11084 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11085
Id prsb03-dataelement-11085 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11086
Id prsb03-dataelement-11086 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11087
Id prsb03-dataelement-11087 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11088
Id prsb03-dataelement-11088 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11089
Id prsb03-dataelement-11089 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11090
Id prsb03-dataelement-11090 (2019‑05‑24 11:31:54)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Accessible information - requires communication professional
prsb03-dataelement-10061
Id prsb03-dataelement-10061 (2018‑10‑31)
Description Identifies that the person needs support from a communication professional in order for information to be accessible.
Operationalization SNOMED CT



Refset ^999002141000000102



https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/660
draft Date
prsb03-dataelement-11703
Id prsb03-dataelement-11703 (2019‑05‑31 13:04:26)
Description The date the accessible information requirement was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Location
prsb03-dataelement-11704
Id prsb03-dataelement-11704 (2019‑05‑31 13:04:51)
Description The location where the accessible information requirement was identified.
Relationship
draft Coded value
prsb03-dataelement-13377
Id prsb03-dataelement-13377 (2020‑08‑06 19:09:30)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13378
Id prsb03-dataelement-13378 (2020‑08‑06 19:10:29)
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
folder draft Requires communication professional
prsb03-dataelement-13368
Id prsb03-dataelement-13368 (2020‑08‑06 18:50:18)
Description Identifies that the person needs support from a communication professional in order for information to be accessible.
draft Coded value
prsb03-dataelement-13369
Id prsb03-dataelement-13369 (2020‑08‑06 18:55:08)
Description The coded value of communication professional. https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/660
Operationalization SNOMED CT :- ^999002151000000104 | Accessible information - requires communication professional simple reference set (foundation metadata concept) |
Value Domain
draft Free text
prsb03-dataelement-13370
Id prsb03-dataelement-13370 (2020‑08‑06 18:56:16)
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
folder draft Performing professional
prsb03-dataelement-11453
Id prsb03-dataelement-11453 (2019‑05‑30 14:21:39)
Description The professional who identified the accessible information requirement.
Relationship
draft Name
prsb03-dataelement-11454
Id prsb03-dataelement-11454 (2019‑05‑30 14:22:06)
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
draft Role
prsb03-dataelement-11455
Id prsb03-dataelement-11455 (2019‑05‑30 14:22:06)
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
draft Grade
prsb03-dataelement-11456
Id prsb03-dataelement-11456 (2019‑05‑30 14:22:06)
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
draft Speciality
prsb03-dataelement-11457
Id prsb03-dataelement-11457 (2019‑05‑30 14:22:06)
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
draft Professional identifier
prsb03-dataelement-11458
Id prsb03-dataelement-11458 (2019‑05‑30 14:22:06)
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
folder draft Organisation
prsb03-dataelement-11459
Id prsb03-dataelement-11459 (2019‑05‑30 14:22:06)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11460
Id prsb03-dataelement-11460 (2019‑05‑30 14:22:06)
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
folder draft Person completing record
prsb03-dataelement-11461
Id prsb03-dataelement-11461 (2019‑05‑30 14:23:01)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11462
Id prsb03-dataelement-11462 (2019‑05‑30 14:23:26)
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
draft Role
prsb03-dataelement-11463
Id prsb03-dataelement-11463 (2019‑05‑30 14:23:26)
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
draft Grade
prsb03-dataelement-11464
Id prsb03-dataelement-11464 (2019‑05‑30 14:23:26)
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
draft Specialty
prsb03-dataelement-11465
Id prsb03-dataelement-11465 (2019‑05‑30 14:23:26)
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
folder draft Organisation
prsb03-dataelement-11466
Id prsb03-dataelement-11466 (2019‑05‑30 14:23:26)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11467
Id prsb03-dataelement-11467 (2019‑05‑30 14:23:26)
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
draft Date completed
prsb03-dataelement-11468
Id prsb03-dataelement-11468 (2019‑05‑30 14:23:26)
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
draft Contact details
prsb03-dataelement-11469
Id prsb03-dataelement-11469 (2019‑05‑30 14:23:26)
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
folder cancelled Performing professional
prsb03-dataelement-11238
Id prsb03-dataelement-11238 (2019‑05‑28 18:14:43)
Concept inherits from cancelled prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
cancelled Name
prsb03-dataelement-11239
Id prsb03-dataelement-11239 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11240
Id prsb03-dataelement-11240 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11241
Id prsb03-dataelement-11241 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11242
Id prsb03-dataelement-11242 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11243
Id prsb03-dataelement-11243 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11244
Id prsb03-dataelement-11244 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Professional identifier
prsb03-dataelement-11245
Id prsb03-dataelement-11245 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
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)
Value Domain
cancelled Start date
prsb03-dataelement-11246
Id prsb03-dataelement-11246 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11247
Id prsb03-dataelement-11247 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11248
Id prsb03-dataelement-11248 (2019‑05‑28 18:15:22)
Concept inherits from cancelled prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
folder cancelled Person completing record
prsb03-dataelement-11249
Id prsb03-dataelement-11249 (2019‑05‑28 18:16:41)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11250
Id prsb03-dataelement-11250 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11251
Id prsb03-dataelement-11251 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11252
Id prsb03-dataelement-11252 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11253
Id prsb03-dataelement-11253 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11254
Id prsb03-dataelement-11254 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11255
Id prsb03-dataelement-11255 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11256
Id prsb03-dataelement-11256 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11257
Id prsb03-dataelement-11257 (2019‑05‑28 18:17:17)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
folder cancelled Performing professional
prsb03-dataelement-11091
Id prsb03-dataelement-11091 (2019‑05‑24 11:32:54)
Concept inherits from cancelled prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
cancelled Name
prsb03-dataelement-11092
Id prsb03-dataelement-11092 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11093
Id prsb03-dataelement-11093 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11094
Id prsb03-dataelement-11094 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11095
Id prsb03-dataelement-11095 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11096
Id prsb03-dataelement-11096 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11097
Id prsb03-dataelement-11097 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11098
Id prsb03-dataelement-11098 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11099
Id prsb03-dataelement-11099 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11100
Id prsb03-dataelement-11100 (2019‑05‑24 11:33:21)
Concept inherits from cancelled prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
folder cancelled Person completing record
prsb03-dataelement-11101
Id prsb03-dataelement-11101 (2019‑05‑24 11:33:32)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11102
Id prsb03-dataelement-11102 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11103
Id prsb03-dataelement-11103 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11104
Id prsb03-dataelement-11104 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11105
Id prsb03-dataelement-11105 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11106
Id prsb03-dataelement-11106 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11107
Id prsb03-dataelement-11107 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11108
Id prsb03-dataelement-11108 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11109
Id prsb03-dataelement-11109 (2019‑05‑24 11:33:56)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Reasonable adjustment
prsb03-dataelement-12991
Id prsb03-dataelement-12991 (2020‑04‑23 19:50:39)
Description A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
folder draft Reasonable adjustment record entry
prsb03-dataelement-13061
Id prsb03-dataelement-13061 (2020‑05‑12 14:38:35)
Description This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
folder draft Location
prsb03-dataelement-13098
Id prsb03-dataelement-13098 (2020‑06‑24 11:17:33)
Description The location where the reasonable adjustment was identified.
draft Coded value
prsb03-dataelement-13357
Id prsb03-dataelement-13357 (2020‑08‑06 17:41:52)
Description The coded value for location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13358
Id prsb03-dataelement-13358 (2020‑08‑06 17:44:19)
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
draft Reasonable adjustment flag
prsb03-dataelement-13874
Id prsb03-dataelement-13874 (2021‑01‑29 12:59:53)
Description

Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.

Reasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with physical or sensory disabilities, learning disabilities or long-term conditions such as dementia.

Other adjustments include longer appointments, providing easy read materials or communications via a carer. This legal duty is anticipatory which means a service should know about a person’s need for adjustments when they are referred or present for care. For this to happen, and for optimum care to be delivered, adjustments need to be recorded and shared across the NHS.

Operationalization SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|
Value Domain
folder draft Reasonable adjustment
prsb03-dataelement-13017
Id prsb03-dataelement-13017 (2020‑04‑28 18:57:15)
Description The reasonable adjustment required e.g. requires specific contact method, requires communication professional
draft Coded value
prsb03-dataelement-13505
Id prsb03-dataelement-13505 (2020‑09‑02 18:40:38)
Description The coded value for reasonable adjustment
Operationalization SNOMED CT : - Accessible information standard

^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|

^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|

^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|

^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|

Refsets for other categories in development
Value Domain
draft Free text
prsb03-dataelement-13506
Id prsb03-dataelement-13506 (2020‑09‑02 18:41:44)
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
draft Reasonable adjustment additional detail
prsb03-dataelement-13018
Id prsb03-dataelement-13018 (2020‑04‑28 19:01:03)
Description Further detail about the support required and the consequence of not providing it.
Operationalization Free text
Value Domain
draft Date
prsb03-dataelement-13020
Id prsb03-dataelement-13020 (2020‑04‑28 19:14:37)
Description The date the reasonable adjustment was identified.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Performing professional
prsb03-dataelement-13027
Id prsb03-dataelement-13027 (2020‑04‑28 19:30:46)
Description The professional who confirmed the need for the reasonable adjustment.
Relationship
draft Name
prsb03-dataelement-13028
Id prsb03-dataelement-13028 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12185 (2019‑05‑31 16:19:35)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13029
Id prsb03-dataelement-13029 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12186 (2019‑05‑31 16:19:35)
Description The role the professional has in relation to the person.
Relationship
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Grade
prsb03-dataelement-13030
Id prsb03-dataelement-13030 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12187 (2019‑05‑31 16:19:35)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-13031
Id prsb03-dataelement-13031 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12188 (2019‑05‑31 16:19:35)
Description The specialty of the professional.
Relationship
Operationalization NHS data dictionary - Main specialty code
Value Domain
Property
max length
3
draft Professional identifier
prsb03-dataelement-13032
Id prsb03-dataelement-13032 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12189 (2019‑05‑31 16:19:35)
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
folder draft Organisation
prsb03-dataelement-13033
Id prsb03-dataelement-13033 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12190 (2019‑05‑31 16:19:35)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13034
Id prsb03-dataelement-13034 (2020‑04‑28 19:31:24)
Concept inherits from draft prsb03-dataelement-12191 (2019‑05‑31 16:19:35)
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
folder draft Person completing record
prsb03-dataelement-13035
Id prsb03-dataelement-13035 (2020‑04‑28 19:33:13)
Description A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-13036
Id prsb03-dataelement-13036 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Role
prsb03-dataelement-13037
Id prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Grade
prsb03-dataelement-13038
Id prsb03-dataelement-13038 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Specialty
prsb03-dataelement-13039
Id prsb03-dataelement-13039 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
folder draft Organisation
prsb03-dataelement-13040
Id prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Professional identifier
prsb03-dataelement-13041
Id prsb03-dataelement-13041 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Date completed
prsb03-dataelement-13042
Id prsb03-dataelement-13042 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
draft Contact details
prsb03-dataelement-13043
Id prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
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 0 transactions, 0 templates, inherited 3 times
 
cancelled Performing Professional
prsb03-dataelement-13026
Id prsb03-dataelement-13026 (2020‑04‑28 19:29:36) 0.2
Concept inherits from draft prsb03-dataelement-10316 (2018‑10‑31)
Description Details of the professional performing the immunisation (including name and role)
Value Domain
cancelled Performing Professional
prsb03-dataelement-13021
Id prsb03-dataelement-13021 (2020‑04‑28 19:15:45) 0.1
Description Details of the professional assigning the reasonable adjustment (including name and role).
Relationship
Value Domain
cancelled Person completing record
prsb03-dataelement-13019
Id prsb03-dataelement-13019 (2020‑04‑28 19:13:17) 0.2
Concept inherits from cancelled prsb03-dataelement-10954 (2019‑05‑18 21:07:16)
Description This is the person completing the record.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
cancelled Autism
prsb03-dataelement-12992
Id prsb03-dataelement-12992 (2020‑04‑23 19:51:53) 0.1
Description
Impairment related to autism (Equality Act 2010)
Operationalization Free text
Value Domain
cancelled Developmental conditions (excluding autism)
prsb03-dataelement-12993
Id prsb03-dataelement-12993 (2020‑04‑23 19:53:01) 0.1
Description Impairment related to developmental conditions (excluding autism) (Equality Act 2010), such as dyslexia or dyspraxia
Operationalization

Free text
Value Domain
cancelled Dementia
prsb03-dataelement-12994
Id prsb03-dataelement-12994 (2020‑04‑23 19:55:03) 0.1
Description Impairment related to dementia (Equality Act 2010)
Operationalization Free text
Value Domain
cancelled Learning disability
prsb03-dataelement-12995
Id prsb03-dataelement-12995 (2020‑04‑23 19:56:39) 0.1
Description
Impairment related to learning disability (Equality Act 2010)
Operationalization Free text
Value Domain
cancelled Mental health condition
prsb03-dataelement-12996
Id prsb03-dataelement-12996 (2020‑04‑23 19:57:50) 0.1
Description
Impairment related to learning disability (Equality Act 2010)
Operationalization Free text
Value Domain
cancelled Physical disability
prsb03-dataelement-12997
Id prsb03-dataelement-12997 (2020‑04‑23 19:59:41) 0.1
Description
Impairment related to physical disability (Equality Act 2010), produced by injury to the body, including to the brain.
Operationalization Free text
Value Domain
cancelled Sensory disability - such as sight, hearing or verbal
prsb03-dataelement-12998
Id prsb03-dataelement-12998 (2020‑04‑23 20:01:42) 0.1
Description Impairment related to sensory disability (Equality Act 2010), such as those affecting sight or hearing;
Operationalization Free text
Value Domain
cancelled Long-term condition
prsb03-dataelement-12999
Id prsb03-dataelement-12999 (2020‑04‑23 20:04:04) 0.1
Description
Impairment related to long-term condition (Equality Act 2010), including impairments with fluctuating or recurring effects such as rheumatoid arthritis, myalgic encephalitis (ME), chronic fatigue syndrome (CFS), fibromyalgia, depression and epilepsy;progressive, such as motor neurone disease, muscular dystrophy, and forms of dementia; auto-immune conditions such as systemic lupus erythematosus (SLE); organ specific, including respiratory conditions, such as asthma, and cardiovascular diseases, including thrombosis, stroke and heart disease.
There is specific guidance in relation to HIV, cancer and multiple sclerosis
Operationalization Free text
Value Domain
cancelled Prefers not to say
prsb03-dataelement-13000
Id prsb03-dataelement-13000 (2020‑04‑23 20:05:12) 0.1
Description Person prefers not to share impairment on reasonable adjustment record.
Operationalization Free text
Value Domain
folder draft Impairment
prsb03-dataelement-13001
Id prsb03-dataelement-13001 (2020‑04‑23 20:09:01)
Description A record of any impairments for the person relating to reasonable adjustments.
folder draft Impairment record entry
prsb03-dataelement-13062
Id prsb03-dataelement-13062 (2020‑05‑12 15:52:51)
Description This is an impairment 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
folder draft Location
prsb03-dataelement-13099
Id prsb03-dataelement-13099 (2020‑06‑24 11:19:59)
Description The location where the impairment was identified.
draft Coded value
prsb03-dataelement-13429
Id prsb03-dataelement-13429 (2020‑08‑13 15:01:40)
Description The coded value for location.
Operationalization NHS data dictionary: - Organisation code service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13430
Id prsb03-dataelement-13430 (2020‑08‑13 15:38:25)
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
folder draft Impairment category
prsb03-dataelement-13022
Id prsb03-dataelement-13022 (2020‑04‑28 19:21:25)
Description
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
draft Coded value
prsb03-dataelement-13507
Id prsb03-dataelement-13507 (2020‑09‑02 18:45:17)
Description The coded value for impairment.
Operationalization SNOMED CT
Value Domain
draft Free text
prsb03-dataelement-13508
Id prsb03-dataelement-13508 (2020‑09‑02 18:46:00)
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
draft Impairment additional detail
prsb03-dataelement-13023
Id prsb03-dataelement-13023 (2020‑04‑28 19:23:16)
Description

Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
Operationalization Free text
Value Domain
Property
max length
150
draft Date
prsb03-dataelement-13024
Id prsb03-dataelement-13024 (2020‑04‑28 19:24:22)
Description The date the impairment was identified.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Performing professional
prsb03-dataelement-13044
Id prsb03-dataelement-13044 (2020‑04‑28 19:34:59)
Description The professional who confirmed the impairment.
Relationship
draft Name
prsb03-dataelement-13045
Id prsb03-dataelement-13045 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13046
Id prsb03-dataelement-13046 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
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
draft Grade
prsb03-dataelement-13047
Id prsb03-dataelement-13047 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-13048
Id prsb03-dataelement-13048 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
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
draft Professional identifier
prsb03-dataelement-13049
Id prsb03-dataelement-13049 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
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
folder draft Organisation
prsb03-dataelement-13050
Id prsb03-dataelement-13050 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13051
Id prsb03-dataelement-13051 (2020‑04‑28 19:35:28)
Concept inherits from draft prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
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
folder draft Person completing record
prsb03-dataelement-13052
Id prsb03-dataelement-13052 (2020‑04‑28 19:36:14)
Description
A record of the details of the person that entered the impairment and the date on which it was entered.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-13053
Id prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Role
prsb03-dataelement-13054
Id prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Grade
prsb03-dataelement-13055
Id prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Specialty
prsb03-dataelement-13056
Id prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
folder draft Organisation
prsb03-dataelement-13057
Id prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Professional identifier
prsb03-dataelement-13058
Id prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Date completed
prsb03-dataelement-13059
Id prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
draft Contact details
prsb03-dataelement-13060
Id prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited 2 times
 
cancelled Performing Professional
prsb03-dataelement-13025
Id prsb03-dataelement-13025 (2020‑04‑28 19:25:46) 0.2
Description Details of the professional performing diagnosing the impairment (including name and role)
Relationship
Value Domain
folder draft Cognition
prsb03-dataelement-10066
Id prsb03-dataelement-10066 (2018‑10‑31)
Description Details of the persons cognitive impairment.
draft Date
prsb03-dataelement-11705
Id prsb03-dataelement-11705 (2019‑05‑31 13:05:51)
Description The date when the cognitive impairment was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11706
Id prsb03-dataelement-11706 (2019‑05‑31 13:06:37)
Description The location where the cognitive impairment was identified.
Relationship
draft Coded value
prsb03-dataelement-13431
Id prsb03-dataelement-13431 (2020‑08‑13 15:39:55)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13432
Id prsb03-dataelement-13432 (2020‑08‑13 15:41:10)
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
draft Cognition
prsb03-dataelement-13669
Id prsb03-dataelement-13669 (2020‑09‑08 22:42:26)
Description The cognitive impairment to be considered when communicating with the person, child or their primary carer.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11470
Id prsb03-dataelement-11470 (2019‑05‑30 14:25:03)
Description The professional who identified the cognitive impairment.
Relationship
draft Name
prsb03-dataelement-11471
Id prsb03-dataelement-11471 (2019‑05‑30 14:25:24)
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
draft Role
prsb03-dataelement-11472
Id prsb03-dataelement-11472 (2019‑05‑30 14:25:24)
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
draft Grade
prsb03-dataelement-11473
Id prsb03-dataelement-11473 (2019‑05‑30 14:25:24)
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
draft Speciality
prsb03-dataelement-11474
Id prsb03-dataelement-11474 (2019‑05‑30 14:25:24)
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
draft Professional identifier
prsb03-dataelement-11475
Id prsb03-dataelement-11475 (2019‑05‑30 14:25:24)
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
folder draft Organisation
prsb03-dataelement-11476
Id prsb03-dataelement-11476 (2019‑05‑30 14:25:24)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11477
Id prsb03-dataelement-11477 (2019‑05‑30 14:25:24)
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
folder draft Person completing record
prsb03-dataelement-11478
Id prsb03-dataelement-11478 (2019‑05‑30 14:25:35)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11479
Id prsb03-dataelement-11479 (2019‑05‑30 14:26:05)
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
draft Role
prsb03-dataelement-11480
Id prsb03-dataelement-11480 (2019‑05‑30 14:26:05)
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
draft Grade
prsb03-dataelement-11481
Id prsb03-dataelement-11481 (2019‑05‑30 14:26:05)
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
draft Specialty
prsb03-dataelement-11482
Id prsb03-dataelement-11482 (2019‑05‑30 14:26:05)
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
folder draft Organisation
prsb03-dataelement-11483
Id prsb03-dataelement-11483 (2019‑05‑30 14:26:05)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11484
Id prsb03-dataelement-11484 (2019‑05‑30 14:26:05)
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
draft Date completed
prsb03-dataelement-11485
Id prsb03-dataelement-11485 (2019‑05‑30 14:26:05)
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
draft Contact details
prsb03-dataelement-11486
Id prsb03-dataelement-11486 (2019‑05‑30 14:26:05)
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
folder cancelled Performing professional
prsb03-dataelement-11110
Id prsb03-dataelement-11110 (2019‑05‑24 11:37:44)
Concept inherits from cancelled prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
cancelled Name
prsb03-dataelement-11111
Id prsb03-dataelement-11111 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11112
Id prsb03-dataelement-11112 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11113
Id prsb03-dataelement-11113 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11114
Id prsb03-dataelement-11114 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11115
Id prsb03-dataelement-11115 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11116
Id prsb03-dataelement-11116 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11117
Id prsb03-dataelement-11117 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11118
Id prsb03-dataelement-11118 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11119
Id prsb03-dataelement-11119 (2019‑05‑24 11:38:06)
Concept inherits from cancelled prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
folder cancelled Person completing record
prsb03-dataelement-11120
Id prsb03-dataelement-11120 (2019‑05‑24 11:38:33)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11121
Id prsb03-dataelement-11121 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11122
Id prsb03-dataelement-11122 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11123
Id prsb03-dataelement-11123 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11124
Id prsb03-dataelement-11124 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11125
Id prsb03-dataelement-11125 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11126
Id prsb03-dataelement-11126 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11127
Id prsb03-dataelement-11127 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11128
Id prsb03-dataelement-11128 (2019‑05‑24 11:38:55)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Mobility
prsb03-dataelement-10067
Id prsb03-dataelement-10067 (2018‑10‑31)
Description Details of the person's mobility needs.
draft Date
prsb03-dataelement-11707
Id prsb03-dataelement-11707 (2019‑05‑31 13:08:03)
Description The date when the mobility needs were identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11710
Id prsb03-dataelement-11710 (2019‑05‑31 13:11:14)
Description The location where the mobility needs were identified.
Relationship
draft Coded value
prsb03-dataelement-13433
Id prsb03-dataelement-13433 (2020‑08‑13 15:42:39)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13434
Id prsb03-dataelement-13434 (2020‑08‑13 15:44:10)
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
folder draft Mobility needs
prsb03-dataelement-13670
Id prsb03-dataelement-13670 (2020‑09‑08 22:45:14)
Description The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
draft Coded value
prsb03-dataelement-13671
Id prsb03-dataelement-13671 (2020‑09‑08 22:47:06)
Description The coded value for mobility needs
Operationalization SNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13672
Id prsb03-dataelement-13672 (2020‑09‑08 22:47:50)
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
cancelled Location
prsb03-dataelement-11709
Id prsb03-dataelement-11709 (2019‑05‑31 13:09:26)
Value Domain
cancelled Location
prsb03-dataelement-11708
Id prsb03-dataelement-11708 (2019‑05‑31 13:08:30)
Value Domain
folder draft Performing professional
prsb03-dataelement-11487
Id prsb03-dataelement-11487 (2019‑05‑30 14:26:29)
Description The professional who identified the mobility needs.
Relationship
draft Name
prsb03-dataelement-11488
Id prsb03-dataelement-11488 (2019‑05‑30 14:27:10)
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
draft Role
prsb03-dataelement-11489
Id prsb03-dataelement-11489 (2019‑05‑30 14:27:10)
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
draft Grade
prsb03-dataelement-11490
Id prsb03-dataelement-11490 (2019‑05‑30 14:27:10)
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
draft Speciality
prsb03-dataelement-11491
Id prsb03-dataelement-11491 (2019‑05‑30 14:27:10)
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
draft Professional identifier
prsb03-dataelement-11492
Id prsb03-dataelement-11492 (2019‑05‑30 14:27:10)
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
folder draft Organisation
prsb03-dataelement-11493
Id prsb03-dataelement-11493 (2019‑05‑30 14:27:10)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11494
Id prsb03-dataelement-11494 (2019‑05‑30 14:27:10)
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
folder draft Person completing record
prsb03-dataelement-11495
Id prsb03-dataelement-11495 (2019‑05‑30 14:27:24)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11496
Id prsb03-dataelement-11496 (2019‑05‑30 14:27:45)
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
draft Role
prsb03-dataelement-11497
Id prsb03-dataelement-11497 (2019‑05‑30 14:27:45)
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
draft Grade
prsb03-dataelement-11498
Id prsb03-dataelement-11498 (2019‑05‑30 14:27:45)
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
draft Specialty
prsb03-dataelement-11499
Id prsb03-dataelement-11499 (2019‑05‑30 14:27:45)
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
folder draft Organisation
prsb03-dataelement-11500
Id prsb03-dataelement-11500 (2019‑05‑30 14:27:45)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11501
Id prsb03-dataelement-11501 (2019‑05‑30 14:27:45)
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
draft Date completed
prsb03-dataelement-11502
Id prsb03-dataelement-11502 (2019‑05‑30 14:27:45)
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
draft Contact details
prsb03-dataelement-11503
Id prsb03-dataelement-11503 (2019‑05‑30 14:27:45)
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
folder cancelled Performing professional
prsb03-dataelement-11129
Id prsb03-dataelement-11129 (2019‑05‑24 11:40:07)
Concept inherits from cancelled prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
Description The performing professional identifying the requirement.
Relationship
cancelled Name
prsb03-dataelement-11130
Id prsb03-dataelement-11130 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11131
Id prsb03-dataelement-11131 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11132
Id prsb03-dataelement-11132 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11133
Id prsb03-dataelement-11133 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11134
Id prsb03-dataelement-11134 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11135
Id prsb03-dataelement-11135 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Start date
prsb03-dataelement-11136
Id prsb03-dataelement-11136 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11137
Id prsb03-dataelement-11137 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11138
Id prsb03-dataelement-11138 (2019‑05‑24 11:40:41)
Concept inherits from cancelled prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
folder cancelled Person completing record
prsb03-dataelement-11139
Id prsb03-dataelement-11139 (2019‑05‑24 11:41:00)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11140
Id prsb03-dataelement-11140 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11141
Id prsb03-dataelement-11141 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11142
Id prsb03-dataelement-11142 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11143
Id prsb03-dataelement-11143 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11144
Id prsb03-dataelement-11144 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11145
Id prsb03-dataelement-11145 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11146
Id prsb03-dataelement-11146 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11147
Id prsb03-dataelement-11147 (2019‑05‑24 11:41:23)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
folder draft Other individual requirements
prsb03-dataelement-10835
Id prsb03-dataelement-10835 (2019‑03‑22 16:24:41)
Description Details of any other individual requirements the person may have
draft Date
prsb03-dataelement-11711
Id prsb03-dataelement-11711 (2019‑05‑31 13:12:01)
Description The date when the other individual requirements were identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Location
prsb03-dataelement-11712
Id prsb03-dataelement-11712 (2019‑05‑31 13:12:31)
Description The location where the other individual requirements were identified.
Relationship
draft Coded value
prsb03-dataelement-13435
Id prsb03-dataelement-13435 (2020‑08‑13 15:46:58)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13436
Id prsb03-dataelement-13436 (2020‑08‑13 15:48:03)
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
draft Other individual requirement
prsb03-dataelement-13673
Id prsb03-dataelement-13673 (2020‑09‑08 22:51:48)
Description Other individual requirements that a person may have.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11504
Id prsb03-dataelement-11504 (2019‑05‑30 14:34:59)
Description The professional who identified the other individual requirements.
Relationship
draft Name
prsb03-dataelement-11505
Id prsb03-dataelement-11505 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-11506
Id prsb03-dataelement-11506 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-11507
Id prsb03-dataelement-11507 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
draft Speciality
prsb03-dataelement-11508
Id prsb03-dataelement-11508 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-11509
Id prsb03-dataelement-11509 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-11510
Id prsb03-dataelement-11510 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-11511
Id prsb03-dataelement-11511 (2019‑05‑30 14:35:29)
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 0 transactions, 0 templates, inherited once
 
folder draft Person completing record
prsb03-dataelement-11512
Id prsb03-dataelement-11512 (2019‑05‑30 14:35:41)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11513
Id prsb03-dataelement-11513 (2019‑05‑30 14:36:02)
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
draft Role
prsb03-dataelement-11514
Id prsb03-dataelement-11514 (2019‑05‑30 14:36:02)
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
draft Grade
prsb03-dataelement-11515
Id prsb03-dataelement-11515 (2019‑05‑30 14:36:02)
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
draft Specialty
prsb03-dataelement-11516
Id prsb03-dataelement-11516 (2019‑05‑30 14:36:02)
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
folder draft Organisation
prsb03-dataelement-11517
Id prsb03-dataelement-11517 (2019‑05‑30 14:36:02)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11518
Id prsb03-dataelement-11518 (2019‑05‑30 14:36:02)
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
draft Date completed
prsb03-dataelement-11519
Id prsb03-dataelement-11519 (2019‑05‑30 14:36:02)
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
draft Contact details
prsb03-dataelement-11520
Id prsb03-dataelement-11520 (2019‑05‑30 14:36:02)
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
folder cancelled Performing professional
prsb03-dataelement-11260
Id prsb03-dataelement-11260 (2019‑05‑29 13:38:29)
Concept inherits from cancelled prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
cancelled Name
prsb03-dataelement-11261
Id prsb03-dataelement-11261 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-11262
Id prsb03-dataelement-11262 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
cancelled Speciality
prsb03-dataelement-11263
Id prsb03-dataelement-11263 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
cancelled Team
prsb03-dataelement-11264
Id prsb03-dataelement-11264 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
folder cancelled Organisation
prsb03-dataelement-11265
Id prsb03-dataelement-11265 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Description The name of the organisation.
cancelled Contact details
prsb03-dataelement-11266
Id prsb03-dataelement-11266 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
cancelled Professional identifier
prsb03-dataelement-11267
Id prsb03-dataelement-11267 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
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)
Value Domain
cancelled Start date
prsb03-dataelement-11268
Id prsb03-dataelement-11268 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled End date
prsb03-dataelement-11269
Id prsb03-dataelement-11269 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Professional contacts record entry
prsb03-dataelement-11270
Id prsb03-dataelement-11270 (2019‑05‑29 13:39:03)
Concept inherits from cancelled prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
folder cancelled Person completing record
prsb03-dataelement-11271
Id prsb03-dataelement-11271 (2019‑05‑29 13:40:37)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11272
Id prsb03-dataelement-11272 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11273
Id prsb03-dataelement-11273 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11274
Id prsb03-dataelement-11274 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11275
Id prsb03-dataelement-11275 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11276
Id prsb03-dataelement-11276 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11277
Id prsb03-dataelement-11277 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11278
Id prsb03-dataelement-11278 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11279
Id prsb03-dataelement-11279 (2019‑05‑29 13:40:57)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Performing professional
prsb03-dataelement-11258
Id prsb03-dataelement-11258 (2019‑05‑29 11:24:50)
Value Domain
cancelled IRRE
prsb03-dataelement-10648
Id prsb03-dataelement-10648 (2018‑11‑12 15:35:54)
Value Domain
cancelled IRRE
prsb03-dataelement-10647
Id prsb03-dataelement-10647 (2018‑11‑12 15:34:56)
Value Domain
folder draft Individual requirements record entry
prsb03-dataelement-10645
Id prsb03-dataelement-10645 (2018‑11‑12 15:00:49)
Description This is an individual requirement 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.
draft Individual requirement
prsb03-dataelement-10060
Id prsb03-dataelement-10060 (2018‑10‑31)
Description Individual requirement that a person has. These may be communication, cultural, cognitive or mobility needs.

Properties

FHIR Patient. nhsCommunications
Operationalization Information volunteered by the person or their representative or carer, or known about locally.Text or coded text (SNOMED CT), constrained as specified in SCCI1605.



Accessible Information standard

Accessible information - communications support refset ^999002121000000109https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/657

Accessible information - requires communications professional refset ^999002141000000102https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/660

Accessible information - requires specific contact method refset ^999002151000000104https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/658

Accessible information - requires specific information format refset ^999002131000000106https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/659
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Date
prsb03-dataelement-10858
Id prsb03-dataelement-10858 (2019‑03‑27 17:44:40)
Description The date on which the individual requirement was identified.
Relationship
Operationalization Date and time.
Value Domain
draft Location
prsb03-dataelement-10859
Id prsb03-dataelement-10859 (2019‑03‑27 17:45:48)
Description The location where the accessible information was identified.
Relationship
Operationalization ODS Code or free text.
Value Domain
cancelled Performing professional
prsb03-dataelement-10970
Id prsb03-dataelement-10970 (2019‑05‑22 15:20:30)
Description Details of the professional identifying the individual requirements.
Relationship
Value Domain
cancelled Person completing record
prsb03-dataelement-10860
Id prsb03-dataelement-10860 (2019‑03‑27 17:46:45)
Description This is the person recording the individual requirement.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
target Used by 0 transactions, 0 templates, inherited 4 times
 
folder cancelled Accessible Information
prsb03-dataelement-10064
Id prsb03-dataelement-10064 (2018‑10‑31)
Description Details of the accessible information
draft Child or Parent/Carer/Guardian
prsb03-dataelement-10065
Id prsb03-dataelement-10065 (2018‑10‑31)
Description An indicator of whether the individual requirement relates to the child or their primary carer.
Value Domain
folder draft Alerts
prsb03-dataelement-10741
Id prsb03-dataelement-10741 (2019‑03‑06 17:55:12)
Description Details of alerts.
folder draft Alerts record entry
prsb03-dataelement-10916
Id prsb03-dataelement-10916 (2019‑04‑09 12:53:12)
Description This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
draft Date
prsb03-dataelement-10755
Id prsb03-dataelement-10755 (2019‑03‑07 18:40:35)
Description The date the alert was recorded.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location of alert
prsb03-dataelement-10756
Id prsb03-dataelement-10756 (2019‑03‑07 18:40:55)
Description The organisation raising the alert.
draft Coded value
prsb03-dataelement-13568
Id prsb03-dataelement-13568 (2020‑09‑07 12:15:55)
Description The coded value of location
Operationalization NHS data dictionary: - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13569
Id prsb03-dataelement-13569 (2020‑09‑07 12:19:02)
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
draft Alert
prsb03-dataelement-10742
Id prsb03-dataelement-10742 (2019‑03‑06 18:10:58)
Description Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).
Operationalization Free text
Value Domain
folder draft Performing professional
prsb03-dataelement-10758
Id prsb03-dataelement-10758 (2019‑03‑08 12:59:18)
Concept inherits from draft prsb03-dataelement-12150 (2019‑05‑31 16:08:40)
Description The professional who performed the procedure.
Relationship
draft Name
prsb03-dataelement-12977
Id prsb03-dataelement-12977 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12151 (2019‑05‑31 16:09:20)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-12978
Id prsb03-dataelement-12978 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12152 (2019‑05‑31 16:09:20)
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
draft Grade
prsb03-dataelement-12979
Id prsb03-dataelement-12979 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12153 (2019‑05‑31 16:09:20)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-12980
Id prsb03-dataelement-12980 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12154 (2019‑05‑31 16:09:20)
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
draft Professional identifier
prsb03-dataelement-12981
Id prsb03-dataelement-12981 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12155 (2019‑05‑31 16:09:20)
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
folder draft Organisation
prsb03-dataelement-12982
Id prsb03-dataelement-12982 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12156 (2019‑05‑31 16:09:20)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-12983
Id prsb03-dataelement-12983 (2020‑04‑23 12:56:38)
Concept inherits from draft prsb03-dataelement-12157 (2019‑05‑31 16:09:20)
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
folder draft Person completing record
prsb03-dataelement-12399
Id prsb03-dataelement-12399 (2019‑06‑05 13:09:30)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-12400
Id prsb03-dataelement-12400 (2019‑06‑05 13:10:34)
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
draft Role
prsb03-dataelement-12401
Id prsb03-dataelement-12401 (2019‑06‑05 13:10:34)
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
draft Grade
prsb03-dataelement-12402
Id prsb03-dataelement-12402 (2019‑06‑05 13:10:34)
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
draft Specialty
prsb03-dataelement-12403
Id prsb03-dataelement-12403 (2019‑06‑05 13:10:34)
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
folder draft Organisation
prsb03-dataelement-12404
Id prsb03-dataelement-12404 (2019‑06‑05 13:10:34)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-12405
Id prsb03-dataelement-12405 (2019‑06‑05 13:10:34)
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
draft Date completed
prsb03-dataelement-12406
Id prsb03-dataelement-12406 (2019‑06‑05 13:10:34)
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
draft Contact details
prsb03-dataelement-12407
Id prsb03-dataelement-12407 (2019‑06‑05 13:10:34)
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
folder draft Legal information
prsb03-dataelement-520
Id prsb03-dataelement-520 (2018‑10‑31)
Description The legal information relating to the person.
folder draft Consent for treatment record
prsb03-dataelement-10420
Id prsb03-dataelement-10420 (2018‑10‑31)
Description Details of the person's consent for treatment.
draft Date
prsb03-dataelement-13457
Id prsb03-dataelement-13457 (2020‑09‑02 12:31:32)
Description The date the consent was taken
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-13459
Id prsb03-dataelement-13459 (2020‑09‑02 12:33:42)
Description The location of where the consent was taken.
Relationship
draft Coded value
prsb03-dataelement-13460
Id prsb03-dataelement-13460 (2020‑09‑02 12:34:21)
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
draft Free text
prsb03-dataelement-13461
Id prsb03-dataelement-13461 (2020‑09‑02 12:34:21)
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
draft Consent for treatment record
prsb03-dataelement-13574
Id prsb03-dataelement-13574 (2020‑09‑07 16:40:51)
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
draft Location of document
prsb03-dataelement-13777
Id prsb03-dataelement-13777 (2020‑10‑16 16:32:46)
Description The location of the consent for treatment record.
Relationship
Operationalization Free text or URL
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-13462
Id prsb03-dataelement-13462 (2020‑09‑02 12:35:54)
Description The professional who took the consent for treatment.
Relationship
draft Name
prsb03-dataelement-13463
Id prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
draft Role
prsb03-dataelement-13464
Id prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
draft Grade
prsb03-dataelement-13465
Id prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
draft Speciality
prsb03-dataelement-13466
Id prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
draft Professional identifier
prsb03-dataelement-13467
Id prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
folder draft Organisation
prsb03-dataelement-13468
Id prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
draft Contact details
prsb03-dataelement-13469
Id prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
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 0 transactions, 0 templates, inherited 2 times
 
folder draft Person completing record
prsb03-dataelement-13470
Id prsb03-dataelement-13470 (2020‑09‑02 12:40:15)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-13471
Id prsb03-dataelement-13471 (2020‑09‑02 12:41:04)
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
draft Role
prsb03-dataelement-13472
Id prsb03-dataelement-13472 (2020‑09‑02 12:41:04)
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
draft Grade
prsb03-dataelement-13473
Id prsb03-dataelement-13473 (2020‑09‑02 12:41:04)
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
draft Specialty
prsb03-dataelement-13474
Id prsb03-dataelement-13474 (2020‑09‑02 12:41:04)
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
folder draft Organisation
prsb03-dataelement-13475
Id prsb03-dataelement-13475 (2020‑09‑02 12:41:04)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-13476
Id prsb03-dataelement-13476 (2020‑09‑02 12:41:04)
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
draft Date completed
prsb03-dataelement-13477
Id prsb03-dataelement-13477 (2020‑09‑02 12:41:04)
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
draft Contact details
prsb03-dataelement-13478
Id prsb03-dataelement-13478 (2020‑09‑02 12:41:04)
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
cancelled Location
prsb03-dataelement-13458
Id prsb03-dataelement-13458 (2020‑09‑02 12:32:19) 0.1
Concept inherits from draft prsb03-dataelement-10139 (2018‑10‑31)
Description The location where the procedure was performed.
Operationalization ODS code or free text
Value Domain
folder draft Consent for information sharing
prsb03-dataelement-10421
Id prsb03-dataelement-10421 (2018‑10‑31)
Description Details of the person's consent for information sharing
draft Date
prsb03-dataelement-11713
Id prsb03-dataelement-11713 (2019‑05‑31 13:15:18)
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
folder draft Location
prsb03-dataelement-11714
Id prsb03-dataelement-11714 (2019‑05‑31 13:15:54)
Description The location where the consent was taken.
Relationship
draft Coded value
prsb03-dataelement-13451
Id prsb03-dataelement-13451 (2020‑08‑27 16:51:03)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13452
Id prsb03-dataelement-13452 (2020‑08‑27 16:52:16)
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
draft Consent for information sharing
prsb03-dataelement-13575
Id prsb03-dataelement-13575 (2020‑09‑07 16:47:31)
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
draft Reason for consent not given
prsb03-dataelement-13778
Id prsb03-dataelement-13778 (2020‑10‑16 16:34:53)
Description Reason not given for consent
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11715
Id prsb03-dataelement-11715 (2019‑05‑31 13:16:35)
Description The professional who took the consent for information sharing
Relationship
draft Name
prsb03-dataelement-11716
Id prsb03-dataelement-11716 (2019‑05‑31 13:17:18)
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
draft Role
prsb03-dataelement-11717
Id prsb03-dataelement-11717 (2019‑05‑31 13:17:18)
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
draft Grade
prsb03-dataelement-11718
Id prsb03-dataelement-11718 (2019‑05‑31 13:17:18)
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
draft Speciality
prsb03-dataelement-11719
Id prsb03-dataelement-11719 (2019‑05‑31 13:17:18)
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
draft Professional identifier
prsb03-dataelement-11720
Id prsb03-dataelement-11720 (2019‑05‑31 13:17:18)
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
folder draft Organisation
prsb03-dataelement-11721
Id prsb03-dataelement-11721 (2019‑05‑31 13:17:18)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11722
Id prsb03-dataelement-11722 (2019‑05‑31 13:17:18)
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
folder draft Person completing record
prsb03-dataelement-11723
Id prsb03-dataelement-11723 (2019‑05‑31 13:17:29)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11724
Id prsb03-dataelement-11724 (2019‑05‑31 13:17:58)
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
draft Role
prsb03-dataelement-11725
Id prsb03-dataelement-11725 (2019‑05‑31 13:17:58)
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
draft Grade
prsb03-dataelement-11726
Id prsb03-dataelement-11726 (2019‑05‑31 13:17:58)
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
draft Specialty
prsb03-dataelement-11727
Id prsb03-dataelement-11727 (2019‑05‑31 13:17:58)
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
folder draft Organisation
prsb03-dataelement-11728
Id prsb03-dataelement-11728 (2019‑05‑31 13:17:58)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11729
Id prsb03-dataelement-11729 (2019‑05‑31 13:17:58)
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
draft Date completed
prsb03-dataelement-11730
Id prsb03-dataelement-11730 (2019‑05‑31 13:17:58)
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
draft Contact details
prsb03-dataelement-11731
Id prsb03-dataelement-11731 (2019‑05‑31 13:17:58)
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
folder draft Consent relating to child
prsb03-dataelement-10422
Id prsb03-dataelement-10422 (2018‑10‑31)
Description Details of the person's consent relating to child
draft Date
prsb03-dataelement-11732
Id prsb03-dataelement-11732 (2019‑05‑31 13:21:58)
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
folder draft Location
prsb03-dataelement-11733
Id prsb03-dataelement-11733 (2019‑05‑31 13:22:27)
Description The location where the person with responsibility for the child was identified.
Relationship
draft Coded value
prsb03-dataelement-13674
Id prsb03-dataelement-13674 (2020‑09‑08 23:44:15)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13675
Id prsb03-dataelement-13675 (2020‑09‑08 23:45:35)
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
draft Consent relating to child
prsb03-dataelement-13576
Id prsb03-dataelement-13576 (2020‑09‑07 16:50:40)
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
folder draft Performing professional
prsb03-dataelement-11734
Id prsb03-dataelement-11734 (2019‑05‑31 13:23:06)
Description The professional who identified the person responsible for the child.
Relationship
draft Name
prsb03-dataelement-11735
Id prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-11736
Id prsb03-dataelement-11736 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-11737
Id prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
draft Speciality
prsb03-dataelement-11738
Id prsb03-dataelement-11738 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-11739
Id prsb03-dataelement-11739 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-11740
Id prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-11741
Id prsb03-dataelement-11741 (2019‑05‑31 13:23:55)
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 0 transactions, 0 templates, inherited once
 
folder draft Person completing record
prsb03-dataelement-11742
Id prsb03-dataelement-11742 (2019‑05‑31 13:23:59)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11743
Id prsb03-dataelement-11743 (2019‑05‑31 13:24:18)
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
draft Role
prsb03-dataelement-11744
Id prsb03-dataelement-11744 (2019‑05‑31 13:24:18)
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
draft Grade
prsb03-dataelement-11745
Id prsb03-dataelement-11745 (2019‑05‑31 13:24:18)
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
draft Specialty
prsb03-dataelement-11746
Id prsb03-dataelement-11746 (2019‑05‑31 13:24:18)
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
folder draft Organisation
prsb03-dataelement-11747
Id prsb03-dataelement-11747 (2019‑05‑31 13:24:18)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11748
Id prsb03-dataelement-11748 (2019‑05‑31 13:24:18)
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
draft Date completed
prsb03-dataelement-11749
Id prsb03-dataelement-11749 (2019‑05‑31 13:24:18)
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
draft Contact details
prsb03-dataelement-11750
Id prsb03-dataelement-11750 (2019‑05‑31 13:24:18)
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
folder draft Mental capacity assessment
prsb03-dataelement-10424
Id prsb03-dataelement-10424 (2018‑10‑31)
Description Details of the persons mental capacity assessment
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Date
prsb03-dataelement-11688
Id prsb03-dataelement-11688 (2019‑05‑31 11:50:22)
Description The date when the mental capacity assessment was made.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 3 times
 
folder draft Location
prsb03-dataelement-11689
Id prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
Description The location where the mental capacity assessment was made.
target Used by 0 transactions, 0 templates, inherited 3 times
 
draft Coded value
prsb03-dataelement-13449
Id prsb03-dataelement-13449 (2020‑08‑27 16:43:20)
Description The coded value for location
Operationalization
NHS data dictionary : - Organisation code

Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13450
Id 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 0 transactions, 0 templates, inherited 3 times
 
draft Mental capacity assessment
prsb03-dataelement-13724
Id prsb03-dataelement-13724 (2020‑09‑16 11:32:28)
Description Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.
Operationalization Free text
Value Domain
Property
max length
150
draft Location of document
prsb03-dataelement-13779
Id prsb03-dataelement-13779 (2020‑10‑16 16:40:41)
Description The location of the mental capacity assessment information.
Relationship
Operationalization Free text or URL
Value Domain
Property
max length
150
cancelled Mental capacity assessment
prsb03-dataelement-13090
Id prsb03-dataelement-13090 (2020‑06‑08 18:04:55) 0.1
Description Record where a person diagnosed with a mental disorder is formally detained under the Mental Health Act or equivalent, including the section number and start date, start time and end date. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
Operationalization NHS data dictionary : - Mental health act legal status classification code
Value Domain
Property
fixed
2an
folder draft Performing professional
prsb03-dataelement-11281
Id prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
Description The professional who made the mental capacity assessment.
target Used by 0 transactions, 0 templates, inherited 3 times
 
draft Name
prsb03-dataelement-11282
Id 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 0 transactions, 0 templates, inherited 61 times
 
draft Role
prsb03-dataelement-11283
Id 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 0 transactions, 0 templates, inherited 60 times
 
draft Grade
prsb03-dataelement-11288
Id 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 0 transactions, 0 templates, inherited 61 times
 
draft Speciality
prsb03-dataelement-11284
Id 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 0 transactions, 0 templates, inherited 60 times
 
draft Professional identifier
prsb03-dataelement-11285
Id 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 0 transactions, 0 templates, inherited 61 times
 
folder draft Organisation
prsb03-dataelement-11286
Id prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
target Used by 0 transactions, 0 templates, inherited 61 times
 
draft Coded value
prsb03-dataelement-13521
Id prsb03-dataelement-13521 (2020‑09‑04 13:43:41)
Description The coded value for location
Rationale Practitioner.PractitionerRole.organisation.Name
Operationalization NHS data dictionary: - Organisation data service
Value Domain
Property
min length max length
3 7
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13522
Id prsb03-dataelement-13522 (2020‑09‑04 13:45:47)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-11287
Id 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 0 transactions, 0 templates, inherited 61 times
 
folder draft Person completing record
prsb03-dataelement-11289
Id prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
target Used by 0 transactions, 0 templates, inherited 67 times
 
draft Name
prsb03-dataelement-11290
Id 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 0 transactions, 0 templates, inherited 69 times
 
draft Role
prsb03-dataelement-11291
Id 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 0 transactions, 0 templates, inherited 69 times
 
draft Grade
prsb03-dataelement-11292
Id 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 0 transactions, 0 templates, inherited 69 times
 
draft Specialty
prsb03-dataelement-11293
Id 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 0 transactions, 0 templates, inherited 69 times
 
folder draft Organisation
prsb03-dataelement-11294
Id prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
target Used by 0 transactions, 0 templates, inherited 69 times
 
draft Coded value
prsb03-dataelement-13523
Id prsb03-dataelement-13523 (2020‑09‑04 13:52:48)
Description The coded value for location
Rationale Composition.author.Practitioner.PractitionerRole.organisation.Name
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 7
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13524
Id prsb03-dataelement-13524 (2020‑09‑04 13:54:04)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-11295
Id 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 0 transactions, 0 templates, inherited 69 times
 
draft Date completed
prsb03-dataelement-11296
Id 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 0 transactions, 0 templates, inherited 69 times
 
draft Contact details
prsb03-dataelement-11297
Id 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 0 transactions, 0 templates, inherited 69 times
 
folder draft Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
prsb03-dataelement-10425
Id prsb03-dataelement-10425 (2018‑10‑31)
Description Details of the person's LPA record or equivalent
target Used by 0 transactions, 0 templates, inherited once
 
draft Date
prsb03-dataelement-13630
Id prsb03-dataelement-13630 (2020‑09‑08 20:03:11)
Description The date the LPA was recorded
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-13631
Id prsb03-dataelement-13631 (2020‑09‑08 20:04:28)
Description The location where the LPA was given
Relationship
draft Coded value
prsb03-dataelement-13632
Id prsb03-dataelement-13632 (2020‑09‑08 20:05:20)
Concept inherits from draft prsb03-dataelement-13453 (2020‑08‑27 16:54:58)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation code



Value Domain
Property
min length max length
3 9
draft Free text
prsb03-dataelement-13633
Id prsb03-dataelement-13633 (2020‑09‑08 20:05:20)
Concept inherits from draft prsb03-dataelement-13454 (2020‑08‑27 16:56:28)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
folder draft Lasting power of attorney for personal welfare or court appointed deputy (or equivalent)
prsb03-dataelement-13634
Id prsb03-dataelement-13634 (2020‑09‑08 20:05:47)
Description Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
draft Coded value
prsb03-dataelement-13636
Id prsb03-dataelement-13636 (2020‑09‑08 20:10:08)
Description The coded value for the LPA
Operationalization SNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
Value Domain
draft Location of document
prsb03-dataelement-13776
Id prsb03-dataelement-13776 (2020‑10‑12 13:50:45)
Description The location of the LPA information
Operationalization Free text or URL
Value Domain
Property
max length
150
draft Name of LPA
prsb03-dataelement-13635
Id prsb03-dataelement-13635 (2020‑09‑08 20:08:39)
Description The names of any appointed people or deputies
Operationalization Free text
Value Domain
Property
max length
150
draft Contact details
prsb03-dataelement-13637
Id prsb03-dataelement-13637 (2020‑09‑08 20:11:29)
Description The contact details of the LPA
Operationalization NHS data dictionary:- UK telephone number
Value Domain
Property
max length
35
folder draft Performing professional
prsb03-dataelement-13638
Id prsb03-dataelement-13638 (2020‑09‑08 20:13:16)
Description The professional who took the details of the LPA or equivalent
Relationship
draft Name
prsb03-dataelement-13639
Id prsb03-dataelement-13639 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13640
Id prsb03-dataelement-13640 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
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
draft Grade
prsb03-dataelement-13641
Id prsb03-dataelement-13641 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-13642
Id prsb03-dataelement-13642 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
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
draft Professional identifier
prsb03-dataelement-13643
Id prsb03-dataelement-13643 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
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
folder draft Organisation
prsb03-dataelement-13644
Id prsb03-dataelement-13644 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13645
Id prsb03-dataelement-13645 (2020‑09‑08 20:13:55)
Concept inherits from draft prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
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
folder draft Person completing record
prsb03-dataelement-13646
Id prsb03-dataelement-13646 (2020‑09‑08 20:14:17)
Description Details of the person who took the LPA.
Relationship
draft Name
prsb03-dataelement-13647
Id prsb03-dataelement-13647 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13493 (2020‑09‑02 17:10:59)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13648
Id prsb03-dataelement-13648 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
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
draft Grade
prsb03-dataelement-13649
Id prsb03-dataelement-13649 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13495 (2020‑09‑02 17:10:59)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
draft Specialty
prsb03-dataelement-13650
Id prsb03-dataelement-13650 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13496 (2020‑09‑02 17:10:59)
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
folder draft Organisation
prsb03-dataelement-13651
Id prsb03-dataelement-13651 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13497 (2020‑09‑02 17:10:59)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-13652
Id prsb03-dataelement-13652 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13498 (2020‑09‑02 17:10:59)
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
draft Date completed
prsb03-dataelement-13653
Id prsb03-dataelement-13653 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13499 (2020‑09‑02 17:10:59)
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
draft Contact details
prsb03-dataelement-13654
Id prsb03-dataelement-13654 (2020‑09‑08 20:14:49)
Concept inherits from draft prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
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
folder draft Deprivation of Liberty Safeguards or equivalent
prsb03-dataelement-10426
Id prsb03-dataelement-10426 (2018‑10‑31)
Description Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
target Used by 0 transactions, 0 templates, inherited once
 
draft Application date
prsb03-dataelement-13068
Id prsb03-dataelement-13068 (2020‑05‑21 18:04:27)
Description The date the application was made
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Application status
prsb03-dataelement-13069
Id prsb03-dataelement-13069 (2020‑05‑21 18:05:36)
Description The status of the DOLs application.
Operationalization Free text : - Requested or authorised
Value Domain
Property
max length
10
Example Requested
Example Authorised
draft Deprivation of liberty safeguards or equivalent
prsb03-dataelement-13626
Id prsb03-dataelement-13626 (2020‑09‑08 19:49:07)
Description Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.
Operationalization Free text
Value Domain
Property
max length
150
draft Start date of authorisation
prsb03-dataelement-13071
Id prsb03-dataelement-13071 (2020‑05‑21 18:16:32)
Description The date the DOLs was authorised.
Operationalization Data and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Planned or actual end date of authorisation
prsb03-dataelement-13072
Id prsb03-dataelement-13072 (2020‑05‑21 18:18:19)
Description The planned or actual end date of authorisation.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Performing professional
prsb03-dataelement-13073
Id prsb03-dataelement-13073 (2020‑05‑21 18:20:41)
Description The professional who applied for the DOLs.
Relationship
draft Name
prsb03-dataelement-13074
Id prsb03-dataelement-13074 (2020‑05‑21 18:21:29)
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
draft Role
prsb03-dataelement-13075
Id prsb03-dataelement-13075 (2020‑05‑21 18:21:29)
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
draft Grade
prsb03-dataelement-13076
Id prsb03-dataelement-13076 (2020‑05‑21 18:21:29)
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
draft Speciality
prsb03-dataelement-13077
Id prsb03-dataelement-13077 (2020‑05‑21 18:21:29)
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
draft Professional identifier
prsb03-dataelement-13078
Id prsb03-dataelement-13078 (2020‑05‑21 18:21:29)
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
folder draft Organisation
prsb03-dataelement-13079
Id prsb03-dataelement-13079 (2020‑05‑21 18:21:29)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13080
Id prsb03-dataelement-13080 (2020‑05‑21 18:21:29)
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
cancelled Performing professional
prsb03-dataelement-13070
Id prsb03-dataelement-13070 (2020‑05‑21 18:09:04)
Description Details of the professional applying for the DOLs.
Relationship
Value Domain
cancelled Date
prsb03-dataelement-11690
Id prsb03-dataelement-11690 (2019‑05‑31 12:45:04)
Description The date when the deprivation of liberty safeguard decision was made.
Relationship
Value Domain
Property
Timestamp precision
at least day, month and year
cancelled Location
prsb03-dataelement-11691
Id prsb03-dataelement-11691 (2019‑05‑31 12:47:02)
Description The location where the deprivation of liberty safeguard decision was made.
Relationship
Value Domain
folder cancelled Performing professional
prsb03-dataelement-11298
Id prsb03-dataelement-11298 (2019‑05‑30 12:50:51)
Description The professional who made the deprivation of liberty safeguard decision.
Relationship
cancelled Name
prsb03-dataelement-11299
Id prsb03-dataelement-11299 (2019‑05‑30 12:51:19)
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
cancelled Role
prsb03-dataelement-11300
Id prsb03-dataelement-11300 (2019‑05‑30 12:51:19)
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
cancelled Grade
prsb03-dataelement-11301
Id prsb03-dataelement-11301 (2019‑05‑30 12:51:19)
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
cancelled Speciality
prsb03-dataelement-11302
Id prsb03-dataelement-11302 (2019‑05‑30 12:51:19)
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
cancelled Professional identifier
prsb03-dataelement-11303
Id prsb03-dataelement-11303 (2019‑05‑30 12:51:19)
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
folder cancelled Organisation
prsb03-dataelement-11304
Id prsb03-dataelement-11304 (2019‑05‑30 12:51:19)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
cancelled Contact details
prsb03-dataelement-11305
Id prsb03-dataelement-11305 (2019‑05‑30 12:51:19)
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
folder cancelled Person completing record
prsb03-dataelement-11306
Id prsb03-dataelement-11306 (2019‑05‑30 12:51:31)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
cancelled Name
prsb03-dataelement-11307
Id prsb03-dataelement-11307 (2019‑05‑30 12:52:15)
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
cancelled Role
prsb03-dataelement-11308
Id prsb03-dataelement-11308 (2019‑05‑30 12:52:15)
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
cancelled Grade
prsb03-dataelement-11309
Id prsb03-dataelement-11309 (2019‑05‑30 12:52:15)
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
cancelled Specialty
prsb03-dataelement-11310
Id prsb03-dataelement-11310 (2019‑05‑30 12:52:15)
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
folder cancelled Organisation
prsb03-dataelement-11311
Id prsb03-dataelement-11311 (2019‑05‑30 12:52:15)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
cancelled Professional identifier
prsb03-dataelement-11312
Id prsb03-dataelement-11312 (2019‑05‑30 12:52:15)
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
cancelled Date completed
prsb03-dataelement-11313
Id prsb03-dataelement-11313 (2019‑05‑30 12:52:15)
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
cancelled Contact details
prsb03-dataelement-11314
Id prsb03-dataelement-11314 (2019‑05‑30 12:52:15)
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
folder draft Mental health act or equivalent status
prsb03-dataelement-10427
Id prsb03-dataelement-10427 (2018‑10‑31)
Description Details of the persons mental health act record
target Used by 0 transactions, 0 templates, inherited once
 
cancelled Mental health act or equivalent status
prsb03-dataelement-10922
Id prsb03-dataelement-10922 (2019‑04‑26 14:22:17)
Description Record where a person diagnosed with a mental disorder is formally detained under the Mental Health Act or equivalent, including the section number.

If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
Value Domain
draft Section start date
prsb03-dataelement-10920
Id prsb03-dataelement-10920 (2019‑04‑26 14:17:19)
Description The date the person was detained.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Section end date
prsb03-dataelement-10921
Id prsb03-dataelement-10921 (2019‑04‑26 14:19:05)
Description The date the person was no longer detained.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11692
Id prsb03-dataelement-11692 (2019‑05‑31 12:51:56)
Description The location where the decision to detain the person was made under the mental health act.
Relationship
draft Coded value
prsb03-dataelement-13453
Id prsb03-dataelement-13453 (2020‑08‑27 16:54:58)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation code



Value Domain
Property
min length max length
3 9
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13454
Id prsb03-dataelement-13454 (2020‑08‑27 16:56:28)
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 0 transactions, 0 templates, inherited once
 
folder draft Mental health act or equivalent status
prsb03-dataelement-13627
Id prsb03-dataelement-13627 (2020‑09‑08 19:52:25)
Description Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
draft Coded value
prsb03-dataelement-13628
Id prsb03-dataelement-13628 (2020‑09‑08 19:57:06)
Description The coded value for mental health act
Operationalization NHS data dictionary: - Mental health act legal status classification code
Value Domain
Property
max length
2
Example Formally detained under Mental Health Act Section 2
draft Free text
prsb03-dataelement-13629
Id prsb03-dataelement-13629 (2020‑09‑08 19:58:49)
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
draft Supporting information
prsb03-dataelement-13755
Id prsb03-dataelement-13755 (2020‑09‑29 11:48:32)
Description If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
Operationalization NHS data dictionary : - Community treatment order
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11315
Id prsb03-dataelement-11315 (2019‑05‑30 12:53:22)
Description The professional who made the decision to detain the person under the mental health act.
Relationship
draft Name
prsb03-dataelement-11316
Id prsb03-dataelement-11316 (2019‑05‑30 12:53:54)
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
draft Role
prsb03-dataelement-11317
Id prsb03-dataelement-11317 (2019‑05‑30 12:53:54)
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
draft Grade
prsb03-dataelement-11318
Id prsb03-dataelement-11318 (2019‑05‑30 12:53:54)
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
draft Speciality
prsb03-dataelement-11319
Id prsb03-dataelement-11319 (2019‑05‑30 12:53:54)
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
draft Professional identifier
prsb03-dataelement-11320
Id prsb03-dataelement-11320 (2019‑05‑30 12:53:54)
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
folder draft Organisation
prsb03-dataelement-11321
Id prsb03-dataelement-11321 (2019‑05‑30 12:53:54)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11322
Id prsb03-dataelement-11322 (2019‑05‑30 12:53:54)
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
folder draft Person completing record
prsb03-dataelement-11323
Id prsb03-dataelement-11323 (2019‑05‑30 12:54:57)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11324
Id prsb03-dataelement-11324 (2019‑05‑30 12:55:19)
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
draft Role
prsb03-dataelement-11325
Id prsb03-dataelement-11325 (2019‑05‑30 12:55:19)
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
draft Grade
prsb03-dataelement-11326
Id prsb03-dataelement-11326 (2019‑05‑30 12:55:19)
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
draft Specialty
prsb03-dataelement-11327
Id prsb03-dataelement-11327 (2019‑05‑30 12:55:19)
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
folder draft Organisation
prsb03-dataelement-11328
Id prsb03-dataelement-11328 (2019‑05‑30 12:55:19)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11329
Id prsb03-dataelement-11329 (2019‑05‑30 12:55:19)
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
draft Date completed
prsb03-dataelement-11330
Id prsb03-dataelement-11330 (2019‑05‑30 12:55:19)
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
draft Contact details
prsb03-dataelement-11331
Id prsb03-dataelement-11331 (2019‑05‑30 12:55:19)
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
folder draft Advance decision to refuse treatment (ADRT)
prsb03-dataelement-10428
Id prsb03-dataelement-10428 (2018‑10‑31)
Description Details of the person's ADRT status.
target Used by 0 transactions, 0 templates, inherited once
 
draft Date
prsb03-dataelement-13479
Id prsb03-dataelement-13479 (2020‑09‑02 16:59:59)
Description The date the ADRT was recorded.
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Location
prsb03-dataelement-13480
Id prsb03-dataelement-13480 (2020‑09‑02 17:01:08)
Description The location where the ADRT was recorded.
draft Coded value
prsb03-dataelement-13481
Id prsb03-dataelement-13481 (2020‑09‑02 17:01:48)
Description The coded value of location
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13482
Id prsb03-dataelement-13482 (2020‑09‑02 17:03:31)
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
folder draft Advance decision to refuse treatment
prsb03-dataelement-13502
Id prsb03-dataelement-13502 (2020‑09‑02 17:36:30)
Description A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
draft Coded value
prsb03-dataelement-13503
Id prsb03-dataelement-13503 (2020‑09‑02 17:46:53)
Description The coded value for advance decision to refuse treatment.
Operationalization SNOMED CT:- ^ 999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13504
Id prsb03-dataelement-13504 (2020‑09‑02 17:48:38)
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
cancelled Advance decision to refuse treatment (ADRT)
prsb03-dataelement-13501
Id prsb03-dataelement-13501 (2020‑09‑02 17:31:20) 0.1
Concept inherits from draft prsb03-dataelement-12488 (2019‑10‑04 18:44:06)
Description A record of whether an advance decision to refuse one or more specific types of future treatment, exists or not.
The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered.
An ADRT must be in writing, signed and witnessed.
If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
Operationalization
Yes/ No
No further information should be sent as anything that is sent must be actionable and therefore must be completely unimpeachable.

Where the response is yes, use the SNOMED CT concepts from the National Information Standard (SCCI1580) and associated text:

816301000000100 | Has advance decision to refuse treatment (Mental Capacity Act 2005) (finding)

816321000000109 | Has advance decision to refuse life sustaining treatment (Mental Capacity Act 2005) (finding)

820621000000107 | Has involved healthcare professional in discussion about advance decision to refuse treatment (Mental Capacity Act 2005) (finding)
Value Domain
folder draft Performing professional
prsb03-dataelement-13484
Id prsb03-dataelement-13484 (2020‑09‑02 17:08:08)
Description The professional who recorded the ADRT
Relationship
draft Name
prsb03-dataelement-13485
Id prsb03-dataelement-13485 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13486
Id prsb03-dataelement-13486 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
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
draft Grade
prsb03-dataelement-13487
Id prsb03-dataelement-13487 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-13488
Id prsb03-dataelement-13488 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
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
draft Professional identifier
prsb03-dataelement-13489
Id prsb03-dataelement-13489 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
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
folder draft Organisation
prsb03-dataelement-13490
Id prsb03-dataelement-13490 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13491
Id prsb03-dataelement-13491 (2020‑09‑02 17:08:45)
Concept inherits from draft prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
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
folder draft Person completing record
prsb03-dataelement-13492
Id prsb03-dataelement-13492 (2020‑09‑02 17:10:28)
Description Details of the person who recorded the ADRT.
Relationship
draft Name
prsb03-dataelement-13493
Id prsb03-dataelement-13493 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-13494
Id prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-13495
Id prsb03-dataelement-13495 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
draft Specialty
prsb03-dataelement-13496
Id prsb03-dataelement-13496 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-13497
Id prsb03-dataelement-13497 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
Description The organisation the person completing the record works for.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-13498
Id prsb03-dataelement-13498 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
draft Date completed
prsb03-dataelement-13499
Id prsb03-dataelement-13499 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-13500
Id prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
Concept inherits from draft prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
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 0 transactions, 0 templates, inherited once
 
cancelled Performing Professional
prsb03-dataelement-13483
Id prsb03-dataelement-13483 (2020‑09‑02 17:04:45) 0.1
Concept inherits from cancelled prsb03-dataelement-10460 (2018‑10‑31)
Description Details of the professional performing the examination (including name and role).
Operationalization Free text
Value Domain
cancelled Date
prsb03-dataelement-11693
Id prsb03-dataelement-11693 (2019‑05‑31 12:53:37)
Concept inherits from draft prsb03-dataelement-11688 (2019‑05‑31 11:50:22)
Description The date when the mental capacity assessment was made.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder cancelled Location
prsb03-dataelement-11694
Id prsb03-dataelement-11694 (2019‑05‑31 12:54:52)
Concept inherits from draft prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
Description The location where the mental capacity assessment was made.
folder cancelled Performing professional
prsb03-dataelement-11332
Id prsb03-dataelement-11332 (2019‑05‑30 12:56:57)
Concept inherits from draft prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
Description The professional who made the mental capacity assessment.
cancelled Name
prsb03-dataelement-11333
Id prsb03-dataelement-11333 (2019‑05‑30 12:57:23)
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
cancelled Role
prsb03-dataelement-11334
Id prsb03-dataelement-11334 (2019‑05‑30 12:57:23)
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
cancelled Grade
prsb03-dataelement-11335
Id prsb03-dataelement-11335 (2019‑05‑30 12:57:23)
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
cancelled Speciality
prsb03-dataelement-11336
Id prsb03-dataelement-11336 (2019‑05‑30 12:57:23)
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
cancelled Professional identifier
prsb03-dataelement-11337
Id prsb03-dataelement-11337 (2019‑05‑30 12:57:23)
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
folder cancelled Organisation
prsb03-dataelement-11338
Id prsb03-dataelement-11338 (2019‑05‑30 12:57:23)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
cancelled Contact details
prsb03-dataelement-11339
Id prsb03-dataelement-11339 (2019‑05‑30 12:57:23)
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
folder cancelled Person completing record
prsb03-dataelement-11340
Id prsb03-dataelement-11340 (2019‑05‑30 12:57:49)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
cancelled Name
prsb03-dataelement-11341
Id prsb03-dataelement-11341 (2019‑05‑30 12:58:08)
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
cancelled Role
prsb03-dataelement-11342
Id prsb03-dataelement-11342 (2019‑05‑30 12:58:08)
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
cancelled Grade
prsb03-dataelement-11343
Id prsb03-dataelement-11343 (2019‑05‑30 12:58:08)
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
cancelled Specialty
prsb03-dataelement-11344
Id prsb03-dataelement-11344 (2019‑05‑30 12:58:08)
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
folder cancelled Organisation
prsb03-dataelement-11345
Id prsb03-dataelement-11345 (2019‑05‑30 12:58:08)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
cancelled Professional identifier
prsb03-dataelement-11346
Id prsb03-dataelement-11346 (2019‑05‑30 12:58:08)
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
cancelled Date completed
prsb03-dataelement-11347
Id prsb03-dataelement-11347 (2019‑05‑30 12:58:08)
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
cancelled Contact details
prsb03-dataelement-11348
Id prsb03-dataelement-11348 (2019‑05‑30 12:58:08)
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
draft Advance decision to refuse treatment (ADRT)
prsb03-dataelement-12488
Id prsb03-dataelement-12488 (2019‑10‑04 18:44:06)
Description A record of whether an advance decision to refuse one or more specific types of future treatment, exists or not.
The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered.
An ADRT must be in writing, signed and witnessed.
If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
Operationalization
Yes/ No
No further information should be sent as anything that is sent must be actionable and therefore must be completely unimpeachable.

Where the response is yes, use the SNOMED CT concepts from the National Information Standard (SCCI1580) and associated text:

816301000000100 | Has advance decision to refuse treatment (Mental Capacity Act 2005) (finding)

816321000000109 | Has advance decision to refuse life sustaining treatment (Mental Capacity Act 2005) (finding)

820621000000107 | Has involved healthcare professional in discussion about advance decision to refuse treatment (Mental Capacity Act 2005) (finding)
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Safeguarding issues
prsb03-dataelement-10429
Id prsb03-dataelement-10429 (2018‑10‑31)
Description Any legal matters relating to safeguarding of a vulnerable child or adult, e.g., child protection plan, protection of vulnerable adult.
Operationalization Information obtained locally, Free Text.
Value Domain
draft Parental responsibility
prsb03-dataelement-10423
Id prsb03-dataelement-10423 (2018‑10‑31)
Description For children this is a record of person(s) with parental responsibility
Operationalization This is a record of the name as volunteered by the parents or recorded on local systems. The contact information for these individuals should be included under the relevant contacts heading.
Value Domain
draft Consent for creation of end of life care plan
prsb03-dataelement-10431
Id prsb03-dataelement-10431 (2018‑10‑31)
Description Separate explicit consent is required for creation of an end of life care record. This records how this consent has been granted in order to differentiate between person’s explicit consent, best interest decision, Lasting Power of Attorney decision and withdrawal of consent.
Operationalization End of life care plan use case only. This is a record of consent to create an end of life care plan.
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder cancelled Legal information record entry
prsb03-dataelement-12381
Id prsb03-dataelement-12381 (2019‑06‑03 12:32:21) 0.1
Description This is the legal information 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
cancelled Looked after child
prsb03-dataelement-10432
Id prsb03-dataelement-10432 (2018‑10‑31) 0.1
Description The details of whether the child is a 'Looked after child'
Value Domain
cancelled Child Protection Plan
prsb03-dataelement-10433
Id prsb03-dataelement-10433 (2018‑10‑31) 0.1
Description The details of the Childs Protection Plan
Value Domain
cancelled Local Authority
prsb03-dataelement-10434
Id prsb03-dataelement-10434 (2018‑10‑31) 0.1
Description The named local authority.
Value Domain
folder draft Safeguarding
prsb03-dataelement-271
Id prsb03-dataelement-271 (2018‑10‑31)
Description The safeguarding details of the person.
folder draft Safeguarding concerns
prsb03-dataelement-10821
Id prsb03-dataelement-10821 (2019‑03‑21 12:14:49)
Description Details of safeguarding concerns
draft Safeguarding indicator
prsb03-dataelement-13428
Id prsb03-dataelement-13428 (2020‑08‑12 15:01:11) 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
draft Safeguarding concerns date
prsb03-dataelement-10172
Id prsb03-dataelement-10172 (2018‑10‑31)
Description The date the safeguarding concerns were identified.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Safeguarding concerns end date
prsb03-dataelement-10766
Id prsb03-dataelement-10766 (2019‑03‑18 17:51:29)
Description The date safeguarding concerns ended.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-10173
Id prsb03-dataelement-10173 (2018‑10‑31)
Description The location where the safeguarding concerns were identified.
draft Coded value
prsb03-dataelement-13437
Id prsb03-dataelement-13437 (2020‑08‑14 15:30:27)
Description The coded value of location
Operationalization NHS data dictionary : - Organisation code

Value Domain
Property
min length max length
3 9
draft Free text
prsb03-dataelement-13438
Id prsb03-dataelement-13438 (2020‑08‑14 15:32:13)
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
cancelled Performing professional
prsb03-dataelement-10969
Id prsb03-dataelement-10969 (2019‑05‑22 14:39:23)
Description Details of the professional identifying the safeguarding concerns.
Relationship
Value Domain
cancelled Person completing record
prsb03-dataelement-10963
Id prsb03-dataelement-10963 (2019‑05‑20 15:53:16)
Description This is the person recording the safeguarding concerns.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
cancelled Performing Professional
prsb03-dataelement-10174
Id prsb03-dataelement-10174 (2018‑10‑31)
Description Details of the professional recording the safeguarding details (including name and role)
Value Domain
folder draft Safeguarding concerns
prsb03-dataelement-10171
Id prsb03-dataelement-10171 (2018‑10‑31)
Description Identified safeguarding concerns.

Properties

FHIR Composition.text
draft Coded value
prsb03-dataelement-13756
Id prsb03-dataelement-13756 (2020‑09‑29 12:22:26)
Description The coded value for safeguarding concerns
Operationalization SNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
Value Domain
draft Free text
prsb03-dataelement-13757
Id prsb03-dataelement-13757 (2020‑09‑29 12:23:18)
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
folder draft Performing professional
prsb03-dataelement-11358
Id prsb03-dataelement-11358 (2019‑05‑30 13:51:50)
Description The professional who identified the safeguarding concerns.
Relationship
draft Name
prsb03-dataelement-11359
Id prsb03-dataelement-11359 (2019‑05‑30 13:52:16)
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
draft Role
prsb03-dataelement-11360
Id prsb03-dataelement-11360 (2019‑05‑30 13:52:16)
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
draft Grade
prsb03-dataelement-11361
Id prsb03-dataelement-11361 (2019‑05‑30 13:52:16)
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
draft Speciality
prsb03-dataelement-11362
Id prsb03-dataelement-11362 (2019‑05‑30 13:52:16)
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
draft Professional identifier
prsb03-dataelement-11363
Id prsb03-dataelement-11363 (2019‑05‑30 13:52:16)
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
folder draft Organisation
prsb03-dataelement-11364
Id prsb03-dataelement-11364 (2019‑05‑30 13:52:16)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11365
Id prsb03-dataelement-11365 (2019‑05‑30 13:52:16)
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
folder draft Person completing record
prsb03-dataelement-11366
Id prsb03-dataelement-11366 (2019‑05‑30 13:53:06)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11367
Id prsb03-dataelement-11367 (2019‑05‑30 13:53:34)
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
draft Role
prsb03-dataelement-11368
Id prsb03-dataelement-11368 (2019‑05‑30 13:53:34)
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
draft Grade
prsb03-dataelement-11369
Id prsb03-dataelement-11369 (2019‑05‑30 13:53:34)
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
draft Specialty
prsb03-dataelement-11370
Id prsb03-dataelement-11370 (2019‑05‑30 13:53:34)
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
folder draft Organisation
prsb03-dataelement-11371
Id prsb03-dataelement-11371 (2019‑05‑30 13:53:34)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11372
Id prsb03-dataelement-11372 (2019‑05‑30 13:53:34)
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
draft Date completed
prsb03-dataelement-11373
Id prsb03-dataelement-11373 (2019‑05‑30 13:53:34)
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
draft Contact details
prsb03-dataelement-11374
Id prsb03-dataelement-11374 (2019‑05‑30 13:53:34)
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
draft Comment
prsb03-dataelement-10175
Id prsb03-dataelement-10175 (2018‑10‑31)
Description Further details on safeguarding concerns.
Operationalization Free text
Value Domain
Property
max length
150
folder cancelled Performing professional
prsb03-dataelement-11148
Id prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
Description The professional identifying the safeguarding concern.
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Name
prsb03-dataelement-11149
Id prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Role
prsb03-dataelement-11150
Id prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Speciality
prsb03-dataelement-11151
Id prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Team
prsb03-dataelement-11152
Id prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 5 times
 
folder cancelled Organisation
prsb03-dataelement-11153
Id prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
Description The name of the organisation.
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Contact details
prsb03-dataelement-11154
Id prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Professional identifier
prsb03-dataelement-11167
Id prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled Start date
prsb03-dataelement-11155
Id prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 5 times
 
cancelled End date
prsb03-dataelement-11156
Id prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
Concept inherits from cancelled prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 5 times
 
folder cancelled Professional contacts record entry
prsb03-dataelement-11157
Id prsb03-dataelement-11157 (2019‑05‑24 11:51:53)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Relationship
target Used by 0 transactions, 0 templates, inherited 5 times
 
folder cancelled Person completing record
prsb03-dataelement-319
Id prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
target Used by 0 transactions, 0 templates, inherited 14 times
 
cancelled Name
prsb03-dataelement-10219
Id prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Role
prsb03-dataelement-10220
Id prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Grade
prsb03-dataelement-10221
Id prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Specialty
prsb03-dataelement-10222
Id prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Organisation
prsb03-dataelement-10226
Id prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Professional identifier
prsb03-dataelement-10223
Id prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
target Used by 0 transactions, 0 templates, inherited 16 times
 
cancelled Date completed
prsb03-dataelement-10224
Id prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
cancelled Contact details
prsb03-dataelement-10225
Id prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
target Used by 0 transactions, 0 templates, inherited 15 times
 
folder draft Looked after child
prsb03-dataelement-10797
Id prsb03-dataelement-10797 (2019‑03‑20 13:08:45)
Description Details of the looked after child
draft Looked after child start date
prsb03-dataelement-10746
Id prsb03-dataelement-10746 (2019‑03‑07 11:47:56)
Description The date the child became a looked after child.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Looked after child end date
prsb03-dataelement-10761
Id prsb03-dataelement-10761 (2019‑03‑08 18:36:16)
Description The date the child ceased to be a looked after child.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Local authority
prsb03-dataelement-10799
Id prsb03-dataelement-10799 (2019‑03‑20 13:14:32)
Description The named local authority.
Relationship
draft Coded value
prsb03-dataelement-13614
Id prsb03-dataelement-13614 (2020‑09‑08 18:19:46)
Description The coded value for local authority
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13615
Id prsb03-dataelement-13615 (2020‑09‑08 18:21:36)
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
folder draft Person completing record
prsb03-dataelement-11375
Id prsb03-dataelement-11375 (2019‑05‑30 13:54:10)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11376
Id prsb03-dataelement-11376 (2019‑05‑30 13:54:40)
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
draft Role
prsb03-dataelement-11377
Id prsb03-dataelement-11377 (2019‑05‑30 13:54:40)
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
draft Grade
prsb03-dataelement-11378
Id prsb03-dataelement-11378 (2019‑05‑30 13:54:40)
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
draft Specialty
prsb03-dataelement-11379
Id prsb03-dataelement-11379 (2019‑05‑30 13:54:40)
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
folder draft Organisation
prsb03-dataelement-11380
Id prsb03-dataelement-11380 (2019‑05‑30 13:54:40)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11381
Id prsb03-dataelement-11381 (2019‑05‑30 13:54:40)
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
draft Date completed
prsb03-dataelement-11382
Id prsb03-dataelement-11382 (2019‑05‑30 13:54:40)
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
draft Contact details
prsb03-dataelement-11383
Id prsb03-dataelement-11383 (2019‑05‑30 13:54:40)
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
folder cancelled Person completing record
prsb03-dataelement-11169
Id prsb03-dataelement-11169 (2019‑05‑28 17:42:48)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11170
Id prsb03-dataelement-11170 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11171
Id prsb03-dataelement-11171 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11172
Id prsb03-dataelement-11172 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11173
Id prsb03-dataelement-11173 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Organisation
prsb03-dataelement-11174
Id prsb03-dataelement-11174 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Professional identifier
prsb03-dataelement-11175
Id prsb03-dataelement-11175 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11176
Id prsb03-dataelement-11176 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11177
Id prsb03-dataelement-11177 (2019‑05‑28 17:43:26)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Person completing record
prsb03-dataelement-11168
Id prsb03-dataelement-11168 (2019‑05‑28 17:40:50)
Concept inherits from cancelled prsb03-dataelement-10963 (2019‑05‑20 15:53:16)
Description This is the person recording the safeguarding concerns.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder cancelled Person completing record
prsb03-dataelement-10996
Id prsb03-dataelement-10996 (2019‑05‑24 10:55:43)
Description Person completing record
Relationship
cancelled Name
prsb03-dataelement-10997
Id prsb03-dataelement-10997 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-10998
Id prsb03-dataelement-10998 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-10999
Id prsb03-dataelement-10999 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11000
Id prsb03-dataelement-11000 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11001
Id prsb03-dataelement-11001 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11002
Id prsb03-dataelement-11002 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11003
Id prsb03-dataelement-11003 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11004
Id prsb03-dataelement-11004 (2019‑05‑24 10:56:48)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Person completing record
prsb03-dataelement-10964
Id prsb03-dataelement-10964 (2019‑05‑20 15:56:51)
Description This is the person recording the details of the looked after child.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Child protection plan
prsb03-dataelement-10798
Id prsb03-dataelement-10798 (2019‑03‑20 13:12:02)
Description Details of the child protection plan
draft Child protection plan start date
prsb03-dataelement-10747
Id prsb03-dataelement-10747 (2019‑03‑07 11:48:25)
Description The start date of the child protection plan
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Child protection plan end date
prsb03-dataelement-10762
Id prsb03-dataelement-10762 (2019‑03‑08 18:36:48)
Description The end date of the child protection plan
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Local authority
prsb03-dataelement-10748
Id prsb03-dataelement-10748 (2019‑03‑07 11:48:45)
Description The named local authority.
Relationship
draft Coded value
prsb03-dataelement-13616
Id prsb03-dataelement-13616 (2020‑09‑08 18:37:54)
Description The coded value for a local authority
Operationalization NHS data dictionary : - organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13617
Id prsb03-dataelement-13617 (2020‑09‑08 18:39:19)
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
folder draft Person completing record
prsb03-dataelement-11384
Id prsb03-dataelement-11384 (2019‑05‑30 13:55:02)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11385
Id prsb03-dataelement-11385 (2019‑05‑30 13:55:35)
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
draft Role
prsb03-dataelement-11386
Id prsb03-dataelement-11386 (2019‑05‑30 13:55:35)
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
draft Grade
prsb03-dataelement-11387
Id prsb03-dataelement-11387 (2019‑05‑30 13:55:35)
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
draft Specialty
prsb03-dataelement-11388
Id prsb03-dataelement-11388 (2019‑05‑30 13:55:35)
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
folder draft Organisation
prsb03-dataelement-11389
Id prsb03-dataelement-11389 (2019‑05‑30 13:55:35)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11390
Id prsb03-dataelement-11390 (2019‑05‑30 13:55:35)
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
draft Date completed
prsb03-dataelement-11391
Id prsb03-dataelement-11391 (2019‑05‑30 13:55:35)
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
draft Contact details
prsb03-dataelement-11392
Id prsb03-dataelement-11392 (2019‑05‑30 13:55:35)
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
folder cancelled Person completing record
prsb03-dataelement-11005
Id prsb03-dataelement-11005 (2019‑05‑24 10:57:24)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11006
Id prsb03-dataelement-11006 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11007
Id prsb03-dataelement-11007 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11008
Id prsb03-dataelement-11008 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11009
Id prsb03-dataelement-11009 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11010
Id prsb03-dataelement-11010 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11011
Id prsb03-dataelement-11011 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11012
Id prsb03-dataelement-11012 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11013
Id prsb03-dataelement-11013 (2019‑05‑24 10:57:52)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Person completing record
prsb03-dataelement-10965
Id prsb03-dataelement-10965 (2019‑05‑20 15:58:45)
Description This is the person recording the details of the child protection plan.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Unborn child protection plan
prsb03-dataelement-10923
Id prsb03-dataelement-10923 (2019‑04‑26 17:54:37)
Description Details of the unborn child protection plan.
draft Unborn child protection plan start date
prsb03-dataelement-10924
Id prsb03-dataelement-10924 (2019‑04‑26 17:55:45)
Description Start date of the unborn child protection plan.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Unborn child protection plan end date
prsb03-dataelement-10925
Id prsb03-dataelement-10925 (2019‑04‑26 17:56:43)
Description End date of the unborn child protection plan.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Local authority
prsb03-dataelement-10926
Id prsb03-dataelement-10926 (2019‑04‑26 17:58:25)
Description The named local authority.
draft Coded value
prsb03-dataelement-13618
Id prsb03-dataelement-13618 (2020‑09‑08 18:41:51)
Description The coded value for local authority
Operationalization NHS data dictionary: - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13619
Id prsb03-dataelement-13619 (2020‑09‑08 18:43:11)
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
folder draft Person completing record
prsb03-dataelement-11393
Id prsb03-dataelement-11393 (2019‑05‑30 13:56:01)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11394
Id prsb03-dataelement-11394 (2019‑05‑30 13:56:18)
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
draft Role
prsb03-dataelement-11395
Id prsb03-dataelement-11395 (2019‑05‑30 13:56:18)
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
draft Grade
prsb03-dataelement-11396
Id prsb03-dataelement-11396 (2019‑05‑30 13:56:18)
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
draft Specialty
prsb03-dataelement-11397
Id prsb03-dataelement-11397 (2019‑05‑30 13:56:18)
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
folder draft Organisation
prsb03-dataelement-11398
Id prsb03-dataelement-11398 (2019‑05‑30 13:56:18)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11399
Id prsb03-dataelement-11399 (2019‑05‑30 13:56:18)
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
draft Date completed
prsb03-dataelement-11400
Id prsb03-dataelement-11400 (2019‑05‑30 13:56:18)
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
draft Contact details
prsb03-dataelement-11401
Id prsb03-dataelement-11401 (2019‑05‑30 13:56:18)
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
folder cancelled Person completing record
prsb03-dataelement-11014
Id prsb03-dataelement-11014 (2019‑05‑24 10:58:35)
Concept inherits from cancelled prsb03-dataelement-319 (2018‑10‑31)
Description Details of the person completing the record.
cancelled Name
prsb03-dataelement-11015
Id prsb03-dataelement-11015 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10219 (2018‑10‑31)
Description The name of the person completing the record, preferably in a structured format.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, and suffix).
Value Domain
cancelled Role
prsb03-dataelement-11016
Id prsb03-dataelement-11016 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10220 (2018‑10‑31)
Description The role of the person completing record.

Properties

FHIR PractitionerRole.code of the practitioner completing the record
Operationalization The role may be held on the source system, be from an authoritative source such as SDS, or use an existing vocabulary such as the job role title (from the national workforce dataset).
Value Domain
cancelled Grade
prsb03-dataelement-11017
Id prsb03-dataelement-11017 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10221 (2018‑10‑31)
Description The grade of the person completing the record
Operationalization The grade of the person completing the record held on the source system or from an authoritative source
Value Domain
cancelled Specialty
prsb03-dataelement-11018
Id prsb03-dataelement-11018 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10222 (2018‑10‑31)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Operationalization The main clinical specialty as held on the source system.
Value Domain
cancelled Professional identifier
prsb03-dataelement-11019
Id prsb03-dataelement-11019 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10223 (2018‑10‑31)
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)
Value Domain
cancelled Date completed
prsb03-dataelement-11020
Id prsb03-dataelement-11020 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10224 (2018‑10‑31)
Description The date and time the record was updated.
Operationalization The date/time the record was updated.
Value Domain
cancelled Contact details
prsb03-dataelement-11021
Id prsb03-dataelement-11021 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10225 (2018‑10‑31)
Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Properties

FHIR PractitionerRole.telecom
Operationalization The contact details may be for the individual completing the record, or wider team details (for example a phone number for a hospital department).
Value Domain
cancelled Organisation
prsb03-dataelement-11022
Id prsb03-dataelement-11022 (2019‑05‑24 10:58:56)
Concept inherits from cancelled prsb03-dataelement-10226 (2018‑10‑31)
Description The organisation the person completing the record works for.
Operationalization An ODS identifier for the organisation or site, the name of the organisation or site, and a postal address (if available).
Value Domain
cancelled Person completing record
prsb03-dataelement-10966
Id prsb03-dataelement-10966 (2019‑05‑20 16:00:34)
Description This is the person recording the details of the unborn child protection plan.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder cancelled Safeguarding record entry
prsb03-dataelement-10656
Id prsb03-dataelement-10656 (2018‑11‑13 12:19:53)
Description This is a Safeguarding 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.
folder draft Referrer Details
prsb03-dataelement-10714
Id prsb03-dataelement-10714 (2018‑12‑04 15:38:18)
draft Date and time of referral
prsb03-dataelement-10717
Id prsb03-dataelement-10717 (2018‑12‑04 15:39:07)
Description Date and time the patient was referred to the service.
Value Domain
draft Reason for referral
prsb03-dataelement-10716
Id prsb03-dataelement-10716 (2018‑12‑04 15:38:52)
Description A clear statement of the purpose of the person making the referral e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carers' concerns.
Value Domain
draft Referrer details
prsb03-dataelement-10715
Id prsb03-dataelement-10715 (2018‑12‑04 15:38:38)
Description Details of the source of the referral. Name, role, grade, organisation and contact details of referrer, or details of the person making the contact for ambulance or urgent care services. If not an individual, this could be e.g. GP surgery, department, specialty, sub-specialty, educational institution, mental health team etc. Also needs to include self-referral.
Operationalization Sent as per the ECDS Emergency Care Attendance Source code set (SNOMED CT).
Value Domain
folder draft Consent
prsb03-dataelement-10702
Id prsb03-dataelement-10702 (2018‑12‑04 15:27:12)
Description Legal information captured relating to patient care, such as consent.
draft Consent relating to child
prsb03-dataelement-10705
Id prsb03-dataelement-10705 (2018‑12‑04 15:28:03)
Description Consideration of age and competency, applying Gillick competency or Fraser guidelines. Record of person with parental responsibility or appointed guardian where child lacks competency. Record if there is disagreement between patient and parent.
Operationalization Free text
Value Domain
draft Consent for information sharing
prsb03-dataelement-10704
Id prsb03-dataelement-10704 (2018‑12‑04 15:27:48)
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.
Operationalization Free text.
Value Domain
draft Consent for treatment record
prsb03-dataelement-10703
Id prsb03-dataelement-10703 (2018‑12‑04 15:27:26)
Description Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent.
Operationalization Free text
Value Domain
folder draft Eligibility Criteria
prsb03-dataelement-10700
Id prsb03-dataelement-10700 (2018‑12‑04 15:25:08)
draft Eligibility criteria
prsb03-dataelement-10701
Id prsb03-dataelement-10701 (2018‑12‑04 15:25:39)
Description Records which specific eligibility criteria have been met in order to administer the vaccine.
Operationalization Free text
Value Domain
Property
max length
150
cancelled Referral Details
prsb03-dataelement-10644
Id prsb03-dataelement-10644 (2018‑11‑12 14:46:39)
Description The details of the individual or team who referred the person.
Value Domain
folder draft Disability
prsb03-dataelement-10816
Id prsb03-dataelement-10816 (2019‑03‑20 18:55:36)
Description Any details relating to a persons disability
draft Onset date
prsb03-dataelement-10819
Id prsb03-dataelement-10819 (2019‑03‑20 19:03:27)
Description The date the of onset for the disability
Value Domain
draft Disability code
prsb03-dataelement-10818
Id prsb03-dataelement-10818 (2019‑03‑20 19:03:00)
Description Code relating to the disability
Operationalization

https://www.datadictionary.nhs.uk/data_dictionary/attributes/d/den/disability_code_de.asp?shownav=1
Value Domain
draft Description
prsb03-dataelement-10817
Id prsb03-dataelement-10817 (2019‑03‑20 18:58:30)
Description The description of the disability relating to the person
Value Domain
folder draft Local authority
prsb03-dataelement-13298
Id prsb03-dataelement-13298 (2020‑08‑06 12:38:23)
Description The details of the Local Authority that is responsible for providing care and support to the person.
draft Organisation code
prsb03-dataelement-13299
Id prsb03-dataelement-13299 (2020‑08‑06 12:39:25)
Description The ODS (Organisation Data Service) code of the local authority that is responsible for providing care and support to the person.
Operationalization NHS data dictionary :- Organisation data service
Value Domain
Property
min length max length
3 5
draft Local authority name
prsb03-dataelement-13300
Id prsb03-dataelement-13300 (2020‑08‑06 12:40:27)
Description The name of the local authority that is responsible for providing care and support to the person.
Operationalization Free text
Value Domain
Property
max length
150
draft Social services team
prsb03-dataelement-13301
Id prsb03-dataelement-13301 (2020‑08‑06 12:41:15)
Description The name of the local authority social services team or department that is responsible for undertaking the care and support assessment for the person.
Operationalization Free text
Value Domain
Property
max length
150
draft Local authority contact name
prsb03-dataelement-13302
Id prsb03-dataelement-13302 (2020‑08‑06 12:42:09)
Description The name of the person at the local authority who is responsible for liaising with the hospital in relation to the person’s discharge.
Operationalization Free text
Value Domain
Property
max length
35
draft Local authority contact details
prsb03-dataelement-13303
Id prsb03-dataelement-13303 (2020‑08‑06 12:43:10)
Description The contact details of the person at the local authority who is responsible for liaising with the hospital in relation to the person’s discharge.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Professional contacts
prsb03-dataelement-452
Id prsb03-dataelement-452 (2018‑10‑31)
Description The details of the person’s professional contacts.
folder draft Professional contacts record entry
prsb03-dataelement-10767
Id prsb03-dataelement-10767 (2019‑03‑18 18:07:16)
Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Name
prsb03-dataelement-10352
Id prsb03-dataelement-10352 (2018‑10‑31)
Description The name of the professional with responsibility for the care of the person.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Role
prsb03-dataelement-10353
Id prsb03-dataelement-10353 (2018‑10‑31)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Operationalization FHIR value set : - SDSjobrole
Value Domain
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Key worker
prsb03-dataelement-12973
Id prsb03-dataelement-12973 (2020‑04‑06 20:02:00)
Description A flag that identifies the personal contact is the key worker assigned to the person.
Operationalization Flag : - Yes or No
Value Domain
draft Speciality
prsb03-dataelement-10354
Id prsb03-dataelement-10354 (2018‑10‑31)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Team
prsb03-dataelement-10355
Id prsb03-dataelement-10355 (2018‑10‑31)
Description The name of the team.
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 2 times
 
folder draft Organisation
prsb03-dataelement-10356
Id prsb03-dataelement-10356 (2018‑10‑31)
Description The name of the organisation.
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Coded value
prsb03-dataelement-13564
Id prsb03-dataelement-13564 (2020‑09‑04 18:18:34)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13565
Id prsb03-dataelement-13565 (2020‑09‑04 18:19:37)
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
draft Contact details
prsb03-dataelement-10357
Id prsb03-dataelement-10357 (2018‑10‑31)
Description Contact details of the professional (e.g. telephone number, email address etc.).
Operationalization Free text
Value Domain
Property
max length
35
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Start date
prsb03-dataelement-10358
Id prsb03-dataelement-10358 (2018‑10‑31)
Description The start date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft End date
prsb03-dataelement-10359
Id prsb03-dataelement-10359 (2018‑10‑31)
Description The end date of the professional relationship with the person.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited 2 times
 
folder draft Personal contacts
prsb03-dataelement-445
Id prsb03-dataelement-445 (2018‑10‑31)
Description The details of the individual's personal contacts.
folder draft Personal contacts record entry
prsb03-dataelement-10768
Id prsb03-dataelement-10768 (2019‑03‑19 13:05:13)
Description This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
draft Name
prsb03-dataelement-10345
Id prsb03-dataelement-10345 (2018‑10‑31)
Description The name of the personal contact.
Operationalization Free text
Value Domain
Property
max length
70
draft Relationship
prsb03-dataelement-10346
Id prsb03-dataelement-10346 (2018‑10‑31)
Description The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.
Operationalization FHIR value set : - Related person
Value Domain
Property
default
10
draft Relationship type
prsb03-dataelement-12968
Id prsb03-dataelement-12968 (2020‑04‑06 13:13:10)
Description Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)
Operationalization Free text
Value Domain
Property
max length
150
draft Parental Responsibility
prsb03-dataelement-10347
Id prsb03-dataelement-10347 (2018‑10‑31)
Description Flag to indicate whether the personal contact has parental responsibility
Operationalization Flag ; - Yes or No
Value Domain
Property
max length
3
draft Household member
prsb03-dataelement-10348
Id prsb03-dataelement-10348 (2018‑10‑31)
Description Status identifying whether the personal contact is a member of the same household
Operationalization Flag : - Yes or No
Value Domain
Property
max length
3
draft Next of Kin
prsb03-dataelement-10349
Id prsb03-dataelement-10349 (2018‑10‑31)
Description A flag that identifies the personal contact is the next of kin
Operationalization Flag : - Yes or No
Value Domain
draft Contact details
prsb03-dataelement-10350
Id prsb03-dataelement-10350 (2018‑10‑31)
Description Contact details of the personal contact (e.g. telephone number, email address etc.)
Operationalization Free Text
Value Domain
Property
max length
70
draft NHS Number
prsb03-dataelement-10351
Id prsb03-dataelement-10351 (2018‑10‑31)
Description The NHS number of the personal contact
Operationalization NHS data dictionary:- NHS NUMBER
Value Domain
Property
max length
10
target Used by 0 transactions, 0 templates, inherited once
 
draft Comments
prsb03-dataelement-10937
Id prsb03-dataelement-10937 (2019‑05‑02 17:15:44)
Description Notes on the significance of the personal contact to the person.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Health and care professional details
prsb03-dataelement-10912
Id prsb03-dataelement-10912 (2019‑04‑02 15:33:05)
draft Responsible health or care professional
prsb03-dataelement-10913
Id prsb03-dataelement-10913 (2019‑04‑02 15:34:54)
Description The name, role and/or personal identification number (if used) of the health or care professional with responsibility for the person within this contact. Where multiple professionals have responsibility, provide details of the duration and extent of responsibility held. State whether identified professional was present, in communication, on call etc.
Operationalization Free text. Where codes are provided by the local system the associated text should be displayed.
Value Domain
draft Health or care professional(s) present
prsb03-dataelement-10914
Id prsb03-dataelement-10914 (2019‑04‑02 15:36:15)
Description The name, designation and/or personal identification number (if used) of all other health or care professionals present.
Operationalization Free text. Where codes are provided by the local system the associated text should be displayed.
Value Domain
cancelled IRRE
prsb03-dataelement-10649
Id prsb03-dataelement-10649 (2018‑11‑12 15:41:28)
Value Domain
folder draft Participation in research
prsb03-dataelement-168
Id prsb03-dataelement-168 (2018‑10‑31)
Description Participation in research
folder draft Participation in research record entry
prsb03-dataelement-10646
Id prsb03-dataelement-10646 (2018‑11‑12 15:14:45)
Description This is a Participation in research record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
draft Participation in research
prsb03-dataelement-13834
Id prsb03-dataelement-13834 (2020‑12‑26 15:50:24)
Description Flag to indicate whether the person is actively engaged in a research study or clinical trial
Operationalization Flag : - Yes or No
Value Domain
draft Name of research study
prsb03-dataelement-10068
Id prsb03-dataelement-10068 (2018‑10‑31)
Description Name and details of the research study/trial and/or drug/intervention
Operationalization Free text or URL
Value Domain
Property
max length
250
draft Identification code
prsb03-dataelement-10739
Id prsb03-dataelement-10739 (2019‑02‑12 17:27:10)
Description Identification code of research study
Operationalization NHS data dictionary :- Clinical trial identifier
Value Domain
Property
max length
20
folder draft Person completing record
prsb03-dataelement-12201
Id prsb03-dataelement-12201 (2019‑05‑31 16:24:08)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-12202
Id prsb03-dataelement-12202 (2019‑05‑31 16:24:35)
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
draft Role
prsb03-dataelement-12203
Id prsb03-dataelement-12203 (2019‑05‑31 16:24:35)
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
draft Grade
prsb03-dataelement-12204
Id prsb03-dataelement-12204 (2019‑05‑31 16:24:35)
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
draft Specialty
prsb03-dataelement-12205
Id prsb03-dataelement-12205 (2019‑05‑31 16:24:35)
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
folder draft Organisation
prsb03-dataelement-12206
Id prsb03-dataelement-12206 (2019‑05‑31 16:24:35)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-12207
Id prsb03-dataelement-12207 (2019‑05‑31 16:24:35)
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
draft Date completed
prsb03-dataelement-12208
Id prsb03-dataelement-12208 (2019‑05‑31 16:24:35)
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
draft Contact details
prsb03-dataelement-12209
Id prsb03-dataelement-12209 (2019‑05‑31 16:24:35)
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
folder draft Referral details
prsb03-dataelement-105
Id prsb03-dataelement-105 (2018‑10‑31)
Description The details of the referral.
folder draft Referral details record entry
prsb03-dataelement-10917
Id prsb03-dataelement-10917 (2019‑04‑09 15:59:55)
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.
draft Date
prsb03-dataelement-10006
Id prsb03-dataelement-10006 (2018‑10‑31)
Description The date of referral
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Referrer details
prsb03-dataelement-10005
Id prsb03-dataelement-10005 (2018‑10‑31)
Description The details of the referrer that is making the transfer.

This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.

Properties

FHIR Encounter.incomingreferral
draft Name
prsb03-dataelement-10971
Id prsb03-dataelement-10971 (2019‑05‑22 16:29:39)
Description The name of the referrer.
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10972
Id prsb03-dataelement-10972 (2019‑05‑22 16:30:25)
Description Role of the referrer.
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Grade
prsb03-dataelement-10973
Id prsb03-dataelement-10973 (2019‑05‑22 16:31:10)
Description The grade of the referrer.
Operationalization Free text
Value Domain
Property
max length
150
draft Team
prsb03-dataelement-12409
Id prsb03-dataelement-12409 (2019‑06‑05 18:11:50)
Description The team or department of the referrer.
Operationalization Free text
Value Domain
Property
max length
150
draft Specialty
prsb03-dataelement-12410
Id prsb03-dataelement-12410 (2019‑06‑05 18:12:15)
Description The specialty of the referrer.
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
folder draft Service
prsb03-dataelement-12411
Id prsb03-dataelement-12411 (2019‑06‑05 18:20:01)
Description The service of the referrer.
draft Coded value
prsb03-dataelement-13397
Id prsb03-dataelement-13397 (2020‑08‑10 19:10:14)
Description The coded value for service
Operationalization SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13398
Id prsb03-dataelement-13398 (2020‑08‑10 19:11:12)
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
folder draft Organisation
prsb03-dataelement-10974
Id prsb03-dataelement-10974 (2019‑05‑22 16:31:40)
Description The organisation of the referrer.
draft Coded value
prsb03-dataelement-13399
Id prsb03-dataelement-13399 (2020‑08‑10 19:14:38)
Description The coded value for organisation code
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13400
Id prsb03-dataelement-13400 (2020‑08‑10 19:17:07)
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
draft Contact details
prsb03-dataelement-10975
Id prsb03-dataelement-10975 (2019‑05‑22 16:33:49)
Description The contact details of the referrer.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Comments
prsb03-dataelement-12408
Id prsb03-dataelement-12408 (2019‑06‑05 18:09:11)
Description Further details on the referrer details.
Value Domain
draft Referral type
prsb03-dataelement-12967
Id prsb03-dataelement-12967 (2020‑04‑03 18:18:08)
Description An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)
Value Domain
Property
max length
150
draft Referral method
prsb03-dataelement-10007
Id prsb03-dataelement-10007 (2018‑10‑31)
Description The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.
Operationalization Allow National Codes only
  1. Fax
  2. Phone
  3. Secure Messaging
  4. Secure Email
  5. Letter
  6. NHS E-Referral Service
  7. Self referral
Value Domain
folder draft Reason for referral
prsb03-dataelement-10011
Id prsb03-dataelement-10011 (2018‑10‑31)
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
draft Coded value
prsb03-dataelement-13455
Id prsb03-dataelement-13455 (2020‑08‑27 18:17:32)
Description The coded value for reason for referral
Operationalization SNOMED CT :- ^1127581000000103 |Health issues simple reference set|
Value Domain
draft Free text
prsb03-dataelement-13456
Id prsb03-dataelement-13456 (2020‑08‑27 18:18:45)
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
draft Expectation of referral
prsb03-dataelement-10699
Id prsb03-dataelement-10699 (2018‑12‑04 15:19:46)
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
folder draft Clinical urgency of referral
prsb03-dataelement-10010
Id prsb03-dataelement-10010 (2018‑10‑31)
Description The details of the clinical urgency of referral
draft Urgency
prsb03-dataelement-13835
Id prsb03-dataelement-13835 (2020‑12‑28 13:54:55)
Description This is the priority of a request for services
Operationalization NHS data dictionary : - PRIORITY TYPE
Value Domain
Property
max length
1
target Used by 0 transactions, 0 templates, inherited once
 
draft Reason for urgency of referral
prsb03-dataelement-10976
Id prsb03-dataelement-10976 (2019‑05‑22 17:54:38)
Description The reason for urgency of referral if not routine.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Referral to
prsb03-dataelement-10008
Id prsb03-dataelement-10008 (2018‑10‑31)
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.
draft Name
prsb03-dataelement-10977
Id prsb03-dataelement-10977 (2019‑05‑22 17:56:22)
Description Name of person the referral is to be sent to.
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10978
Id prsb03-dataelement-10978 (2019‑05‑22 17:56:39)
Description Role of person where the referral is to be sent to.
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Grade
prsb03-dataelement-10979
Id prsb03-dataelement-10979 (2019‑05‑22 17:56:51)
Description The grade of the person where the referral is sent to.
Operationalization Free text
Value Domain
Property
max length
150
draft Team
prsb03-dataelement-10982
Id prsb03-dataelement-10982 (2019‑05‑22 17:59:49)
Description The team or department of the person where the referral is being sent to
Operationalization Free text.
Value Domain
Property
max length
150
draft Specialty
prsb03-dataelement-10983
Id prsb03-dataelement-10983 (2019‑05‑22 18:00:28)
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
folder draft Service
prsb03-dataelement-12412
Id prsb03-dataelement-12412 (2019‑06‑05 18:20:52)
Description The service of where the referral is sent to.
draft Coded value
prsb03-dataelement-13509
Id prsb03-dataelement-13509 (2020‑09‑03 17:50:24)
Description The coded value for service
Operationalization SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13510
Id prsb03-dataelement-13510 (2020‑09‑03 17:51:06)
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
folder draft Organisation
prsb03-dataelement-10980
Id prsb03-dataelement-10980 (2019‑05‑22 17:57:10)
Description The organisation of where the referral is to be sent.
draft Coded value
prsb03-dataelement-13511
Id prsb03-dataelement-13511 (2020‑09‑03 17:54:29)
Description The coded value for organisation
Operationalization NHS data dictionary :- Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13512
Id prsb03-dataelement-13512 (2020‑09‑03 17:55:57)
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
draft Contact details
prsb03-dataelement-10981
Id prsb03-dataelement-10981 (2019‑05‑22 17:57:26)
Description The contact details of where the referral is to be sent.
Operationalization Free text.
Value Domain
Property
max length
70
cancelled Speciality referred from
prsb03-dataelement-10009
Id prsb03-dataelement-10009 (2018‑10‑31)
Description The type of service or team that the person has been referred from
Operationalization NHS data dictionary
Value Domain
draft Details of other referrals
prsb03-dataelement-10013
Id prsb03-dataelement-10013 (2018‑10‑31)
Description Other referrals related to this or associated conditions.
Operationalization The organisation referred to (ODS code)

Specialty/service (eRS Directory of Services)

Date of referral

Narrative text

Auto-populated UBRN (where available)

Default - 12 months (editable)
Value Domain
draft Referral criteria
prsb03-dataelement-10014
Id prsb03-dataelement-10014 (2018‑10‑31)
Description Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.
Operationalization Free text
Value Domain
Property
max length
150
draft Return response to
prsb03-dataelement-10015
Id prsb03-dataelement-10015 (2018‑10‑31)
Description Name of professional to be communicated with, if not the referrer
Operationalization Free text.
Value Domain
Property
max length
70
draft Attachments
prsb03-dataelement-10012
Id prsb03-dataelement-10012 (2018‑10‑31)
Description Documents included as attachments which accompany the communication Data items:

* number of attachments

* type of attachments

* attached documents.
Operationalization Number of attachments by category: present, pending, missing.

Supporting narrative: text for each attachment

Attachments: various formats, eg jpeg, word

Metadata about the attachments: document name standard under development by PRSB. Possibly use FHIR 'composition'.
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Reason for Referral
prsb03-dataelement-460
Id prsb03-dataelement-460 (2018‑10‑31)
Description Reason for Referral
folder draft Reason for referral
prsb03-dataelement-10360
Id prsb03-dataelement-10360 (2018‑10‑31)
Description The reason for referral/transfer - e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carers' concerns.
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
cancelled Coded value
prsb03-dataelement-13562
Id prsb03-dataelement-13562 (2020‑09‑04 18:09:40) 0.1
Description The coded value for reason for referral
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Value Domain
cancelled Free text
prsb03-dataelement-13563
Id prsb03-dataelement-13563 (2020‑09‑04 18:10:37) 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
folder draft Clinical urgency of referral
prsb03-dataelement-10361
Id prsb03-dataelement-10361 (2018‑10‑31)
Description The details of the clinical urgency of referral
draft Urgency
prsb03-dataelement-13836
Id prsb03-dataelement-13836 (2020‑12‑28 14:39:53)
Concept inherits from draft prsb03-dataelement-13835 (2020‑12‑28 13:54:55)
Description This is the priority of a request for services
Operationalization NHS data dictionary : - PRIORITY TYPE
Value Domain
Property
max length
1
draft Reason for urgency of referral
prsb03-dataelement-13837
Id prsb03-dataelement-13837 (2020‑12‑28 14:40:56)
Concept inherits from draft prsb03-dataelement-10976 (2019‑05‑22 17:54:38)
Description The reason for urgency of referral if not routine.
Operationalization Free text
Value Domain
Property
max length
150
draft Expectation of referral
prsb03-dataelement-10362
Id prsb03-dataelement-10362 (2018‑10‑31)
Description A clear statement of the expectations of the person making the referral as to the management of the patient e.g. advice only, diagnosis, treatment, etc. To Include any specific patient expectation. In general text. Risk not put in a procedure not already received
Operationalization Free text
Value Domain
Property
max length
150
draft Presenting complaints or issues
prsb03-dataelement-10363
Id prsb03-dataelement-10363 (2018‑10‑31)
Description The list and description of the health problems and issues experienced by the patient precipitating referral. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow-up from admission, falls, a specific procedure, investigation, family history or treatment.
Operationalization Free text
Value Domain
Property
max length
150
draft History of each presenting complaint or issue
prsb03-dataelement-10364
Id prsb03-dataelement-10364 (2018‑10‑31)
Description Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer.
Operationalization Free text
Value Domain
Property
max length
150
draft Management to date
prsb03-dataelement-10365
Id prsb03-dataelement-10365 (2018‑10‑31)
Description Referrals, management, investigations and treatment that have already been undertaken, including patient managing their symptoms. Including: procedures conducted - procedures carried out (and the date) and procedure report.
Operationalization Free text
Value Domain
Property
max length
150
folder cancelled Problem list
prsb03-dataelement-12617
Id prsb03-dataelement-12617 (2019‑11‑19 12:59:13)
Concept inherits from draft prsb03-dataelement-10927 (2019‑04‑30 17:00:00)
Description A summary of the problems that require investigation or treatment.
folder cancelled Problem list record entry
prsb03-dataelement-12618
Id prsb03-dataelement-12618 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10928 (2019‑04‑30 17:01:01)
Description This is a problem list record entry.

There may be 0 to many record entries under problem list.

Each record entry is made up of a number of elements or data items.
cancelled Date
prsb03-dataelement-12619
Id prsb03-dataelement-12619 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10929 (2019‑04‑30 17:04:55)
Description The date the problem was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled Performing professional
prsb03-dataelement-12620
Id prsb03-dataelement-12620 (2019‑11‑19 13:01:28)
Concept inherits from cancelled prsb03-dataelement-10930 (2019‑04‑30 17:06:52)
Description Details of the professional identifying the problem.
Relationship
Value Domain
folder cancelled Performing professional
prsb03-dataelement-12621
Id prsb03-dataelement-12621 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12133 (2019‑05‑31 16:03:47)
Description The professional who identified the problem.
Relationship
cancelled Name
prsb03-dataelement-12622
Id prsb03-dataelement-12622 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12134 (2019‑05‑31 16:04:17)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-12623
Id prsb03-dataelement-12623 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12135 (2019‑05‑31 16:04:17)
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
cancelled Grade
prsb03-dataelement-12624
Id prsb03-dataelement-12624 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12136 (2019‑05‑31 16:04:17)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
cancelled Speciality
prsb03-dataelement-12625
Id prsb03-dataelement-12625 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12137 (2019‑05‑31 16:04:17)
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
cancelled Professional identifier
prsb03-dataelement-12626
Id prsb03-dataelement-12626 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12138 (2019‑05‑31 16:04:17)
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
folder cancelled Organisation
prsb03-dataelement-12627
Id prsb03-dataelement-12627 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12139 (2019‑05‑31 16:04:17)
Description The name of the organisation the professional works for.
cancelled Contact details
prsb03-dataelement-12628
Id prsb03-dataelement-12628 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12140 (2019‑05‑31 16:04:17)
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
folder cancelled Location
prsb03-dataelement-12629
Id prsb03-dataelement-12629 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
Description The location the problem was identified.
Relationship
folder cancelled Problem
prsb03-dataelement-12630
Id prsb03-dataelement-12630 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
Description A condition which needs addressing and so is important for every professional to know about when seeing the person.

Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Relationship
cancelled Onset date
prsb03-dataelement-12631
Id prsb03-dataelement-12631 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10933 (2019‑04‑30 17:10:25)
Description A date or estimated date that the problem began
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least month and year
cancelled End Date
prsb03-dataelement-12632
Id prsb03-dataelement-12632 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10934 (2019‑04‑30 17:10:59)
Description The date or estimated date the problem was resolved.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled Stage of disease
prsb03-dataelement-12633
Id prsb03-dataelement-12633 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10935 (2019‑04‑30 17:11:55)
Description The stage of the disease where relevant.
Relationship
Operationalization Free text
Value Domain
Property
max length
150
folder cancelled Person completing record
prsb03-dataelement-12634
Id prsb03-dataelement-12634 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12141 (2019‑05‑31 16:04:31)
Description Details of the person completing the record.
Relationship
cancelled Name
prsb03-dataelement-12635
Id prsb03-dataelement-12635 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12142 (2019‑05‑31 16:04:53)
Description The name of the person completing the record.
Relationship
Rationale Composition.author.Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-12636
Id prsb03-dataelement-12636 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12143 (2019‑05‑31 16:04:53)
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
cancelled Grade
prsb03-dataelement-12637
Id prsb03-dataelement-12637 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12144 (2019‑05‑31 16:04:53)
Description The grade of the person completing the record.
Relationship
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
cancelled Specialty
prsb03-dataelement-12638
Id prsb03-dataelement-12638 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12145 (2019‑05‑31 16:04:53)
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
folder cancelled Organisation
prsb03-dataelement-12639
Id prsb03-dataelement-12639 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12146 (2019‑05‑31 16:04:53)
Description The organisation the person completing the record works for.
Relationship
cancelled Professional identifier
prsb03-dataelement-12640
Id prsb03-dataelement-12640 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12147 (2019‑05‑31 16:04:53)
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
cancelled Date completed
prsb03-dataelement-12641
Id prsb03-dataelement-12641 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12148 (2019‑05‑31 16:04:53)
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
cancelled Contact details
prsb03-dataelement-12642
Id prsb03-dataelement-12642 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-12149 (2019‑05‑31 16:04:53)
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
cancelled Person completing record
prsb03-dataelement-12643
Id prsb03-dataelement-12643 (2019‑11‑19 13:01:28)
Concept inherits from cancelled prsb03-dataelement-10952 (2019‑05‑18 21:04:15)
Description This is the person recording the problem.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
cancelled Comment
prsb03-dataelement-12644
Id prsb03-dataelement-12644 (2019‑11‑19 13:01:28)
Concept inherits from draft prsb03-dataelement-10936 (2019‑04‑30 17:13:22)
Description Supporting text may be given covering the problem.
Relationship
Operationalization Free text
Value Domain
Property
max length
150
folder draft Problem
prsb03-dataelement-12645
Id prsb03-dataelement-12645 (2019‑11‑19 13:04:13)
Concept inherits from draft prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
Description A condition which needs addressing and so is important for every professional to know about when seeing the person.

Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Relationship
folder draft Contacts with professionals
prsb03-dataelement-169
Id prsb03-dataelement-169 (2018‑10‑31)
Description The details of the person’s contact with a professional.
folder draft Contacts with professionals record entry
prsb03-dataelement-10718
Id prsb03-dataelement-10718 (2019‑02‑08 13:49:22)
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.
draft Date of contact
prsb03-dataelement-10069
Id prsb03-dataelement-10069 (2018‑10‑31)
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
folder draft Location of contact
prsb03-dataelement-10075
Id prsb03-dataelement-10075 (2018‑10‑31)
Description The location where the contact took place.
draft Coded value
prsb03-dataelement-13513
Id prsb03-dataelement-13513 (2020‑09‑03 18:01:56)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13514
Id prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
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 0 transactions, 0 templates, inherited once
 
folder draft Seen by
prsb03-dataelement-10077
Id prsb03-dataelement-10077 (2018‑10‑31)
Description The professional that saw the person.

Properties

FHIR Encounter.participant
draft Name
prsb03-dataelement-13515
Id prsb03-dataelement-13515 (2020‑09‑03 18:13:01)
Description The name of the professional that saw the person
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-13758
Id prsb03-dataelement-13758 (2020‑09‑29 12:37:26)
Concept inherits from draft prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Description The role of the person providing the service.
Operationalization FHIR values set : - sdsjobrole
Value Domain
cancelled Free text
prsb03-dataelement-13516
Id prsb03-dataelement-13516 (2020‑09‑03 18:15:56) 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
folder draft Responsible professional
prsb03-dataelement-10072
Id prsb03-dataelement-10072 (2018‑10‑31)
Description The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).

Properties

FHIR Encounter.participant
draft Name
prsb03-dataelement-10988
Id prsb03-dataelement-10988 (2019‑05‑23 18:36:10)
Description The name of the responsible professional.
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10989
Id prsb03-dataelement-10989 (2019‑05‑23 18:36:53)
Description The role of the responsible professional
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Location type
prsb03-dataelement-10076
Id prsb03-dataelement-10076 (2018‑10‑31)
Description The type of location where the contact took place e.g. person's home
Operationalization NHS data dictionary - Activity location type code
Value Domain
Property
max length
3
draft Reason for service
prsb03-dataelement-13751
Id prsb03-dataelement-13751 (2020‑09‑28 11:15:42)
Description The reason why the person has been offered the service
Operationalization Free text
Value Domain
Property
max length
150
draft Contact type
prsb03-dataelement-10070
Id prsb03-dataelement-10070 (2018‑10‑31)
Description Type of contact e.g. GP consultation, outpatient attendance

Properties

FHIR Encounter.type
Operationalization Free text
Value Domain
Property
max length
150
draft Consultation method
prsb03-dataelement-10071
Id prsb03-dataelement-10071 (2018‑10‑31)
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
draft Specialty
prsb03-dataelement-10073
Id prsb03-dataelement-10073 (2018‑10‑31)
Description The specialty e.g. physiotherapy, oncology, mental health etc

Properties

FHIR Encounter.participant.individual.Practitioner.PractitionerRole.speciality (of the consultant responsible for the encounter)
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
draft Service
prsb03-dataelement-10074
Id prsb03-dataelement-10074 (2018‑10‑31)
Description The service that was provided.

Properties

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



Value Domain
folder draft Professionals present
prsb03-dataelement-10078
Id prsb03-dataelement-10078 (2018‑10‑31)
Description The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)

Properties

FHIR Encounter.participant
draft Name
prsb03-dataelement-10990
Id prsb03-dataelement-10990 (2019‑05‑23 18:51:51)
Description The name of the professional present
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10991
Id prsb03-dataelement-10991 (2019‑05‑23 18:52:37)
Description The role of the professional present.
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Outcome of contact
prsb03-dataelement-10080
Id prsb03-dataelement-10080 (2018‑10‑31)
Description This records the outcome of the contact.

Properties

FHIR Handled as text in the transfer of care
Operationalization
NHS data dictionary :- Attended or did not attend code
Value Domain
Property
max length
1
draft Person accompanying patient
prsb03-dataelement-10079
Id prsb03-dataelement-10079 (2018‑10‑31)
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
draft Organisation name
prsb03-dataelement-10706
Id prsb03-dataelement-10706 (2018‑12‑04 15:30:13)
Description The name, including the identifier, of the organisation providing the service
Operationalization NHS data dictionary : - Organisation name
Value Domain
Property
max length
255
draft Organisation address
prsb03-dataelement-10713
Id prsb03-dataelement-10713 (2018‑12‑04 15:37:02)
Description The name of the organisation, including the identifier.
Operationalization NHS data dictionary : - Organisation address
Value Domain
Property
max length
175
draft Organisation contact details
prsb03-dataelement-10707
Id prsb03-dataelement-10707 (2018‑12‑04 15:31:05)
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
draft Reason for non-provision of service
prsb03-dataelement-10708
Id prsb03-dataelement-10708 (2018‑12‑04 15:31:26)
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
draft Clinician name
prsb03-dataelement-10709
Id prsb03-dataelement-10709 (2018‑12‑04 15:31:49)
Description The name of the person providing the service.
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10710
Id prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Description The role of the person providing the service.
Operationalization FHIR values set : - sdsjobrole
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Chaperone
prsb03-dataelement-10712
Id prsb03-dataelement-10712 (2018‑12‑04 15:33:12)
Description The name of any chaperone(s).
Operationalization Free text
Value Domain
Property
max length
70
draft Person collecting the medicine
prsb03-dataelement-13783
Id prsb03-dataelement-13783 (2020‑10‑22 15:43:21)
Description
Name, relationship, role (if formal role), contact details
Operationalization Free text
Value Domain
draft Professional identifier
prsb03-dataelement-10711
Id prsb03-dataelement-10711 (2018‑12‑04 15:32:25)
Description Professional identifier of the person providing the service.
Operationalization NHS data dictionary : - professional identifier
Value Domain
Property
max length
32
folder draft Admission details
prsb03-dataelement-181
Id prsb03-dataelement-181 (2018‑10‑31)
Description Admission details
folder draft Admission details record entry
prsb03-dataelement-10918
Id prsb03-dataelement-10918 (2019‑04‑09 16:16:31)
Description This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
draft Date of admission
prsb03-dataelement-10085
Id prsb03-dataelement-10085 (2018‑10‑31)
Description Date and time the person was admitted to hospital.

Properties

FHIR Encounter.period
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Admitted to
prsb03-dataelement-10090
Id prsb03-dataelement-10090 (2018‑10‑31)
notice There are open issues with this item:
Description The hospital the person was admitted to.
draft Coded value
prsb03-dataelement-13380
Id prsb03-dataelement-13380 (2020‑08‑10 18:02:32)
Description The coded value for admission to
Operationalization NHS data dictionary : - Organisations code of provider
Value Domain
Property
min length max length
3 6
draft Free text
prsb03-dataelement-13381
Id prsb03-dataelement-13381 (2020‑08‑10 18:03:47)
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
folder draft Responsible care professional
prsb03-dataelement-10087
Id prsb03-dataelement-10087 (2018‑10‑31)
Description The care professional who has overall responsibility for the person (may not actually see the person)
draft Name
prsb03-dataelement-10992
Id prsb03-dataelement-10992 (2019‑05‑23 23:16:09)
Description The name of the responsible care professional.
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10993
Id prsb03-dataelement-10993 (2019‑05‑23 23:17:05)
Description The role of the responsible consultant.
Operationalization FHIR value set: - sdsjobrole
Value Domain
folder draft Reason for admission
prsb03-dataelement-10081
Id prsb03-dataelement-10081 (2018‑10‑31)
Description The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.

Properties

FHIR Encounter.reason
draft Coded value
prsb03-dataelement-13382
Id prsb03-dataelement-13382 (2020‑08‑10 18:08:34)
Description The coded value for reason for admission
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Value Domain
draft Free text
prsb03-dataelement-13384
Id prsb03-dataelement-13384 (2020‑08‑10 18:18:25)
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
folder draft Admission method
prsb03-dataelement-10082
Id prsb03-dataelement-10082 (2018‑10‑31)
Description How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.

Properties

FHIR Handled as text in the transfer of care
draft Coded value
prsb03-dataelement-13385
Id prsb03-dataelement-13385 (2020‑08‑10 18:21:26)
Description The coded value for admission method
Operationalization NHS data dictionary : - Admission method
Value Domain
Property
max length
2
draft Free text
prsb03-dataelement-13387
Id prsb03-dataelement-13387 (2020‑08‑10 18:22:33)
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
draft Legal status on admission
prsb03-dataelement-10083
Id prsb03-dataelement-10083 (2018‑10‑31)
Description Whether the person was admitted as informal or formal/detained.

Properties

FHIR Encounter,Subject.Observation
Operationalization NHS data dictionary : - Mental health act legal status classification code
Value Domain
Property
max length
2
folder draft Source of admission
prsb03-dataelement-10084
Id prsb03-dataelement-10084 (2018‑10‑31)
Description Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.

Properties

FHIR Encounter.hospitalisation.admitsource
draft Coded value
prsb03-dataelement-13388
Id prsb03-dataelement-13388 (2020‑08‑10 18:25:26)
Description The coded value of source of admission
Operationalization NHS data dictionary :- Source of admission
Value Domain
Property
max length fixed
2 an2
draft Free text
prsb03-dataelement-13389
Id prsb03-dataelement-13389 (2020‑08‑10 18:27:00)
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
draft Patient location
prsb03-dataelement-10086
Id prsb03-dataelement-10086 (2018‑10‑31)
Description This is the physical locations of the patient. For inpatient, e.g., hospital ward, bed, theatre. For ambulatory care, e.g., health center, clinic, resources center, patient’s home.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Individual accompanying person
prsb03-dataelement-10088
Id prsb03-dataelement-10088 (2018‑10‑31)
Description Details of the accompanying individual and the extent to which they have provided the information about the person.
draft Name
prsb03-dataelement-10984
Id prsb03-dataelement-10984 (2019‑05‑23 12:59:39)
Description Name of individual accompanying person.
Operationalization Free text
Value Domain
Property
max length
70
cancelled Role
prsb03-dataelement-10985
Id prsb03-dataelement-10985 (2019‑05‑23 13:00:07) 0.1
Description Role of the individual accompanying the person.
Operationalization NHS data dictionary : - Care professional
Value Domain
folder draft Relationship
prsb03-dataelement-10986
Id prsb03-dataelement-10986 (2019‑05‑23 13:02:20)
Description Relationship of individual accompanying the person.
draft Coded value
prsb03-dataelement-13517
Id prsb03-dataelement-13517 (2020‑09‑04 12:30:42)
Description The coded value for relationship to person.
Operationalization FHIR value set: - Relationship type
Value Domain
draft Free text
prsb03-dataelement-13518
Id prsb03-dataelement-13518 (2020‑09‑04 12:31:40)
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
draft Comment
prsb03-dataelement-12447
Id prsb03-dataelement-12447 (2019‑06‑17 14:41:14)
Description Information about the extent to which the accompanying individual provided information about the person.
Operationalization Free text.
Value Domain
Property
max length
150
folder draft Specialty
prsb03-dataelement-10089
Id prsb03-dataelement-10089 (2018‑10‑31)
Description The specialty e.g. physiotherapy, oncology, mental health etc
draft Coded value
prsb03-dataelement-13390
Id prsb03-dataelement-13390 (2020‑08‑10 18:29:53)
Description The coded value for specialty
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
draft Free text
prsb03-dataelement-13391
Id prsb03-dataelement-13391 (2020‑08‑10 18:31:31)
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
folder draft Discharge details
prsb03-dataelement-191
Id prsb03-dataelement-191 (2018‑10‑31)
Description Discharge details
folder draft Discharge details record entry
prsb03-dataelement-10919
Id prsb03-dataelement-10919 (2019‑04‑09 16:31:23)
Description This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
draft Expected date of discharge
prsb03-dataelement-13424
Id prsb03-dataelement-13424 (2020‑08‑11 14:16:33) 0.1
Description The expected/ proposed date the person will be discharged.
Operationalization SNOMED CT: - 861031000000101 |Expected date of discharge from service (observable entity)|
Value Domain
Property
Timestamp precision
at least day, month and year
draft Date of discharge
prsb03-dataelement-10096
Id prsb03-dataelement-10096 (2018‑10‑31)
Description The date and time of discharge

Properties

FHIR Encounter.period
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Discharge location
prsb03-dataelement-10095
Id prsb03-dataelement-10095 (2018‑10‑31)
Description The hospital the person was discharged from.

Properties

FHIR Encounter.location.name
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
folder draft Discharging consultant
prsb03-dataelement-10093
Id prsb03-dataelement-10093 (2018‑10‑31)
Description The consultant responsible for the person at time of discharge.

Properties

FHIR Encounter.Prartitioner.PractitionerRole.identifier (local ID) Encounter.Prartitioner.PractitionerRole.code Encounter.Prartitioner.Practitioner.identifier Encounter.Prartitioner.PractitionerRole.Practitioner.name
draft Name
prsb03-dataelement-10994
Id prsb03-dataelement-10994 (2019‑05‑23 23:22:01)
Description The name of the discharging consultant
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-10995
Id prsb03-dataelement-10995 (2019‑05‑23 23:22:48)
Description The role of the discharging consultant
Operationalization FHIR value set : - sdsjobrole
Value Domain
draft Discharge destination
prsb03-dataelement-10091
Id prsb03-dataelement-10091 (2018‑10‑31)
Description The destination of the person on discharge.

Properties

FHIR Encounter.hospitalisation.dischargedisposition
Operationalization Sent as per the ECDS Emergency Care Discharge Destination code set (SNOMED CT).
Value Domain
Property
max length
2
draft Discharge status
prsb03-dataelement-10092
Id prsb03-dataelement-10092 (2018‑10‑31)
Description Patient status on discharge from emergency care.

Properties

FHIR Encounter,Subject.Observation
Operationalization Sent as per the ECDS Emergency Care DischargeStatus code set (SNOMED CT):
Value Domain
folder draft Discharge method
prsb03-dataelement-10098
Id prsb03-dataelement-10098 (2018‑10‑31)
Description The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.

Properties

FHIR Handled as text in the transfer of care
draft Coded value
prsb03-dataelement-13393
Id prsb03-dataelement-13393 (2020‑08‑10 18:53:34)
Description The coded value for discharge method
Operationalization NHS data dictionary : - Discharge method
Value Domain
Property
max length
1
draft Free text
prsb03-dataelement-13394
Id prsb03-dataelement-13394 (2020‑08‑10 18:55:25)
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
folder draft Discharging specialty
prsb03-dataelement-10094
Id prsb03-dataelement-10094 (2018‑10‑31)
Description The specialty of the consultant responsible for the person at the time of discharge.
draft Coded value
prsb03-dataelement-13395
Id prsb03-dataelement-13395 (2020‑08‑10 18:57:49)
Description The coded value for discharge speciality
Operationalization NHS data dictionary : - Activity treatment function code
Value Domain
Property
max length
3
draft Free text
prsb03-dataelement-13396
Id prsb03-dataelement-13396 (2020‑08‑10 18:59:31)
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
draft Discharging department
prsb03-dataelement-10987
Id prsb03-dataelement-10987 (2019‑05‑23 13:21:24)
Description The department from which the person is discharged.
Operationalization Free text
Value Domain
Property
max length
150
draft Legal status on discharge
prsb03-dataelement-10097
Id prsb03-dataelement-10097 (2018‑10‑31)
Description Whether the person was discharged as informal or formal/detained.

Properties

FHIR Encounter,Subject.Observation
Operationalization NHS data dictionary : - Mental health act classification code
Value Domain
Property
max length
2
folder draft Discharge destination
prsb03-dataelement-10099
Id prsb03-dataelement-10099 (2018‑10‑31)

Properties

FHIR Encounter.hospitalisation.destination.location. Address
draft Discharge destination
prsb03-dataelement-10100
Id prsb03-dataelement-10100 (2018‑10‑31)
Description The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.

Properties

FHIR A code from the NHS Data Dictionary Discharge Destination
Operationalization NHS data dictionary - Discharge destination.
Value Domain
Property
max length
2
draft Discharge address
prsb03-dataelement-10101
Id prsb03-dataelement-10101 (2018‑10‑31)
Description Address to which the person is discharged if not the usual place of residence.

Properties

FHIR If the patient is discharged to their normal place of residence, no address is recorded on the discharge summary. Otherwise, an address other than the patient's usual place of residence may be provided by the patient or their representative.
Operationalization NHS data dictionary :- Address
Value Domain
Property
min length max length
35 175
cancelled Expected date of discharge
prsb03-dataelement-10102
Id prsb03-dataelement-10102 (2018‑10‑31)
Description The date the person is currently expected to be discharged.
Operationalization Date/time
Value Domain
folder cancelled Discharge date informed status
prsb03-dataelement-13386
Id prsb03-dataelement-13386 (2020‑08‑10 18:22:05) 0.1
Description A statement confirming that the patient or carer has been informed of the date on which it is proposed that the patient be discharged
cancelled Discharge date patient informed indicator
prsb03-dataelement-13392
Id prsb03-dataelement-13392 (2020‑08‑10 18:32:48) 0.1
Description Indicates whether or not the patient has been informed of the proposed discharge date.
Value Domain
folder draft Discharge date informed status
prsb03-dataelement-13383
Id prsb03-dataelement-13383 (2020‑08‑10 18:08:49) 0.1
Description A statement confirming that the person or carer has been informed of the date on which it is proposed that the person be discharged
draft Discharge date person informed indicator
prsb03-dataelement-13423
Id prsb03-dataelement-13423 (2020‑08‑11 14:07:04) 0.1
Description Indicates whether or not the patient has been informed of the proposed discharge date.
Operationalization Flag;- yes or no
Value Domain
draft Discharge date carer informed indicator
prsb03-dataelement-13422
Id prsb03-dataelement-13422 (2020‑08‑11 14:02:51) 0.1
Description Indicates whether or not the carer (where applicable) has been informed of the proposed discharge date.
Operationalization
Flag : - N: No;Y: Yes; NKC: No Known Carer
Value Domain
folder draft Emergency Care Attendance
prsb03-dataelement-379
Id prsb03-dataelement-379 (2018‑10‑31)
Description Emergency Care Attendance
draft Clinical narrative
prsb03-dataelement-10279
Id prsb03-dataelement-10279 (2018‑10‑31)
Description A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.
Operationalization Free text
Value Domain
Property
max length
150
draft Date and time of attendance
prsb03-dataelement-10280
Id prsb03-dataelement-10280 (2018‑10‑31)
Description Date and time patient arrived at the unscheduled care unit.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Date and time of discharge
prsb03-dataelement-10281
Id prsb03-dataelement-10281 (2018‑10‑31)
Description The actual date and time of discharge.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Diagnosis
prsb03-dataelement-10282
Id prsb03-dataelement-10282 (2018‑10‑31)
Description Confirmed diagnosis; active diagnosis being treated. Include the stage of the disease where relevant.
Value Domain
draft Discharge destination
prsb03-dataelement-10283
Id prsb03-dataelement-10283 (2018‑10‑31)
Description The destination of the patient on discharge. National codes. E.g., High Dependency Unit.
Value Domain
draft Discharge status
prsb03-dataelement-10284
Id prsb03-dataelement-10284 (2018‑10‑31)
Description Patient status on discharge from emergency care.
Value Domain
draft Location
prsb03-dataelement-10285
Id prsb03-dataelement-10285 (2018‑10‑31)
Description Details of where the unscheduled care attendance took place.
Value Domain
draft Person accompanying patient
prsb03-dataelement-10286
Id prsb03-dataelement-10286 (2018‑10‑31)
Description Identify others accompanying the patient, e.g., relative, friend, patient informal carer, advocate. If the patient was not present, was an authorised representative present. Include name and relationship (friend, relative, etc.)
Value Domain
draft Plan and Requested Actions
prsb03-dataelement-10287
Id prsb03-dataelement-10287 (2018‑10‑31)
Description A simple free text description of the plan of action following the contact with the person. This may include actions for the parent, healthcare professional (e.g. health visitor) and review.
Value Domain
draft Presenting complaint or issue
prsb03-dataelement-10288
Id prsb03-dataelement-10288 (2018‑10‑31)
Description The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.
Value Domain
cancelled Senior reviewing clinician
prsb03-dataelement-10800
Id prsb03-dataelement-10800 (2019‑03‑20 13:45:58)
Value Domain
folder draft Senior Reviewing Clinician
prsb03-dataelement-327
Id prsb03-dataelement-327 (2018‑10‑31)
Description Senior Reviewing Clinician
target Used by 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-10227
Id prsb03-dataelement-10227 (2018‑10‑31)
Description The name of the senior clinician responsible for reviewing the patient treatment and discharge plan.
Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, suffix).
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-10228
Id prsb03-dataelement-10228 (2018‑10‑31)
Description The unique identifier issued by the regulatory body e.g., GMC number, HCPC number etc.
Operationalization The professional identifier type and the identifier itself as held on the source system. An identifier for the person completing the record will be sent (but may not be displayed in the rendered message).
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Procedure
prsb03-dataelement-10289
Id prsb03-dataelement-10289 (2018‑10‑31)
Description The therapeutic or diagnostic procedure performed on the patient. This may be coded, or represented as free text.
Value Domain
draft Referral Source
prsb03-dataelement-10290
Id prsb03-dataelement-10290 (2018‑10‑31)
Description Source of referral for Unscheduled care
Value Domain
draft Safety Alerts
prsb03-dataelement-10291
Id prsb03-dataelement-10291 (2018‑10‑31)
Description Safety Alerts at the Emergency Care Attendance suggested to be pulled through from the Safety Alerts heading.
Value Domain
folder draft Future appointments
prsb03-dataelement-10720
Id prsb03-dataelement-10720 (2019‑02‑08 15:58:04)
Description Details of future appointments.
folder draft Future appointments record entry
prsb03-dataelement-10721
Id prsb03-dataelement-10721 (2019‑02‑08 15:58:39)
Description This is the future appointments 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.
draft Date of appointment
prsb03-dataelement-10722
Id prsb03-dataelement-10722 (2019‑02‑08 15:59:19)
Description Date and time of future appointment.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
draft Appointment status
prsb03-dataelement-10723
Id prsb03-dataelement-10723 (2019‑02‑08 16:00:39)
Description The status of the appointment e.g. proposed, booked, confirmed, rejected.
Operationalization Free text
Value Domain
Property
max length
150
draft Reason for appointment
prsb03-dataelement-10724
Id prsb03-dataelement-10724 (2019‑02‑08 16:02:23)
Description Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessment
Operationalization Free text
Value Domain
Property
max length
150
draft Clinical urgency of appointment
prsb03-dataelement-10725
Id prsb03-dataelement-10725 (2019‑02‑08 16:03:54)
Description Urgency of appointment.
Operationalization NHS data dictionary : - Priority
Value Domain
Property
max length
1
folder draft Location of future appointment
prsb03-dataelement-10726
Id prsb03-dataelement-10726 (2019‑02‑08 16:05:14)
Description The location of the appointment.
draft Coded value
prsb03-dataelement-13519
Id prsb03-dataelement-13519 (2020‑09‑04 13:23:38)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13520
Id prsb03-dataelement-13520 (2020‑09‑04 13:25:24)
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
draft Specialty
prsb03-dataelement-10727
Id prsb03-dataelement-10727 (2019‑02‑08 16:10:35)
Description The specialty e.g. physiotherapy, oncology, mental health etc.

Properties

FHIR Encounter.participant.individual.Practitioner.PractitionerRole.speciality (of the consultant responsible for the encounter)
Relationship
Operationalization
NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
draft Service
prsb03-dataelement-10728
Id prsb03-dataelement-10728 (2019‑02‑08 16:11:32)
Description The service being provided.

Properties

FHIR Encounter.Appointment.servicetype
Relationship
Operationalization SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Value Domain
folder draft Professional seeing the person
prsb03-dataelement-10729
Id prsb03-dataelement-10729 (2019‑02‑08 16:12:10)
Description The name and role of the professional e.g. consultant, care worker, nurse consultant.

Properties

FHIR Encounter.participant
Relationship
draft Name
prsb03-dataelement-12413
Id prsb03-dataelement-12413 (2019‑06‑05 18:59:13)
Description The name of the professional seeing the person.
Operationalization Free text
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-12414
Id prsb03-dataelement-12414 (2019‑06‑05 18:59:35)
Description The role of the professional seeing the person.
Operationalization FHIR value set : - sdsjobrole
Value Domain
folder draft Incident details
prsb03-dataelement-10887
Id prsb03-dataelement-10887 (2019‑03‑29 13:05:03)
Description Details of ambulance incidents.
draft Source of call
prsb03-dataelement-10888
Id prsb03-dataelement-10888 (2019‑03‑29 13:05:52)
Description Where the call originated from e.g. 999, NHS 111, police, GP, hospital etc.
Operationalization Record generated from the local system.
Value Domain
draft Ambulance service
prsb03-dataelement-10889
Id prsb03-dataelement-10889 (2019‑03‑29 13:07:10)
Description The ambulance service provider. This could be NHS, air ambulance, voluntary or private provider.
Operationalization This should be the Organisation Data Services name for the ambulance service.
Value Domain
draft Incident number
prsb03-dataelement-10890
Id prsb03-dataelement-10890 (2019‑03‑29 13:14:27)
Description The number that identifies the incident and is generated by the dispatcher in response to a call.
Operationalization This is a number generated by the local system.
Value Domain
draft Unique person identifier
prsb03-dataelement-10891
Id prsb03-dataelement-10891 (2019‑03‑29 13:22:03)
Description A unique identifier to identifiy the person.
Operationalization This is a number generated by the local system. Note: The exact values for this heading are expected to be defined by the Ambulance Dataset Project.
Value Domain
draft Incident location
prsb03-dataelement-10892
Id prsb03-dataelement-10892 (2019‑03‑29 13:33:38)
Description The location of the incident.
Operationalization The record of the address provided by the local system.
Value Domain
draft Individual accompanying person
prsb03-dataelement-10893
Id prsb03-dataelement-10893 (2019‑03‑29 13:34:37)
Description Individual who has family, carer or other relationship who accompanies the person.
Operationalization Record as provided by the ambulance clinician, in free text.
Value Domain
draft Incident date and time
prsb03-dataelement-10894
Id prsb03-dataelement-10894 (2019‑03‑29 13:35:24)
Description The date and time of the incident.
Operationalization This is the date as reported by the person or the person reporting the incident.
Value Domain
draft Time of symptom onset
prsb03-dataelement-10895
Id prsb03-dataelement-10895 (2019‑03‑29 13:36:11)
Description The approximate time the person’s symptoms began. Where there is a prodrome of intermittent pain the time recorded should be the time of onset of those symptoms which led the person to call for help.
Operationalization This is the time as reported by the person or the person reporting the incident.
Value Domain
draft Arrival time at incident
prsb03-dataelement-10896
Id prsb03-dataelement-10896 (2019‑03‑29 13:37:59)
Description The time the crew or individual responder arrived at the scene of the incident
Operationalization The information is provided by the local system.
Value Domain
draft Time left incident location
prsb03-dataelement-10897
Id prsb03-dataelement-10897 (2019‑03‑29 13:38:51)
Description Time the crew or individual responder left the incident
Operationalization The information is provided by the local system.
Value Domain
draft Time of arrival at handover destination
prsb03-dataelement-10898
Id prsb03-dataelement-10898 (2019‑03‑29 13:39:37)
Description
The time the ambulance parks at the handover
destination (eg A&E, clinic, etc).
Operationalization The information is provided by the local system.
Value Domain
folder draft Injury
prsb03-dataelement-10899
Id prsb03-dataelement-10899 (2019‑04‑02 12:05:36)
Description Details of the person's injury.
draft Injury activity status
prsb03-dataelement-10900
Id prsb03-dataelement-10900 (2019‑04‑02 12:07:28)
Description The status of activity being undertaken by the person at the moment the injury occurred (e.g. education, work, leisure activity etc).
Operationalization
To obtain the subset click on members under concept details along the top right section
Value Domain
draft Injury activity
prsb03-dataelement-10901
Id prsb03-dataelement-10901 (2019‑04‑02 12:09:04)
Description The type of activity being undertaken by the person at the moment the injury occurred.
Operationalization
To obtain the subset click on members under concept details along the top right section
Value Domain
draft Injury intent
prsb03-dataelement-10902
Id prsb03-dataelement-10902 (2019‑04‑02 12:12:31)
Description The most likely human intent in the occurrence of the injury or poisoning as assessed by clinician.
Operationalization
To obtain the subset click on members under concept details along the top right section
Value Domain
draft Injury mechanism
prsb03-dataelement-10903
Id prsb03-dataelement-10903 (2019‑04‑02 12:13:24)
Description How the injury was caused.
Operationalization
To obtain the subset click on members under concept details along the top right section
Value Domain
draft Alcohol or drug involvement in injury
prsb03-dataelement-10904
Id prsb03-dataelement-10904 (2019‑04‑02 12:14:19)
Description A record of any drugs or alcohol used by the person, which are thought likely to have contributed to the need to attend the ED.
Operationalization
To obtain the subset click on members under concept details along the top right section
Value Domain
folder draft Relevant past medical, surgical and mental health history
prsb03-dataelement-547
Id prsb03-dataelement-547 (2018‑10‑31)
Description The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc (with obstetric history).
draft Date
prsb03-dataelement-10447
Id prsb03-dataelement-10447 (2018‑10‑31)
Description The date on which the medical history was recorded
Value Domain
draft Location
prsb03-dataelement-10448
Id prsb03-dataelement-10448 (2018‑10‑31)
Description The location where the medical history was recorded
Value Domain
draft Performing Professional
prsb03-dataelement-10449
Id prsb03-dataelement-10449 (2018‑10‑31)
Description Details of the professional performing the medical history (including name and role)
Value Domain
draft Gynaecology
prsb03-dataelement-10450
Id prsb03-dataelement-10450 (2018‑10‑31)
Description A record of the woman’s gynaecology medical history relevant to the maternity episode, including relevant previous diagnoses, problems and issues, procedures, surgeries and investigations.
Value Domain
draft Past obstetric
prsb03-dataelement-10451
Id prsb03-dataelement-10451 (2018‑10‑31)
Description A record of the woman’s obstetric medical history relevant to the maternity episode. To include each previous pregnancy details and the outcome.
Value Domain
draft Relevant past medical history
prsb03-dataelement-10452
Id prsb03-dataelement-10452 (2018‑10‑31)
Description The record of the person's significant medical, history. Including relevant previous diagnoses, health history problems and issues.
Value Domain
draft Relevant past surgical history
prsb03-dataelement-10453
Id prsb03-dataelement-10453 (2018‑10‑31)
Description The record of the person’s significant surgical history. Including relevant issues, procedures, investigations, specific anaesthesia issues, etc.
Value Domain
draft Relevant past mental health history
prsb03-dataelement-10454
Id prsb03-dataelement-10454 (2018‑10‑31)
Description A record of the person’s mental health history relevant to the episode
Value Domain
draft Acute Hospital Episodes
prsb03-dataelement-10455
Id prsb03-dataelement-10455 (2018‑10‑31)
Description Reported details of any history of acute hospital episodes including ITU, HDU and A&E attendances the woman has had.
Value Domain
draft Mental Health Admissions
prsb03-dataelement-10456
Id prsb03-dataelement-10456 (2018‑10‑31)
Description Reported details of any history of mental health admissions.
Value Domain
draft Relevant past medical, surgical and mental health history
prsb03-dataelement-12476
Id prsb03-dataelement-12476 (2019‑06‑27 12:35:48)
Description The record of the person's significant medical, surgical and mental health history (will include dental and obstetric history). Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc.
Relationship
Operationalization A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form.
Value Domain
folder draft Relevant clinical risk factors
prsb03-dataelement-203
Id prsb03-dataelement-203 (2018‑10‑31)
Description Relevant clinical risk factors
folder draft Relevant clinical risk factor record entry
prsb03-dataelement-10650
Id prsb03-dataelement-10650 (2018‑11‑12 19:39:02)
Description This is a Relevant clinical risk factor record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
draft Relevant clinical risk factor
prsb03-dataelement-10103
Id prsb03-dataelement-10103 (2018‑10‑31)
Description Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis/differential diagnosis. E.g. being overweight, smoker, no use of sun screen, enzyme deficiency.

Properties

FHIR composition.text
Operationalization Free text
Value Domain
draft Date
prsb03-dataelement-10104
Id prsb03-dataelement-10104 (2018‑10‑31)
Description The date on which the clinical risk factor was recorded
Value Domain
draft Location
prsb03-dataelement-10105
Id prsb03-dataelement-10105 (2018‑10‑31)
Description The location where the clinical risk factor was recorded.
Value Domain
draft Performing Professional
prsb03-dataelement-10106
Id prsb03-dataelement-10106 (2018‑10‑31)
Description Details of the professional recording the clinical risk factor (including name and role)
Value Domain
draft Clinical risk assessment
prsb03-dataelement-10107
Id prsb03-dataelement-10107 (2018‑10‑31)
Description Specific risk assessments required/undertaken.
Operationalization Coded (SNOMED CT) or text
Value Domain
draft Risk mitigation
prsb03-dataelement-10108
Id prsb03-dataelement-10108 (2018‑10‑31)
Description Action taken to reduce the clinical risk and date actions.
Operationalization Free text
Value Domain
draft Patient at high risk
prsb03-dataelement-10109
Id prsb03-dataelement-10109 (2018‑10‑31)
Description This patient is at high risk of clinical deterioration and will need an immediate response if called
Value Domain
folder draft Vaccinations
prsb03-dataelement-10685
Id prsb03-dataelement-10685 (2018‑12‑04 11:33:10)
Description Details of vaccinations.
folder draft Vaccinations record entry
prsb03-dataelement-10686
Id prsb03-dataelement-10686 (2018‑12‑04 11:34:26) 0.1
Description

This is the vaccinations record entry.

There may be 0 to many record entries under a section.

Each record entry is made up of a number of elements or data items.

draft Date
prsb03-dataelement-10695
Id prsb03-dataelement-10695 (2018‑12‑04 11:38:40)
Description The date on which the vaccination was administered or the reported/partial date on which it was reported.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-10759
Id prsb03-dataelement-10759 (2019‑03‑08 17:50:00)
Description The location where the vaccine was administered.
Relationship
draft Coded value
prsb03-dataelement-13577
Id prsb03-dataelement-13577 (2020‑09‑07 17:08:23)
Description The coded value for location
Operationalization NHS data dictionary: - Organisation data service
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13578
Id prsb03-dataelement-13578 (2020‑09‑07 17:09:39)
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
cancelled Performing professional
prsb03-dataelement-10760
Id prsb03-dataelement-10760 (2019‑03‑08 17:50:41)
Description Details of the professional administering the vaccine or the professional to whom the vaccination was reported.
Relationship
Operationalization Free text
Value Domain
folder draft Performing professional
prsb03-dataelement-12184
Id prsb03-dataelement-12184 (2019‑05‑31 16:19:14)
Description The professional who administered the vaccine.
Relationship
draft Name
prsb03-dataelement-12185
Id prsb03-dataelement-12185 (2019‑05‑31 16:19:35)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-12186
Id prsb03-dataelement-12186 (2019‑05‑31 16:19:35)
Description The role the professional has in relation to the person.
Relationship
Operationalization FHIR value set : - sdsjobrole
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-12187
Id prsb03-dataelement-12187 (2019‑05‑31 16:19:35)
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 0 transactions, 0 templates, inherited once
 
draft Speciality
prsb03-dataelement-12188
Id prsb03-dataelement-12188 (2019‑05‑31 16:19:35)
Description The specialty of the professional.
Relationship
Operationalization NHS data dictionary - Main specialty code
Value Domain
Property
max length
3
target Used by 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-12189
Id prsb03-dataelement-12189 (2019‑05‑31 16:19:35)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-12190
Id prsb03-dataelement-12190 (2019‑05‑31 16:19:35)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-12191
Id prsb03-dataelement-12191 (2019‑05‑31 16:19:35)
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 0 transactions, 0 templates, inherited once
 
folder draft Vaccine product
prsb03-dataelement-10687
Id prsb03-dataelement-10687 (2018‑12‑04 11:36:00)
Description The vaccine product administered.
draft Coded value
prsb03-dataelement-13237
Id prsb03-dataelement-13237 (2020‑07‑21 16:44:15)
Description The coded value for vaccine product.
Operationalization SNOMED CT

AMP 999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| or

VMP 999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)| or dm+d
Value Domain
draft Free text
prsb03-dataelement-13238
Id prsb03-dataelement-13238 (2020‑07‑21 16:45:32)
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
folder draft Manufacturer
prsb03-dataelement-10698
Id prsb03-dataelement-10698 (2018‑12‑04 15:11:19)
Description Name of vaccine manufacturer.
draft Coded value
prsb03-dataelement-13239
Id prsb03-dataelement-13239 (2020‑07‑21 17:14:02)
Description The coded value of the manufacturer.
Operationalization SNOMED CT: - DM+D or GS1
Value Domain
draft Free text
prsb03-dataelement-13240
Id prsb03-dataelement-13240 (2020‑07‑21 17:15:48)
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
folder draft Vaccine procedure
prsb03-dataelement-10688
Id prsb03-dataelement-10688 (2018‑12‑04 11:36:30)
Description The procedure which was used to administer the vaccine.
draft Coded value
prsb03-dataelement-13219
Id prsb03-dataelement-13219 (2020‑07‑08 12:29:41)
Description The coded value for vaccine procedure
Operationalization SNOMED CT :- < 127785005 |Administration of substance to produce immunity, either active or passive (procedure)|
Value Domain
draft Free text
prsb03-dataelement-13220
Id 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 0 transactions, 0 templates, inherited 113 times
 
folder draft Batch number
prsb03-dataelement-10697
Id prsb03-dataelement-10697 (2018‑12‑04 15:10:59)
Description The batch number of the product.
target Used by 0 transactions, 0 templates, inherited once
 
draft Coded value
prsb03-dataelement-13233
Id 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 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13234
Id prsb03-dataelement-13234 (2020‑07‑21 15:17:14)
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 0 transactions, 0 templates, inherited once
 
draft Expiry date
prsb03-dataelement-10696
Id prsb03-dataelement-10696 (2018‑12‑04 15:10:32)
Description The date on which the vaccine will expire.
Operationalization Date/time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Serialisation code
prsb03-dataelement-10690
Id prsb03-dataelement-10690 (2018‑12‑04 11:37:07)
Description A code that separately identifies two identical vaccines (i.e. same product, same batch).
draft Coded value
prsb03-dataelement-13235
Id prsb03-dataelement-13235 (2020‑07‑21 15:21:31)
Description The coded value for serialisation code.
Operationalization FMD code : - Derived from Falsified medicines directive
Value Domain
draft Free text
prsb03-dataelement-13236
Id prsb03-dataelement-13236 (2020‑07‑21 15:22:23)
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
folder draft Body site
prsb03-dataelement-10691
Id prsb03-dataelement-10691 (2018‑12‑04 11:37:33)
Description Body site vaccine was administered.
draft Coded value
prsb03-dataelement-13222
Id prsb03-dataelement-13222 (2020‑07‑08 17:37:37)
Description The coded value for body site
Operationalization SNOMED CT : - 1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13223
Id 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 0 transactions, 0 templates, inherited 17 times
 
folder draft Route
prsb03-dataelement-10692
Id prsb03-dataelement-10692 (2018‑12‑04 11:37:53)
Description How the vaccine entered the body.
draft Coded value
prsb03-dataelement-13224
Id prsb03-dataelement-13224 (2020‑07‑08 18:23:10)
Description The coded value for vaccination route
Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13225
Id prsb03-dataelement-13225 (2020‑07‑08 18:25:39)
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
folder draft Indication
prsb03-dataelement-10693
Id prsb03-dataelement-10693 (2018‑12‑04 11:38:05)
Description The clinical indication or reason for administering the vaccine.
draft Coded value
prsb03-dataelement-13226
Id prsb03-dataelement-13226 (2020‑07‑14 17:03:18)
Description The coded value for Indication.
Operationalization SNOMED CT:-

Routine mass immunisation


171279008|Immunization due (finding)|

Travel to endemic area

414448007|Identified as high risk for travel immunization (finding)|Planned travel to high risk area

161096004|Going to travel abroad (finding)|Recent travel to high risk area

506931000000109|Recent travel to disease affected area (finding)|

Subpopulation at special or unusual risk

78648007|At risk for infection (finding)|High risk due to occupation

14679004 Occupation (occupation)High risk due to lifestyle

134436002|Lifestyle (finding)|High risk due to existing medical condition

398192003|Co-morbid conditions (finding)|

Control of known sporadic outbreak

443684005|Disease outbreak (event)|

Patient request

183995001|Patient requested procedure (situation)|

Post-exposure prophyaxis

444107005|Exposure to communicable disease (event)|

Maternity record

<404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

Other

723620004|Requires vaccination (finding)
Value Domain
draft Free text
prsb03-dataelement-13227
Id prsb03-dataelement-13227 (2020‑07‑14 17:08:12)
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
folder draft Dose amount
prsb03-dataelement-10694
Id prsb03-dataelement-10694 (2018‑12‑04 11:38:24) 0.1
Description Amount of vaccine administered.
draft Coded value
prsb03-dataelement-13228
Id prsb03-dataelement-13228 (2020‑07‑15 18:42:20)
Description Amount of vaccine administered.
Operationalization SNOMED CT : - dm+d
Value Domain
draft Value
prsb03-dataelement-13838
Id prsb03-dataelement-13838 (2020‑12‑28 22:49:54)
Description The amount of vaccine administered
Relationship
Operationalization Free text
Value Domain
draft Units of measure
prsb03-dataelement-13839
Id prsb03-dataelement-13839 (2020‑12‑28 22:51:47)
Description The units of measure for the dose amount
Relationship
Operationalization UCUM code
Value Domain
Property
max length
10
draft Free text
prsb03-dataelement-13229
Id 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 0 transactions, 0 templates, inherited 2 times
 
draft Dose sequence
prsb03-dataelement-10824
Id prsb03-dataelement-10824 (2019‑03‑21 13:38:54)
Description Nominal position in a series of vaccines.
Relationship
Operationalization Numeric value
Value Domain
Property
max include
1
folder draft Outcome status
prsb03-dataelement-10838
Id prsb03-dataelement-10838 (2019‑03‑26 12:32:46)
Description Whether the vaccine was administered or not, including the reason why
Relationship
draft Not given flag
prsb03-dataelement-13230
Id prsb03-dataelement-13230 (2020‑07‑16 14:54:34)
Description Flag to indicate that the vaccination was NOT given at this time by a healthcare professional
Operationalization Flag: - Yes or No
Value Domain
Property
fixed
3
draft Vaccination situation (not given reason)
prsb03-dataelement-13231
Id prsb03-dataelement-13231 (2020‑07‑16 15:00:05)
Description The reason why a vaccination was not administered.
Operationalization Free text 
Value Domain
Property
max length
150
folder draft Person completing record
prsb03-dataelement-12192
Id prsb03-dataelement-12192 (2019‑05‑31 16:19:51)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-12193
Id prsb03-dataelement-12193 (2019‑05‑31 16:20:12)
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
draft Role
prsb03-dataelement-12194
Id prsb03-dataelement-12194 (2019‑05‑31 16:20:12)
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
draft Grade
prsb03-dataelement-12195
Id prsb03-dataelement-12195 (2019‑05‑31 16:20:12)
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
draft Specialty
prsb03-dataelement-12196
Id prsb03-dataelement-12196 (2019‑05‑31 16:20:12)
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
folder draft Organisation
prsb03-dataelement-12197
Id prsb03-dataelement-12197 (2019‑05‑31 16:20:12)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-12198
Id prsb03-dataelement-12198 (2019‑05‑31 16:20:12)
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
draft Date completed
prsb03-dataelement-12199
Id prsb03-dataelement-12199 (2019‑05‑31 16:20:12)
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
draft Contact details
prsb03-dataelement-12200
Id prsb03-dataelement-12200 (2019‑05‑31 16:20:12)
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
cancelled Person completing record
prsb03-dataelement-10951
Id prsb03-dataelement-10951 (2019‑05‑18 20:30:31) 0.1
Description This is the person recording the vaccination.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Reported
prsb03-dataelement-10825
Id prsb03-dataelement-10825 (2019‑03‑21 13:40:11)
Description Details of the vaccination reported to the professional
Relationship
draft Date
prsb03-dataelement-10837
Id prsb03-dataelement-10837 (2019‑03‑26 12:29:22)
Description The date or partial date that the reported vaccination was given in the opinion of the person.
Operationalization Date/time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
draft Reported
prsb03-dataelement-13849
Id prsb03-dataelement-13849 (2021‑01‑05 12:59:10)
Description A flag to indicate the information was reported to a professional
Operationalization Flag: - Yes or No
Value Domain
Property
default
3
draft Report origin
prsb03-dataelement-13232
Id prsb03-dataelement-13232 (2020‑07‑21 12:49:00)
Description The source of the data when the report of the vaccination event is not based on information from the person who administered the vaccine.
Operationalization FHIR value set:- https://www.hl7.org/fhir/valueset-immunization-origin.html
Value Domain
cancelled Manufacturer
prsb03-dataelement-10689
Id prsb03-dataelement-10689 (2018‑12‑04 11:36:46)
Value Domain
folder draft Appliances
prsb03-dataelement-13762
Id prsb03-dataelement-13762 (2020‑09‑30 12:33:21)
Description Details of appliances
folder draft Appliance records entry
prsb03-dataelement-13763
Id prsb03-dataelement-13763 (2020‑09‑30 12:41:04)
Description This is the appliance records entry.
draft Appliance name
prsb03-dataelement-13764
Id prsb03-dataelement-13764 (2020‑09‑30 12:44:26)
Description May be generic name or brand name (as appropriate).
Operationalization As per dm+d (AMP)
Value Domain
draft Product order number
prsb03-dataelement-13765
Id prsb03-dataelement-13765 (2020‑09‑30 12:59:10)
Description The product order number for the appliance.
Value Domain
draft Manufacturer
prsb03-dataelement-13766
Id prsb03-dataelement-13766 (2020‑09‑30 13:01:00)
Description Name of appliance manufacturer
Operationalization Free text
Value Domain
draft Batch number
prsb03-dataelement-13767
Id prsb03-dataelement-13767 (2020‑09‑30 13:03:53)
Description The batch number of the appliance.
Operationalization Free text
Value Domain
draft Size
prsb03-dataelement-13768
Id prsb03-dataelement-13768 (2020‑09‑30 13:07:19)
Description The size of the appliance.
Operationalization UCUM
Value Domain
draft Weight
prsb03-dataelement-13769
Id prsb03-dataelement-13769 (2020‑09‑30 13:09:16)
Description The weight of the appliance.
Operationalization UCUM
Value Domain
draft Colour
prsb03-dataelement-13770
Id prsb03-dataelement-13770 (2020‑09‑30 13:11:53)
Description The colour of the appliance
Operationalization Free text
Value Domain
folder draft Route
prsb03-dataelement-13771
Id prsb03-dataelement-13771 (2020‑09‑30 13:14:22)
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)|
draft Coded Value
prsb03-dataelement-14268
Id prsb03-dataelement-14268 (2021‑03‑31 12:16:55)
Description Coded value for appliance route
Operationalization

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

SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
Value Domain
draft Free text
prsb03-dataelement-14270
Id prsb03-dataelement-14270 (2021‑03‑31 12:48:09)
Description Free text where no coded value is available
Operationalization Free text
Value Domain
cancelled Coded value
prsb03-dataelement-13797
Id prsb03-dataelement-13797 (2020‑11‑04 12:33:31) 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
cancelled Free text
prsb03-dataelement-13796
Id prsb03-dataelement-13796 (2020‑11‑04 12:33:18) 1
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
draft Quantity
prsb03-dataelement-13773
Id prsb03-dataelement-13773 (2020‑09‑30 14:00:10)
Description The quantity of the appliance (including the units).
Operationalization UCUM
Value Domain
draft Indication
prsb03-dataelement-13774
Id prsb03-dataelement-13774 (2020‑09‑30 14:04:52)
Description Reason for appliance being prescribed, where known.
Operationalization Free text
Value Domain
draft Matters identified during the discussion
prsb03-dataelement-13775
Id prsb03-dataelement-13775 (2020‑09‑30 14:06:42)
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
draft Date/time
prsb03-dataelement-13802
Id prsb03-dataelement-13802 (2020‑11‑12 20:45:55) 1
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Presenting complaints or issues
prsb03-dataelement-210
Id prsb03-dataelement-210 (2018‑10‑31)
Description Presenting complaints or issues
draft Presenting complaint or issue
prsb03-dataelement-10110
Id prsb03-dataelement-10110 (2018‑10‑31)
Description The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

Properties

FHIR Condition.code
Operationalization Only ONE (chief complaint) sent as per the ECDS Emergency Care Chief Complaint code set (SNOMED CT).
Value Domain
folder draft Presenting complaint or issue
prsb03-dataelement-13784
Id prsb03-dataelement-13784 (2020‑10‑22 17:40:08)
Description The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. E.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

Properties

FHIR Condition.code
Relationship
draft Coded value
prsb03-dataelement-13785
Id prsb03-dataelement-13785 (2020‑10‑22 17:41:38)
notice There is an open issue with this item:
Description The coded value for presenting complaint or issue
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
draft Free text
prsb03-dataelement-13786
Id prsb03-dataelement-13786 (2020‑10‑22 17:42:28)
Relationship
Operationalization Free text
Value Domain
Property
max length
150
draft Chief complaint
prsb03-dataelement-10905
Id prsb03-dataelement-10905 (2019‑04‑02 12:33:30)
Description The nature of the person's chief complaint as assessed by the care professional first assessing the person.
Operationalization Only ONE (chief complaint) sent as per the ECDS Emergency Care Chief Complaint code set (SNOMED CT).
Value Domain
draft Person reported complaints or issues
prsb03-dataelement-10906
Id prsb03-dataelement-10906 (2019‑04‑02 12:34:17)
Description Person stated description of the health problems and issues. This may differ from the clinicians impression. This may also be expressed on behalf of the person, eg by parent or carer.
Operationalization Free text
Value Domain
Property
max length
150
draft Acuity assessment
prsb03-dataelement-10907
Id prsb03-dataelement-10907 (2019‑04‑02 12:35:14)
Description The most recent acuity of the person's condition on the paramedic's assessment.
Operationalization Emergency Care Acuity



To obtain the subset click on members under concept details along the top right section
Value Domain
folder draft Problem list
prsb03-dataelement-10927
Id prsb03-dataelement-10927 (2019‑04‑30 17:00:00)
Description A summary of the problems that require investigation or treatment.
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Problem list record entry
prsb03-dataelement-10928
Id prsb03-dataelement-10928 (2019‑04‑30 17:01:01)
Description This is a problem list record entry.

There may be 0 to many record entries under problem list.

Each record entry is made up of a number of elements or data items.
target Used by 0 transactions, 0 templates, inherited once
 
draft Date
prsb03-dataelement-10929
Id prsb03-dataelement-10929 (2019‑04‑30 17:04:55)
Description The date the problem was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited once
 
cancelled Performing professional
prsb03-dataelement-10930
Id prsb03-dataelement-10930 (2019‑04‑30 17:06:52) 0.1
Description Details of the professional identifying the problem.
Relationship
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Performing professional
prsb03-dataelement-12133
Id prsb03-dataelement-12133 (2019‑05‑31 16:03:47)
Description The professional who identified the problem.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-12134
Id prsb03-dataelement-12134 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-12135
Id prsb03-dataelement-12135 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-12136
Id prsb03-dataelement-12136 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
draft Speciality
prsb03-dataelement-12137
Id prsb03-dataelement-12137 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-12138
Id prsb03-dataelement-12138 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-12139
Id prsb03-dataelement-12139 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-12140
Id prsb03-dataelement-12140 (2019‑05‑31 16:04:17)
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 0 transactions, 0 templates, inherited once
 
folder draft Location
prsb03-dataelement-10931
Id prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
Description The location the problem was identified.
Relationship
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Coded value
prsb03-dataelement-13242
Id 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 0 transactions, 0 templates, inherited 4 times
 
draft Free text
prsb03-dataelement-13243
Id prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
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 0 transactions, 0 templates, inherited 4 times
 
folder draft Problem
prsb03-dataelement-10932
Id prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
Description A condition which needs addressing and so is important for every professional to know about when seeing the person.

Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Relationship
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Coded value
prsb03-dataelement-13244
Id prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
Description The coded value for the problem list.
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13245
Id prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
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 0 transactions, 0 templates, inherited once
 
draft Onset date
prsb03-dataelement-10933
Id prsb03-dataelement-10933 (2019‑04‑30 17:10:25)
Description A date or estimated date that the problem began
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least month and year
target Used by 0 transactions, 0 templates, inherited once
 
draft End Date
prsb03-dataelement-10934
Id prsb03-dataelement-10934 (2019‑04‑30 17:10:59)
Description The date or estimated date the problem was resolved.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Problem on discharge
prsb03-dataelement-14262
Id prsb03-dataelement-14262 (2021‑03‑10 15:51:43)
Description PLACEHOLDER: The main problem or diagnosis on discharge.

Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Relationship
draft Coded value
prsb03-dataelement-14263
Id prsb03-dataelement-14263 (2021‑03‑10 15:53:09)
Concept inherits from draft prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
Description The coded value for the problem list.
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
draft Free text
prsb03-dataelement-14264
Id prsb03-dataelement-14264 (2021‑03‑10 15:53:09)
Concept inherits from draft prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
folder cancelled Problem on discharge
prsb03-dataelement-14261
Id prsb03-dataelement-14261 (2021‑03‑10 15:49:19) 0.1
Description PLACEHOLDER. Anoop and Nilesh to write description
draft Stage of disease
prsb03-dataelement-10935
Id prsb03-dataelement-10935 (2019‑04‑30 17:11:55)
Description The stage of the disease where relevant.
Relationship
Operationalization Free text
Value Domain
Property
max length
150
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Person completing record
prsb03-dataelement-12141
Id prsb03-dataelement-12141 (2019‑05‑31 16:04:31)
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 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-12142
Id prsb03-dataelement-12142 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-12143
Id prsb03-dataelement-12143 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-12144
Id prsb03-dataelement-12144 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Specialty
prsb03-dataelement-12145
Id prsb03-dataelement-12145 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-12146
Id prsb03-dataelement-12146 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-12147
Id prsb03-dataelement-12147 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Date completed
prsb03-dataelement-12148
Id prsb03-dataelement-12148 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-12149
Id prsb03-dataelement-12149 (2019‑05‑31 16:04:53)
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 0 transactions, 0 templates, inherited once
 
cancelled Person completing record
prsb03-dataelement-10952
Id prsb03-dataelement-10952 (2019‑05‑18 21:04:15) 0.1
Description This is the person recording the problem.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Comment
prsb03-dataelement-10936
Id prsb03-dataelement-10936 (2019‑04‑30 17:13:22)
Description Supporting text may be given covering the problem.
Relationship
Operationalization Free text
Value Domain
Property
max length
150
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Problems and issues
prsb03-dataelement-211
Id prsb03-dataelement-211 (2018‑10‑31)
Description Problems and issues
folder draft Problems and Issues record entry
prsb03-dataelement-10719
Id prsb03-dataelement-10719 (2019‑02‑08 15:18:59)
draft Date Recorded
prsb03-dataelement-10111
Id prsb03-dataelement-10111 (2018‑10‑31)
Description The date on which the problem was recorded
Value Domain
draft Performing Professional
prsb03-dataelement-10112
Id prsb03-dataelement-10112 (2018‑10‑31)
Description Details of the professional recording (including name and role)
Value Domain
draft Location
prsb03-dataelement-10113
Id prsb03-dataelement-10113 (2018‑10‑31)
Description Details of where the problem was recorded
Value Domain
draft Problem
prsb03-dataelement-10114
Id prsb03-dataelement-10114 (2018‑10‑31)
Description A condition which needs addressing and so is important for every health professional to know about when seeing the person. Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Value Domain
draft Onset date
prsb03-dataelement-10115
Id prsb03-dataelement-10115 (2018‑10‑31)
Description A date or estimated date that the Problem began
Value Domain
draft End Date
prsb03-dataelement-10116
Id prsb03-dataelement-10116 (2018‑10‑31)
Description The date or estimated date the problem was resolved (will be blank for active)
Value Domain
draft Stage of Disease
prsb03-dataelement-10117
Id prsb03-dataelement-10117 (2018‑10‑31)
Description The stage of the disease where relevant.
Value Domain
draft Clinical risks
prsb03-dataelement-10119
Id prsb03-dataelement-10119 (2018‑10‑31)
Description Description of clinical risks identified e.g. problematic intubation, person with brittle diabetes, immuno-compromised/risk of infection etc.
Operationalization Free text or coded form (SNOMED CT).
Value Domain
draft Comment
prsb03-dataelement-10120
Id prsb03-dataelement-10120 (2018‑10‑31)
Description Any further textual comment to clarify, such as statement that information is partial or incomplete.
Operationalization Free text
Value Domain
draft Problems and issues
prsb03-dataelement-10118
Id prsb03-dataelement-10118 (2018‑10‑31)
Description Summary of problems that require investigation or treatment. This would include significant examination findings, symptoms and signs, which are likely to have relevance and are not a diagnosis.
Operationalization Text. The problems and issues heading is for the clinician or healthcare professional's recording of medical problems and issues.

Or

Free text or coded form (SNOMED CT).
Value Domain
folder draft Diagnoses
prsb03-dataelement-221
Id prsb03-dataelement-221 (2018‑10‑31)
Description Diagnoses
folder draft Diagnosis record entry
prsb03-dataelement-10651
Id prsb03-dataelement-10651 (2018‑11‑13 11:54:29)
Description This is a Diagnosis record entry. There may be 0 to many record entries under Diagnosis. Each record entry is made up of a number of elements or data items.
draft Date diagnosis made
prsb03-dataelement-10125
Id prsb03-dataelement-10125 (2018‑10‑31)
Description The date when the diagnosis was made.
Value Domain
draft Location
prsb03-dataelement-10848
Id prsb03-dataelement-10848 (2019‑03‑27 17:10:12)
Description The location where the diagnosis was recorded.
Relationship
Value Domain
draft Performing professional
prsb03-dataelement-10849
Id prsb03-dataelement-10849 (2019‑03‑27 17:13:41)
Description Details of the professional recording the diagnosis (including name and role).
Relationship
Value Domain
draft Diagnosis
prsb03-dataelement-10121
Id prsb03-dataelement-10121 (2018‑10‑31)
Description Confirmed diagnosis (or symptom); active diagnosis being treated.

Properties

FHIR Encounter.Diagnosis .Condition
Operationalization Choice of Text, Coded text - constraint: SNOMED CT. A subset / refset containing a list of diagnoses and symptoms. Constraint binding: [SNOMED CT] subset=???

Or

Sent as per the ECDS Emergency Care Diagnosis code set (SNOMED CT). Where the ECDS diagnosis qualifier is 'suspected diagnosis', the chief complaint should be entered here (see implementation guidance).

or

SNOMED CT concept and/or free text.

By preference the diagnosis is represented by a SNOMED CT concept. If this is not possible, a free text description of the diagnosis may be given. Supporting text may be given covering diagnosis confirmation, active diagnosis being treated, stage of the disease where relevant.

or

SNOMED CT concept and/or free text. By preference the diagnosis or symptom is represented by a SNOMED CT concept. If this is not possible, a free text description of the diagnosis or symptom may be given.
Value Domain
draft Diagnosis (Clinical Impression)
prsb03-dataelement-12477
Id prsb03-dataelement-12477 (2019‑06‑27 13:45:47)
Description The clinical assessment by the ambulance of crew of the persons clinical situation at the conclusion of their treatment. This will be one of confirmed diagnosis, suspected diagnosis or chief complaint.

Properties

FHIR Encounter.Diagnosis .Condition
Relationship
Operationalization Confirmed or suspected diagnosis where this is available using the ECDS Emergency care diagnosis simple reference set (SNOMED CT). If no diagnosis is available then enter the chief clinical concern using the ECDS Emergency Care Chief Complaint code set (SNOMED CT) (see implementation guidance).



Emergency Care Diagnosis simple reference set



Emergency care diagnosis qualifier simple reference set
Value Domain
draft Stage
prsb03-dataelement-10122
Id prsb03-dataelement-10122 (2018‑10‑31)
Description Stage of the disease or disorder, where relevant
Operationalization Choice of:TextCoded text
Value Domain
draft Awareness of diagnosis
prsb03-dataelement-10124
Id prsb03-dataelement-10124 (2018‑10‑31)
Description Description of the level of awareness the person and or their carer/family has regarding their diagnosis.
Operationalization The awareness statement made by a clinician.
Value Domain
draft Person completing record
prsb03-dataelement-10953
Id prsb03-dataelement-10953 (2019‑05‑18 21:06:01)
Concept inherits from cancelled prsb03-dataelement-10860 (2019‑03‑27 17:46:45)
Description This is the person recording the individual requirement.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
draft Comment
prsb03-dataelement-10123
Id prsb03-dataelement-10123 (2018‑10‑31)
Description Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. Include severity, occurrence (first, recurrence, ongoing).
Operationalization Free text.

Or

Free text. Supporting text may be given covering diagnosis confirmation, active diagnosis being treated.

Or

Free text. This is the place to record differential and excluded diagnosis.
Value Domain
folder draft Procedures and therapies
prsb03-dataelement-238
Id prsb03-dataelement-238 (2018‑10‑31)
Description The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
folder draft Procedure record entry
prsb03-dataelement-10652
Id prsb03-dataelement-10652 (2018‑11‑13 12:02:22)
Description This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
draft Date
prsb03-dataelement-10138
Id prsb03-dataelement-10138 (2018‑10‑31)
Description The date the procedure was performed.
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-13246
Id prsb03-dataelement-13246 (2020‑07‑27 19:13:27)
Concept inherits from draft prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
Description The location the problem was identified.
Relationship
draft Coded value
prsb03-dataelement-13247
Id prsb03-dataelement-13247 (2020‑07‑27 19:14:31)
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
draft Free text
prsb03-dataelement-13248
Id prsb03-dataelement-13248 (2020‑07‑27 19:14:31)
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
draft Location
prsb03-dataelement-10139
Id prsb03-dataelement-10139 (2018‑10‑31)
Description The location where the procedure was performed.
Operationalization ODS code or free text
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Performing professional
prsb03-dataelement-12150
Id prsb03-dataelement-12150 (2019‑05‑31 16:08:40)
Description The professional who performed the procedure.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Name
prsb03-dataelement-12151
Id prsb03-dataelement-12151 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
draft Role
prsb03-dataelement-12152
Id prsb03-dataelement-12152 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
draft Grade
prsb03-dataelement-12153
Id prsb03-dataelement-12153 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
draft Speciality
prsb03-dataelement-12154
Id prsb03-dataelement-12154 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
draft Professional identifier
prsb03-dataelement-12155
Id prsb03-dataelement-12155 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
folder draft Organisation
prsb03-dataelement-12156
Id prsb03-dataelement-12156 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
draft Contact details
prsb03-dataelement-12157
Id prsb03-dataelement-12157 (2019‑05‑31 16:09:20)
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 0 transactions, 0 templates, inherited once
 
cancelled Performing professional
prsb03-dataelement-10140
Id prsb03-dataelement-10140 (2018‑10‑31) 0.1
Description Details of the professional performing the procedure.
Operationalization Free text
Value Domain
folder draft Procedure
prsb03-dataelement-10141
Id prsb03-dataelement-10141 (2018‑10‑31)
Description The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.

Properties

FHIR Procedure.code
draft Coded value
prsb03-dataelement-13249
Id prsb03-dataelement-13249 (2020‑07‑27 19:35:09)
Description The procedure code.
Operationalization SNOMED CT : - << 71388002 |Procedure| OR << 129125009 |Procedure with explicit context|
Value Domain
draft Free text
prsb03-dataelement-13250
Id prsb03-dataelement-13250 (2020‑07‑27 19:40:38)
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
folder draft Anatomical site
prsb03-dataelement-10142
Id prsb03-dataelement-10142 (2018‑10‑31)
Description The body site of the procedure

Properties

FHIR Procedure.bodySite
draft Coded value
prsb03-dataelement-13251
Id prsb03-dataelement-13251 (2020‑07‑27 19:46:07)
Description The coded value of the anatomical site.
Operationalization SNOMED CT :- < 123037004 |Body structure (body structure)|
Value Domain
draft Free text
prsb03-dataelement-13252
Id prsb03-dataelement-13252 (2020‑07‑27 19:48:24)
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
folder draft Laterality
prsb03-dataelement-10143
Id prsb03-dataelement-10143 (2018‑10‑31)
Description Laterality of the procedure

Properties

FHIR ??Procedure.Code as an EXPRESSION Procedure.bodySite
draft Coded value
prsb03-dataelement-13253
Id prsb03-dataelement-13253 (2020‑07‑27 19:50:39)
Description The coded value for laterality.
Operationalization SNOMED CT:- < 182353008 |Side (qualifier value)|
Value Domain
draft Free text
prsb03-dataelement-13254
Id prsb03-dataelement-13254 (2020‑07‑27 19:52:35)
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
folder draft Complications related to procedure
prsb03-dataelement-10144
Id prsb03-dataelement-10144 (2018‑10‑31)
Description Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.

Properties

FHIR Procedure.complication Procedure.complicationDetail
draft Coded value
prsb03-dataelement-13255
Id prsb03-dataelement-13255 (2020‑07‑27 19:56:23)
Description The coded value for complications relating to procedure.
Operationalization SNOMED CT : - < 404684003 |Clinical finding (finding)|

Value Domain
draft Free text
prsb03-dataelement-13256
Id prsb03-dataelement-13256 (2020‑07‑27 19:58:17)
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
folder draft Specific anesthesia issues
prsb03-dataelement-10145
Id prsb03-dataelement-10145 (2018‑10‑31)
Description Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.

Properties

FHIR Procedure. Procedure.AnestheticIssues
draft Coded value
prsb03-dataelement-13257
Id prsb03-dataelement-13257 (2020‑07‑27 20:00:25)
Description The coded value for specific anesthesia issues.
Operationalization SNOMED CT
Value Domain
draft Free text
prsb03-dataelement-13258
Id prsb03-dataelement-13258 (2020‑07‑27 20:01:36)
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
folder draft Person completing record
prsb03-dataelement-12158
Id prsb03-dataelement-12158 (2019‑05‑31 16:09:35)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-12159
Id prsb03-dataelement-12159 (2019‑05‑31 16:10:02)
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
draft Role
prsb03-dataelement-12160
Id prsb03-dataelement-12160 (2019‑05‑31 16:10:02)
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
draft Grade
prsb03-dataelement-12161
Id prsb03-dataelement-12161 (2019‑05‑31 16:10:02)
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
draft Specialty
prsb03-dataelement-12162
Id prsb03-dataelement-12162 (2019‑05‑31 16:10:02)
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
folder draft Organisation
prsb03-dataelement-12163
Id prsb03-dataelement-12163 (2019‑05‑31 16:10:02)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-12164
Id prsb03-dataelement-12164 (2019‑05‑31 16:10:02)
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
draft Date completed
prsb03-dataelement-12165
Id prsb03-dataelement-12165 (2019‑05‑31 16:10:02)
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
draft Contact details
prsb03-dataelement-12166
Id prsb03-dataelement-12166 (2019‑05‑31 16:10:02)
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
cancelled Person completing record
prsb03-dataelement-10954
Id prsb03-dataelement-10954 (2019‑05‑18 21:07:16)
Description This is the person completing the record.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
target Used by 0 transactions, 0 templates, inherited 2 times
 
draft Comment
prsb03-dataelement-10146
Id prsb03-dataelement-10146 (2018‑10‑31)
Description Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.

Properties

FHIR Procedure.note
Operationalization Free text
Value Domain
Property
max length
150
folder draft History
prsb03-dataelement-226
Id prsb03-dataelement-226 (2018‑10‑31)
Description History
folder draft Patient’s reason for referral
prsb03-dataelement-10126
Id prsb03-dataelement-10126 (2018‑10‑31)
Description Patient stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about patient’s source of advice. This may be expressed on behalf of the patient, e.g. by parent or carer. 
draft Coded value
prsb03-dataelement-14265
Id prsb03-dataelement-14265 (2021‑03‑11 16:32:44)
Description The coded value for patients reason for referral
Operationalization SNOMED CT :-  ^1127581000000103 |Health issues simple reference set|
Value Domain
draft Free text
prsb03-dataelement-14266
Id prsb03-dataelement-14266 (2021‑03‑11 16:34:08)
Concept inherits from draft prsb03-dataelement-13984 (2021‑02‑11 12:46:37)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
draft Presenting complaints or issues
prsb03-dataelement-10127
Id prsb03-dataelement-10127 (2018‑10‑31)
Description The list and description of the health problems and issues experienced by the patient resulting in the attendance. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow-up from admission, falls, a specific procedure, investigation or treatment.
Operationalization May be a SNOMED CT term or free text
Value Domain
draft History of each presenting complaint or issue
prsb03-dataelement-10128
Id prsb03-dataelement-10128 (2018‑10‑31)
Description Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer.
Operationalization This textual description may be provided by the referral document or during the consultation
Value Domain
draft History since last contact
prsb03-dataelement-10129
Id prsb03-dataelement-10129 (2018‑10‑31)
Description History since last attendance, discharge from hospital, etc.
Operationalization Free text and to include adherence to treatment plan, where appropriate
Value Domain
folder draft Relevant past medical, surgical and mental health history
prsb03-dataelement-10130
Id prsb03-dataelement-10130 (2018‑10‑31)
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.
draft Coded value
prsb03-dataelement-13787
Id prsb03-dataelement-13787 (2020‑10‑22 17:51:01)
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
draft Free text
prsb03-dataelement-13788
Id prsb03-dataelement-13788 (2020‑10‑22 17:53:28)
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
draft Reason for referral
prsb03-dataelement-10131
Id prsb03-dataelement-10131 (2018‑10‑31)
Description A clear statement of the purpose of the person making the referral e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carers' concerns.
Operationalization Free text SNOMED CT coded & free text
Value Domain
draft Expectation of referral
prsb03-dataelement-10132
Id prsb03-dataelement-10132 (2018‑10‑31)
Description A clear statement of the expectations of the person making the referral as to the management of the patient e.g. advice only, diagnosis, treatment, etc.
Operationalization Free text
Value Domain
draft Patient's expectation of referral
prsb03-dataelement-10133
Id prsb03-dataelement-10133 (2018‑10‑31)
Description Patient‘s expectations of the referral including preferences. This may include any discussions that took place, the level of shared decision making involved, information about patient’s source of advice.
Value Domain
draft Management to date
prsb03-dataelement-10134
Id prsb03-dataelement-10134 (2018‑10‑31)
Description Referrals, management, investigations and treatment that have already been undertaken, including patient managing their symptoms. Including:

*procedures conducted - procedures carried out (and the date) and procedure report.
Operationalization Free text
Value Domain
draft Urgency of referral
prsb03-dataelement-10135
Id prsb03-dataelement-10135 (2018‑10‑31)
Description Referrer’s assessment of urgency (e.g. urgent/ soon/ routine). May include reason if other than routine. E.g. two data items:

* level of urgency

* reason.
Operationalization PRIORITY TYPE (NHS Data Dictionary) free text reasonhttps://www.datadictionary.nhs.uk/web_site_content/pages/search_pages/dosearch.asp
Value Domain
draft Reason for admission
prsb03-dataelement-10136
Id prsb03-dataelement-10136 (2018‑10‑31)
Description

The health problems and issues experienced by the patient resulting in their referral by a healthcare professional for hospital admission, e.g., chest pains blackouts, falls, a specific procedure, investigation or treatment.

Value Domain
draft Information brought by patient
prsb03-dataelement-10137
Id prsb03-dataelement-10137 (2018‑10‑31)
Description E.g. Patient Passport, example diary data, pre-completed questionnaires, person-held maternity record, personal child health record, etc.
Value Domain
folder draft Clinical Summary
prsb03-dataelement-247
Id prsb03-dataelement-247 (2018‑10‑31)
Description Clinical Summary
draft Date
prsb03-dataelement-13308
Id prsb03-dataelement-13308 (2020‑08‑06 13:53:22)
Description The date the clinical summary was written.
Operationalization Date
Value Domain
Property
Timestamp precision
day, month and year
folder draft Location
prsb03-dataelement-13309
Id prsb03-dataelement-13309 (2020‑08‑06 13:56:22)
Description The location the clinical summary was written.
Relationship
draft Coded value
prsb03-dataelement-13310
Id prsb03-dataelement-13310 (2020‑08‑06 13:56:53)
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
draft Free text
prsb03-dataelement-13311
Id prsb03-dataelement-13311 (2020‑08‑06 13:56:53)
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
draft Clinical summary
prsb03-dataelement-10147
Id prsb03-dataelement-10147 (2018‑10‑31)
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 0 transactions, 0 templates, inherited once
 
folder draft Performing professional
prsb03-dataelement-13312
Id prsb03-dataelement-13312 (2020‑08‑06 13:57:51)
Description The professional who wrote the clinical summary
Relationship
draft Name
prsb03-dataelement-13313
Id prsb03-dataelement-13313 (2020‑08‑06 13:58:21)
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
draft Role
prsb03-dataelement-13314
Id prsb03-dataelement-13314 (2020‑08‑06 13:58:21)
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
draft Grade
prsb03-dataelement-13315
Id prsb03-dataelement-13315 (2020‑08‑06 13:58:21)
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
draft Speciality
prsb03-dataelement-13316
Id prsb03-dataelement-13316 (2020‑08‑06 13:58:21)
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
draft Professional identifier
prsb03-dataelement-13317
Id prsb03-dataelement-13317 (2020‑08‑06 13:58:21)
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
folder draft Organisation
prsb03-dataelement-13318
Id prsb03-dataelement-13318 (2020‑08‑06 13:58:21)
Concept inherits from draft prsb03-dataelement-11510 (2019‑05‑30 14:35:29)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-13319
Id prsb03-dataelement-13319 (2020‑08‑06 13:58:21)
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
folder draft Person completing record
prsb03-dataelement-13320
Id prsb03-dataelement-13320 (2020‑08‑06 13:59:10)
Description A record of the details of the person that entered the clinical summary and the date on which is was entered.
Relationship
draft Name
prsb03-dataelement-13321
Id prsb03-dataelement-13321 (2020‑08‑06 13:59:45)
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
draft Role
prsb03-dataelement-13322
Id prsb03-dataelement-13322 (2020‑08‑06 13:59:45)
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
draft Grade
prsb03-dataelement-13323
Id prsb03-dataelement-13323 (2020‑08‑06 13:59:45)
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
draft Specialty
prsb03-dataelement-13324
Id prsb03-dataelement-13324 (2020‑08‑06 13:59:45)
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
folder draft Organisation
prsb03-dataelement-13325
Id prsb03-dataelement-13325 (2020‑08‑06 13:59:45)
Concept inherits from draft prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-13326
Id prsb03-dataelement-13326 (2020‑08‑06 13:59:45)
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
draft Date completed
prsb03-dataelement-13327
Id prsb03-dataelement-13327 (2020‑08‑06 13:59:45)
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
draft Contact details
prsb03-dataelement-13328
Id prsb03-dataelement-13328 (2020‑08‑06 13:59:45)
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
draft Formulation
prsb03-dataelement-10148
Id prsb03-dataelement-10148 (2018‑10‑31)
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 0 transactions, 0 templates, inherited 3 times
 
draft Treatments and interventions and changes made to treatments.
prsb03-dataelement-10149
Id prsb03-dataelement-10149 (2018‑10‑31)
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 0 transactions, 0 templates, inherited once
 
draft Clinical narrative
prsb03-dataelement-10150
Id prsb03-dataelement-10150 (2018‑10‑31)
Description A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.
Operationalization Free text
Value Domain
folder draft Treatments and interventions
prsb03-dataelement-12480
Id prsb03-dataelement-12480 (2019‑07‑01 11:30:36)
Description Treatments and interventions carried out
folder draft Treatments and interventions and changes made to treatments.
prsb03-dataelement-12481
Id prsb03-dataelement-12481 (2019‑07‑01 11:32:03)
Description The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.
Relationship
target Used by 0 transactions, 0 templates, inherited once
 
draft Coded value
prsb03-dataelement-13259
Id prsb03-dataelement-13259 (2020‑07‑28 11:51:38)
Description The coded value for treatment and interventions.
Operationalization SNOMED CT
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13260
Id prsb03-dataelement-13260 (2020‑07‑28 11:52:30)
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 0 transactions, 0 templates, inherited once
 
folder draft Social context
prsb03-dataelement-136
Id prsb03-dataelement-136 (2018‑10‑31)
Description The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
draft Services and care
prsb03-dataelement-12482
Id prsb03-dataelement-12482 (2019‑07‑01 12:40:21)
Description The description of services and care providing support for person's health and social well-being.
Operationalization Free text. The record of the services and care as provided by the person or their representative.
Value Domain
folder draft Household composition
prsb03-dataelement-10036
Id prsb03-dataelement-10036 (2018‑10‑31)
Description Details of the person's household composition.
draft Date
prsb03-dataelement-11770
Id prsb03-dataelement-11770 (2019‑05‑31 14:13:42)
Description The date when the household composition was taken.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
cancelled Location
prsb03-dataelement-11771
Id prsb03-dataelement-11771 (2019‑05‑31 14:14:32) 0.1
Description The location where the household composition was taken.
Relationship
Operationalization ODS code or free text
Value Domain
folder draft Location
prsb03-dataelement-13271
Id prsb03-dataelement-13271 (2020‑07‑28 14:07:57)
Description The location where the household composition was taken.
Relationship
draft Coded value
prsb03-dataelement-13272
Id prsb03-dataelement-13272 (2020‑07‑28 14:09:11)
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
draft Free text
prsb03-dataelement-13273
Id prsb03-dataelement-13273 (2020‑07‑28 14:09:11)
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
folder draft Household composition
prsb03-dataelement-13261
Id prsb03-dataelement-13261 (2020‑07‑28 12:00:25)
Description Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
draft Coded value
prsb03-dataelement-13262
Id prsb03-dataelement-13262 (2020‑07‑28 12:15:50)
Description The coded value of household composition
Operationalization SNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
Value Domain
draft Free text
prsb03-dataelement-13263
Id prsb03-dataelement-13263 (2020‑07‑28 12:20:28)
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
folder draft Performing professional
prsb03-dataelement-11648
Id prsb03-dataelement-11648 (2019‑05‑30 18:03:53)
Description The professional who took the household composition.
Relationship
draft Name
prsb03-dataelement-11649
Id prsb03-dataelement-11649 (2019‑05‑30 18:07:33)
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
draft Role
prsb03-dataelement-11650
Id prsb03-dataelement-11650 (2019‑05‑30 18:07:33)
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
draft Grade
prsb03-dataelement-11651
Id prsb03-dataelement-11651 (2019‑05‑30 18:07:33)
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
draft Speciality
prsb03-dataelement-11652
Id prsb03-dataelement-11652 (2019‑05‑30 18:07:33)
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
draft Professional identifier
prsb03-dataelement-11653
Id prsb03-dataelement-11653 (2019‑05‑30 18:07:33)
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
folder draft Organisation
prsb03-dataelement-11654
Id prsb03-dataelement-11654 (2019‑05‑30 18:07:33)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11655
Id prsb03-dataelement-11655 (2019‑05‑30 18:07:33)
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
folder draft Person completing record
prsb03-dataelement-11521
Id prsb03-dataelement-11521 (2019‑05‑30 14:50:23)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11522
Id prsb03-dataelement-11522 (2019‑05‑30 14:50:56)
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
draft Role
prsb03-dataelement-11523
Id prsb03-dataelement-11523 (2019‑05‑30 14:50:56)
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
draft Grade
prsb03-dataelement-11524
Id prsb03-dataelement-11524 (2019‑05‑30 14:50:56)
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
draft Specialty
prsb03-dataelement-11525
Id prsb03-dataelement-11525 (2019‑05‑30 14:50:56)
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
folder draft Organisation
prsb03-dataelement-11526
Id prsb03-dataelement-11526 (2019‑05‑30 14:50:56)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11527
Id prsb03-dataelement-11527 (2019‑05‑30 14:50:56)
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
draft Date completed
prsb03-dataelement-11528
Id prsb03-dataelement-11528 (2019‑05‑30 14:50:56)
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
draft Contact details
prsb03-dataelement-11529
Id prsb03-dataelement-11529 (2019‑05‑30 14:50:56)
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
folder draft Occupational history
prsb03-dataelement-10037
Id prsb03-dataelement-10037 (2018‑10‑31)
Description The current and/or previous occupation(s) of the person.

Properties

FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
draft Date
prsb03-dataelement-11772
Id prsb03-dataelement-11772 (2019‑05‑31 14:15:12)
Description The date when the occupational history was taken.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11773
Id prsb03-dataelement-11773 (2019‑05‑31 14:15:38)
Description The location where the occupational history was taken.
Relationship
draft Coded value
prsb03-dataelement-13274
Id prsb03-dataelement-13274 (2020‑07‑30 14:41:27)
Description The coded value for the location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13275
Id prsb03-dataelement-13275 (2020‑07‑30 14:44:58)
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
folder draft Occupational history
prsb03-dataelement-13264
Id prsb03-dataelement-13264 (2020‑07‑28 12:26:39)
Description The current and/or previous occupation(s) of the person.
draft Coded value
prsb03-dataelement-13265
Id prsb03-dataelement-13265 (2020‑07‑28 12:27:26)
Description The coded value for occupational history
Operationalization SNOMED CT : - ^ 999001571000000109 | Occupation simple reference set (foundation metadata concept)
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Free text
prsb03-dataelement-13266
Id prsb03-dataelement-13266 (2020‑07‑28 12:29:14)
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
folder draft Performing professional
prsb03-dataelement-11656
Id prsb03-dataelement-11656 (2019‑05‑30 18:08:03)
Description The professional who took the occupational history.
Relationship
draft Name
prsb03-dataelement-11657
Id prsb03-dataelement-11657 (2019‑05‑30 18:08:20)
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
draft Role
prsb03-dataelement-11658
Id prsb03-dataelement-11658 (2019‑05‑30 18:08:20)
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
draft Grade
prsb03-dataelement-11659
Id prsb03-dataelement-11659 (2019‑05‑30 18:08:20)
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
draft Speciality
prsb03-dataelement-11660
Id prsb03-dataelement-11660 (2019‑05‑30 18:08:20)
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
draft Professional identifier
prsb03-dataelement-11661
Id prsb03-dataelement-11661 (2019‑05‑30 18:08:20)
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
folder draft Organisation
prsb03-dataelement-11662
Id prsb03-dataelement-11662 (2019‑05‑30 18:08:20)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11663
Id prsb03-dataelement-11663 (2019‑05‑30 18:08:20)
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
folder draft Person completing record
prsb03-dataelement-11530
Id prsb03-dataelement-11530 (2019‑05‑30 14:51:51)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11531
Id prsb03-dataelement-11531 (2019‑05‑30 14:52:22)
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
draft Role
prsb03-dataelement-11532
Id prsb03-dataelement-11532 (2019‑05‑30 14:52:22)
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
draft Grade
prsb03-dataelement-11533
Id prsb03-dataelement-11533 (2019‑05‑30 14:52:22)
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
draft Specialty
prsb03-dataelement-11534
Id prsb03-dataelement-11534 (2019‑05‑30 14:52:22)
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
folder draft Organisation
prsb03-dataelement-11535
Id prsb03-dataelement-11535 (2019‑05‑30 14:52:22)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11536
Id prsb03-dataelement-11536 (2019‑05‑30 14:52:22)
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
draft Date completed
prsb03-dataelement-11537
Id prsb03-dataelement-11537 (2019‑05‑30 14:52:22)
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
draft Contact details
prsb03-dataelement-11538
Id prsb03-dataelement-11538 (2019‑05‑30 14:52:22)
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
folder draft Educational history
prsb03-dataelement-10038
Id prsb03-dataelement-10038 (2018‑10‑31)
Description Details of the person's educational history.
draft Date
prsb03-dataelement-11774
Id prsb03-dataelement-11774 (2019‑05‑31 14:16:22)
Description The date when the educational history was taken.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11775
Id prsb03-dataelement-11775 (2019‑05‑31 14:16:57)
Description The location where the education history was taken.
Relationship
draft Coded value
prsb03-dataelement-13276
Id prsb03-dataelement-13276 (2020‑07‑30 14:53:55)
Description The coded value for location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13277
Id prsb03-dataelement-13277 (2020‑07‑30 14:55:09)
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
folder cancelled Educational history
prsb03-dataelement-13267
Id prsb03-dataelement-13267 (2020‑07‑28 13:20:32) 0.1
Description The current and/or previous relevant educational history of the person.
Operationalization Free text
draft Educational history
prsb03-dataelement-13840
Id prsb03-dataelement-13840 (2020‑12‑29 11:11:55)
Description The current and/or previous relevant educational history of the person.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11776
Id prsb03-dataelement-11776 (2019‑05‑31 14:17:28)
Description The professional who took the educational history.
Relationship
draft Name
prsb03-dataelement-11777
Id prsb03-dataelement-11777 (2019‑05‑31 14:17:50)
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
draft Role
prsb03-dataelement-11778
Id prsb03-dataelement-11778 (2019‑05‑31 14:17:50)
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
draft Grade
prsb03-dataelement-11779
Id prsb03-dataelement-11779 (2019‑05‑31 14:17:50)
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
draft Speciality
prsb03-dataelement-11780
Id prsb03-dataelement-11780 (2019‑05‑31 14:17:50)
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
draft Professional identifier
prsb03-dataelement-11781
Id prsb03-dataelement-11781 (2019‑05‑31 14:17:50)
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
folder draft Organisation
prsb03-dataelement-11782
Id prsb03-dataelement-11782 (2019‑05‑31 14:17:50)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11783
Id prsb03-dataelement-11783 (2019‑05‑31 14:17:50)
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
folder draft Person completing record
prsb03-dataelement-11539
Id prsb03-dataelement-11539 (2019‑05‑30 14:52:55)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11540
Id prsb03-dataelement-11540 (2019‑05‑30 14:53:14)
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
draft Role
prsb03-dataelement-11541
Id prsb03-dataelement-11541 (2019‑05‑30 14:53:14)
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
draft Grade
prsb03-dataelement-11542
Id prsb03-dataelement-11542 (2019‑05‑30 14:53:14)
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
draft Specialty
prsb03-dataelement-11543
Id prsb03-dataelement-11543 (2019‑05‑30 14:53:14)
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
folder draft Organisation
prsb03-dataelement-11544
Id prsb03-dataelement-11544 (2019‑05‑30 14:53:14)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11545
Id prsb03-dataelement-11545 (2019‑05‑30 14:53:14)
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
draft Date completed
prsb03-dataelement-11546
Id prsb03-dataelement-11546 (2019‑05‑30 14:53:14)
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
draft Contact details
prsb03-dataelement-11547
Id prsb03-dataelement-11547 (2019‑05‑30 14:53:14)
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
folder draft Lifestyle choices
prsb03-dataelement-10039
Id prsb03-dataelement-10039 (2018‑10‑31)
Description The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits

Properties

FHIR Text only
draft Date
prsb03-dataelement-11784
Id prsb03-dataelement-11784 (2019‑05‑31 14:18:12)
Description The date when the lifestyle choices were taken.
Relationship
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11785
Id prsb03-dataelement-11785 (2019‑05‑31 14:18:40)
Description The location where the lifestyle choices were taken.
Relationship
draft Coded value
prsb03-dataelement-13278
Id prsb03-dataelement-13278 (2020‑07‑30 14:58:15)
Description The coded value for location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13279
Id prsb03-dataelement-13279 (2020‑07‑30 14:59:21)
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
folder cancelled Lifestyle choices
prsb03-dataelement-13268
Id prsb03-dataelement-13268 (2020‑07‑28 13:29:22) 0.1
Description The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.
Operationalization Free text
cancelled Coded value
prsb03-dataelement-13269
Id prsb03-dataelement-13269 (2020‑07‑28 13:30:20) 0.1
Description The coded value of the person's lifestyle choice.
Operationalization SNOMED CT
Value Domain
cancelled Free text
prsb03-dataelement-13270
Id prsb03-dataelement-13270 (2020‑07‑28 13:31:11) 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
draft Lifestyle choices
prsb03-dataelement-13841
Id prsb03-dataelement-13841 (2020‑12‑29 11:26:28)
Description The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11786
Id prsb03-dataelement-11786 (2019‑05‑31 14:19:14)
Description The professional who took the lifestyle choices.
Relationship
draft Name
prsb03-dataelement-11787
Id prsb03-dataelement-11787 (2019‑05‑31 14:19:39)
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
draft Role
prsb03-dataelement-11788
Id prsb03-dataelement-11788 (2019‑05‑31 14:19:39)
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
draft Grade
prsb03-dataelement-11789
Id prsb03-dataelement-11789 (2019‑05‑31 14:19:39)
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
draft Speciality
prsb03-dataelement-11790
Id prsb03-dataelement-11790 (2019‑05‑31 14:19:39)
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
draft Professional identifier
prsb03-dataelement-11791
Id prsb03-dataelement-11791 (2019‑05‑31 14:19:39)
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
folder draft Organisation
prsb03-dataelement-11792
Id prsb03-dataelement-11792 (2019‑05‑31 14:19:39)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11793
Id prsb03-dataelement-11793 (2019‑05‑31 14:19:39)
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
folder draft Person completing record
prsb03-dataelement-11548
Id prsb03-dataelement-11548 (2019‑05‑30 14:53:59)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11549
Id prsb03-dataelement-11549 (2019‑05‑30 14:54:28)
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
draft Role
prsb03-dataelement-11550
Id prsb03-dataelement-11550 (2019‑05‑30 14:54:28)
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
draft Grade
prsb03-dataelement-11551
Id prsb03-dataelement-11551 (2019‑05‑30 14:54:28)
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
draft Specialty
prsb03-dataelement-11552
Id prsb03-dataelement-11552 (2019‑05‑30 14:54:28)
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
folder draft Organisation
prsb03-dataelement-11553
Id prsb03-dataelement-11553 (2019‑05‑30 14:54:28)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11554
Id prsb03-dataelement-11554 (2019‑05‑30 14:54:28)
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
draft Date completed
prsb03-dataelement-11555
Id prsb03-dataelement-11555 (2019‑05‑30 14:54:28)
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
draft Contact details
prsb03-dataelement-11556
Id prsb03-dataelement-11556 (2019‑05‑30 14:54:28)
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
folder draft Smoking status
prsb03-dataelement-10040
Id prsb03-dataelement-10040 (2018‑10‑31)
Description Details of the person's smoking status.

Properties

FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
draft Date
prsb03-dataelement-11794
Id prsb03-dataelement-11794 (2019‑05‑31 14:20:05)
Description The date when the smoking status was taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11795
Id prsb03-dataelement-11795 (2019‑05‑31 14:20:40)
Description The location where the smoking status was taken.
Relationship
draft Coded value
prsb03-dataelement-13281
Id prsb03-dataelement-13281 (2020‑07‑30 15:03:12)
Description The coded value for location
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13282
Id prsb03-dataelement-13282 (2020‑07‑30 15:04:27)
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
cancelled Coded value
prsb03-dataelement-13280
Id prsb03-dataelement-13280 (2020‑07‑30 15:00:43) v.01
Concept inherits from draft prsb03-dataelement-13265 (2020‑07‑28 12:27:26)
Description The coded value for occupational history
Operationalization SNOMED CT : - ^ 999001571000000109 | Occupation simple reference set (foundation metadata concept)
Value Domain
folder draft Smoking status
prsb03-dataelement-13283
Id prsb03-dataelement-13283 (2020‑07‑30 17:12:22)
Description
Record of any drug/substance use by the person.
draft Coded value
prsb03-dataelement-13284
Id prsb03-dataelement-13284 (2020‑07‑30 17:14:44)
Description The smoking status of the person.
Operationalization SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
Value Domain
draft Free text
prsb03-dataelement-13285
Id prsb03-dataelement-13285 (2020‑07‑30 17:16:04)
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
draft Smoking status - details
prsb03-dataelement-13286
Id prsb03-dataelement-13286 (2020‑07‑31 15:58:03)
Description Further details recorded about the smoking status of the person
Operationalization Free text
Value Domain
Property
max length
150
folder draft Smoking record
prsb03-dataelement-13995
Id prsb03-dataelement-13995 (2021‑02‑11 18:40:13)
Concept inherits from draft prsb03-dataelement-12489 (2019‑10‑29 14:19:57)
Description Details of the person's smoking record
draft Overall smoking status
prsb03-dataelement-13996
Id prsb03-dataelement-13996 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12490 (2019‑10‑29 14:22:56)
Description

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

Defined by current smoking status and ever smoking status.

Operationalization

Coded text:

Current Smoker

Former Smoker

Never Smoked

^999000891000000102 |Smoking simple reference set (foundation metadata concept)|

Value Domain
draft Date of quitting
prsb03-dataelement-13997
Id prsb03-dataelement-13997 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12491 (2019‑10‑29 14:35:16)
Description Date when the individual stopped smoking (if a former smoker).
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
draft Other tobacco products used
prsb03-dataelement-13998
Id prsb03-dataelement-13998 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12492 (2019‑10‑29 14:40:14)
Description Details of other tobacco products used (e.g. shisha, pipe, cigar, heated tobacco products)
Operationalization

No other tobacco products used

Patient uses other tobacco products.

Plus free text details of products used.

Value Domain
draft Information and advice given
prsb03-dataelement-13999
Id prsb03-dataelement-13999 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12493 (2019‑10‑29 14:42:47)
Description Record of whether brief advice about available smoking cessation treatment/support was given at the time of consultation.

Properties

FHIR Free text only
Relationship
Operationalization

No advice given about available smoking cessation treatment/support

Brief advice given about available smoking cessation treatment/support

Plus free text with any additional information

Value Domain
draft Nicotine Replacement Therapy used
prsb03-dataelement-14000
Id prsb03-dataelement-14000 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12495 (2019‑10‑29 16:11:19)
Description A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment
Operationalization

NRT not currently used

NRT currently used

NRT prescribed at this appointment

Value Domain
draft Varenicline or other pharmacotherapy used
prsb03-dataelement-14001
Id prsb03-dataelement-14001 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12496 (2019‑10‑29 16:26:30)
Description Record of whether varenicline or other smoking cessation pharmacotherapy (other than nicotine replacement therapy) is currently used or prescribed in this appointment.
Operationalization

Varenicline/other pharmacotherapy not used

Varenicline/other pharmacotherapy currently used

Varenicline/other pharmacotherapy prescribed in this appointment

Value Domain
draft e-cigarettes used
prsb03-dataelement-14002
Id prsb03-dataelement-14002 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12497 (2019‑10‑29 16:35:51)
Description Record of current use of e-cigarettes
Operationalization

Coded - SNOMED CT:

722499006 |Electronic cigarette user (finding)|

Value Domain
draft Therapy prescribed (see medication item entry information model)
prsb03-dataelement-14003
Id prsb03-dataelement-14003 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12506 (2019‑10‑29 17:07:06)
Description Record of nicotine replacement therapy, varenicline or bupropion (or other smoking cessation pharmacotherapy) being prescribed at the time of the consultation
Operationalization To be entered via Medication item entry (see medications and medical devices information model - PRSB Standards for the Structure and Content of Health and Care Records (2018): https://theprsb.org/standards/healthandcarerecords/
Value Domain
draft Referral details
prsb03-dataelement-14004
Id prsb03-dataelement-14004 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12508 (2019‑10‑29 17:08:47)
Description Record of whether referral to smoking cessation services was offered and/or made at the time of the consultation.
Operationalization

Referral to smoking cessation services

Referral not offered

Referral offered but declined

And free text with any additional information

Value Domain
draft Comment
prsb03-dataelement-14005
Id prsb03-dataelement-14005 (2021‑02‑11 18:40:44)
Concept inherits from draft prsb03-dataelement-12510 (2019‑10‑29 17:16:21)
Description Additional information about tobacco use or its management not captured in other fields.
Operationalization Free text
Value Domain
draft Set quit date
prsb03-dataelement-14007
Id prsb03-dataelement-14007 (2021‑02‑12 11:20:10)
Concept inherits from draft prsb03-dataelement-14006 (2021‑02‑11 19:20:06)
Description Date set to quit smoking
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Treatments and interventions and changes made to treatments.
prsb03-dataelement-13992
Id prsb03-dataelement-13992 (2021‑02‑11 16:46:41)
Concept inherits from draft prsb03-dataelement-12481 (2019‑07‑01 11:32:03)
Description The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.
Relationship
draft Coded value
prsb03-dataelement-13993
Id prsb03-dataelement-13993 (2021‑02‑11 16:48:23)
Concept inherits from draft prsb03-dataelement-13259 (2020‑07‑28 11:51:38)
Description The coded value for treatment and interventions.
Operationalization SNOMED CT
Value Domain
draft Free text
prsb03-dataelement-13994
Id prsb03-dataelement-13994 (2021‑02‑11 16:48:23)
Concept inherits from draft prsb03-dataelement-13260 (2020‑07‑28 11:52:30)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
folder draft Date stopped smoking
prsb03-dataelement-13287
Id prsb03-dataelement-13287 (2020‑07‑31 16:00:37)
Description The date the person stopped smoking (if known)
draft Coded value
prsb03-dataelement-13288
Id prsb03-dataelement-13288 (2020‑07‑31 16:01:49)
Description The coded value for date stopped smoking.
Operationalization SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
Value Domain
draft Date
prsb03-dataelement-13289
Id prsb03-dataelement-13289 (2020‑07‑31 16:06:38)
Description The date the person stopped smoking.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Performing professional
prsb03-dataelement-11796
Id prsb03-dataelement-11796 (2019‑05‑31 14:21:14)
Description The professional who took the smoking status.
Relationship
draft Name
prsb03-dataelement-11797
Id prsb03-dataelement-11797 (2019‑05‑31 14:21:51)
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
draft Role
prsb03-dataelement-11798
Id prsb03-dataelement-11798 (2019‑05‑31 14:21:51)
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
draft Grade
prsb03-dataelement-11799
Id prsb03-dataelement-11799 (2019‑05‑31 14:21:51)
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
draft Speciality
prsb03-dataelement-11800
Id prsb03-dataelement-11800 (2019‑05‑31 14:21:51)
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
draft Professional identifier
prsb03-dataelement-11801
Id prsb03-dataelement-11801 (2019‑05‑31 14:21:51)
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
folder draft Organisation
prsb03-dataelement-11802
Id prsb03-dataelement-11802 (2019‑05‑31 14:21:51)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11803
Id prsb03-dataelement-11803 (2019‑05‑31 14:21:51)
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
folder draft Person completing record
prsb03-dataelement-11557
Id prsb03-dataelement-11557 (2019‑05‑30 14:55:25)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11558
Id prsb03-dataelement-11558 (2019‑05‑30 14:55:47)
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
draft Role
prsb03-dataelement-11559
Id prsb03-dataelement-11559 (2019‑05‑30 14:55:47)
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
draft Grade
prsb03-dataelement-11560
Id prsb03-dataelement-11560 (2019‑05‑30 14:55:47)
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
draft Specialty
prsb03-dataelement-11561
Id prsb03-dataelement-11561 (2019‑05‑30 14:55:47)
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
folder draft Organisation
prsb03-dataelement-11562
Id prsb03-dataelement-11562 (2019‑05‑30 14:55:47)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11563
Id prsb03-dataelement-11563 (2019‑05‑30 14:55:47)
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
draft Date completed
prsb03-dataelement-11564
Id prsb03-dataelement-11564 (2019‑05‑30 14:55:47)
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
draft Contact details
prsb03-dataelement-11565
Id prsb03-dataelement-11565 (2019‑05‑30 14:55:47)
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
folder draft Alcohol intake
prsb03-dataelement-10041
Id prsb03-dataelement-10041 (2018‑10‑31)
Description Details of the person's alcohol intake

Properties

FHIR Composition.text
draft Date
prsb03-dataelement-11804
Id prsb03-dataelement-11804 (2019‑05‑31 14:23:05)
Description The date when the alcohol intake was noted.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11805
Id prsb03-dataelement-11805 (2019‑05‑31 14:23:38)
Description The location where the alcohol intake was noted.
Relationship
draft Coded value
prsb03-dataelement-13332
Id prsb03-dataelement-13332 (2020‑08‑06 16:26:51)
Description The coded value for location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13333
Id prsb03-dataelement-13333 (2020‑08‑06 16:30:11)
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
folder draft Alcohol intake
prsb03-dataelement-13290
Id prsb03-dataelement-13290 (2020‑07‑31 17:02:46)
Description Latest or current alcohol consumption.
draft Coded value
prsb03-dataelement-13291
Id prsb03-dataelement-13291 (2020‑07‑31 17:04:14)
Description The coded value of the person alcohol intake
Operationalization SNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|
Value Domain
draft Free text
prsb03-dataelement-13292
Id prsb03-dataelement-13292 (2020‑07‑31 17:11:04)
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
draft Alcohol use details
prsb03-dataelement-13759
Id prsb03-dataelement-13759 (2020‑09‑29 14:36:49)
Description Detailed history of their alcohol use, amount/frequency, bingeing. Questionnaire/Assessment used Audit C, FAST etc
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11806
Id prsb03-dataelement-11806 (2019‑05‑31 14:24:13)
Description The professional who noted the alcohol intake.
Relationship
draft Name
prsb03-dataelement-11807
Id prsb03-dataelement-11807 (2019‑05‑31 14:24:33)
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
draft Role
prsb03-dataelement-11808
Id prsb03-dataelement-11808 (2019‑05‑31 14:24:33)
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
draft Grade
prsb03-dataelement-11809
Id prsb03-dataelement-11809 (2019‑05‑31 14:24:33)
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
draft Speciality
prsb03-dataelement-11810
Id prsb03-dataelement-11810 (2019‑05‑31 14:24:33)
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
draft Professional identifier
prsb03-dataelement-11811
Id prsb03-dataelement-11811 (2019‑05‑31 14:24:33)
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
folder draft Organisation
prsb03-dataelement-11812
Id prsb03-dataelement-11812 (2019‑05‑31 14:24:33)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11813
Id prsb03-dataelement-11813 (2019‑05‑31 14:24:33)
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
folder draft Person completing record
prsb03-dataelement-11566
Id prsb03-dataelement-11566 (2019‑05‑30 14:56:23)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11567
Id prsb03-dataelement-11567 (2019‑05‑30 14:57:06)
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
draft Role
prsb03-dataelement-11568
Id prsb03-dataelement-11568 (2019‑05‑30 14:57:06)
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
draft Grade
prsb03-dataelement-11569
Id prsb03-dataelement-11569 (2019‑05‑30 14:57:06)
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
draft Specialty
prsb03-dataelement-11570
Id prsb03-dataelement-11570 (2019‑05‑30 14:57:06)
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
folder draft Organisation
prsb03-dataelement-11571
Id prsb03-dataelement-11571 (2019‑05‑30 14:57:06)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11572
Id prsb03-dataelement-11572 (2019‑05‑30 14:57:06)
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
draft Date completed
prsb03-dataelement-11573
Id prsb03-dataelement-11573 (2019‑05‑30 14:57:06)
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
draft Contact details
prsb03-dataelement-11574
Id prsb03-dataelement-11574 (2019‑05‑30 14:57:06)
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
folder draft Drug/substance use
prsb03-dataelement-10042
Id prsb03-dataelement-10042 (2018‑10‑31)
Description Details of the person's drug and substance use.
draft Date
prsb03-dataelement-11814
Id prsb03-dataelement-11814 (2019‑05‑31 14:24:49)
Description The date when the drug/substance use was noted.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11815
Id prsb03-dataelement-11815 (2019‑05‑31 14:25:16)
Description The location where the drug/substance use was noted.
Relationship
draft Coded value
prsb03-dataelement-13334
Id prsb03-dataelement-13334 (2020‑08‑06 16:31:42)
Description The coded value for location.
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13335
Id prsb03-dataelement-13335 (2020‑08‑06 16:33:14)
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
folder draft Drug/substance use
prsb03-dataelement-13336
Id prsb03-dataelement-13336 (2020‑08‑06 16:36:01)
Description Latest or current drug/substance use.
draft Coded value
prsb03-dataelement-13337
Id prsb03-dataelement-13337 (2020‑08‑06 16:44:34)
Description The coded value for drug and substance misuse.
Operationalization SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|
Value Domain
draft Free text
prsb03-dataelement-13338
Id prsb03-dataelement-13338 (2020‑08‑06 16:45:44)
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
folder draft Performing professional
prsb03-dataelement-11816
Id prsb03-dataelement-11816 (2019‑05‑31 14:25:51)
Description The professional who noted the drug/substance use.
Relationship
draft Name
prsb03-dataelement-11817
Id prsb03-dataelement-11817 (2019‑05‑31 14:26:11)
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
draft Role
prsb03-dataelement-11818
Id prsb03-dataelement-11818 (2019‑05‑31 14:26:11)
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
draft Grade
prsb03-dataelement-11819
Id prsb03-dataelement-11819 (2019‑05‑31 14:26:11)
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
draft Speciality
prsb03-dataelement-11820
Id prsb03-dataelement-11820 (2019‑05‑31 14:26:11)
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
draft Professional identifier
prsb03-dataelement-11821
Id prsb03-dataelement-11821 (2019‑05‑31 14:26:11)
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
folder draft Organisation
prsb03-dataelement-11822
Id prsb03-dataelement-11822 (2019‑05‑31 14:26:11)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11823
Id prsb03-dataelement-11823 (2019‑05‑31 14:26:11)
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
folder draft Person completing record
prsb03-dataelement-11575
Id prsb03-dataelement-11575 (2019‑05‑30 14:57:36)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11576
Id prsb03-dataelement-11576 (2019‑05‑30 14:57:58)
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
draft Role
prsb03-dataelement-11577
Id prsb03-dataelement-11577 (2019‑05‑30 14:57:58)
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
draft Grade
prsb03-dataelement-11578
Id prsb03-dataelement-11578 (2019‑05‑30 14:57:58)
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
draft Specialty
prsb03-dataelement-11579
Id prsb03-dataelement-11579 (2019‑05‑30 14:57:58)
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
folder draft Organisation
prsb03-dataelement-11580
Id prsb03-dataelement-11580 (2019‑05‑30 14:57:58)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11581
Id prsb03-dataelement-11581 (2019‑05‑30 14:57:58)
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
draft Date completed
prsb03-dataelement-11582
Id prsb03-dataelement-11582 (2019‑05‑30 14:57:58)
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
draft Contact details
prsb03-dataelement-11583
Id prsb03-dataelement-11583 (2019‑05‑30 14:57:58)
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
folder draft Social circumstances
prsb03-dataelement-10043
Id prsb03-dataelement-10043 (2018‑10‑31)
Description Details of the persons social circumstances
draft Date
prsb03-dataelement-11824
Id prsb03-dataelement-11824 (2019‑05‑31 14:26:31)
Description The date when the social circumstances were taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11825
Id prsb03-dataelement-11825 (2019‑05‑31 14:27:00)
Description The location where the social circumstances were taken.
Relationship
draft Coded value
prsb03-dataelement-13339
Id prsb03-dataelement-13339 (2020‑08‑06 16:47:55)
Description The coded value for the location
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13340
Id prsb03-dataelement-13340 (2020‑08‑06 16:49:24)
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
draft Social circumstances
prsb03-dataelement-13341
Id prsb03-dataelement-13341 (2020‑08‑06 16:51:45)
Description A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11826
Id prsb03-dataelement-11826 (2019‑05‑31 14:27:37)
Description The professional who took the social circumstances.
Relationship
draft Name
prsb03-dataelement-11827
Id prsb03-dataelement-11827 (2019‑05‑31 14:27:55)
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
draft Role
prsb03-dataelement-11828
Id prsb03-dataelement-11828 (2019‑05‑31 14:27:55)
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
draft Grade
prsb03-dataelement-11829
Id prsb03-dataelement-11829 (2019‑05‑31 14:27:55)
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
draft Speciality
prsb03-dataelement-11830
Id prsb03-dataelement-11830 (2019‑05‑31 14:27:55)
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
draft Professional identifier
prsb03-dataelement-11831
Id prsb03-dataelement-11831 (2019‑05‑31 14:27:55)
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
folder draft Organisation
prsb03-dataelement-11832
Id prsb03-dataelement-11832 (2019‑05‑31 14:27:55)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11833
Id prsb03-dataelement-11833 (2019‑05‑31 14:27:55)
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
folder draft Person completing record
prsb03-dataelement-11584
Id prsb03-dataelement-11584 (2019‑05‑30 14:58:43)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11585
Id prsb03-dataelement-11585 (2019‑05‑30 14:59:16)
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
draft Role
prsb03-dataelement-11586
Id prsb03-dataelement-11586 (2019‑05‑30 14:59:16)
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
draft Grade
prsb03-dataelement-11587
Id prsb03-dataelement-11587 (2019‑05‑30 14:59:16)
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
draft Specialty
prsb03-dataelement-11588
Id prsb03-dataelement-11588 (2019‑05‑30 14:59:16)
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
folder draft Organisation
prsb03-dataelement-11589
Id prsb03-dataelement-11589 (2019‑05‑30 14:59:16)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11590
Id prsb03-dataelement-11590 (2019‑05‑30 14:59:16)
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
draft Date completed
prsb03-dataelement-11591
Id prsb03-dataelement-11591 (2019‑05‑30 14:59:16)
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
draft Contact details
prsb03-dataelement-11592
Id prsb03-dataelement-11592 (2019‑05‑30 14:59:16)
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
folder draft Access
prsb03-dataelement-10045
Id prsb03-dataelement-10045 (2018‑10‑31)
Description Details of access for the person.
draft Date
prsb03-dataelement-11844
Id prsb03-dataelement-11844 (2019‑05‑31 14:30:01)
Description The date when the special access requirements were taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11845
Id prsb03-dataelement-11845 (2019‑05‑31 14:30:30)
Description The location where the special access requirements were taken.
Relationship
draft Coded value
prsb03-dataelement-13343
Id prsb03-dataelement-13343 (2020‑08‑06 17:01:07)
Description The coded value for location
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13344
Id prsb03-dataelement-13344 (2020‑08‑06 17:01:46)
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
draft Access
prsb03-dataelement-13342
Id prsb03-dataelement-13342 (2020‑08‑06 16:54:43)
Description Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11846
Id prsb03-dataelement-11846 (2019‑05‑31 14:31:02)
Description The professional who took the special access requirements.
Relationship
draft Name
prsb03-dataelement-11847
Id prsb03-dataelement-11847 (2019‑05‑31 14:31:19)
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
draft Role
prsb03-dataelement-11848
Id prsb03-dataelement-11848 (2019‑05‑31 14:31:19)
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
draft Grade
prsb03-dataelement-11849
Id prsb03-dataelement-11849 (2019‑05‑31 14:31:19)
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
draft Speciality
prsb03-dataelement-11850
Id prsb03-dataelement-11850 (2019‑05‑31 14:31:19)
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
draft Professional identifier
prsb03-dataelement-11851
Id prsb03-dataelement-11851 (2019‑05‑31 14:31:19)
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
folder draft Organisation
prsb03-dataelement-11852
Id prsb03-dataelement-11852 (2019‑05‑31 14:31:19)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11853
Id prsb03-dataelement-11853 (2019‑05‑31 14:31:19)
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
folder draft Person completing record
prsb03-dataelement-11602
Id prsb03-dataelement-11602 (2019‑05‑30 15:01:10)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11603
Id prsb03-dataelement-11603 (2019‑05‑30 15:01:27)
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
draft Role
prsb03-dataelement-11604
Id prsb03-dataelement-11604 (2019‑05‑30 15:01:27)
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
draft Grade
prsb03-dataelement-11605
Id prsb03-dataelement-11605 (2019‑05‑30 15:01:27)
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
draft Specialty
prsb03-dataelement-11606
Id prsb03-dataelement-11606 (2019‑05‑30 15:01:27)
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
folder draft Organisation
prsb03-dataelement-11607
Id prsb03-dataelement-11607 (2019‑05‑30 15:01:27)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11608
Id prsb03-dataelement-11608 (2019‑05‑30 15:01:27)
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
draft Date completed
prsb03-dataelement-11609
Id prsb03-dataelement-11609 (2019‑05‑30 15:01:27)
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
draft Contact details
prsb03-dataelement-11610
Id prsb03-dataelement-11610 (2019‑05‑30 15:01:27)
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
folder draft Dependants
prsb03-dataelement-10046
Id prsb03-dataelement-10046 (2018‑10‑31)
Description Details of any responsibility the person has for dependants.
draft Date
prsb03-dataelement-11854
Id prsb03-dataelement-11854 (2019‑05‑31 14:31:40)
Description The date when the dependents details were taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11855
Id prsb03-dataelement-11855 (2019‑05‑31 14:32:07)
Description The location where the dependents details were taken.
Relationship
draft Coded value
prsb03-dataelement-13346
Id prsb03-dataelement-13346 (2020‑08‑06 17:07:12)
Description The coded value for location
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13347
Id prsb03-dataelement-13347 (2020‑08‑06 17:08:03)
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
draft Dependants
prsb03-dataelement-13345
Id prsb03-dataelement-13345 (2020‑08‑06 17:05:40)
Description Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.
Operationalization Free text
Value Domain
Property
max length
150
folder draft Performing professional
prsb03-dataelement-11856
Id prsb03-dataelement-11856 (2019‑05‑31 14:32:34)
Description The professional who took the dependents details.
Relationship
draft Name
prsb03-dataelement-11857
Id prsb03-dataelement-11857 (2019‑05‑31 14:32:53)
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
draft Role
prsb03-dataelement-11858
Id prsb03-dataelement-11858 (2019‑05‑31 14:32:53)
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
draft Grade
prsb03-dataelement-11859
Id prsb03-dataelement-11859 (2019‑05‑31 14:32:53)
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
draft Speciality
prsb03-dataelement-11860
Id prsb03-dataelement-11860 (2019‑05‑31 14:32:53)
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
draft Professional identifier
prsb03-dataelement-11861
Id prsb03-dataelement-11861 (2019‑05‑31 14:32:53)
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
folder draft Organisation
prsb03-dataelement-11862
Id prsb03-dataelement-11862 (2019‑05‑31 14:32:53)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11863
Id prsb03-dataelement-11863 (2019‑05‑31 14:32:53)
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
folder draft Person completing record
prsb03-dataelement-11611
Id prsb03-dataelement-11611 (2019‑05‑30 15:03:35)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11612
Id prsb03-dataelement-11612 (2019‑05‑30 15:03:59)
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
draft Role
prsb03-dataelement-11613
Id prsb03-dataelement-11613 (2019‑05‑30 15:03:59)
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
draft Grade
prsb03-dataelement-11614
Id prsb03-dataelement-11614 (2019‑05‑30 15:03:59)
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
draft Specialty
prsb03-dataelement-11615
Id prsb03-dataelement-11615 (2019‑05‑30 15:03:59)
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
folder draft Organisation
prsb03-dataelement-11616
Id prsb03-dataelement-11616 (2019‑05‑30 15:03:59)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11617
Id prsb03-dataelement-11617 (2019‑05‑30 15:03:59)
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
draft Date completed
prsb03-dataelement-11618
Id prsb03-dataelement-11618 (2019‑05‑30 15:03:59)
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
draft Contact details
prsb03-dataelement-11619
Id prsb03-dataelement-11619 (2019‑05‑30 15:03:59)
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
folder draft Accommodation status
prsb03-dataelement-10047
Id prsb03-dataelement-10047 (2018‑10‑31)
Description Details of the type of accommodation where the person lives.
draft Date
prsb03-dataelement-11864
Id prsb03-dataelement-11864 (2019‑05‑31 14:33:22)
Description The date when the accommodation status was taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11865
Id prsb03-dataelement-11865 (2019‑05‑31 14:33:51)
Description The location where the accommodation was taken.
Relationship
draft Coded value
prsb03-dataelement-13352
Id prsb03-dataelement-13352 (2020‑08‑06 17:23:01)
Description The coded value of location
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13353
Id prsb03-dataelement-13353 (2020‑08‑06 17:23:48)
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
folder draft Accommodation status
prsb03-dataelement-13348
Id prsb03-dataelement-13348 (2020‑08‑06 17:12:04)
Description An indication of the type of accommodation where the person lives.

This should be based on the main or permanent residence.
draft Coded value
prsb03-dataelement-13349
Id prsb03-dataelement-13349 (2020‑08‑06 17:13:26)
Description The coded value for accommodation status
Operationalization NHS data dictionary :- Accommodation status
Value Domain
Property
max length
4
draft Free text
prsb03-dataelement-13350
Id prsb03-dataelement-13350 (2020‑08‑06 17:16:53)
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
folder draft Performing professional
prsb03-dataelement-11866
Id prsb03-dataelement-11866 (2019‑05‑31 14:34:24)
Description The professional who took the accommodation status.
Relationship
draft Name
prsb03-dataelement-11867
Id prsb03-dataelement-11867 (2019‑05‑31 14:34:45)
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
draft Role
prsb03-dataelement-11868
Id prsb03-dataelement-11868 (2019‑05‑31 14:34:45)
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
draft Grade
prsb03-dataelement-11869
Id prsb03-dataelement-11869 (2019‑05‑31 14:34:45)
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
draft Speciality
prsb03-dataelement-11870
Id prsb03-dataelement-11870 (2019‑05‑31 14:34:45)
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
draft Professional identifier
prsb03-dataelement-11871
Id prsb03-dataelement-11871 (2019‑05‑31 14:34:45)
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
folder draft Organisation
prsb03-dataelement-11872
Id prsb03-dataelement-11872 (2019‑05‑31 14:34:45)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11873
Id prsb03-dataelement-11873 (2019‑05‑31 14:34:45)
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
folder draft Person completing record
prsb03-dataelement-11874
Id prsb03-dataelement-11874 (2019‑05‑31 14:35:09)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11875
Id prsb03-dataelement-11875 (2019‑05‑31 14:35:30)
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
draft Role
prsb03-dataelement-11876
Id prsb03-dataelement-11876 (2019‑05‑31 14:35:30)
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
draft Grade
prsb03-dataelement-11877
Id prsb03-dataelement-11877 (2019‑05‑31 14:35:30)
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
draft Specialty
prsb03-dataelement-11878
Id prsb03-dataelement-11878 (2019‑05‑31 14:35:30)
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
folder draft Organisation
prsb03-dataelement-11879
Id prsb03-dataelement-11879 (2019‑05‑31 14:35:30)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11880
Id prsb03-dataelement-11880 (2019‑05‑31 14:35:30)
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
draft Date completed
prsb03-dataelement-11881
Id prsb03-dataelement-11881 (2019‑05‑31 14:35:30)
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
draft Contact details
prsb03-dataelement-11882
Id prsb03-dataelement-11882 (2019‑05‑31 14:35:30)
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
folder cancelled Person completing record
prsb03-dataelement-11620
Id prsb03-dataelement-11620 (2019‑05‑30 15:04:53)
folder draft Household environment
prsb03-dataelement-10051
Id prsb03-dataelement-10051 (2018‑10‑31)
Description Details of the person's household environment.
draft Date
prsb03-dataelement-11883
Id prsb03-dataelement-11883 (2019‑05‑31 14:36:04)
Description The date when the household environment details were taken.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
folder draft Location
prsb03-dataelement-11884
Id prsb03-dataelement-11884 (2019‑05‑31 14:36:30)
Description The location where the household environment details were taken.
Relationship
draft Coded value
prsb03-dataelement-13351
Id prsb03-dataelement-13351 (2020‑08‑06 17:19:22)
Description The coded value for location
Operationalization NHS Data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
draft Free text
prsb03-dataelement-13354
Id prsb03-dataelement-13354 (2020‑08‑06 17:25:31)
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
folder cancelled Household environment
prsb03-dataelement-13355
Id prsb03-dataelement-13355 (2020‑08‑06 17:27:04) 0.1
Description Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Operationalization Free text
cancelled Coded value
prsb03-dataelement-13356
Id prsb03-dataelement-13356 (2020‑08‑06 17:30:15) 0.1
Value Domain
draft Household environment
prsb03-dataelement-13842
Id prsb03-dataelement-13842 (2020‑12‑29 12:11:12)
Description Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Operationalization Free text
Value Domain
Property
min length max length
3 5
folder draft Performing professional
prsb03-dataelement-11885
Id prsb03-dataelement-11885 (2019‑05‑31 14:37:03)
Description The professional who took the household environment details.
Relationship
draft Name
prsb03-dataelement-11886
Id prsb03-dataelement-11886 (2019‑05‑31 14:37:24)
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
draft Role
prsb03-dataelement-11887
Id prsb03-dataelement-11887 (2019‑05‑31 14:37:24)
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
draft Grade
prsb03-dataelement-11888
Id prsb03-dataelement-11888 (2019‑05‑31 14:37:24)
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
draft Speciality
prsb03-dataelement-11889
Id prsb03-dataelement-11889 (2019‑05‑31 14:37:24)
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
draft Professional identifier
prsb03-dataelement-11890
Id prsb03-dataelement-11890 (2019‑05‑31 14:37:24)
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
folder draft Organisation
prsb03-dataelement-11891
Id prsb03-dataelement-11891 (2019‑05‑31 14:37:24)
Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-11892
Id prsb03-dataelement-11892 (2019‑05‑31 14:37:24)
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
folder draft Person completing record
prsb03-dataelement-11621
Id prsb03-dataelement-11621 (2019‑05‑30 15:06:19)
Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
Description Details of the person completing the record.
Relationship
draft Name
prsb03-dataelement-11622
Id prsb03-dataelement-11622 (2019‑05‑30 15:06:41)
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
draft Role
prsb03-dataelement-11623
Id prsb03-dataelement-11623 (2019‑05‑30 15:06:41)
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
draft Grade
prsb03-dataelement-11624
Id prsb03-dataelement-11624 (2019‑05‑30 15:06:41)
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
draft Specialty
prsb03-dataelement-11625
Id prsb03-dataelement-11625 (2019‑05‑30 15:06:41)
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
folder draft Organisation
prsb03-dataelement-11626
Id prsb03-dataelement-11626 (2019‑05‑30 15:06:41)
Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
Description The organisation the person completing the record works for.
Relationship
draft Professional identifier
prsb03-dataelement-11627
Id prsb03-dataelement-11627 (2019‑05‑30 15:06:41)
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
draft Date completed
prsb03-dataelement-11628
Id prsb03-dataelement-11628 (2019‑05‑30 15:06:41)
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
draft Contact details
prsb03-dataelement-11629
Id prsb03-dataelement-11629 (2019‑05‑30 15:06:41)
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
folder cancelled Social context record entry
prsb03-dataelement-12398
Id prsb03-dataelement-12398 (2019‑06‑03 16:08:35) 0.1
Description This is a social context record entry. There may be 0 to many record entries under Diagnosis. Each record entry is made up of a number of elements or data items.
cancelled Date
prsb03-dataelement-10861
Id prsb03-dataelement-10861 (2019‑03‑27 17:50:45) 0.1
Description The date the social context was recorded.
Relationship
Value Domain
cancelled Location
prsb03-dataelement-10862
Id prsb03-dataelement-10862 (2019‑03‑27 17:51:38) 0.1
Description Details of where the social context was recorded.
Relationship
Operationalization ODS/ODR
Value Domain
cancelled Family and Household
prsb03-dataelement-10048
Id prsb03-dataelement-10048 (2018‑10‑31) 0.1
Description Family and Household details of Social Context.
Value Domain
cancelled Father's employment status
prsb03-dataelement-10049
Id prsb03-dataelement-10049 (2018‑10‑31) 0.1
Description The employment status of the Father and his occupation.
Value Domain
cancelled Household Social Services support
prsb03-dataelement-10050
Id prsb03-dataelement-10050 (2018‑10‑31) 0.1
Description Whether or not any household member had/has social services support.
Value Domain
cancelled Asylum Status
prsb03-dataelement-10052
Id prsb03-dataelement-10052 (2018‑10‑31) 0.1
Description The asylum status of the woman
Value Domain
cancelled Number of years in Education
prsb03-dataelement-10053
Id prsb03-dataelement-10053 (2018‑10‑31) 0.1
Description The number of years that the woman has spent in education
Value Domain
cancelled Social Risk Factors
prsb03-dataelement-10054
Id prsb03-dataelement-10054 (2018‑10‑31) 0.1
Description A record of social factors which should be taken into account when providing care and support for the woman and the child when born
Value Domain
cancelled Partner's employment status
prsb03-dataelement-10055
Id prsb03-dataelement-10055 (2018‑10‑31) 0.1
Description The employment status of the Partner and their occupation
Value Domain
cancelled Mother's employment status
prsb03-dataelement-10056
Id prsb03-dataelement-10056 (2018‑10‑31) 0.1
Description The employment status of the Mother and her occupation.
Value Domain
cancelled Mother’s educational status
prsb03-dataelement-10057
Id prsb03-dataelement-10057 (2018‑10‑31) 0.1
Description The highest educational qualification attained by the child’s mother.
Value Domain
cancelled Other Significant Individuals
prsb03-dataelement-10058
Id prsb03-dataelement-10058 (2018‑10‑31) 0.1
Description People deemed as key by family and or Health Care Professional in the child's life that do not live in the home (s).
Value Domain
cancelled Personal
prsb03-dataelement-10059
Id prsb03-dataelement-10059 (2018‑10‑31) 0.1
Description Personal details of Social Context.
Value Domain
cancelled Person completing record
prsb03-dataelement-10864
Id prsb03-dataelement-10864 (2019‑03‑27 17:53:18)
Description This is the person recording the social context. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
cancelled Person completing record
prsb03-dataelement-10863
Id prsb03-dataelement-10863 (2019‑03‑27 17:52:28)
Concept inherits from cancelled prsb03-dataelement-10850 (2019‑03‑27 17:15:40)
Description This is the person contributing to the family history record. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Smoking record
prsb03-dataelement-12489
Id prsb03-dataelement-12489 (2019‑10‑29 14:19:57)
Description Details of the person's smoking record
target Used by 0 transactions, 0 templates, inherited once
 
draft Overall smoking status
prsb03-dataelement-12490
Id prsb03-dataelement-12490 (2019‑10‑29 14:22:56) 0.1
Description

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

Defined by current smoking status and ever smoking status.

Operationalization

Coded text:

Current Smoker

Former Smoker

Never Smoked

^999000891000000102 |Smoking simple reference set (foundation metadata concept)|

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Set quit date
prsb03-dataelement-14006
Id prsb03-dataelement-14006 (2021‑02‑11 19:20:06)
Description Date set to quit smoking
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 0 transactions, 0 templates, inherited once
 
draft Date of quitting
prsb03-dataelement-12491
Id prsb03-dataelement-12491 (2019‑10‑29 14:35:16)
Description Date when the individual stopped smoking (if a former smoker).
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 0 transactions, 0 templates, inherited once
 
draft Other tobacco products used
prsb03-dataelement-12492
Id prsb03-dataelement-12492 (2019‑10‑29 14:40:14)
Description Details of other tobacco products used (e.g. shisha, pipe, cigar, heated tobacco products)
Operationalization

No other tobacco products used

Patient uses other tobacco products.

Plus free text details of products used.

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Information and advice given
prsb03-dataelement-12493
Id prsb03-dataelement-12493 (2019‑10‑29 14:42:47)
Description Record of whether brief advice about available smoking cessation treatment/support was given at the time of consultation.

Properties

FHIR Free text only
Relationship
Operationalization

No advice given about available smoking cessation treatment/support

Brief advice given about available smoking cessation treatment/support

Plus free text with any additional information

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Nicotine Replacement Therapy used
prsb03-dataelement-12495
Id prsb03-dataelement-12495 (2019‑10‑29 16:11:19)
Description A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment
Operationalization

NRT not currently used

NRT currently used

NRT prescribed at this appointment

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Varenicline or other pharmacotherapy used
prsb03-dataelement-12496
Id prsb03-dataelement-12496 (2019‑10‑29 16:26:30)
Description Record of whether varenicline or other smoking cessation pharmacotherapy (other than nicotine replacement therapy) is currently used or prescribed in this appointment.
Operationalization

Varenicline/other pharmacotherapy not used

Varenicline/other pharmacotherapy currently used

Varenicline/other pharmacotherapy prescribed in this appointment

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft e-cigarettes used
prsb03-dataelement-12497
Id prsb03-dataelement-12497 (2019‑10‑29 16:35:51)
Description Record of current use of e-cigarettes
Operationalization

Coded - SNOMED CT:

722499006 |Electronic cigarette user (finding)|

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Therapy prescribed (see medication item entry information model)
prsb03-dataelement-12506
Id prsb03-dataelement-12506 (2019‑10‑29 17:07:06)
Description Record of nicotine replacement therapy, varenicline or bupropion (or other smoking cessation pharmacotherapy) being prescribed at the time of the consultation
Operationalization To be entered via Medication item entry (see medications and medical devices information model - PRSB Standards for the Structure and Content of Health and Care Records (2018): https://theprsb.org/standards/healthandcarerecords/
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Referral details
prsb03-dataelement-12508
Id prsb03-dataelement-12508 (2019‑10‑29 17:08:47)
Description Record of whether referral to smoking cessation services was offered and/or made at the time of the consultation.
Operationalization

Referral to smoking cessation services

Referral not offered

Referral offered but declined

And free text with any additional information

Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
draft Comment
prsb03-dataelement-12510
Id prsb03-dataelement-12510 (2019‑10‑29 17:16:21)
Description Additional information about tobacco use or its management not captured in other fields.
Operationalization Free text
Value Domain
target Used by 0 transactions, 0 templates, inherited once
 
folder draft Alcohol record
prsb03-dataelement-12498
Id prsb03-dataelement-12498 (2019‑10‑29 16:51:15)
Description Details of a person's alcohol record
folder draft Audit questionnaire
prsb03-dataelement-12499
Id prsb03-dataelement-12499 (2019‑10‑29 16:52:18)
Description Alcohol use disorder identification test (AUDIT) questionnaire
Operationalization

SNOMED-CT coded.

Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

Assessment using Alcohol Use Disorders Identification Test Consumption [SNOMED-CT::1084571000000109]

Alcohol use disorder identification test consumption questionnaire [SNOMED-CT::335811000000106]

Alcohol consumption screening test declined [SNOMED-CT::428073005]

Alcohol assessment declined [SNOMED-CT::361731000000101]

draft Date
prsb03-dataelement-12524
Id prsb03-dataelement-12524 (2019‑10‑29 17:53:29)
Description

Date of person's AUDIT questionnaire.

Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft AUDIT-C cluster
prsb03-dataelement-12500
Id prsb03-dataelement-12500 (2019‑10‑29 16:55:54)
Description

AUDIT-C questions: Frequency of consumption, Typical consumption, Binge drinking.
draft Frequency of consumption
prsb03-dataelement-12501
Id prsb03-dataelement-12501 (2019‑10‑29 16:57:59)
Description How often did you have a drink containing alcohol in the past year?
Operationalization

0: Never [No drinking of alcohol in the past year.]

1: Monthly or Less [Drinking alcohol monthly or less frequently during the past year.]

2: 2 to 4 Times a Month [Drinking alcohol two to four times a month during the past year.]

3: 2 to 3 Times a Week [Drinking alcohol two to three times a week during the past year.]

4: 4 or More Times a Week [Drinking alcohol four or more times a week during the past year.]

Value Domain
folder draft Typical consumption cluster
prsb03-dataelement-12502
Id prsb03-dataelement-12502 (2019‑10‑29 17:00:28)
Description Details of the person's typical consumption
draft Absolute value
prsb03-dataelement-12503
Id prsb03-dataelement-12503 (2019‑10‑29 17:02:06)
Description

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

Operationalization

Integer (0 to n)

Value Domain
draft Categorical value
prsb03-dataelement-12504
Id prsb03-dataelement-12504 (2019‑10‑29 17:04:12)
Description

How many drinks did you have on a typical day when you were drinking in the past year? This item is generated from Typical consumption (absolute value).

Operationalization

0: 0 to 2 [Zero to two drinks of alcohol on a typical day in the past year.]

1: 3 or 4 [Three or four drinks of alcohol on a typical day in the past year.]

2: 5 or 6 [Five or six drinks of alcohol on a typical day in the past year.]

3: 7 to 9 [Seven, eight or nine drinks of alcohol on a typical day in the past year.]

4: 10 or More [Ten or more drinks of alcohol on a typical day in the past year.]

Value Domain
draft Binge drinking
prsb03-dataelement-12505
Id prsb03-dataelement-12505 (2019‑10‑29 17:05:54)
Description

How often did you have six or more drinks on one occasion in the past year?

Operationalization

0:Never [Never, in the past year.]

1: Less than Monthly [Less than monthly, during the past year.]

2: Monthly [Monthly, during the past year.]

3: Weekly [Weekly, during the past year.]

4: Daily or Almost Daily [Daily, or almost daily, during the past year.]

Value Domain
draft AUDIT-C total score
prsb03-dataelement-12525
Id prsb03-dataelement-12525 (2019‑10‑31 13:52:46)
Description AUDIT-C total score calculated from the 3 questions only: Frequency of consumption, Typical consumption (categorical value), Binge drinking.
Operationalization

SNOMED-CT coded with associated value calculated from the first 3 questions only.

Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

[SNOMED-CT::1084581000000106] (Alcohol Use Disorders Identification Test - Consumption score)

And add a value to a field associated with the code to record the score. The score are as follows:

Current non-drinker (AUDIT-C score = 0)

Low risk of alcohol misuse (AUDIT-C score 1-4)

High risk of alcohol misuse (AUDIT-C score >=5)

Value Domain
folder draft if AUDIT-C score >=5
prsb03-dataelement-12507
Id prsb03-dataelement-12507 (2019‑10‑29 17:08:20)
Description Populate this section if the AUDIT-C score is >=5.
cancelled AUDIT questionnaire
prsb03-dataelement-12509
Id prsb03-dataelement-12509 (2019‑10‑29 17:10:47)
Description

Alcohol use disorder identification test (AUDIT) questionnaire

Operationalization

SNOMED-CT coded.

Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

Assessment using alcohol use disorders identification [SNOMED-CT::450760003]

Alcohol use disorders identification test [SNOMED-CT::273265007]

Alcohol Use Disorders Identification Test declined [SNOMED-CT::922471000000101]

Value Domain
draft Inability to stop
prsb03-dataelement-12511
Id prsb03-dataelement-12511 (2019‑10‑29 17:17:08)
Description

How often during the last year have you found that you were not able to stop drinking once you had started?

Operationalization

0: Never [Never, in the past year.]

1: Less than Monthly [Less than monthly, during the past year.]

2: Monthly [Monthly, during the past year.]

3: Weekly [Weekly, during the past year.]

4: Daily or Almost Daily [Daily, or almost daily, during the past year.]

Value Domain
draft Failed expectations
prsb03-dataelement-12512
Id prsb03-dataelement-12512 (2019‑10‑29 17:18:25)
Description

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

Value Domain
draft Morning drinking
prsb03-dataelement-12513
Id prsb03-dataelement-12513 (2019‑10‑29 17:19:40)
Description

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Operationalization

0: Never [Never, in the past year.]

1: Less than Monthly [Less than monthly, during the past year.]

2: Monthly [Monthly, during the past year.]

3: Weekly [Weekly, during the past year.]

4: Daily or Almost Daily [Daily, or almost daily, during the past year.]

Value Domain
draft Guilt/remorse
prsb03-dataelement-12514
Id prsb03-dataelement-12514 (2019‑10‑29 17:21:13)
Description

How often during the last year have you had a feeling of guilt or remorse after drinking?

Operationalization

0: Never [Never, in the past year.]

1: Less than Monthly [Less than monthly, during the past year.]

2: Monthly [Monthly, during the past year.]

3: Weekly [Weekly, during the past year.]

4: Daily or Almost Daily [Daily, or almost daily, during the past year.]

Value Domain
draft Loss of memory
prsb03-dataelement-12515
Id prsb03-dataelement-12515 (2019‑10‑29 17:22:19)
Description

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Operationalization

0: Never [Never, in the past year.]

1: Less than Monthly [Less than monthly, during the past year.]

2: Monthly [Monthly, during the past year.]

3: Weekly [Weekly, during the past year.]

4: Daily or Almost Daily [Daily, or almost daily, during the past year.]

Value Domain
draft Injuries
prsb03-dataelement-12516
Id prsb03-dataelement-12516 (2019‑10‑29 17:23:40)
Description

Have you or someone else been injured because of your drinking?

Operationalization

0: No [No occurrence.]

2: Yes, but not in the last year. [Yes, this has occurred, but not in the last year.]

4: Yes, during the last year. [Yes this has occurred during the last year.]

Value Domain
draft External concern
prsb03-dataelement-12517
Id prsb03-dataelement-12517 (2019‑10‑29 17:27:36)
Description

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

Value Domain
draft AUDIT total score
prsb03-dataelement-12518
Id prsb03-dataelement-12518 (2019‑10‑29 17:32:10)
Description

AUDIT total score calculated from the 10 AUDIT questions.

Operationalization

SNOMED-CT coded with associated value calculated from the 10 AUDIT questions.

Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

Alcohol use disorders identification test score [SNOMED-CT::443280005]



And add a value to a field associated with the code to record the score. The score are as follows:

• 0–7 indicates sensible or lower risk drinking

• 8–15 indicates increasing risk drinking

• 16–19 indicates higher risk drinking

• 20 and over indicates possible alcohol dependence

Value Domain
folder draft Medications and medical devices
prsb03-dataelement-12526
Id prsb03-dataelement-12526 (2019‑11‑04 14:00:57)
Concept inherits from draft prsb03-dataelement-636 (2018‑10‑31)
Description Medications and medical devices
folder draft Medication administration record entry
prsb03-dataelement-12527
Id prsb03-dataelement-12527 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12483 (2019‑07‑03 12:24:36)
Description Each entry holds details of medications administered
folder draft Medication name
prsb03-dataelement-12528
Id prsb03-dataelement-12528 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12484 (2019‑07‑03 12:27:06)
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)
folder draft Route
prsb03-dataelement-12529
Id prsb03-dataelement-12529 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12485 (2019‑07‑03 12:28:40)
Description The route by which the medication is administered e.g. oral, IM, IV

Properties

FHIR MedicationStatement.dosage.route
draft Dose administered
prsb03-dataelement-12530
Id prsb03-dataelement-12530 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12487 (2019‑07‑03 12:35:08)
Description The quantity and units of medication administered
Operationalization Free text. The quantity and units administered
Value Domain
draft Administration date and time
prsb03-dataelement-12531
Id prsb03-dataelement-12531 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12486 (2019‑07‑03 12:28:41)
Description The date and time when the medication was administered.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
folder draft Medication item entry
prsb03-dataelement-12532
Id prsb03-dataelement-12532 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
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.
folder draft Medication item cluster
prsb03-dataelement-12533
Id prsb03-dataelement-12533 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
Description Medication item cluster
draft Date
prsb03-dataelement-12534
Id prsb03-dataelement-12534 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
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
folder draft Location
prsb03-dataelement-12535
Id prsb03-dataelement-12535 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
Description The location where the medication or the medical device was prescribed.
draft Performing professional
prsb03-dataelement-12536
Id prsb03-dataelement-12536 (2019‑11‑04 14:01:34)
Concept inherits from cancelled prsb03-dataelement-10845 (2019‑03‑27 17:01:47)
Description Details of the professional prescribing the medication or medical device.
Value Domain
folder draft Performing professional
prsb03-dataelement-12537
Id prsb03-dataelement-12537 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
Description The professional who prescribed the medication or medical device.
Relationship
draft Name
prsb03-dataelement-12538
Id prsb03-dataelement-12538 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
draft Role
prsb03-dataelement-12539
Id prsb03-dataelement-12539 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
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
draft Grade
prsb03-dataelement-12540
Id prsb03-dataelement-12540 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
draft Speciality
prsb03-dataelement-12541
Id prsb03-dataelement-12541 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
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
draft Professional identifier
prsb03-dataelement-12542
Id prsb03-dataelement-12542 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
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
folder draft Organisation
prsb03-dataelement-12543
Id prsb03-dataelement-12543 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
Description The name of the organisation the professional works for.
draft Contact details
prsb03-dataelement-12544
Id prsb03-dataelement-12544 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
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
folder draft Medication name
prsb03-dataelement-12545
Id prsb03-dataelement-12545 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
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)
folder draft Form
prsb03-dataelement-12546
Id prsb03-dataelement-12546 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10537 (2018‑10‑31)
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
folder draft Quantity supplied
prsb03-dataelement-12547
Id prsb03-dataelement-12547 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10539 (2018‑10‑31)
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
folder draft Route
prsb03-dataelement-12548
Id prsb03-dataelement-12548 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
Description The route by which the medication is administered e.g. oral, IM, IV

Properties

FHIR MedicationStatement.dosage.route
folder draft Site
prsb03-dataelement-12549
Id prsb03-dataelement-12549 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10540 (2018‑10‑31)
Description The anatomical site at which the medication is to be administered.

Properties

FHIR MedicationStatement.dosage.site
folder draft Method
prsb03-dataelement-12550
Id prsb03-dataelement-12550 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10541 (2018‑10‑31)
Description The technique or method by which the medication is to be administered.

Properties

FHIR MedicationStatement.dosage.method
draft Dose directions description
prsb03-dataelement-12551
Id prsb03-dataelement-12551 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10544 (2018‑10‑31)
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
draft Dose amount description
prsb03-dataelement-12552
Id prsb03-dataelement-12552 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10542 (2018‑10‑31)
Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

Properties

FHIR MedicationStatement.dosage.text
Operationalization Free text
Value Domain
draft Dose timing description
prsb03-dataelement-12553
Id prsb03-dataelement-12553 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10543 (2018‑10‑31)
Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

Properties

FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
Operationalization Free text
Value Domain
draft Parsable dose directions
prsb03-dataelement-12554
Id prsb03-dataelement-12554 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10552 (2018‑10‑31)
Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
Value Domain
Property
max length
150
folder draft Structured dose direction cluster
prsb03-dataelement-12555
Id prsb03-dataelement-12555 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
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.
draft Structured dose direction
prsb03-dataelement-12556
Id prsb03-dataelement-12556 (2019‑11‑04 14:01:34)
Concept inherits from cancelled prsb03-dataelement-10553 (2018‑10‑31)
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.
Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
Value Domain
draft Structured dose amount
prsb03-dataelement-12557
Id prsb03-dataelement-12557 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10554 (2018‑10‑31)
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
draft Structured dose timing
prsb03-dataelement-12558
Id prsb03-dataelement-12558 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10555 (2018‑10‑31)
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
draft Dose direction duration
prsb03-dataelement-12559
Id prsb03-dataelement-12559 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10548 (2018‑10‑31)
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
draft Additional instructions
prsb03-dataelement-12560
Id prsb03-dataelement-12560 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10545 (2018‑10‑31)
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
draft Request for advice
prsb03-dataelement-12561
Id prsb03-dataelement-12561 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10559 (2018‑10‑31)
Description Request for advice and recommendation about medication
Operationalization Free text
Value Domain
Property
max length
150
draft Person completing record
prsb03-dataelement-12562
Id prsb03-dataelement-12562 (2019‑11‑04 14:01:34)
Concept inherits from cancelled prsb03-dataelement-10961 (2019‑05‑18 21:23:41)
Description This is the person recording the medication.

Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
Relationship
Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
Value Domain
folder draft Course details cluster
prsb03-dataelement-12563
Id prsb03-dataelement-12563 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10561 (2018‑10‑31)
Description Details of the overall course of medication.
draft Course status
prsb03-dataelement-12564
Id prsb03-dataelement-12564 (2019‑11‑04 14:01:34)
Concept inherits from draft prsb03-dataelement-10666 (2018‑11‑13 16:47:55)
Description The status of this prescription.
Operationalization FHIR value set : - Medication status
    Value Domain
    draft Indication
    prsb03-dataelement-12565
    Id prsb03-dataelement-12565 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10546 (2018‑10‑31)
    Description Reason for medication being prescribed, where known.

    Properties

    FHIR MedicationStatement.reasonCode
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    draft Start date/time
    prsb03-dataelement-12566
    Id prsb03-dataelement-12566 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10667 (2018‑11‑13 16:49:22)
    Description The date and/or time that the medication course should begin.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    draft End date/time
    prsb03-dataelement-12567
    Id prsb03-dataelement-12567 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10557 (2018‑10‑31)
    Description The date and/or time that the medication course should finish.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    draft Link to indication record
    prsb03-dataelement-12568
    Id prsb03-dataelement-12568 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10668 (2018‑11‑13 16:59:09)
    Description A link to the record which contains the indication for this medication order.
    Operationalization Free text with URL
    Value Domain
    Property
    max length
    150
    draft Comment/recommendation
    prsb03-dataelement-12569
    Id prsb03-dataelement-12569 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10547 (2018‑10‑31)
    Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

    Properties

    FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    folder draft Medication change summary cluster
    prsb03-dataelement-12570
    Id prsb03-dataelement-12570 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10568 (2018‑10‑31)
    Description Records the changes made to medication.
    draft Status
    prsb03-dataelement-12571
    Id prsb03-dataelement-12571 (2019‑11‑04 14:01:34)
    Concept inherits from draft prsb03-dataelement-10669 (2018‑11‑13 17:00:50)
    Description The nature of any change made to the medication.
    Operationalization FHIR value set : Medication status
      Value Domain
      draft Indication
      prsb03-dataelement-12572
      Id prsb03-dataelement-12572 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10670 (2018‑11‑13 17:02:07)
      Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Date of change
      prsb03-dataelement-12573
      Id prsb03-dataelement-12573 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10671 (2018‑11‑13 17:03:03)
      Description The date of the change - addition, or amendment
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Description of amendment
      prsb03-dataelement-12574
      Id prsb03-dataelement-12574 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10672 (2018‑11‑13 17:03:42)
      Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Total dose daily quantity
      prsb03-dataelement-12575
      Id prsb03-dataelement-12575 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10665 (2018‑11‑13 16:44:41)
      Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
      Operationalization Free text
      Value Domain
      folder draft Person completing record
      prsb03-dataelement-12576
      Id prsb03-dataelement-12576 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-12577
      Id prsb03-dataelement-12577 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
      Description The name of the person completing the record.
      Relationship
      Rationale Composition.author.Practitioner.name
      Operationalization Free text.
      Value Domain
      Property
      max length
      70
      draft Role
      prsb03-dataelement-12578
      Id prsb03-dataelement-12578 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
      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
      draft Grade
      prsb03-dataelement-12579
      Id prsb03-dataelement-12579 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
      Description The grade of the person completing the record.
      Relationship
      Rationale PractitionerRole.code
      Operationalization Free text.
      Value Domain
      Property
      max length
      150
      draft Specialty
      prsb03-dataelement-12580
      Id prsb03-dataelement-12580 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
      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
      folder draft Organisation
      prsb03-dataelement-12581
      Id prsb03-dataelement-12581 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-12582
      Id prsb03-dataelement-12582 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
      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
      draft Date completed
      prsb03-dataelement-12583
      Id prsb03-dataelement-12583 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
      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
      draft Contact details
      prsb03-dataelement-12584
      Id prsb03-dataelement-12584 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
      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
      folder draft Medication discontinued entry
      prsb03-dataelement-12585
      Id prsb03-dataelement-12585 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10576 (2018‑10‑31)
      Description Medication discontinued entry
      folder draft Name of discontinued medication
      prsb03-dataelement-12586
      Id prsb03-dataelement-12586 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10577 (2018‑10‑31)
      Description The name of the medication or medical device being discontinued
      draft Status
      prsb03-dataelement-12587
      Id prsb03-dataelement-12587 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-12472 (2019‑06‑25 11:42:23)
      Description The status of any change made to the medication. MUST CONTAIN STOPPED.
      Operationalization FHIR value set: - Medication status
      Value Domain
      draft Status
      prsb03-dataelement-12588
      Id prsb03-dataelement-12588 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10578 (2018‑10‑31)
      Description The nature of any change made to the medication.
      Operationalization Free text
      Value Domain
      draft Indication
      prsb03-dataelement-12589
      Id prsb03-dataelement-12589 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10579 (2018‑10‑31)
      Description The clinical indication for any changes in medication status
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Date of change
      prsb03-dataelement-12590
      Id prsb03-dataelement-12590 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10580 (2018‑10‑31)
      Description The date of the discontinuation
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Description of amendment
      prsb03-dataelement-12591
      Id prsb03-dataelement-12591 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10581 (2018‑10‑31)
      Description A description of any amendment
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Comment
      prsb03-dataelement-12592
      Id prsb03-dataelement-12592 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10582 (2018‑10‑31)
      Description Any additional comment about the discontinuation or amendment.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Medical devices entry
      prsb03-dataelement-12593
      Id prsb03-dataelement-12593 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10583 (2018‑10‑31)
      Description Medical devices
      draft Medical device
      prsb03-dataelement-12594
      Id prsb03-dataelement-12594 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10673 (2018‑11‑13 17:10:15)
      Description Any medical device that isn't prescribed.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Comments
      prsb03-dataelement-12595
      Id prsb03-dataelement-12595 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-11280 (2019‑05‑29 17:47:02)
      Description Any information regarding the medical device.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Performing Professional
      prsb03-dataelement-12596
      Id prsb03-dataelement-12596 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10549 (2018‑10‑31)
      Description Details of the professional administering the Medication (including name and role)
      Value Domain
      draft Location
      prsb03-dataelement-12597
      Id prsb03-dataelement-12597 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10550 (2018‑10‑31)
      Description Details of where the Medication was administered
      Value Domain
      draft Date
      prsb03-dataelement-12598
      Id prsb03-dataelement-12598 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10551 (2018‑10‑31)
      Description The date on which the Medication was administered
      Value Domain
      draft Start date/time
      prsb03-dataelement-12599
      Id prsb03-dataelement-12599 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10556 (2018‑10‑31)
      Description The date and/or time that the medication course should begin.
      Value Domain
      draft Authorised date
      prsb03-dataelement-12600
      Id prsb03-dataelement-12600 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10558 (2018‑10‑31)
      Description Date prescriber created prescription
      Operationalization Date and Time
      Value Domain
      draft Valid from date
      prsb03-dataelement-12601
      Id prsb03-dataelement-12601 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10560 (2018‑10‑31)
      Description Date the prescription can be issued from. Valid for 6 months
      Operationalization Date and Time
      Value Domain
      folder draft Repeat medications
      prsb03-dataelement-12602
      Id prsb03-dataelement-12602 (2019‑11‑04 14:01:34)
      Concept inherits from draft prsb03-dataelement-10585 (2018‑10‑31)
      Description This is the sub-section where all repeat medications within a specific period are recorded
      folder draft For medications that have been changed
      prsb03-dataelement-12603
      Id prsb03-dataelement-12603 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10607 (2018‑10‑31)
      Description i.e. additions, amendments and discontinued, in addition to the above, also record: is the sub-section where all current repeat medications are recorded.
      folder draft •Prescribed elsewhere
      prsb03-dataelement-12604
      Id prsb03-dataelement-12604 (2019‑11‑04 14:01:34)
      Concept inherits from cancelled prsb03-dataelement-10629 (2018‑10‑31)
      Description Prescribed elsewhere: Medication managed by another organisation
      draft Number of alcohol units consumed per week
      prsb03-dataelement-12519
      Id prsb03-dataelement-12519 (2019‑10‑29 17:43:43)
      Description

      The number of alcohol units consumed by the patient per week.

      Operationalization

      Integer (0 to n)

      Value Domain
      draft History of heavy alcohol use
      prsb03-dataelement-12520
      Id prsb03-dataelement-12520 (2019‑10‑29 17:45:50)
      Description

      Whether the patient reports a history of heavy alcohol use in the past.

      Operationalization

      History of heavy alcohol use

      No history of heavy alcohol use

      Not known

      Value Domain
      draft Information and advice given
      prsb03-dataelement-12521
      Id prsb03-dataelement-12521 (2019‑10‑29 17:47:52)
      Description

      Record of whether brief advice about alcohol use was offered and/or given.

      Properties

      FHIR Free text only
      Relationship
      Operationalization

      SNOMED-CT coded.

      Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

      Brief intervention for excessive alcohol consumption completed [SNOMED-CT::366371000000105]

      Brief intervention for excessive alcohol consumption declined [SNOMED-CT::379411000000105]

      Value Domain
      draft Referral details
      prsb03-dataelement-12522
      Id prsb03-dataelement-12522 (2019‑10‑29 17:49:43)
      Description

      Record of whether referral to alcohol support services was offered and/or made.

      Relationship
      Operationalization

      Free text and coded form (SNOMED CT).

      Please note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819

      Referral to specialist alcohol treatment service [SNOMED-CT::431260004]

      Declined referral to specialist alcohol treatment service [SNOMED-CT::380861000000109]

      Declined referral to specialist alcohol treatment service [SNOMED-CT::781191000000101]

      Referral to specialist alcohol treatment service declined by patient [SNOMED-CT::442444001]

      Value Domain
      draft Comment
      prsb03-dataelement-12523
      Id prsb03-dataelement-12523 (2019‑10‑29 17:52:11)
      Description Additional information about alcohol use or its management not captured in other fields.
      Operationalization Free text
      Value Domain
      folder draft Services and care
      prsb03-dataelement-10044
      Id prsb03-dataelement-10044 (2018‑10‑31)
      Description The services and care provided for the person.
      folder draft Services and care record entry
      prsb03-dataelement-12421
      Id prsb03-dataelement-12421 (2019‑06‑11 16:55:24)
      Description This is a services and care 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.
      draft Social care package name
      prsb03-dataelement-12965
      Id prsb03-dataelement-12965 (2020‑04‑03 17:21:47)
      Description Name of specific type of package being provided (e.g. Reablement, Home Based Care XYZ, etc)
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Social care package type
      prsb03-dataelement-12966
      Id prsb03-dataelement-12966 (2020‑04‑03 17:25:36)
      Description Higher level categorisation of package type, e.g. Adults Home Support
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Service provided
      prsb03-dataelement-12448
      Id prsb03-dataelement-12448 (2019‑06‑17 16:05:21)
      Description Details of the service providing support for the person's health or well-being.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Service start date
      prsb03-dataelement-11834
      Id prsb03-dataelement-11834 (2019‑05‑31 14:28:13)
      Description The date service started to be provided.
      Relationship
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Service end date
      prsb03-dataelement-12420
      Id prsb03-dataelement-12420 (2019‑06‑07 19:30:52)
      Description The date the service is planned to be ended or the actual end date.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Local authority
      prsb03-dataelement-11835
      Id prsb03-dataelement-11835 (2019‑05‑31 14:28:42)
      Description The name of the local authority providing the care package.
      Relationship
      draft Coded value
      prsb03-dataelement-13566
      Id prsb03-dataelement-13566 (2020‑09‑04 18:45:25)
      Description The coded value for local authority
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13567
      Id prsb03-dataelement-13567 (2020‑09‑04 18:46:37)
      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
      draft Care funding source
      prsb03-dataelement-13067
      Id prsb03-dataelement-13067 (2020‑05‑21 13:41:46)
      Concept inherits from draft prsb03-dataelement-10410 (2018‑10‑31)
      Description A reference to the funding source and any conditions or limitations associated.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Performing professional
      prsb03-dataelement-11836
      Id prsb03-dataelement-11836 (2019‑05‑31 14:29:23)
      Description The professional providing the service.
      Relationship
      Operationalization Free text
      draft Name
      prsb03-dataelement-11837
      Id prsb03-dataelement-11837 (2019‑05‑31 14:29:41)
      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
      draft Role
      prsb03-dataelement-11838
      Id prsb03-dataelement-11838 (2019‑05‑31 14:29:41)
      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
      draft Grade
      prsb03-dataelement-11839
      Id prsb03-dataelement-11839 (2019‑05‑31 14:29:41)
      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
      draft Speciality
      prsb03-dataelement-11840
      Id prsb03-dataelement-11840 (2019‑05‑31 14:29:41)
      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
      draft Professional identifier
      prsb03-dataelement-11841
      Id prsb03-dataelement-11841 (2019‑05‑31 14:29:41)
      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
      folder draft Organisation
      prsb03-dataelement-11842
      Id prsb03-dataelement-11842 (2019‑05‑31 14:29:41)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11843
      Id prsb03-dataelement-11843 (2019‑05‑31 14:29:41)
      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
      folder draft Person completing record
      prsb03-dataelement-11593
      Id prsb03-dataelement-11593 (2019‑05‑30 14:59:53)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11594
      Id prsb03-dataelement-11594 (2019‑05‑30 15:00:18)
      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
      draft Role
      prsb03-dataelement-11595
      Id prsb03-dataelement-11595 (2019‑05‑30 15:00:18)
      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
      draft Grade
      prsb03-dataelement-11596
      Id prsb03-dataelement-11596 (2019‑05‑30 15:00:18)
      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
      draft Specialty
      prsb03-dataelement-11597
      Id prsb03-dataelement-11597 (2019‑05‑30 15:00:18)
      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
      folder draft Organisation
      prsb03-dataelement-11598
      Id prsb03-dataelement-11598 (2019‑05‑30 15:00:18)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11599
      Id prsb03-dataelement-11599 (2019‑05‑30 15:00:18)
      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
      draft Date completed
      prsb03-dataelement-11600
      Id prsb03-dataelement-11600 (2019‑05‑30 15:00:18)
      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
      draft Contact details
      prsb03-dataelement-11601
      Id prsb03-dataelement-11601 (2019‑05‑30 15:00:18)
      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
      folder draft Care needs summary
      prsb03-dataelement-13063
      Id prsb03-dataelement-13063 (2020‑05‑15 16:38:45)
      Description A description of the person's current care needs.
      cancelled Care needs summary
      prsb03-dataelement-13097
      Id prsb03-dataelement-13097 (2020‑06‑22 15:53:40) 0.1
      Description A summary of the person's nursing care needs e.g. catheter / continence / stoma care, skin care (wounds, ulcers), tracteostomy, nutrition and fluids, behavioural care and support.
      Value Domain
      draft Care needs summary
      prsb03-dataelement-13064
      Id prsb03-dataelement-13064 (2020‑05‑15 16:40:47) 0.2
      Description A narrative summary of the person's nursing and care needs e.g. catheter/ continence/ stoma care, skin care (wounds, ulcers), tracteostomy, nutrition and fluids, behavioural care and support.. Attach additional support plans as required.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Performing professional
      prsb03-dataelement-13174
      Id prsb03-dataelement-13174 (2020‑06‑24 17:17:43)
      Description The professional who completed the care needs summary.
      Relationship
      draft Name
      prsb03-dataelement-13182
      Id prsb03-dataelement-13182 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
      Description The name of the professional.
      Rationale Practitioner.name
      Operationalization Free text.
      Value Domain
      Property
      max length
      70
      draft Role
      prsb03-dataelement-13183
      Id prsb03-dataelement-13183 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
      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
      draft Grade
      prsb03-dataelement-13184
      Id prsb03-dataelement-13184 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
      Description The grade of the professional.
      Rationale PractitionerRole.code
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Speciality
      prsb03-dataelement-13185
      Id prsb03-dataelement-13185 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
      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
      draft Professional identifier
      prsb03-dataelement-13186
      Id prsb03-dataelement-13186 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
      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
      folder draft Organisation
      prsb03-dataelement-13187
      Id prsb03-dataelement-13187 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-13188
      Id prsb03-dataelement-13188 (2020‑06‑24 17:19:47)
      Concept inherits from draft prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
      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
      folder draft Location
      prsb03-dataelement-13189
      Id prsb03-dataelement-13189 (2020‑06‑24 17:22:23)
      Description The location where the care needs summary was written.
      Relationship
      draft Coded value
      prsb03-dataelement-13729
      Id prsb03-dataelement-13729 (2020‑09‑25 16:20:00)
      Description The coded value for location
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13730
      Id prsb03-dataelement-13730 (2020‑09‑25 16:24:30)
      Operationalization Free text
      Value Domain
      draft Date
      prsb03-dataelement-13190
      Id prsb03-dataelement-13190 (2020‑06‑24 17:25:46)
      Description The date the care needs summary was written.
      Relationship
      Operationalization Date and time.
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Person completing record
      prsb03-dataelement-13191
      Id prsb03-dataelement-13191 (2020‑06‑24 17:27:12)
      Description A record of the details of the person that entered the care needs summary, and the date on which it was entered.
      Relationship
      draft Name
      prsb03-dataelement-13192
      Id prsb03-dataelement-13192 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13101 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      draft Role
      prsb03-dataelement-13193
      Id prsb03-dataelement-13193 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      draft Grade
      prsb03-dataelement-13194
      Id prsb03-dataelement-13194 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13103 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      draft Specialty
      prsb03-dataelement-13195
      Id prsb03-dataelement-13195 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13104 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Organisation
      prsb03-dataelement-13196
      Id prsb03-dataelement-13196 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13105 (2020‑06‑24 16:00:08)
      Description The organisation the person completing the record works for.
      Relationship
      target Used by 0 transactions, 0 templates, inherited once
       
      draft Professional identifier
      prsb03-dataelement-13197
      Id prsb03-dataelement-13197 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13106 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      draft Date completed
      prsb03-dataelement-13198
      Id prsb03-dataelement-13198 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13107 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      draft Contact details
      prsb03-dataelement-13199
      Id prsb03-dataelement-13199 (2020‑06‑24 17:27:59)
      Concept inherits from draft prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Assessed level of care
      prsb03-dataelement-13425
      Id prsb03-dataelement-13425 (2020‑08‑11 14:29:31) 0.1
      Description Record whether Enhanced care observation was required during the admission and details of level of enhanced care observation needed and why.
      draft Level of enhanced care observation
      prsb03-dataelement-13427
      Id prsb03-dataelement-13427 (2020‑08‑11 14:35:51) 0.1
      Description Record the level of enhanced care observation the person required during the admission and prior to discharge if different.
      Record why needed e.g. to reduce risk and protect the person because of high risk of falling and sustaining injury or person very confused.
      Operationalization Levels:

      A - General level i.e. needed usual inpatient observation

      B = Intermittent observation i.e. every 30 to 60 minutes

      C = Continuous observation within eyesight i.e. in a cohort bay

      D= High level multi professional continuous observation
      Value Domain
      Property
      max length
      150
      folder draft Person completing record
      prsb03-dataelement-13731
      Id prsb03-dataelement-13731 (2020‑09‑25 16:25:22)
      Concept inherits from draft prsb03-dataelement-13100 (2020‑06‑24 15:58:27)
      Description A record of the details of the person that entered the property or equipment the resident is taking into hospital, and the date on which it was entered.
      Relationship
      draft Name
      prsb03-dataelement-13732
      Id prsb03-dataelement-13732 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13101 (2020‑06‑24 16:00:08)
      Description The name of the person completing the record.
      Relationship
      Rationale Composition.author.Practitioner.name
      Operationalization Free text.
      Value Domain
      Property
      max length
      70
      draft Role
      prsb03-dataelement-13733
      Id prsb03-dataelement-13733 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
      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
      draft Grade
      prsb03-dataelement-13734
      Id prsb03-dataelement-13734 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13103 (2020‑06‑24 16:00:08)
      Description The grade of the person completing the record.
      Relationship
      Rationale PractitionerRole.code
      Operationalization Free text.
      Value Domain
      Property
      max length
      150
      draft Specialty
      prsb03-dataelement-13735
      Id prsb03-dataelement-13735 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13104 (2020‑06‑24 16:00:08)
      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
      folder draft Organisation
      prsb03-dataelement-13736
      Id prsb03-dataelement-13736 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13105 (2020‑06‑24 16:00:08)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-13737
      Id prsb03-dataelement-13737 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13106 (2020‑06‑24 16:00:08)
      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
      draft Date completed
      prsb03-dataelement-13738
      Id prsb03-dataelement-13738 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13107 (2020‑06‑24 16:00:08)
      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
      draft Contact details
      prsb03-dataelement-13739
      Id prsb03-dataelement-13739 (2020‑09‑25 16:26:25)
      Concept inherits from draft prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
      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
      cancelled Person completing record
      prsb03-dataelement-13426
      Id prsb03-dataelement-13426 (2020‑08‑11 14:31:47) 0.1
      Value Domain
      folder draft Primary support reason
      prsb03-dataelement-12974
      Id prsb03-dataelement-12974 (2020‑04‑06 20:09:53)
      Description The primary support reason for social care.
      folder draft Primary support reason record entry
      prsb03-dataelement-12975
      Id prsb03-dataelement-12975 (2020‑04‑06 20:14:11)
      Description This is a primary support reason record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
      draft Primary support reason
      prsb03-dataelement-12976
      Id prsb03-dataelement-12976 (2020‑04‑06 20:15:36)
      Description The Primary Support Reason used to classify a person for National Reporting on Short and Long Term Services (SALT) e.g. Learning disability support, mental health support, physical support
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Active
      prsb03-dataelement-13305
      Id prsb03-dataelement-13305 (2020‑08‑06 13:21:08)
      Description Flag to indicate whether the primary support reason is currently active
      Operationalization Flag: - Yes or No
      Value Domain
      draft Start date
      prsb03-dataelement-13306
      Id prsb03-dataelement-13306 (2020‑08‑06 13:22:22)
      Description The date a primary support reason was authorised as active.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date
      prsb03-dataelement-13307
      Id prsb03-dataelement-13307 (2020‑08‑06 13:22:57)
      Description The end date of authorisation.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Family history
      prsb03-dataelement-251
      Id prsb03-dataelement-251 (2018‑10‑31)
      Description Family history
      folder draft Family history record entry
      prsb03-dataelement-10653
      Id prsb03-dataelement-10653 (2018‑11‑13 12:07:47)
      Description This is a family history record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
      draft Date
      prsb03-dataelement-10153
      Id prsb03-dataelement-10153 (2018‑10‑31)
      Description The date the family history was taken.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Location
      prsb03-dataelement-10851
      Id prsb03-dataelement-10851 (2019‑03‑27 17:17:04)
      Description The location where the family history was taken.
      draft Coded value
      prsb03-dataelement-13682
      Id prsb03-dataelement-13682 (2020‑09‑09 12:51:27)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13683
      Id prsb03-dataelement-13683 (2020‑09‑09 12:52:38)
      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
      folder draft Performing professional
      prsb03-dataelement-11640
      Id prsb03-dataelement-11640 (2019‑05‑30 17:58:57)
      Description The professional who took the family history.
      Relationship
      draft Name
      prsb03-dataelement-11641
      Id prsb03-dataelement-11641 (2019‑05‑30 17:59:44)
      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
      draft Role
      prsb03-dataelement-11642
      Id prsb03-dataelement-11642 (2019‑05‑30 17:59:44)
      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
      draft Grade
      prsb03-dataelement-11643
      Id prsb03-dataelement-11643 (2019‑05‑30 17:59:44)
      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
      draft Speciality
      prsb03-dataelement-11644
      Id prsb03-dataelement-11644 (2019‑05‑30 17:59:44)
      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
      draft Professional identifier
      prsb03-dataelement-11645
      Id prsb03-dataelement-11645 (2019‑05‑30 17:59:44)
      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
      folder draft Organisation
      prsb03-dataelement-11646
      Id prsb03-dataelement-11646 (2019‑05‑30 17:59:44)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11647
      Id prsb03-dataelement-11647 (2019‑05‑30 17:59:44)
      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
      cancelled Person completing record
      prsb03-dataelement-10850
      Id prsb03-dataelement-10850 (2019‑03‑27 17:15:40)
      Description This is the person contributing to the family history record. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      target Used by 0 transactions, 0 templates, inherited once
       
      folder draft Relationship to person
      prsb03-dataelement-10155
      Id prsb03-dataelement-10155 (2018‑10‑31)
      Description The relationship of the family member with the condition to the person.
      draft Coded value
      prsb03-dataelement-13676
      Id prsb03-dataelement-13676 (2020‑09‑09 12:28:47)
      Description The coded value for relationship to person
      Operationalization SNOMED CT: - <303071001 |Person in the family (person)|

      Value Domain
      draft Free text
      prsb03-dataelement-13677
      Id prsb03-dataelement-13677 (2020‑09‑09 12:29:29)
      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
      folder draft Family history
      prsb03-dataelement-10151
      Id prsb03-dataelement-10151 (2018‑10‑31)
      Description The record of relevant illness in family relations deemed to be significant to the care or health of the person, including mental illness and suicide, genetic information etc.
      draft Coded value
      prsb03-dataelement-13678
      Id prsb03-dataelement-13678 (2020‑09‑09 12:35:18)
      Description The coded value for family history
      Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

      Value Domain
      draft Free text
      prsb03-dataelement-13679
      Id prsb03-dataelement-13679 (2020‑09‑09 12:38:35)
      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
      folder cancelled Condition or diagnosis
      prsb03-dataelement-10152
      Id prsb03-dataelement-10152 (2018‑10‑31) 0.1
      Description The condition or diagnosis of the family member deemed to be significant to the care or health of the person.
      cancelled Coded value
      prsb03-dataelement-13680
      Id prsb03-dataelement-13680 (2020‑09‑09 12:45:15) 0.1
      Description The coded value for condition or diagnosis
      Operationalization SNOMED CT: - 999000771000000106 | Family history simple reference set (foundation metadata concept) |
      Value Domain
      cancelled Free text
      prsb03-dataelement-13681
      Id prsb03-dataelement-13681 (2020‑09‑09 12:48:08) 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
      folder draft Person completing record
      prsb03-dataelement-11630
      Id prsb03-dataelement-11630 (2019‑05‑30 15:28:16)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11631
      Id prsb03-dataelement-11631 (2019‑05‑30 15:28:41)
      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
      draft Role
      prsb03-dataelement-11632
      Id prsb03-dataelement-11632 (2019‑05‑30 15:28:41)
      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
      draft Grade
      prsb03-dataelement-11633
      Id prsb03-dataelement-11633 (2019‑05‑30 15:28:41)
      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
      draft Specialty
      prsb03-dataelement-11634
      Id prsb03-dataelement-11634 (2019‑05‑30 15:28:41)
      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
      folder draft Organisation
      prsb03-dataelement-11635
      Id prsb03-dataelement-11635 (2019‑05‑30 15:28:41)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11636
      Id prsb03-dataelement-11636 (2019‑05‑30 15:28:41)
      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
      draft Date completed
      prsb03-dataelement-11637
      Id prsb03-dataelement-11637 (2019‑05‑30 15:28:41)
      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
      draft Contact details
      prsb03-dataelement-11638
      Id prsb03-dataelement-11638 (2019‑05‑30 15:28:41)
      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
      cancelled Maternal or paternal relation
      prsb03-dataelement-10154
      Id prsb03-dataelement-10154 (2018‑10‑31) 0.1
      Description Record of whether the condition or diagnosis was on the mother’s or father’s side of the family, where needed e.g. paternal grandfather.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Comment
      prsb03-dataelement-10156
      Id prsb03-dataelement-10156 (2018‑10‑31)
      Description Any further textual comment.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Investigation results
      prsb03-dataelement-257
      Id prsb03-dataelement-257 (2018‑10‑31)
      Description Investigation results
      folder draft Investigation results record entry
      prsb03-dataelement-10654
      Id prsb03-dataelement-10654 (2018‑11‑13 12:10:48)
      Description This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
      draft Date
      prsb03-dataelement-10157
      Id prsb03-dataelement-10157 (2018‑10‑31)
      Description The date and time when the investigation was performed
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      cancelled Performing professional
      prsb03-dataelement-10158
      Id prsb03-dataelement-10158 (2018‑10‑31)
      Description Details of the professional performing the investigation (including name and role)
      Value Domain
      folder draft Performing professional
      prsb03-dataelement-12099
      Id prsb03-dataelement-12099 (2019‑05‑31 15:55:11)
      Description The professional who performed the investigation.
      Relationship
      draft Name
      prsb03-dataelement-12100
      Id prsb03-dataelement-12100 (2019‑05‑31 15:55:33)
      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
      draft Role
      prsb03-dataelement-12101
      Id prsb03-dataelement-12101 (2019‑05‑31 15:55:33)
      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
      draft Grade
      prsb03-dataelement-12102
      Id prsb03-dataelement-12102 (2019‑05‑31 15:55:33)
      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
      draft Speciality
      prsb03-dataelement-12103
      Id prsb03-dataelement-12103 (2019‑05‑31 15:55:33)
      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
      draft Professional identifier
      prsb03-dataelement-12104
      Id prsb03-dataelement-12104 (2019‑05‑31 15:55:33)
      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
      folder draft Organisation
      prsb03-dataelement-12105
      Id prsb03-dataelement-12105 (2019‑05‑31 15:55:33)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-12106
      Id prsb03-dataelement-12106 (2019‑05‑31 15:55:33)
      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
      folder draft Location
      prsb03-dataelement-10159
      Id prsb03-dataelement-10159 (2018‑10‑31)
      Description The location where the investigation took place.
      draft Coded location
      prsb03-dataelement-13725
      Id prsb03-dataelement-13725 (2020‑09‑16 12:46:40)
      Description The coded value for location
      Operationalization NHS data dictionary : Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13726
      Id prsb03-dataelement-13726 (2020‑09‑16 13:10:32)
      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
      folder draft Investigation
      prsb03-dataelement-10160
      Id prsb03-dataelement-10160 (2018‑10‑31)
      Description The investigation performed.
      draft Coded value
      prsb03-dataelement-13525
      Id prsb03-dataelement-13525 (2020‑09‑04 14:11:36)
      Description The coded value for investigation
      Operationalization SNOMED CT: - <71388002 |Procedure (procedure)|

      Value Domain
      draft Free text
      prsb03-dataelement-13526
      Id prsb03-dataelement-13526 (2020‑09‑04 14:22:43)
      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
      folder draft Investigation result
      prsb03-dataelement-10161
      Id prsb03-dataelement-10161 (2018‑10‑31)
      Description For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
      draft Coded value
      prsb03-dataelement-13527
      Id prsb03-dataelement-13527 (2020‑09‑04 14:25:41)
      Description The coded value for investigation results
      Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

      Value Domain
      draft Free text
      prsb03-dataelement-13528
      Id prsb03-dataelement-13528 (2020‑09‑04 14:29:50)
      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
      draft Investigation Method
      prsb03-dataelement-14094
      Id prsb03-dataelement-14094 (2021‑02‑18 13:46:34)
      Description Method used in carrying out investigation
      Operationalization Coded entry - Point of care test, Laboratory test
      Value Domain
      folder draft Structured investigation result
      prsb03-dataelement-12415
      Id prsb03-dataelement-12415 (2019‑06‑07 16:21:34)
      Description A structured set of information for each investigation result.
      draft Value
      prsb03-dataelement-12416
      Id prsb03-dataelement-12416 (2019‑06‑07 16:22:08)
      Description The value of the investigation result.
      Operationalization Numeric
      Value Domain
      Property
      max length
      10
      draft Units of measure
      prsb03-dataelement-12417
      Id prsb03-dataelement-12417 (2019‑06‑07 16:23:50)
      Description The units of the investigation result.
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      draft Reference ranges
      prsb03-dataelement-12418
      Id prsb03-dataelement-12418 (2019‑06‑07 16:24:48)
      Description The reference range for the investigation result.
      Operationalization Free text
      Value Domain
      draft Abnormal indicator
      prsb03-dataelement-12419
      Id prsb03-dataelement-12419 (2019‑06‑07 16:26:00)
      Description Indicator if the investigation is abnormal.
      Operationalization Abnormal or Normal
      Value Domain
      folder draft Person completing record
      prsb03-dataelement-12107
      Id prsb03-dataelement-12107 (2019‑05‑31 15:55:48)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-12108
      Id prsb03-dataelement-12108 (2019‑05‑31 15:56:17)
      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
      draft Role
      prsb03-dataelement-12109
      Id prsb03-dataelement-12109 (2019‑05‑31 15:56:17)
      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
      draft Grade
      prsb03-dataelement-12110
      Id prsb03-dataelement-12110 (2019‑05‑31 15:56:17)
      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
      draft Specialty
      prsb03-dataelement-12111
      Id prsb03-dataelement-12111 (2019‑05‑31 15:56:17)
      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
      folder draft Organisation
      prsb03-dataelement-12112
      Id prsb03-dataelement-12112 (2019‑05‑31 15:56:17)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-12113
      Id prsb03-dataelement-12113 (2019‑05‑31 15:56:17)
      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
      draft Date completed
      prsb03-dataelement-12114
      Id prsb03-dataelement-12114 (2019‑05‑31 15:56:17)
      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
      draft Contact details
      prsb03-dataelement-12115
      Id prsb03-dataelement-12115 (2019‑05‑31 15:56:17)
      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
      cancelled Person completing record
      prsb03-dataelement-10955
      Id prsb03-dataelement-10955 (2019‑05‑18 21:08:06) 0.1
      Description This is the person recording the investigation result.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      folder draft Signpost details
      prsb03-dataelement-13973
      Id prsb03-dataelement-13973 (2021‑02‑11 12:24:29)
      Description Details of signpost
      folder draft Signpost details record entry
      prsb03-dataelement-13974
      Id prsb03-dataelement-13974 (2021‑02‑11 12:26:44)
      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.
      draft Date
      prsb03-dataelement-13975
      Id prsb03-dataelement-13975 (2021‑02‑11 12:28:32)
      Description Date of signpost
      Value Domain
      Property
      Timestamp precision
      at least day, month and year
      folder draft Signpost to
      prsb03-dataelement-13976
      Id prsb03-dataelement-13976 (2021‑02‑11 12:29:57)
      Description Details of where the signpost is to.


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

      Free text
      draft Contact details
      prsb03-dataelement-13987
      Id prsb03-dataelement-13987 (2021‑02‑11 13:06:04)
      Description The contact details of where been signposted to
      Operationalization Free text
      Value Domain
      cancelled Coded value
      prsb03-dataelement-13986
      Id prsb03-dataelement-13986 (2021‑02‑11 12:50:43) 0.1
      Description The coded value for organisation
      Value Domain
      folder draft Reason for signpost
      prsb03-dataelement-13988
      Id prsb03-dataelement-13988 (2021‑02‑11 16:06:08)
      Description Reason for signposting
      draft Coded value
      prsb03-dataelement-13989
      Id prsb03-dataelement-13989 (2021‑02‑11 16:10:28)
      Description Coded value for reason for signpost
      Operationalization SNOMED CT :- ^1127581000000103 |Health issues simple reference set|
      Value Domain
      draft Free text
      prsb03-dataelement-13990
      Id prsb03-dataelement-13990 (2021‑02‑11 16:13:18)
      Description Free text
      Operationalization Free text
      Value Domain
      folder draft Clinical urgency for signpost
      prsb03-dataelement-13991
      Id prsb03-dataelement-13991 (2021‑02‑11 16:24:10)
      Description The details of the clinical urgency of signpost
      Operationalization

      Free text
      folder draft Investigations requested
      prsb03-dataelement-10730
      Id prsb03-dataelement-10730 (2019‑02‑08 16:17:16)
      Description Details of any investigations requested
      folder draft Investigations requested record entry
      prsb03-dataelement-10731
      Id prsb03-dataelement-10731 (2019‑02‑08 16:19:05)
      Description This is an investigation requested 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.
      draft Date
      prsb03-dataelement-10732
      Id prsb03-dataelement-10732 (2019‑02‑08 16:21:40)
      Description The date the investigation was requested.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Location
      prsb03-dataelement-10736
      Id prsb03-dataelement-10736 (2019‑02‑08 16:24:49)
      Description The location where the investigation was requested.
      draft Coded value
      prsb03-dataelement-13727
      Id prsb03-dataelement-13727 (2020‑09‑16 13:22:15)
      Description The coded value for location
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13728
      Id prsb03-dataelement-13728 (2020‑09‑16 13:37:26)
      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
      cancelled Performing professional
      prsb03-dataelement-10735
      Id prsb03-dataelement-10735 (2019‑02‑08 16:24:11) 0.1
      Description The professional requesting the investigation.
      Value Domain
      folder draft Performing professional
      prsb03-dataelement-12081
      Id prsb03-dataelement-12081 (2019‑05‑31 15:49:09)
      Description The professional who requested the investigation.
      Relationship
      draft Name
      prsb03-dataelement-12082
      Id prsb03-dataelement-12082 (2019‑05‑31 15:49:33)
      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
      draft Role
      prsb03-dataelement-12083
      Id prsb03-dataelement-12083 (2019‑05‑31 15:49:33)
      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
      draft Grade
      prsb03-dataelement-12084
      Id prsb03-dataelement-12084 (2019‑05‑31 15:49:33)
      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
      draft Speciality
      prsb03-dataelement-12085
      Id prsb03-dataelement-12085 (2019‑05‑31 15:49:33)
      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
      draft Professional identifier
      prsb03-dataelement-12086
      Id prsb03-dataelement-12086 (2019‑05‑31 15:49:33)
      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
      folder draft Organisation
      prsb03-dataelement-12087
      Id prsb03-dataelement-12087 (2019‑05‑31 15:49:33)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-12088
      Id prsb03-dataelement-12088 (2019‑05‑31 15:49:33)
      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
      folder draft Investigation requested
      prsb03-dataelement-10733
      Id prsb03-dataelement-10733 (2019‑02‑08 16:22:42)
      Description The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
      target Used by 0 transactions, 0 templates, inherited once
       
      draft Coded value
      prsb03-dataelement-13529
      Id prsb03-dataelement-13529 (2020‑09‑04 15:10:24)
      Description The coded value for Investigation requested
      Operationalization SNOMED CT: - <71388002 |Procedure (procedure)|
      Value Domain
      draft Free text
      prsb03-dataelement-13530
      Id prsb03-dataelement-13530 (2020‑09‑04 15:14:59)
      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
      draft Status of request
      prsb03-dataelement-10734
      Id prsb03-dataelement-10734 (2019‑02‑08 16:23:21)
      Description The status of the investigation request.
      Operationalization Code : - draft | active | suspended | completed | entered-in-error | cancelled
      Value Domain
      Property
      max length
      16
      draft Reason for request
      prsb03-dataelement-10737
      Id prsb03-dataelement-10737 (2019‑02‑08 16:25:36)
      Description An explanation or justification for why this investigation is being requested.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Request priority
      prsb03-dataelement-10738
      Id prsb03-dataelement-10738 (2019‑02‑08 16:26:22)
      Description The urgency of the investigation requested.
      Operationalization Code : - routine | urgent | asap | stat
      Value Domain
      Property
      max length
      10
      cancelled Person completing record
      prsb03-dataelement-10956
      Id prsb03-dataelement-10956 (2019‑05‑18 21:09:13) 0.1
      Description This is the person recording the investigation request.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      target Used by 0 transactions, 0 templates, inherited once
       
      cancelled 
      prsb03-dataelement-12089
      Id prsb03-dataelement-12089 (2019‑05‑31 15:49:50)
      Value Domain
      folder draft Person completing record
      prsb03-dataelement-12090
      Id prsb03-dataelement-12090 (2019‑05‑31 15:49:53)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-12091
      Id prsb03-dataelement-12091 (2019‑05‑31 15:50:55)
      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
      draft Role
      prsb03-dataelement-12092
      Id prsb03-dataelement-12092 (2019‑05‑31 15:50:55)
      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
      draft Grade
      prsb03-dataelement-12093
      Id prsb03-dataelement-12093 (2019‑05‑31 15:50:55)
      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
      draft Specialty
      prsb03-dataelement-12094
      Id prsb03-dataelement-12094 (2019‑05‑31 15:50:55)
      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
      folder draft Organisation
      prsb03-dataelement-12095
      Id prsb03-dataelement-12095 (2019‑05‑31 15:50:55)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-12096
      Id prsb03-dataelement-12096 (2019‑05‑31 15:50:55)
      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
      draft Date completed
      prsb03-dataelement-12097
      Id prsb03-dataelement-12097 (2019‑05‑31 15:50:55)
      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
      draft Contact details
      prsb03-dataelement-12098
      Id prsb03-dataelement-12098 (2019‑05‑31 15:50:55)
      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
      folder draft Observations
      prsb03-dataelement-12475
      Id prsb03-dataelement-12475 (2019‑06‑27 12:29:34)
      Description The record of essential physiological observations
      draft Observations
      prsb03-dataelement-12474
      Id prsb03-dataelement-12474 (2019‑06‑27 12:13:35)
      Description The record of essential physiological observations e.g pulse, blood pressure, oxygen saturation/capnography, temperature, pain score, respiration rate, level of consciousness or new confusion. Use of National Early Warning Score (NEWS2) where appropriate.
      Operationalization FHIR NEWS2 specification produced by NHS Digital and the associated observations. See implmentation guidance for restriction of the use of NEWS2 by age.
      Value Domain
      folder draft Examination findings
      prsb03-dataelement-557
      Id prsb03-dataelement-557 (2018‑10‑31)
      Description Examination findings
      folder draft Examination findings record entry
      prsb03-dataelement-10662
      Id prsb03-dataelement-10662 (2018‑11‑13 13:47:29)
      Description This is a examination findings record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
      draft Date
      prsb03-dataelement-10462
      Id prsb03-dataelement-10462 (2018‑10‑31)
      Description The date the examination was performed.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      cancelled Performing Professional
      prsb03-dataelement-10460
      Id prsb03-dataelement-10460 (2018‑10‑31) 0.1
      Description Details of the professional performing the examination (including name and role).
      Operationalization Free text
      Value Domain
      target Used by 0 transactions, 0 templates, inherited once
       
      folder draft Performing professional
      prsb03-dataelement-12116
      Id prsb03-dataelement-12116 (2019‑05‑31 15:59:16)
      Description The professional who performed the examiniation.
      Relationship
      draft Name
      prsb03-dataelement-12117
      Id prsb03-dataelement-12117 (2019‑05‑31 15:59:38)
      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
      draft Role
      prsb03-dataelement-12118
      Id prsb03-dataelement-12118 (2019‑05‑31 15:59:38)
      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
      draft Grade
      prsb03-dataelement-12119
      Id prsb03-dataelement-12119 (2019‑05‑31 15:59:38)
      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
      draft Speciality
      prsb03-dataelement-12120
      Id prsb03-dataelement-12120 (2019‑05‑31 15:59:38)
      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
      draft Professional identifier
      prsb03-dataelement-12121
      Id prsb03-dataelement-12121 (2019‑05‑31 15:59:38)
      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
      folder draft Organisation
      prsb03-dataelement-12122
      Id prsb03-dataelement-12122 (2019‑05‑31 15:59:38)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-12123
      Id prsb03-dataelement-12123 (2019‑05‑31 15:59:38)
      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
      folder draft Location
      prsb03-dataelement-10461
      Id prsb03-dataelement-10461 (2018‑10‑31)
      Description The location where the examination was performed.
      draft Coded value
      prsb03-dataelement-13445
      Id prsb03-dataelement-13445 (2020‑08‑27 15:31:49)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13446
      Id prsb03-dataelement-13446 (2020‑08‑27 15:32:44)
      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
      cancelled Examination
      prsb03-dataelement-10457
      Id prsb03-dataelement-10457 (2018‑10‑31) 0.1
      Description The examination performed, e.g. general appearance, vital signs, mental state, head and neck examination, oral examination, cardiovascular system, respiratory system, abdomen, genitourinary, nervous system, musculoskeletal system, skin. This could include site and must include laterality where applicable.
      Operationalization This is the record of the examinations undertaken during the appointment. Text or coded text (SNOMED CT).The examination performed, eg general appearance, vital signs, mental state, head and neck examination, oral examination, cardiovascular system, respiratory system, abdomen, genitourinary, nervous system, musculoskeletal system, skin.
      Value Domain
      folder draft Examination findings
      prsb03-dataelement-10458
      Id prsb03-dataelement-10458 (2018‑10‑31)
      Description The record of findings from the examinations performed.
      draft Coded value
      prsb03-dataelement-13443
      Id prsb03-dataelement-13443 (2020‑08‑27 11:58:27)
      Description The coded value for examination findings
      Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
      Value Domain
      draft Free text
      prsb03-dataelement-13444
      Id prsb03-dataelement-13444 (2020‑08‑27 15:18:28)
      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
      cancelled General appearance
      prsb03-dataelement-10463
      Id prsb03-dataelement-10463 (2018‑10‑31) 0.1
      Description The record of a clinician’s ‘first impression’ assessment including general clinical examination finding, e.g., clubbing, anaemia, jaundice, obese/malnourished/cachectic, height, weight, etc
      Operationalization Free Text or SNOMED CT
      Value Domain
      folder draft Observations
      prsb03-dataelement-10464
      Id prsb03-dataelement-10464 (2018‑10‑31)
      Description The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
      folder draft Observations record entry
      prsb03-dataelement-13866
      Id prsb03-dataelement-13866 (2021‑01‑27 18:14:05)
      Description This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
      draft Coded value
      prsb03-dataelement-13447
      Id prsb03-dataelement-13447 (2020‑08‑27 16:08:42)
      Description The coded value for observations
      Operationalization SNOMED CT: - <363787002 | Observable entity (observable entity) |
      Value Domain
      draft Value
      prsb03-dataelement-13832
      Id prsb03-dataelement-13832 (2020‑12‑23 15:22:16)
      Description The measured value of the observations
      Operationalization Enumerated value e.g. numeric, natural numbers, mild, moderate
      Value Domain
      draft Units of measure
      prsb03-dataelement-13833
      Id prsb03-dataelement-13833 (2020‑12‑23 15:23:47)
      Description The units of measure for the observation.
      Relationship
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      draft Site
      prsb03-dataelement-13848
      Id prsb03-dataelement-13848 (2020‑12‑30 12:15:58)
      Description The anatomical site at which the observation is taken
      Operationalization SNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
      Value Domain
      draft Interpretation
      prsb03-dataelement-13843
      Id prsb03-dataelement-13843 (2020‑12‑29 15:04:11)
      Description The assessment made based on the result of the observation e.g high, low
      Operationalization FHIR value set: - Interpretation
      Value Domain
      draft Free text
      prsb03-dataelement-13448
      Id prsb03-dataelement-13448 (2020‑08‑27 16:09:58)
      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
      cancelled News 2 score
      prsb03-dataelement-13860
      Id prsb03-dataelement-13860 (2021‑01‑27 17:37:33) 0.1
      Value Domain
      folder draft Height/length
      prsb03-dataelement-13761
      Id prsb03-dataelement-13761 (2020‑09‑29 17:39:18)
      Description The person's height and length measurement
      draft Coded value
      prsb03-dataelement-13812
      Id prsb03-dataelement-13812 (2020‑12‑16 15:09:39)
      Description The coded value for height/length
      Operationalization SNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
      Value Domain
      draft Value
      prsb03-dataelement-13813
      Id prsb03-dataelement-13813 (2020‑12‑16 15:51:30)
      Description The value of the observation.
      Operationalization Numeric
      Value Domain
      Property
      3
      draft Units of measure
      prsb03-dataelement-13817
      Id prsb03-dataelement-13817 (2020‑12‑18 17:57:29)
      Description The units of measure for height/length
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      folder draft Weight
      prsb03-dataelement-13814
      Id prsb03-dataelement-13814 (2020‑12‑18 16:56:16)
      Description The person's weight in kgs
      draft Coded value
      prsb03-dataelement-13815
      Id prsb03-dataelement-13815 (2020‑12‑18 17:03:24)
      Description The coded value of weight
      Operationalization SNOMED CT : - 27113001 |Body weight (observable entity)|
      Value Domain
      draft Value
      prsb03-dataelement-13816
      Id prsb03-dataelement-13816 (2020‑12‑18 17:06:19)
      Description The value of the person's weight
      Operationalization Numeric
      Value Domain
      draft Units of measure
      prsb03-dataelement-13818
      Id prsb03-dataelement-13818 (2020‑12‑18 17:59:33)
      Description The units of measure for weight
      Relationship
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      folder draft BMI
      prsb03-dataelement-13819
      Id prsb03-dataelement-13819 (2020‑12‑18 18:18:02)
      Description The person's BMI calculation
      draft Coded value
      prsb03-dataelement-13820
      Id prsb03-dataelement-13820 (2020‑12‑18 18:18:45)
      Description The coded value of BMI
      Operationalization SNOMED CT: - 60621009 |Body mass index (observable entity)|
      Value Domain
      draft Value
      prsb03-dataelement-13821
      Id prsb03-dataelement-13821 (2020‑12‑18 18:20:35)
      Description The value of the person's BMI
      Operationalization Numeric
      Value Domain
      Property
      2
      draft Units of measure
      prsb03-dataelement-13822
      Id prsb03-dataelement-13822 (2020‑12‑18 18:22:30)
      Description The units of measure for BMI
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      folder draft Blood pressure
      prsb03-dataelement-13823
      Id prsb03-dataelement-13823 (2020‑12‑18 18:52:08)
      Description The person's blood pressure measurement
      folder draft Systolic blood pressure
      prsb03-dataelement-13824
      Id prsb03-dataelement-13824 (2020‑12‑18 18:53:17)
      Description Details of the person's systolic blood pressure
      draft Coded value
      prsb03-dataelement-13825
      Id prsb03-dataelement-13825 (2020‑12‑18 18:54:13)
      Description The coded value for systolic blood pressure
      Operationalization SNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|

      Value Domain
      draft Value
      prsb03-dataelement-13826
      Id prsb03-dataelement-13826 (2020‑12‑18 18:55:32)
      Description The value of the systolic blood pressure reading
      Operationalization Numeric
      Value Domain
      Property
      3
      draft Units of measure
      prsb03-dataelement-13827
      Id prsb03-dataelement-13827 (2020‑12‑18 18:58:12)
      Description The units of measure for systolic blood pressure
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      folder draft Site
      prsb03-dataelement-13829
      Id prsb03-dataelement-13829 (2020‑12‑18 19:10:44)
      Description The anatomical site at which the blood pressure is taken

      Properties

      FHIR MedicationStatement.dosage.site
      Relationship
      draft Coded value
      prsb03-dataelement-13830
      Id prsb03-dataelement-13830 (2020‑12‑18 19:11:37)
      Concept inherits from draft prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
      Description The coded value for site
      Operationalization

      SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
      Value Domain
      draft Free text
      prsb03-dataelement-13831
      Id prsb03-dataelement-13831 (2020‑12‑18 19:11:37)
      Concept inherits from draft prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
      Description Amount of vaccine administered.
      Relationship
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      cancelled Site
      prsb03-dataelement-13828
      Id prsb03-dataelement-13828 (2020‑12‑18 18:59:29) 0.1
      Concept inherits from cancelled prsb03-dataelement-13204 (2020‑06‑24 17:51:17)
      Description The anatomical site at which the medication is administered.

      Properties

      FHIR MedicationStatement.dosage.site
      Relationship
      Operationalization TextCoded text - constraint: SiteOfMedicationAdministration.



      Any valid site for the administration of a medication.



      Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration
      Value Domain
      folder draft Diastolic blood pressure
      prsb03-dataelement-13867
      Id prsb03-dataelement-13867 (2021‑01‑27 18:37:13)
      draft Coded value
      prsb03-dataelement-13868
      Id prsb03-dataelement-13868 (2021‑01‑27 18:38:53)
      Description The coded value for diastolic blood pressure.
      Operationalization SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|

      Value Domain
      draft Value
      prsb03-dataelement-13869
      Id prsb03-dataelement-13869 (2021‑01‑27 18:42:21)
      Description The value of the diastolic blood pressure reading
      Operationalization Numeric
      Value Domain
      Property
      3
      draft Units of measure
      prsb03-dataelement-13870
      Id prsb03-dataelement-13870 (2021‑01‑27 18:45:53)
      Description The units of measure for the diastolic blood pressure
      Relationship
      Operationalization UCUM code
      Value Domain
      Property
      max length
      10
      folder draft Site
      prsb03-dataelement-13871
      Id prsb03-dataelement-13871 (2021‑01‑27 18:49:54)
      Concept inherits from draft prsb03-dataelement-10540 (2018‑10‑31)
      Description The anatomical site at which the medication is to be administered.

      Properties

      FHIR MedicationStatement.dosage.site
      draft Coded value
      prsb03-dataelement-13872
      Id prsb03-dataelement-13872 (2021‑01‑27 18:51:09)
      Concept inherits from draft prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
      Description The coded value for site
      Operationalization

      SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
      Value Domain
      draft Free text
      prsb03-dataelement-13873
      Id prsb03-dataelement-13873 (2021‑01‑27 18:51:09)
      Concept inherits from draft prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
      Description Amount of vaccine administered.
      Relationship
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Heart rate
      prsb03-dataelement-13859
      Id prsb03-dataelement-13859 (2021‑01‑27 17:25:40)
      Description The beat of the heart as felt through the walls of a peripheral artery measured in bpm
      draft Coded value
      prsb03-dataelement-13970
      Id prsb03-dataelement-13970 (2021‑02‑09 14:55:17)
      Description The coded value for heart rate
      Operationalization SNOMED CT : - 364075005 | Heart rate (observable entity) |
      Value Domain
      draft Value
      prsb03-dataelement-13971
      Id prsb03-dataelement-13971 (2021‑02‑09 14:58:01)
      Description The numeric value of heart rate
      Operationalization Numeric
      Value Domain
      Property
      3
      draft Units of measure
      prsb03-dataelement-13972
      Id prsb03-dataelement-13972 (2021‑02‑09 15:39:37)
      Description The units of measure for heart rate
      Operationalization UCUM code
      Value Domain
      folder draft Temperature
      prsb03-dataelement-14235
      Id prsb03-dataelement-14235 (2021‑02‑26 16:04:10)
      Description The measurement of the person's temperature in Celsius (OC)
      draft Coded value
      prsb03-dataelement-14236
      Id prsb03-dataelement-14236 (2021‑02‑26 16:12:14)
      Description The coded value for tempreture
      Operationalization SNOMED CT : -<<386725007 |Body temperature (observable entity)|

      Value Domain
      draft Value
      prsb03-dataelement-14237
      Id prsb03-dataelement-14237 (2021‑02‑26 16:12:47)
      Description The value of the person tempreture
      Operationalization Numeric
      Value Domain
      Property
      min include
      1 2
      draft Units of measure
      prsb03-dataelement-14238
      Id prsb03-dataelement-14238 (2021‑02‑26 16:38:31)
      Description The units of measure for the persons tempreture
      Operationalization UCUM code
      Value Domain
      folder draft Oxygen saturation
      prsb03-dataelement-14239
      Id prsb03-dataelement-14239 (2021‑02‑26 16:51:57)
      Description The measurement of oxygen within the blood (expressed as a percentage of 100)
      draft Coded value
      prsb03-dataelement-14240
      Id prsb03-dataelement-14240 (2021‑02‑26 16:54:49)
      Description The coded value for Oxygen saturation
      Operationalization SNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)|
      Value Domain
      draft Value
      prsb03-dataelement-14241
      Id prsb03-dataelement-14241 (2021‑02‑26 17:00:58)
      Description The value for the persons oxygen saturation
      Operationalization Numeric
      Value Domain
      Property
      3
      draft Units of measure
      prsb03-dataelement-14242
      Id prsb03-dataelement-14242 (2021‑02‑26 17:02:06)
      Description The units of measure for oxygen saturation
      Operationalization UCUM code
      Value Domain
      Property
      max length
      3
      folder draft Pain score
      prsb03-dataelement-14243
      Id prsb03-dataelement-14243 (2021‑02‑26 18:29:57)
      Description The pain score for the person
      draft Coded value
      prsb03-dataelement-14244
      Id prsb03-dataelement-14244 (2021‑02‑26 18:46:05)
      Description The coded value for pain score
      Operationalization SNOMED CT : - 225908003 | Pain score (observable entity) |
      Value Domain
      draft Value
      prsb03-dataelement-14245
      Id prsb03-dataelement-14245 (2021‑02‑26 18:47:15)
      Description The value for the pain score
      Operationalization Numeric
      Value Domain
      draft Units of measure
      prsb03-dataelement-14246
      Id prsb03-dataelement-14246 (2021‑02‑26 18:50:11)
      Description The units of measure for pain score
      Operationalization UCUM
      Value Domain
      folder draft Level of conciousness
      prsb03-dataelement-14247
      Id prsb03-dataelement-14247 (2021‑02‑26 18:57:42)
      Description Person's level of arousal and awareness
      cancelled 
      prsb03-dataelement-14250
      Id prsb03-dataelement-14250 (2021‑03‑01 16:27:28)
      draft Coded value
      prsb03-dataelement-14249
      Id prsb03-dataelement-14249 (2021‑03‑01 16:01:37)
      Description

      Coded value for level of consciousness

      Operationalization SNOMED CT : -  1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score (observable entity) |

      Value Domain
      draft Value
      prsb03-dataelement-14251
      Id prsb03-dataelement-14251 (2021‑03‑02 13:15:32)
      Description Value of the level of consciousness
      Operationalization Numeric
      Value Domain
      draft Units of measure
      prsb03-dataelement-14252
      Id prsb03-dataelement-14252 (2021‑03‑02 13:22:41)
      Description Unit of measure for level of consciousness
      Operationalization UCUM
      Value Domain
      folder draft Respiratory rate
      prsb03-dataelement-14248
      Id prsb03-dataelement-14248 (2021‑02‑26 18:58:54)
      Description Number of breaths you take per minute
      draft Coded value
      prsb03-dataelement-14254
      Id prsb03-dataelement-14254 (2021‑03‑05 15:12:15)
      Description Coded value for respiratory rate
      Operationalization


      SNOMED CT : - 86290005 | Respiratory rate (observable entity) |
      Value Domain
      draft Value
      prsb03-dataelement-14255
      Id prsb03-dataelement-14255 (2021‑03‑05 15:14:26)
      Description Value for respiratory rate
      Operationalization Numeric
      Value Domain
      draft Unit of measure
      prsb03-dataelement-14256
      Id prsb03-dataelement-14256 (2021‑03‑05 15:24:38)
      Description Unit of measure of respiratory rate
      Operationalization

      UCUM code
      Value Domain
      folder draft Air or Oxygen
      prsb03-dataelement-14257
      Id prsb03-dataelement-14257 (2021‑03‑08 14:18:44)
      Description If the person requires Air or Oxygen
      draft Coded value
      prsb03-dataelement-14258
      Id prsb03-dataelement-14258 (2021‑03‑08 14:23:18)
      Description The coded value for Air or Oxygen
      Operationalization SNOMED CT: - 722742002 |Breathing room air| OR 371825009 |Patient on oxygen| OR 315041000 | High concentration oxygen therapy (procedure) | OR 9999016 | High flow oxygen therapy (procedure) |
      Value Domain
      draft Value
      prsb03-dataelement-14259
      Id prsb03-dataelement-14259 (2021‑03‑08 15:05:33)
      Description The value for air or oxygen
      Operationalization Free text
      Value Domain
      Property
      10
      draft Units of measure
      prsb03-dataelement-14260
      Id prsb03-dataelement-14260 (2021‑03‑08 15:09:50)
      Description The unit of measure for the air or oxygen value
      Operationalization UCUM
      Value Domain
      Property
      max length
      10
      folder draft National early warning score (NEWS 2)
      prsb03-dataelement-13861
      Id prsb03-dataelement-13861 (2021‑01‑27 17:39:06)
      Description
      The NEWS is based on a simple aggregate scoring system in which a score is allocated to physiological measurements, already recorded in routine practice, when patients present to, or are being monitored in hospital
      draft Coded value total score
      prsb03-dataelement-13862
      Id prsb03-dataelement-13862 (2021‑01‑27 17:39:43)
      Description The coded value for NEWS 2 total score
      Operationalization SNOMED CT : - 1104051000000101 | Royal College of Physicians National Early Warning Score 2 total score (observable entity) |
      Value Domain
      draft Value for total score
      prsb03-dataelement-13863
      Id prsb03-dataelement-13863 (2021‑01‑27 17:40:34)
      Description The actual NEWS 2 score.
      Operationalization Numeric
      Value Domain
      draft Coded value subscore
      prsb03-dataelement-13864
      Id prsb03-dataelement-13864 (2021‑01‑27 17:42:03)
      Description Coded value for the subscore
      Operationalization SNOMED CT : - 1104301000000104 | Royal College of Physicians National Early Warning Score 2 - respiration rate score (observable entity) |

                                 1104351000000103 | Royal College of Physicians National Early Warning Score 2 - pulse score (observable entity) |

                                 1104311000000102 | Royal College of Physicians National Early Warning Score 2 - oxygen saturation scale 1 score (observable entity) |

                                 1104331000000105 | Royal College of Physicians National Early Warning Score 2 - air or oxygen score (observable entity) |

                                 1104371000000107 | Royal College of Physicians National Early Warning Score 2 - temperature score (observable entity) |

                                 1104341000000101 | Royal College of Physicians National Early Warning Score 2 - systolic blood pressure score (observable entity) |

                                 1104361000000100 | Royal College of Physicians National Early Warning Score 2 - consciousness score (observable entity) |



      Value Domain
      draft Subscore
      prsb03-dataelement-13865
      Id prsb03-dataelement-13865 (2021‑01‑27 17:43:11)
      Description Subscore from each NEWS2 observation
      Operationalization Numeric
      Value Domain
      folder draft Person completing record
      prsb03-dataelement-12124
      Id prsb03-dataelement-12124 (2019‑05‑31 15:59:54)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-12125
      Id prsb03-dataelement-12125 (2019‑05‑31 16:00:31)
      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
      draft Role
      prsb03-dataelement-12126
      Id prsb03-dataelement-12126 (2019‑05‑31 16:00:31)
      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
      draft Grade
      prsb03-dataelement-12127
      Id prsb03-dataelement-12127 (2019‑05‑31 16:00:31)
      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
      draft Specialty
      prsb03-dataelement-12128
      Id prsb03-dataelement-12128 (2019‑05‑31 16:00:31)
      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
      folder draft Organisation
      prsb03-dataelement-12129
      Id prsb03-dataelement-12129 (2019‑05‑31 16:00:31)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-12130
      Id prsb03-dataelement-12130 (2019‑05‑31 16:00:31)
      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
      draft Date completed
      prsb03-dataelement-12131
      Id prsb03-dataelement-12131 (2019‑05‑31 16:00:31)
      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
      draft Contact details
      prsb03-dataelement-12132
      Id prsb03-dataelement-12132 (2019‑05‑31 16:00:31)
      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
      cancelled Person completing record
      prsb03-dataelement-10957
      Id prsb03-dataelement-10957 (2019‑05‑18 21:11:34) 0.1
      Description This is the person recording the examination.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      draft Vital signs
      prsb03-dataelement-10459
      Id prsb03-dataelement-10459 (2018‑10‑31)
      Description The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, respiratory rate, SpO2, level of consciousness etc. Use of Early Warning Score (which may be computed) chart where appropriate.
      Value Domain
      draft Mental health examination
      prsb03-dataelement-10465
      Id prsb03-dataelement-10465 (2018‑10‑31)
      Description The record of findings from mental health examinations and, where appropriate, the type of the examination
      Value Domain
      draft Head and neck examination
      prsb03-dataelement-10466
      Id prsb03-dataelement-10466 (2018‑10‑31)
      Description The record of findings from the head and neck examination.
      Value Domain
      draft Oral examination
      prsb03-dataelement-10467
      Id prsb03-dataelement-10467 (2018‑10‑31)
      Description The record of findings from the oral examination.
      Value Domain
      draft Cardiovascular examination
      prsb03-dataelement-10468
      Id prsb03-dataelement-10468 (2018‑10‑31)
      Description The record of findings from the cardiovascular system examination.
      Value Domain
      draft Respiratory examination
      prsb03-dataelement-10469
      Id prsb03-dataelement-10469 (2018‑10‑31)
      Description The record of findings from the respiratory system examination.
      Value Domain
      draft Obstetric and Gynaecology examination (including abdominal and uterine palpation)
      prsb03-dataelement-10470
      Id prsb03-dataelement-10470 (2018‑10‑31)
      Description The record of findings from the obstetric examination e.g. abdominal uterine palpation, striations or Linea Nigra and whether she has previous operative scars, such as previous caesarean section. To include the record of findings from the vaginal examination, including FGM, presentation, moulding, membranes, observation of liquor and general cervical observations and contractions (including the strength, length and frequency), uterus size etc.
      Value Domain
      draft Neurological system examination
      prsb03-dataelement-10471
      Id prsb03-dataelement-10471 (2018‑10‑31)
      Description The record of findings from the neurological system examination.
      Value Domain
      draft Musculoskeletal examination
      prsb03-dataelement-10472
      Id prsb03-dataelement-10472 (2018‑10‑31)
      Description The record of findings from the musculoskeletal examination
      Value Domain
      draft Dermatology examination
      prsb03-dataelement-10473
      Id prsb03-dataelement-10473 (2018‑10‑31)
      Description The record of findings from the examination of the skin
      Value Domain
      draft Abdomen examination
      prsb03-dataelement-10474
      Id prsb03-dataelement-10474 (2018‑10‑31)
      Description The record of findings from the abdominal examination.
      Value Domain
      draft Genitourinary examination
      prsb03-dataelement-10475
      Id prsb03-dataelement-10475 (2018‑10‑31)
      Description The record of findings from the genitourinary examination.
      Value Domain
      draft Comments
      prsb03-dataelement-10476
      Id prsb03-dataelement-10476 (2018‑10‑31)
      Description Any further comments relating to the examination.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Fetal Examinations
      prsb03-dataelement-10477
      Id prsb03-dataelement-10477 (2018‑10‑31)
      Description To be recorded one per fetus
      folder draft Current pregnancy
      prsb03-dataelement-10814
      Id prsb03-dataelement-10814 (2019‑03‑20 18:49:35)
      Description Pregnancy status of the person.
      draft Date
      prsb03-dataelement-10812
      Id prsb03-dataelement-10812 (2019‑03‑20 18:44:37)
      Description The date the observation was recorded
      Relationship
      hl7ips-dataelement-211 - 2017‑12‑31 12:55:02
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      cancelled Performing Professional
      prsb03-dataelement-10854
      Id prsb03-dataelement-10854 (2019‑03‑27 17:25:51) 0.1
      Description Details of the professional performing the observation (including name and role).
      Relationship
      Operationalization Free text
      Value Domain
      folder draft Location
      prsb03-dataelement-10855
      Id prsb03-dataelement-10855 (2019‑03‑27 17:27:01)
      Description The location where the pregnancy state details were recorded.
      Relationship
      draft Coded value
      prsb03-dataelement-13531
      Id prsb03-dataelement-13531 (2020‑09‑04 16:13:24)
      Description The coded value for location.
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13532
      Id prsb03-dataelement-13532 (2020‑09‑04 16:14:54)
      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
      draft Pregnancy state
      prsb03-dataelement-10815
      Id prsb03-dataelement-10815 (2019‑03‑20 18:51:02)
      Description A flag that indicates whether the person is pregnant.
      Relationship
      hl7ips-dataelement-212 - 2017‑12‑31 12:55:33
      Comment Pregnancy state
      Operationalization Flag : - Yes or No
      Value Domain
      draft Expected delivery date
      prsb03-dataelement-10813
      Id prsb03-dataelement-10813 (2019‑03‑20 18:45:38)
      Description The expected delivery date of the person.
      Relationship
      hl7ips-dataelement-213 - 2017‑12‑31 12:56:56
      Operationalization SNOMED CT: - 161714006 |Estimated date of delivery (observable entity)|
      Value Domain
      Property
      Timestamp precision
      at least day, month and year
      folder draft Performing professional
      prsb03-dataelement-13533
      Id prsb03-dataelement-13533 (2020‑09‑04 16:31:41)
      Description The professional who observed the pregnancy
      Relationship
      draft Name
      prsb03-dataelement-13534
      Id prsb03-dataelement-13534 (2020‑09‑04 16:32:32)
      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
      draft Role
      prsb03-dataelement-13535
      Id prsb03-dataelement-13535 (2020‑09‑04 16:32:32)
      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
      draft Grade
      prsb03-dataelement-13536
      Id prsb03-dataelement-13536 (2020‑09‑04 16:32:32)
      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
      draft Speciality
      prsb03-dataelement-13537
      Id prsb03-dataelement-13537 (2020‑09‑04 16:32:32)
      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
      draft Professional identifier
      prsb03-dataelement-13538
      Id prsb03-dataelement-13538 (2020‑09‑04 16:32:32)
      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
      folder draft Organisation
      prsb03-dataelement-13539
      Id prsb03-dataelement-13539 (2020‑09‑04 16:32:32)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Coded value
      prsb03-dataelement-13540
      Id prsb03-dataelement-13540 (2020‑09‑04 16:32:32)
      Concept inherits from draft prsb03-dataelement-13521 (2020‑09‑04 13:43:41)
      Description The coded value for location
      Rationale Practitioner.PractitionerRole.organisation.Name
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 7
      draft Free text
      prsb03-dataelement-13541
      Id prsb03-dataelement-13541 (2020‑09‑04 16:32:32)
      Concept inherits from draft prsb03-dataelement-13522 (2020‑09‑04 13:45:47)
      Description Free text field to be used if no code is available
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Contact details
      prsb03-dataelement-13542
      Id prsb03-dataelement-13542 (2020‑09‑04 16:32:32)
      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
      folder draft Person completing record
      prsb03-dataelement-13543
      Id prsb03-dataelement-13543 (2020‑09‑04 16:32:51)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-13544
      Id prsb03-dataelement-13544 (2020‑09‑04 16:33:48)
      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
      draft Role
      prsb03-dataelement-13545
      Id prsb03-dataelement-13545 (2020‑09‑04 16:33:48)
      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
      draft Grade
      prsb03-dataelement-13546
      Id prsb03-dataelement-13546 (2020‑09‑04 16:33:48)
      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
      draft Specialty
      prsb03-dataelement-13547
      Id prsb03-dataelement-13547 (2020‑09‑04 16:33:48)
      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
      folder draft Organisation
      prsb03-dataelement-13548
      Id prsb03-dataelement-13548 (2020‑09‑04 16:33:48)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Coded value
      prsb03-dataelement-13549
      Id prsb03-dataelement-13549 (2020‑09‑04 16:33:48)
      Concept inherits from draft prsb03-dataelement-13523 (2020‑09‑04 13:52:48)
      Description The coded value for location
      Rationale Composition.author.Practitioner.PractitionerRole.organisation.Name
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 7
      draft Free text
      prsb03-dataelement-13550
      Id prsb03-dataelement-13550 (2020‑09‑04 16:33:48)
      Concept inherits from draft prsb03-dataelement-13524 (2020‑09‑04 13:54:04)
      Description Free text field to be used if no code is available
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Professional identifier
      prsb03-dataelement-13551
      Id prsb03-dataelement-13551 (2020‑09‑04 16:33:48)
      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
      draft Date completed
      prsb03-dataelement-13552
      Id prsb03-dataelement-13552 (2020‑09‑04 16:33:48)
      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
      draft Contact details
      prsb03-dataelement-13553
      Id prsb03-dataelement-13553 (2020‑09‑04 16:33:48)
      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
      draft Maternity Personalised Care Plan
      prsb03-dataelement-10839
      Id prsb03-dataelement-10839 (2019‑03‑26 18:24:07)
      Concept inherits from draft prsb03-dataelement-10484 (2018‑10‑31)
      Description Personalised care plan details to include the data and plan details
      Value Domain
      folder cancelled Previous pregnancies
      prsb03-dataelement-10827
      Id prsb03-dataelement-10827 (2019‑03‑21 15:29:15)
      Description Details of women's previous pregnancies
      cancelled Date
      prsb03-dataelement-10829
      Id prsb03-dataelement-10829 (2019‑03‑21 15:30:52)
      Concept inherits from draft prsb03-dataelement-10490 (2018‑10‑31)
      Description The date on which the pregnancy outcome/delivery/birth details were recorded
      Value Domain
      cancelled Date and Time of Delivery
      prsb03-dataelement-10836
      Id prsb03-dataelement-10836 (2019‑03‑22 17:08:48)
      Concept inherits from draft prsb03-dataelement-10511 (2018‑10‑31)
      Description The date and time of the delivery of the baby
      Value Domain
      cancelled Location
      prsb03-dataelement-10830
      Id prsb03-dataelement-10830 (2019‑03‑21 15:31:36)
      Concept inherits from draft prsb03-dataelement-10491 (2018‑10‑31)
      Description The location where the pregnancy outcome/delivery/birth details was recorded
      Value Domain
      cancelled Performing Professional
      prsb03-dataelement-10831
      Id prsb03-dataelement-10831 (2019‑03‑21 15:32:29)
      Concept inherits from draft prsb03-dataelement-10492 (2018‑10‑31)
      Description Details of the professional recording the pregnancy outcome/delivery/birth details (including name and role).
      Value Domain
      cancelled Pregnancy Outcome
      prsb03-dataelement-10828
      Id prsb03-dataelement-10828 (2019‑03‑21 15:29:59)
      Concept inherits from draft prsb03-dataelement-10493 (2018‑10‑31)
      Description The pregnancy outcome of each fetus
      Value Domain
      cancelled Complications from previous pregnancy
      prsb03-dataelement-10832
      Id prsb03-dataelement-10832 (2019‑03‑21 15:33:45)
      Description Any complications in previous pregnancies e.g. blood transfusion
      Value Domain
      folder cancelled Investigation requests and results
      prsb03-dataelement-10833
      Id prsb03-dataelement-10833 (2019‑03‑21 15:44:47)
      Description Details of a person's requests and results
      folder cancelled Investigation requested
      prsb03-dataelement-10834
      Id prsb03-dataelement-10834 (2019‑03‑21 15:45:23)
      Concept inherits from draft prsb03-dataelement-10733 (2019‑02‑08 16:22:42)
      Description The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
      folder cancelled Status of pregnancy
      prsb03-dataelement-10805
      Id prsb03-dataelement-10805 (2019‑03‑20 18:41:51)
      Relationship
      hl7ips-dataelement-37 - 2017‑12‑19 11:44:59
      cancelled Pregnancy Description
      prsb03-dataelement-10806
      Id prsb03-dataelement-10806 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-225 (2018‑07‑02 13:40:29)
      Value Domain
      folder cancelled Structured Description
      prsb03-dataelement-10807
      Id prsb03-dataelement-10807 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-168 (2017‑12‑25 09:39:11)
      cancelled Date of Observation
      prsb03-dataelement-10808
      Id prsb03-dataelement-10808 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-211 (2017‑12‑31 12:55:02)
      Value Domain
      Property
      Timestamp precision
      at least day, month and year
      cancelled Pregnancy State
      prsb03-dataelement-10809
      Id prsb03-dataelement-10809 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-212 (2017‑12‑31 12:55:33)
      Value Domain
      cancelled Expected delivery date
      prsb03-dataelement-10810
      Id prsb03-dataelement-10810 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-213 (2017‑12‑31 12:56:56)
      Value Domain
      Property
      Timestamp precision
      at least day, month and year
      cancelled Specialist Contact
      prsb03-dataelement-10811
      Id prsb03-dataelement-10811 (2019‑03‑20 18:42:49)
      Concept inherits from hl7ips-dataelement-200 (2017‑12‑25 20:58:56)

      Properties

      Data Type Healthcare Provider
      Value Domain
      folder draft Assessments
      prsb03-dataelement-262
      Id prsb03-dataelement-262 (2018‑10‑31)
      Description Details of the person's assessments
      folder draft Assessments record entry
      prsb03-dataelement-11664
      Id prsb03-dataelement-11664 (2019‑05‑30 19:29:51)
      Description This is the assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
      draft Assessment scale
      prsb03-dataelement-12962
      Id prsb03-dataelement-12962 (2019‑11‑20 15:46:29)
      Description Assessment scale used, e.g. New York Heart Failure, Activities of Daily Living (ADL)
      Operationalization Free Text. Content could include scale name, date and time of assessment and values recorded, including overall score. Format of assessment would be determined locally and may be tabular.
      Value Domain
      draft Date
      prsb03-dataelement-10763
      Id prsb03-dataelement-10763 (2019‑03‑18 13:51:22)
      Description The date the assessment was done.
      Relationship
      Operationalization Date and time.
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Location
      prsb03-dataelement-10764
      Id prsb03-dataelement-10764 (2019‑03‑18 13:51:59)
      Description The location where the assessment was done.
      Relationship
      Operationalization ODS code or free text.
      draft Coded value
      prsb03-dataelement-13570
      Id prsb03-dataelement-13570 (2020‑09‑07 15:40:22)
      Description The coded value for location
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13571
      Id prsb03-dataelement-13571 (2020‑09‑07 15:41:51)
      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
      cancelled Performing professional
      prsb03-dataelement-10765
      Id prsb03-dataelement-10765 (2019‑03‑18 13:52:36)
      Description Details of the professional performing the assessment (including name and role).
      Relationship
      Value Domain
      draft Assessment type
      prsb03-dataelement-10822
      Id prsb03-dataelement-10822 (2019‑03‑21 12:55:22)
      Description The type of the assessment e.g. social care needs assessment.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Assessment summary
      prsb03-dataelement-10754
      Id prsb03-dataelement-10754 (2019‑03‑07 18:21:12)
      Description The summary of the assessment
      Operationalization Free text
      Value Domain
      Property
      max length
      250
      folder draft Structured assessment
      prsb03-dataelement-10655
      Id prsb03-dataelement-10655 (2018‑11‑13 12:15:56)
      Description Details of the structured assessment.
      cancelled Date
      prsb03-dataelement-10165
      Id prsb03-dataelement-10165 (2018‑10‑31)
      Description The date on which the structured assessment was done.
      Operationalization Date/time
      Value Domain
      cancelled Location
      prsb03-dataelement-10167
      Id prsb03-dataelement-10167 (2018‑10‑31)
      Description The date the structured assessment was done.
      Operationalization ODS site code or free text.
      Value Domain
      cancelled Performing professional
      prsb03-dataelement-10168
      Id prsb03-dataelement-10168 (2018‑10‑31)
      Description Details of the professional performing the assessment scale.
      Operationalization Free text
      Value Domain
      folder cancelled Performing professional
      prsb03-dataelement-12390
      Id prsb03-dataelement-12390 (2019‑06‑03 16:03:07)
      Description The professional who did the structured assessment.
      Relationship
      cancelled Name
      prsb03-dataelement-12391
      Id prsb03-dataelement-12391 (2019‑06‑03 16:03:28)
      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
      cancelled Role
      prsb03-dataelement-12392
      Id prsb03-dataelement-12392 (2019‑06‑03 16:03:28)
      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
      cancelled Grade
      prsb03-dataelement-12393
      Id prsb03-dataelement-12393 (2019‑06‑03 16:03:28)
      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
      cancelled Speciality
      prsb03-dataelement-12394
      Id prsb03-dataelement-12394 (2019‑06‑03 16:03:28)
      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
      cancelled Professional identifier
      prsb03-dataelement-12395
      Id prsb03-dataelement-12395 (2019‑06‑03 16:03:28)
      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
      folder cancelled Organisation
      prsb03-dataelement-12396
      Id prsb03-dataelement-12396 (2019‑06‑03 16:03:28)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      cancelled Contact details
      prsb03-dataelement-12397
      Id prsb03-dataelement-12397 (2019‑06‑03 16:03:28)
      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
      draft Structured assessment name
      prsb03-dataelement-11751
      Id prsb03-dataelement-11751 (2019‑05‑31 13:52:26)
      Description Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
      Operationalization SNOMED CT
      Value Domain
      draft Assessment score
      prsb03-dataelement-10162
      Id prsb03-dataelement-10162 (2018‑10‑31)
      Description The structured assessment score.
      Operationalization Free text.
      Value Domain
      draft Assessment value
      prsb03-dataelement-10163
      Id prsb03-dataelement-10163 (2018‑10‑31)
      Description The structured assessment value.
      Operationalization Numeric
      Value Domain
      draft Global score
      prsb03-dataelement-10166
      Id prsb03-dataelement-10166 (2018‑10‑31)
      Description The total global score from the assessment.
      Operationalization Free text
      Value Domain
      draft Subscale score
      prsb03-dataelement-10169
      Id prsb03-dataelement-10169 (2018‑10‑31)
      Description The subscale score of the structured assessment.
      Operationalization Free text.
      Value Domain
      draft Subscale value
      prsb03-dataelement-10170
      Id prsb03-dataelement-10170 (2018‑10‑31)
      Description The subscale value of the structured assessment.
      Operationalization Numeric
      Value Domain
      folder cancelled Person completing record
      prsb03-dataelement-11761
      Id prsb03-dataelement-11761 (2019‑05‑31 14:09:42)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      cancelled Name
      prsb03-dataelement-11762
      Id prsb03-dataelement-11762 (2019‑05‑31 14:10:49)
      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
      cancelled Role
      prsb03-dataelement-11763
      Id prsb03-dataelement-11763 (2019‑05‑31 14:10:49)
      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
      cancelled Grade
      prsb03-dataelement-11764
      Id prsb03-dataelement-11764 (2019‑05‑31 14:10:49)
      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
      cancelled Specialty
      prsb03-dataelement-11765
      Id prsb03-dataelement-11765 (2019‑05‑31 14:10:49)
      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
      folder cancelled Organisation
      prsb03-dataelement-11766
      Id prsb03-dataelement-11766 (2019‑05‑31 14:10:49)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      cancelled Professional identifier
      prsb03-dataelement-11767
      Id prsb03-dataelement-11767 (2019‑05‑31 14:10:49)
      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
      cancelled Date completed
      prsb03-dataelement-11768
      Id prsb03-dataelement-11768 (2019‑05‑31 14:10:49)
      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
      cancelled Contact details
      prsb03-dataelement-11769
      Id prsb03-dataelement-11769 (2019‑05‑31 14:10:49)
      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
      cancelled Person completing record
      prsb03-dataelement-10962
      Id prsb03-dataelement-10962 (2019‑05‑18 21:30:43)
      Concept inherits from cancelled prsb03-dataelement-10860 (2019‑03‑27 17:46:45)
      Description This is the person recording the individual requirement.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      folder draft Performing professional
      prsb03-dataelement-12382
      Id prsb03-dataelement-12382 (2019‑06‑03 16:02:23)
      Description The professional who did the assessment.
      Relationship
      draft Name
      prsb03-dataelement-12383
      Id prsb03-dataelement-12383 (2019‑06‑03 16:02:46)
      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
      draft Role
      prsb03-dataelement-12384
      Id prsb03-dataelement-12384 (2019‑06‑03 16:02:46)
      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
      draft Grade
      prsb03-dataelement-12385
      Id prsb03-dataelement-12385 (2019‑06‑03 16:02:46)
      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
      draft Speciality
      prsb03-dataelement-12386
      Id prsb03-dataelement-12386 (2019‑06‑03 16:02:46)
      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
      draft Professional identifier
      prsb03-dataelement-12387
      Id prsb03-dataelement-12387 (2019‑06‑03 16:02:46)
      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
      folder draft Organisation
      prsb03-dataelement-12388
      Id prsb03-dataelement-12388 (2019‑06‑03 16:02:46)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-12389
      Id prsb03-dataelement-12389 (2019‑06‑03 16:02:46)
      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
      folder draft Person completing record
      prsb03-dataelement-11752
      Id prsb03-dataelement-11752 (2019‑05‑31 14:08:29)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11753
      Id prsb03-dataelement-11753 (2019‑05‑31 14:08:52)
      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
      draft Role
      prsb03-dataelement-11754
      Id prsb03-dataelement-11754 (2019‑05‑31 14:08:52)
      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
      draft Grade
      prsb03-dataelement-11755
      Id prsb03-dataelement-11755 (2019‑05‑31 14:08:52)
      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
      draft Specialty
      prsb03-dataelement-11756
      Id prsb03-dataelement-11756 (2019‑05‑31 14:08:52)
      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
      folder draft Organisation
      prsb03-dataelement-11757
      Id prsb03-dataelement-11757 (2019‑05‑31 14:08:52)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11758
      Id prsb03-dataelement-11758 (2019‑05‑31 14:08:52)
      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
      draft Date completed
      prsb03-dataelement-11759
      Id prsb03-dataelement-11759 (2019‑05‑31 14:08:52)
      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
      draft Contact details
      prsb03-dataelement-11760
      Id prsb03-dataelement-11760 (2019‑05‑31 14:08:52)
      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
      draft Comment
      prsb03-dataelement-10164
      Id prsb03-dataelement-10164 (2018‑10‑31)
      Description Supporting text may be given regarding the assessment.
      Operationalization Free text
      Value Domain
      cancelled Schwangerschaft
      prsb03-dataelement-10803
      Id prsb03-dataelement-10803 (2019‑03‑20 18:13:39)
      Concept inherits from asic-dataelement-26 (2018‑05‑14 16:24:44)
      Description Achtung: Schwangere Patientinnen sind vom ASIC Use Case ausgeschlossen.

      Properties

      Verwendung Ausschlusskriterium

      Umgang mit Missing Values Einschluss

      Relationship
      mide-dataelement-416 - 2018‑07‑30 10:16:40
      Terminology Asscociation This concept is represented by code "82810-3" (Pregnancy status) from code system 2.16.840.1.113883.6.1 LOINC)
      Value Domain
      Example
      Pregnant
      77386006
      Example
      Not pregnant
      60001007
      cancelled Formulation
      prsb03-dataelement-10749
      Id prsb03-dataelement-10749 (2019‑03‑07 14:50:29)
      Concept inherits from draft prsb03-dataelement-10148 (2018‑10‑31)
      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
      folder cancelled Mental capacity assessment
      prsb03-dataelement-10757
      Id prsb03-dataelement-10757 (2019‑03‑08 12:47:59)
      Concept inherits from draft prsb03-dataelement-10424 (2018‑10‑31)
      Description Details of the persons mental capacity assessment
      cancelled Person completing record
      prsb03-dataelement-10958
      Id prsb03-dataelement-10958 (2019‑05‑18 21:12:38)
      Description This is the person recording the assessment. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      cancelled Clinical summary
      prsb03-dataelement-10750
      Id prsb03-dataelement-10750 (2019‑03‑07 17:13:57) Not needed
      Concept inherits from draft prsb03-dataelement-10147 (2018‑10‑31)
      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
      folder draft Formulation
      prsb03-dataelement-11666
      Id prsb03-dataelement-11666 (2019‑05‑30 20:43:07)
      Description Details of the person's formulation.
      folder draft Formulation record entry
      prsb03-dataelement-11667
      Id prsb03-dataelement-11667 (2019‑05‑30 20:44:32)
      Description This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
      draft Date
      prsb03-dataelement-11669
      Id prsb03-dataelement-11669 (2019‑05‑30 20:47:42)
      Description The date of the formulation was made.
      Operationalization Date and time.
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Location
      prsb03-dataelement-11670
      Id prsb03-dataelement-11670 (2019‑05‑30 20:48:26)
      Description The location where the formulation was made.
      Operationalization NHS data dictionary: - Organisation data service
      draft Coded value
      prsb03-dataelement-13572
      Id prsb03-dataelement-13572 (2020‑09‑07 15:43:58)
      Description The coded value for location
      Operationalization NHS data dictionary: - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13573
      Id prsb03-dataelement-13573 (2020‑09‑07 15:44:39)
      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
      folder draft Performing professional
      prsb03-dataelement-11671
      Id prsb03-dataelement-11671 (2019‑05‑30 20:49:15)
      Description The professional who made the formulation.
      Relationship
      draft Name
      prsb03-dataelement-11672
      Id prsb03-dataelement-11672 (2019‑05‑30 20:49:34)
      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
      draft Role
      prsb03-dataelement-11673
      Id prsb03-dataelement-11673 (2019‑05‑30 20:49:34)
      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
      draft Grade
      prsb03-dataelement-11674
      Id prsb03-dataelement-11674 (2019‑05‑30 20:49:34)
      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
      draft Speciality
      prsb03-dataelement-11675
      Id prsb03-dataelement-11675 (2019‑05‑30 20:49:34)
      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
      draft Professional identifier
      prsb03-dataelement-11676
      Id prsb03-dataelement-11676 (2019‑05‑30 20:49:34)
      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
      folder draft Organisation
      prsb03-dataelement-11677
      Id prsb03-dataelement-11677 (2019‑05‑30 20:49:34)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11678
      Id prsb03-dataelement-11678 (2019‑05‑30 20:49:34)
      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
      draft Formulation
      prsb03-dataelement-11668
      Id prsb03-dataelement-11668 (2019‑05‑30 20:46:15)
      Concept inherits from draft prsb03-dataelement-10148 (2018‑10‑31)
      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
      folder draft Person completing record
      prsb03-dataelement-11679
      Id prsb03-dataelement-11679 (2019‑05‑30 20:49:49)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11680
      Id prsb03-dataelement-11680 (2019‑05‑30 20:50:13)
      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
      draft Role
      prsb03-dataelement-11681
      Id prsb03-dataelement-11681 (2019‑05‑30 20:50:13)
      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
      draft Grade
      prsb03-dataelement-11682
      Id prsb03-dataelement-11682 (2019‑05‑30 20:50:13)
      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
      draft Specialty
      prsb03-dataelement-11683
      Id prsb03-dataelement-11683 (2019‑05‑30 20:50:13)
      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
      folder draft Organisation
      prsb03-dataelement-11684
      Id prsb03-dataelement-11684 (2019‑05‑30 20:50:13)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11685
      Id prsb03-dataelement-11685 (2019‑05‑30 20:50:13)
      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
      draft Date completed
      prsb03-dataelement-11686
      Id prsb03-dataelement-11686 (2019‑05‑30 20:50:13)
      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
      draft Contact details
      prsb03-dataelement-11687
      Id prsb03-dataelement-11687 (2019‑05‑30 20:50:13)
      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
      cancelled Pregnancy State
      prsb03-dataelement-10804
      Id prsb03-dataelement-10804 (2019‑03‑20 18:16:49)
      Concept inherits from hl7ips-dataelement-212 (2017‑12‑31 12:55:33)
      Value Domain
      folder draft Risks
      prsb03-dataelement-276
      Id prsb03-dataelement-276 (2018‑10‑31)
      Description Details of any risks related to the person.
      cancelled Performing Professional
      prsb03-dataelement-10181
      Id prsb03-dataelement-10181 (2018‑10‑31)
      Description Details of the professional recording the risk (including name and role).
      Value Domain
      cancelled Person completing record
      prsb03-dataelement-10967
      Id prsb03-dataelement-10967 (2019‑05‑20 16:32:57)
      Description This is the person recording the risk. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      folder draft Risks to self
      prsb03-dataelement-10176
      Id prsb03-dataelement-10176 (2018‑10‑31)
      Description Details of the persons risk to self

      Properties

      FHIR Composition.text
      draft Start date of risk
      prsb03-dataelement-11893
      Id prsb03-dataelement-11893 (2019‑05‑31 14:50:40)
      Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date of risk
      prsb03-dataelement-11894
      Id prsb03-dataelement-11894 (2019‑05‑31 14:51:05)
      Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Risk to self
      prsb03-dataelement-13579
      Id prsb03-dataelement-13579 (2020‑09‑08 11:10:38)
      Description Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.
      Operationalization SNOMED CT: - <281694009 |Finding of at risk (finding)|
      Value Domain
      folder draft Location
      prsb03-dataelement-11895
      Id prsb03-dataelement-11895 (2019‑05‑31 14:51:50)
      Description The location where the risk was identified.
      Relationship
      draft Coded value
      prsb03-dataelement-13586
      Id prsb03-dataelement-13586 (2020‑09‑08 12:08:47)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation service code
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13587
      Id prsb03-dataelement-13587 (2020‑09‑08 12:09:57)
      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
      folder draft Performing professional
      prsb03-dataelement-11896
      Id prsb03-dataelement-11896 (2019‑05‑31 14:52:35)
      Description The professional who identified the risk.
      Relationship
      draft Name
      prsb03-dataelement-11897
      Id prsb03-dataelement-11897 (2019‑05‑31 14:52:54)
      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
      draft Role
      prsb03-dataelement-11898
      Id prsb03-dataelement-11898 (2019‑05‑31 14:52:54)
      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
      draft Grade
      prsb03-dataelement-11899
      Id prsb03-dataelement-11899 (2019‑05‑31 14:52:54)
      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
      draft Speciality
      prsb03-dataelement-11900
      Id prsb03-dataelement-11900 (2019‑05‑31 14:52:54)
      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
      draft Professional identifier
      prsb03-dataelement-11901
      Id prsb03-dataelement-11901 (2019‑05‑31 14:52:54)
      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
      folder draft Organisation
      prsb03-dataelement-11902
      Id prsb03-dataelement-11902 (2019‑05‑31 14:52:54)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11903
      Id prsb03-dataelement-11903 (2019‑05‑31 14:52:54)
      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
      folder draft Person completing record
      prsb03-dataelement-11904
      Id prsb03-dataelement-11904 (2019‑05‑31 14:53:05)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11905
      Id prsb03-dataelement-11905 (2019‑05‑31 14:53:43)
      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
      draft Role
      prsb03-dataelement-11906
      Id prsb03-dataelement-11906 (2019‑05‑31 14:53:43)
      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
      draft Grade
      prsb03-dataelement-11907
      Id prsb03-dataelement-11907 (2019‑05‑31 14:53:43)
      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
      draft Specialty
      prsb03-dataelement-11908
      Id prsb03-dataelement-11908 (2019‑05‑31 14:53:43)
      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
      folder draft Organisation
      prsb03-dataelement-11909
      Id prsb03-dataelement-11909 (2019‑05‑31 14:53:43)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11910
      Id prsb03-dataelement-11910 (2019‑05‑31 14:53:43)
      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
      draft Date completed
      prsb03-dataelement-11911
      Id prsb03-dataelement-11911 (2019‑05‑31 14:53:43)
      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
      draft Contact details
      prsb03-dataelement-11912
      Id prsb03-dataelement-11912 (2019‑05‑31 14:53:43)
      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
      cancelled Date of self harm
      prsb03-dataelement-10823
      Id prsb03-dataelement-10823 (2019‑03‑21 13:34:44)
      Value Domain
      folder draft Risks to others
      prsb03-dataelement-10177
      Id prsb03-dataelement-10177 (2018‑10‑31)
      Description Details of the person's risk to others

      Properties

      FHIR Composition.text
      draft Start date of risk
      prsb03-dataelement-11913
      Id prsb03-dataelement-11913 (2019‑05‑31 14:54:14)
      Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date of risk
      prsb03-dataelement-11914
      Id prsb03-dataelement-11914 (2019‑05‑31 14:54:38)
      Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Risks to others
      prsb03-dataelement-13580
      Id prsb03-dataelement-13580 (2020‑09‑08 11:21:20)
      Description Risks to professionals or others.
      Operationalization SNOMED CT: - <<391155006 |At risk of harming others (finding)|
      Value Domain
      folder draft Location
      prsb03-dataelement-11915
      Id prsb03-dataelement-11915 (2019‑05‑31 14:55:04)
      Description The location where the risk to others was identified.
      Relationship
      draft Coded value
      prsb03-dataelement-13588
      Id prsb03-dataelement-13588 (2020‑09‑08 12:15:45)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13589
      Id prsb03-dataelement-13589 (2020‑09‑08 12:17:17)
      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
      folder draft Performing professional
      prsb03-dataelement-11916
      Id prsb03-dataelement-11916 (2019‑05‑31 14:55:39)
      Description The professional who identifies the risk to others.
      Relationship
      draft Name
      prsb03-dataelement-11917
      Id prsb03-dataelement-11917 (2019‑05‑31 14:55:55)
      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
      draft Role
      prsb03-dataelement-11918
      Id prsb03-dataelement-11918 (2019‑05‑31 14:55:55)
      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
      draft Grade
      prsb03-dataelement-11919
      Id prsb03-dataelement-11919 (2019‑05‑31 14:55:55)
      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
      draft Speciality
      prsb03-dataelement-11920
      Id prsb03-dataelement-11920 (2019‑05‑31 14:55:55)
      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
      draft Professional identifier
      prsb03-dataelement-11921
      Id prsb03-dataelement-11921 (2019‑05‑31 14:55:55)
      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
      folder draft Organisation
      prsb03-dataelement-11922
      Id prsb03-dataelement-11922 (2019‑05‑31 14:55:55)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11923
      Id prsb03-dataelement-11923 (2019‑05‑31 14:55:55)
      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
      folder draft Person completing record
      prsb03-dataelement-11924
      Id prsb03-dataelement-11924 (2019‑05‑31 14:56:46)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11925
      Id prsb03-dataelement-11925 (2019‑05‑31 14:57:11)
      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
      draft Role
      prsb03-dataelement-11926
      Id prsb03-dataelement-11926 (2019‑05‑31 14:57:11)
      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
      draft Grade
      prsb03-dataelement-11927
      Id prsb03-dataelement-11927 (2019‑05‑31 14:57:11)
      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
      draft Specialty
      prsb03-dataelement-11928
      Id prsb03-dataelement-11928 (2019‑05‑31 14:57:11)
      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
      folder draft Organisation
      prsb03-dataelement-11929
      Id prsb03-dataelement-11929 (2019‑05‑31 14:57:11)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11930
      Id prsb03-dataelement-11930 (2019‑05‑31 14:57:11)
      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
      draft Date completed
      prsb03-dataelement-11931
      Id prsb03-dataelement-11931 (2019‑05‑31 14:57:11)
      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
      draft Contact details
      prsb03-dataelement-11932
      Id prsb03-dataelement-11932 (2019‑05‑31 14:57:11)
      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
      folder draft Risk from others
      prsb03-dataelement-10178
      Id prsb03-dataelement-10178 (2018‑10‑31)
      Description Risks to the person from an identified individual e.g. family member etc.

      Properties

      FHIR Composition.text
      Operationalization Free Text.
      draft Start date of risk
      prsb03-dataelement-11933
      Id prsb03-dataelement-11933 (2019‑05‑31 14:58:12)
      Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date of risk
      prsb03-dataelement-11934
      Id prsb03-dataelement-11934 (2019‑05‑31 14:58:38)
      Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Risk from others
      prsb03-dataelement-13581
      Id prsb03-dataelement-13581 (2020‑09‑08 11:37:50)
      Description Risks to the person from an identified individual e.g. family member etc.
      Operationalization SNOMED CT: - <281694009 |Finding of at risk (finding)|
      Value Domain
      folder draft Location
      prsb03-dataelement-11935
      Id prsb03-dataelement-11935 (2019‑05‑31 14:59:06)
      Description The location where the risk from others was identified.
      Relationship
      draft Coded value
      prsb03-dataelement-13590
      Id prsb03-dataelement-13590 (2020‑09‑08 12:21:08)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13591
      Id prsb03-dataelement-13591 (2020‑09‑08 12:22:47)
      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
      folder draft Performing professional
      prsb03-dataelement-11936
      Id prsb03-dataelement-11936 (2019‑05‑31 14:59:33)
      Description The professional who identified the risk from others.
      Relationship
      draft Name
      prsb03-dataelement-11937
      Id prsb03-dataelement-11937 (2019‑05‑31 14:59:53)
      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
      draft Role
      prsb03-dataelement-11938
      Id prsb03-dataelement-11938 (2019‑05‑31 14:59:53)
      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
      draft Grade
      prsb03-dataelement-11939
      Id prsb03-dataelement-11939 (2019‑05‑31 14:59:53)
      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
      draft Speciality
      prsb03-dataelement-11940
      Id prsb03-dataelement-11940 (2019‑05‑31 14:59:53)
      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
      draft Professional identifier
      prsb03-dataelement-11941
      Id prsb03-dataelement-11941 (2019‑05‑31 14:59:53)
      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
      folder draft Organisation
      prsb03-dataelement-11942
      Id prsb03-dataelement-11942 (2019‑05‑31 14:59:53)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11943
      Id prsb03-dataelement-11943 (2019‑05‑31 14:59:53)
      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
      folder draft Person completing record
      prsb03-dataelement-11944
      Id prsb03-dataelement-11944 (2019‑05‑31 15:00:03)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11945
      Id prsb03-dataelement-11945 (2019‑05‑31 15:00:27)
      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
      draft Role
      prsb03-dataelement-11946
      Id prsb03-dataelement-11946 (2019‑05‑31 15:00:27)
      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
      draft Grade
      prsb03-dataelement-11947
      Id prsb03-dataelement-11947 (2019‑05‑31 15:00:27)
      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
      draft Specialty
      prsb03-dataelement-11948
      Id prsb03-dataelement-11948 (2019‑05‑31 15:00:27)
      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
      folder draft Organisation
      prsb03-dataelement-11949
      Id prsb03-dataelement-11949 (2019‑05‑31 15:00:27)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11950
      Id prsb03-dataelement-11950 (2019‑05‑31 15:00:27)
      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
      draft Date completed
      prsb03-dataelement-11951
      Id prsb03-dataelement-11951 (2019‑05‑31 15:00:27)
      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
      draft Contact details
      prsb03-dataelement-11952
      Id prsb03-dataelement-11952 (2019‑05‑31 15:00:27)
      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
      folder draft Risk of accidents
      prsb03-dataelement-10751
      Id prsb03-dataelement-10751 (2019‑03‑07 17:19:00)
      Description Details of the risks the person poses to themselves from accidents.
      draft Start date of risk
      prsb03-dataelement-11953
      Id prsb03-dataelement-11953 (2019‑05‑31 15:00:58)
      Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date of risk
      prsb03-dataelement-11954
      Id prsb03-dataelement-11954 (2019‑05‑31 15:01:29)
      Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Risk of accidents
      prsb03-dataelement-13582
      Id prsb03-dataelement-13582 (2020‑09‑08 11:57:25)
      Description Risks the person poses to themselves from accidents.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Location
      prsb03-dataelement-11955
      Id prsb03-dataelement-11955 (2019‑05‑31 15:01:51)
      Description The location where the risk of accidents was identified.
      Relationship
      draft Coded value
      prsb03-dataelement-13592
      Id prsb03-dataelement-13592 (2020‑09‑08 12:24:12)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13593
      Id prsb03-dataelement-13593 (2020‑09‑08 12:25:18)
      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
      folder draft Performing professional
      prsb03-dataelement-11956
      Id prsb03-dataelement-11956 (2019‑05‑31 15:02:24)
      Description The professional who identified the risk of accidents.
      Relationship
      draft Name
      prsb03-dataelement-11957
      Id prsb03-dataelement-11957 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      draft Role
      prsb03-dataelement-11958
      Id prsb03-dataelement-11958 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      draft Grade
      prsb03-dataelement-11959
      Id prsb03-dataelement-11959 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      draft Speciality
      prsb03-dataelement-11960
      Id prsb03-dataelement-11960 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      draft Professional identifier
      prsb03-dataelement-11961
      Id prsb03-dataelement-11961 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Organisation
      prsb03-dataelement-11962
      Id prsb03-dataelement-11962 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      draft Contact details
      prsb03-dataelement-11963
      Id prsb03-dataelement-11963 (2019‑05‑31 15:02:41)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Person completing record
      prsb03-dataelement-11964
      Id prsb03-dataelement-11964 (2019‑05‑31 15:02:51)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11965
      Id prsb03-dataelement-11965 (2019‑05‑31 15:03:12)
      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
      draft Role
      prsb03-dataelement-11966
      Id prsb03-dataelement-11966 (2019‑05‑31 15:03:12)
      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
      draft Grade
      prsb03-dataelement-11967
      Id prsb03-dataelement-11967 (2019‑05‑31 15:03:12)
      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
      draft Specialty
      prsb03-dataelement-11968
      Id prsb03-dataelement-11968 (2019‑05‑31 15:03:12)
      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
      folder draft Organisation
      prsb03-dataelement-11969
      Id prsb03-dataelement-11969 (2019‑05‑31 15:03:12)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11970
      Id prsb03-dataelement-11970 (2019‑05‑31 15:03:12)
      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
      draft Date completed
      prsb03-dataelement-11971
      Id prsb03-dataelement-11971 (2019‑05‑31 15:03:12)
      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
      draft Contact details
      prsb03-dataelement-11972
      Id prsb03-dataelement-11972 (2019‑05‑31 15:03:12)
      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
      folder draft Other risks
      prsb03-dataelement-10802
      Id prsb03-dataelement-10802 (2019‑03‑20 14:23:40)
      Description Details of other risks, factors or behaviours relating to the person.
      draft Start date of risk
      prsb03-dataelement-11973
      Id prsb03-dataelement-11973 (2019‑05‑31 15:03:41)
      Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft End date of risk
      prsb03-dataelement-11974
      Id prsb03-dataelement-11974 (2019‑05‑31 15:04:10)
      Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      draft Other risks
      prsb03-dataelement-13583
      Id prsb03-dataelement-13583 (2020‑09‑08 12:01:56)
      Description Other risks, factors or behaviours relating to the person.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Location
      prsb03-dataelement-11975
      Id prsb03-dataelement-11975 (2019‑05‑31 15:04:35)
      Description The location where the other risks were identified.
      Relationship
      draft Coded value
      prsb03-dataelement-13594
      Id prsb03-dataelement-13594 (2020‑09‑08 12:26:43)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13595
      Id prsb03-dataelement-13595 (2020‑09‑08 12:27:58)
      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
      folder draft Performing professional
      prsb03-dataelement-11976
      Id prsb03-dataelement-11976 (2019‑05‑31 15:05:03)
      Description The professional who identified the other risks.
      Relationship
      draft Name
      prsb03-dataelement-11977
      Id prsb03-dataelement-11977 (2019‑05‑31 15:05:19)
      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
      draft Role
      prsb03-dataelement-11978
      Id prsb03-dataelement-11978 (2019‑05‑31 15:05:19)
      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
      draft Grade
      prsb03-dataelement-11979
      Id prsb03-dataelement-11979 (2019‑05‑31 15:05:19)
      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
      draft Speciality
      prsb03-dataelement-11980
      Id prsb03-dataelement-11980 (2019‑05‑31 15:05:19)
      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
      draft Professional identifier
      prsb03-dataelement-11981
      Id prsb03-dataelement-11981 (2019‑05‑31 15:05:19)
      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
      folder draft Organisation
      prsb03-dataelement-11982
      Id prsb03-dataelement-11982 (2019‑05‑31 15:05:19)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-11983
      Id prsb03-dataelement-11983 (2019‑05‑31 15:05:19)
      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
      folder draft Person completing record
      prsb03-dataelement-11984
      Id prsb03-dataelement-11984 (2019‑05‑31 15:05:29)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-11985
      Id prsb03-dataelement-11985 (2019‑05‑31 15:05:47)
      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
      draft Role
      prsb03-dataelement-11986
      Id prsb03-dataelement-11986 (2019‑05‑31 15:05:47)
      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
      draft Grade
      prsb03-dataelement-11987
      Id prsb03-dataelement-11987 (2019‑05‑31 15:05:47)
      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
      draft Specialty
      prsb03-dataelement-11988
      Id prsb03-dataelement-11988 (2019‑05‑31 15:05:47)
      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
      folder draft Organisation
      prsb03-dataelement-11989
      Id prsb03-dataelement-11989 (2019‑05‑31 15:05:47)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-11990
      Id prsb03-dataelement-11990 (2019‑05‑31 15:05:47)
      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
      draft Date completed
      prsb03-dataelement-11991
      Id prsb03-dataelement-11991 (2019‑05‑31 15:05:47)
      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
      draft Contact details
      prsb03-dataelement-11992
      Id prsb03-dataelement-11992 (2019‑05‑31 15:05:47)
      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
      folder draft Infection risk
      prsb03-dataelement-12479
      Id prsb03-dataelement-12479 (2019‑06‑27 15:22:39)
      Description Details of any known infection of the person for which special handling might be required
      draft Start date of risk
      prsb03-dataelement-10179
      Id prsb03-dataelement-10179 (2018‑10‑31)
      Description The start date of the risk.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      target Used by 0 transactions, 0 templates, inherited 5 times
       
      draft End date of risk
      prsb03-dataelement-10801
      Id prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
      Description The date the risk ended.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      target Used by 0 transactions, 0 templates, inherited 5 times
       
      draft Infection risk
      prsb03-dataelement-13596
      Id prsb03-dataelement-13596 (2020‑09‑08 15:58:56)
      Description Any known infection of the person for which special handling might be required
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Location
      prsb03-dataelement-10180
      Id prsb03-dataelement-10180 (2018‑10‑31)
      Description The location where the risk was identified.
      draft Coded value
      prsb03-dataelement-13584
      Id prsb03-dataelement-13584 (2020‑09‑08 12:05:13)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13585
      Id prsb03-dataelement-13585 (2020‑09‑08 12:06:42)
      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
      folder draft Performing professional
      prsb03-dataelement-13597
      Id prsb03-dataelement-13597 (2020‑09‑08 16:01:11)
      Description The professional who identified the risk of infections.
      Relationship
      draft Name
      prsb03-dataelement-13598
      Id prsb03-dataelement-13598 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11957 (2019‑05‑31 15:02:41)
      Description The name of the professional.
      Rationale Practitioner.name
      Operationalization Free text.
      Value Domain
      Property
      max length
      70
      draft Role
      prsb03-dataelement-13599
      Id prsb03-dataelement-13599 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11958 (2019‑05‑31 15:02:41)
      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
      draft Grade
      prsb03-dataelement-13600
      Id prsb03-dataelement-13600 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11959 (2019‑05‑31 15:02:41)
      Description The grade of the professional.
      Rationale PractitionerRole.code
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Speciality
      prsb03-dataelement-13601
      Id prsb03-dataelement-13601 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11960 (2019‑05‑31 15:02:41)
      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
      draft Professional identifier
      prsb03-dataelement-13602
      Id prsb03-dataelement-13602 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11961 (2019‑05‑31 15:02:41)
      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
      folder draft Organisation
      prsb03-dataelement-13603
      Id prsb03-dataelement-13603 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11962 (2019‑05‑31 15:02:41)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-13604
      Id prsb03-dataelement-13604 (2020‑09‑08 16:02:57)
      Concept inherits from draft prsb03-dataelement-11963 (2019‑05‑31 15:02:41)
      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
      folder draft Person completing record
      prsb03-dataelement-13605
      Id prsb03-dataelement-13605 (2020‑09‑08 16:04:28)
      Concept inherits from draft prsb03-dataelement-13035 (2020‑04‑28 19:33:13)
      Description A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
      Relationship
      draft Name
      prsb03-dataelement-13606
      Id prsb03-dataelement-13606 (2020‑09‑08 16:05:09)
      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
      draft Role
      prsb03-dataelement-13607
      Id prsb03-dataelement-13607 (2020‑09‑08 16:05:09)
      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
      draft Grade
      prsb03-dataelement-13608
      Id prsb03-dataelement-13608 (2020‑09‑08 16:05:09)
      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
      draft Specialty
      prsb03-dataelement-13609
      Id prsb03-dataelement-13609 (2020‑09‑08 16:05:09)
      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
      folder draft Organisation
      prsb03-dataelement-13610
      Id prsb03-dataelement-13610 (2020‑09‑08 16:05:09)
      Concept inherits from draft prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-13611
      Id prsb03-dataelement-13611 (2020‑09‑08 16:05:09)
      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
      draft Date completed
      prsb03-dataelement-13612
      Id prsb03-dataelement-13612 (2020‑09‑08 16:05:09)
      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
      draft Contact details
      prsb03-dataelement-13613
      Id prsb03-dataelement-13613 (2020‑09‑08 16:05:09)
      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
      cancelled Person completing record
      prsb03-dataelement-10959
      Id prsb03-dataelement-10959 (2019‑05‑18 21:13:52) 0.1
      Concept inherits from cancelled prsb03-dataelement-10860 (2019‑03‑27 17:46:45)
      Description This is the person recording the individual requirement.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      cancelled Other risk behaviours
      prsb03-dataelement-10752
      Id prsb03-dataelement-10752 (2019‑03‑07 17:21:05) 0.1
      Value Domain
      cancelled Factors affecting risk
      prsb03-dataelement-10753
      Id prsb03-dataelement-10753 (2019‑03‑07 17:21:36) 0.1
      Value Domain
      folder draft Allergies and adverse reactions
      prsb03-dataelement-282
      Id prsb03-dataelement-282 (2018‑10‑31)
      Description Allergies and adverse reactions
      folder draft Allergies and adverse reactions record entry
      prsb03-dataelement-10657
      Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
      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.
      draft Type of reaction
      prsb03-dataelement-10186
      Id prsb03-dataelement-10186 (2018‑10‑31)
      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
      folder draft Causative agent
      prsb03-dataelement-10182
      Id prsb03-dataelement-10182 (2018‑10‑31)
      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
      draft Coded value
      prsb03-dataelement-13441
      Id prsb03-dataelement-13441 (2020‑08‑19 14:12:48)
      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
      draft Free text
      prsb03-dataelement-13442
      Id prsb03-dataelement-13442 (2020‑08‑19 15:33:40)
      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
      folder draft Reaction details cluster
      prsb03-dataelement-10658
      Id prsb03-dataelement-10658 (2018‑11‑13 12:29:25)
      Description Details of the reaction.
      draft Date
      prsb03-dataelement-10190
      Id prsb03-dataelement-10190 (2018‑10‑31)
      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
      folder draft Location
      prsb03-dataelement-10846
      Id prsb03-dataelement-10846 (2019‑03‑27 17:04:11)
      Description Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
      draft Coded value
      prsb03-dataelement-13439
      Id prsb03-dataelement-13439 (2020‑08‑19 13:58:37)
      Description The coded value for location.
      Rationale Location.identifier
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13440
      Id prsb03-dataelement-13440 (2020‑08‑19 14:02:39)
      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
      cancelled Performing professional
      prsb03-dataelement-10847
      Id prsb03-dataelement-10847 (2019‑03‑27 17:08:07)
      Description Details of the professional recording the allergy (including name and role).
      Value Domain
      cancelled Person completing record
      prsb03-dataelement-10968
      Id prsb03-dataelement-10968 (2019‑05‑20 18:12:21)
      Description This is the person recording the allergies or adverse reactions.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      folder draft Substance
      prsb03-dataelement-11665
      Id prsb03-dataelement-11665 (2019‑05‑30 20:17:32)
      Description The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
      draft Coded value
      prsb03-dataelement-13554
      Id prsb03-dataelement-13554 (2020‑09‑04 16:44:48)
      Description The coded value for substance
      Rationale AllergyIntolerance. reaction.substance
      Operationalization SNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |

      Value Domain
      draft Free text
      prsb03-dataelement-13555
      Id prsb03-dataelement-13555 (2020‑09‑04 16:45:54)
      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
      folder draft Description of reaction
      prsb03-dataelement-10183
      Id prsb03-dataelement-10183 (2018‑10‑31)
      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
      draft Coded value
      prsb03-dataelement-13556
      Id prsb03-dataelement-13556 (2020‑09‑04 16:48:37)
      Description The coded value for description of reaction.
      Rationale AllergyIntolerance.reaction.manifestation
      Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
      Value Domain
      draft Free text
      prsb03-dataelement-13557
      Id prsb03-dataelement-13557 (2020‑09‑04 16:51:03)
      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
      draft Onset date
      prsb03-dataelement-13844
      Id prsb03-dataelement-13844 (2020‑12‑29 22:44:39)
      Description Date and time when manifestations showed e.g could be at home a few days earlier than the contact
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least year
      folder draft Severity
      prsb03-dataelement-10184
      Id prsb03-dataelement-10184 (2018‑10‑31)
      Description A description of the severity of the reaction.

      Properties

      FHIR AllergyIntolerance.reaction.severity
      draft Coded value
      prsb03-dataelement-13558
      Id prsb03-dataelement-13558 (2020‑09‑04 17:43:42)
      Description The coded value for severity
      Rationale AllergyIntolerance.reaction.severity
      Operationalization FHIR value set : - Severity
      Value Domain
      draft Free text
      prsb03-dataelement-13559
      Id prsb03-dataelement-13559 (2020‑09‑04 17:48:53)
      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
      folder draft Certainty
      prsb03-dataelement-10185
      Id prsb03-dataelement-10185 (2018‑10‑31)
      Description A description of the certainty that the stated causative agent caused the allergic or adverse reaction.

      Properties

      FHIR AllergyIntolerance.verificationStatus
      draft Coded value
      prsb03-dataelement-13560
      Id prsb03-dataelement-13560 (2020‑09‑04 17:52:26)
      Description The coded value for certainty.
      Rationale AllergyIntolerance.verificationStatus
      Operationalization FHIR value set : - Certainty
      Value Domain
      draft Free text
      prsb03-dataelement-13561
      Id prsb03-dataelement-13561 (2020‑09‑04 17:55:21)
      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
      folder draft Route of exposure
      prsb03-dataelement-13856
      Id prsb03-dataelement-13856 (2021‑01‑18 18:45:19)
      Description The route the person was exposed to the substance
      draft Coded value
      prsb03-dataelement-13857
      Id prsb03-dataelement-13857 (2021‑01‑18 18:50:12)
      Description The coded value for route of exposure
      Rationale AllergyIntolerance.exposureroute
      Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
      Value Domain
      draft Free text
      prsb03-dataelement-13858
      Id prsb03-dataelement-13858 (2021‑01‑18 18:55:02)
      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
      draft Comment
      prsb03-dataelement-10189
      Id prsb03-dataelement-10189 (2018‑10‑31)
      Description Any additional comment or clarification about the adverse reaction.
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Evidence
      prsb03-dataelement-10187
      Id prsb03-dataelement-10187 (2018‑10‑31)
      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
      draft Date first experienced
      prsb03-dataelement-10188
      Id prsb03-dataelement-10188 (2018‑10‑31)
      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
      draft Allergy end date
      prsb03-dataelement-14253
      Id prsb03-dataelement-14253 (2021‑03‑04 13:29:34)
      Description The date the allergy was diagnosed as ended
      Operationalization Date and time 
      Value Domain
      Property
      Timestamp precision
      at least year
      draft Comment
      prsb03-dataelement-14273
      Id prsb03-dataelement-14273 (2021‑04‑09 11:01:11)
      Description Any further comments on the person's allergies or adverse reactions.
      Operationalization Free text
      Value Domain
      cancelled Probability of recurrence
      prsb03-dataelement-10191
      Id prsb03-dataelement-10191 (2018‑10‑31) 0.1
      Description Probability of the reaction (allergic, adverse, intolerant) occurring.

      Properties

      FHIR AllergyIntolerance.extension.ProbabilityOfRecurrence
      Rationale AllergyIntolerance.extension.ProbabilityOfRecurrence
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Performing professional
      prsb03-dataelement-12010
      Id prsb03-dataelement-12010 (2019‑05‑31 15:23:59)
      Description The professional who identified the reaction.
      Relationship
      draft Name
      prsb03-dataelement-12011
      Id prsb03-dataelement-12011 (2019‑05‑31 15:24:24)
      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
      draft Role
      prsb03-dataelement-12012
      Id prsb03-dataelement-12012 (2019‑05‑31 15:24:24)
      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
      draft Grade
      prsb03-dataelement-12013
      Id prsb03-dataelement-12013 (2019‑05‑31 15:24:24)
      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
      draft Speciality
      prsb03-dataelement-12014
      Id prsb03-dataelement-12014 (2019‑05‑31 15:24:24)
      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
      draft Professional identifier
      prsb03-dataelement-12015
      Id prsb03-dataelement-12015 (2019‑05‑31 15:24:24)
      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
      folder draft Organisation
      prsb03-dataelement-12016
      Id prsb03-dataelement-12016 (2019‑05‑31 15:24:24)
      Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
      Description The name of the organisation the professional works for.
      draft Contact details
      prsb03-dataelement-12017
      Id prsb03-dataelement-12017 (2019‑05‑31 15:24:24)
      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
      folder draft Person completing record
      prsb03-dataelement-12018
      Id prsb03-dataelement-12018 (2019‑05‑31 15:24:36)
      Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
      Description Details of the person completing the record.
      Relationship
      draft Name
      prsb03-dataelement-12019
      Id prsb03-dataelement-12019 (2019‑05‑31 15:24:56)
      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
      draft Role
      prsb03-dataelement-12020
      Id prsb03-dataelement-12020 (2019‑05‑31 15:24:56)
      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
      draft Grade
      prsb03-dataelement-12021
      Id prsb03-dataelement-12021 (2019‑05‑31 15:24:56)
      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
      draft Specialty
      prsb03-dataelement-12022
      Id prsb03-dataelement-12022 (2019‑05‑31 15:24:56)
      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
      folder draft Organisation
      prsb03-dataelement-12023
      Id prsb03-dataelement-12023 (2019‑05‑31 15:24:56)
      Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
      Description The organisation the person completing the record works for.
      Relationship
      draft Professional identifier
      prsb03-dataelement-12024
      Id prsb03-dataelement-12024 (2019‑05‑31 15:24:56)
      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
      draft Date completed
      prsb03-dataelement-12025
      Id prsb03-dataelement-12025 (2019‑05‑31 15:24:56)
      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
      draft Contact details
      prsb03-dataelement-12026
      Id prsb03-dataelement-12026 (2019‑05‑31 15:24:56)
      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
      rejected Person completing record
      prsb03-dataelement-10960
      Id prsb03-dataelement-10960 (2019‑05‑18 21:15:23)
      Concept inherits from cancelled prsb03-dataelement-10860 (2019‑03‑27 17:46:45)
      Description This is the person recording the individual requirement.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      folder draft Medications and medical devices
      prsb03-dataelement-636
      Id prsb03-dataelement-636 (2018‑10‑31)
      Description Medications and medical devices
      target Used by 0 transactions, 0 templates, inherited once
       
      folder draft Medication administration record entry
      prsb03-dataelement-12483
      Id prsb03-dataelement-12483 (2019‑07‑03 12:24:36)
      Description Each entry holds details of medications administered
      target Used by 0 transactions, 0 templates, inherited once
       
      folder draft Medication name
      prsb03-dataelement-12484
      Id prsb03-dataelement-12484 (2019‑07‑03 12:27:06)
      Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited once
       
      draft Coded value
      prsb03-dataelement-13663
      Id prsb03-dataelement-13663 (2020‑09‑08 21:49:56)
      Concept inherits from draft prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
      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
      draft Free text
      prsb03-dataelement-13664
      Id prsb03-dataelement-13664 (2020‑09‑08 21:49:56)
      Concept inherits from draft prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
      Description Free text field to be used if no code is available
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      folder draft Route
      prsb03-dataelement-12485
      Id prsb03-dataelement-12485 (2019‑07‑03 12:28:40)
      Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
      Description The route by which the medication is administered e.g. oral, IM, IV

      Properties

      FHIR MedicationStatement.dosage.route
      target Used by 0 transactions, 0 templates, inherited once
       
      draft Coded value
      prsb03-dataelement-13661
      Id prsb03-dataelement-13661 (2020‑09‑08 21:47:04)
      Concept inherits from draft prsb03-dataelement-13655 (2020‑09‑08 20:30:38)
      Description The coded value for route
      Operationalization SNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
      Value Domain
      draft Free text
      prsb03-dataelement-13662
      Id prsb03-dataelement-13662 (2020‑09‑08 21:47:04)
      Concept inherits from draft prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
      Description Free text field to be used if no code is available
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      draft Dose administered
      prsb03-dataelement-12487
      Id prsb03-dataelement-12487 (2019‑07‑03 12:35:08)
      Description The quantity and units of medication administered
      Operationalization Free text. The quantity and units administered
      Value Domain
      target Used by 0 transactions, 0 templates, inherited once
       
      draft Administration date and time
      prsb03-dataelement-12486
      Id prsb03-dataelement-12486 (2019‑07‑03 12:28:41)
      Description The date and time when the medication was administered.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year
      target Used by 0 transactions, 0 templates, inherited once
       
      folder draft Medication item entry
      prsb03-dataelement-10663
      Id prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
      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 0 transactions, 0 templates, inherited 2 times
       
      folder draft Medication item cluster
      prsb03-dataelement-10664
      Id prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
      Description Medication item cluster
      target Used by 0 transactions, 0 templates, inherited 2 times
       
      draft Date
      prsb03-dataelement-10843
      Id prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
      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 0 transactions, 0 templates, inherited 3 times
       
      folder draft Location
      prsb03-dataelement-10844
      Id prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
      Description The location where the medication or the medical device was prescribed.
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Coded value
      prsb03-dataelement-13620
      Id prsb03-dataelement-13620 (2020‑09‑08 19:05:36)
      Description The coded value for location
      Operationalization NHS data dictionary : - Organisation data service
      Value Domain
      Property
      min length max length
      3 5
      draft Free text
      prsb03-dataelement-13621
      Id prsb03-dataelement-13621 (2020‑09‑08 19:07:01)
      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
      cancelled Performing professional
      prsb03-dataelement-10845
      Id prsb03-dataelement-10845 (2019‑03‑27 17:01:47) 0.1
      Description Details of the professional prescribing the medication or medical device.
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      folder draft Performing professional
      prsb03-dataelement-12002
      Id prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
      Description The professional who prescribed the medication or medical device.
      Relationship
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Name
      prsb03-dataelement-12003
      Id prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Role
      prsb03-dataelement-12004
      Id prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Grade
      prsb03-dataelement-12005
      Id prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Speciality
      prsb03-dataelement-12006
      Id prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Professional identifier
      prsb03-dataelement-12007
      Id prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      folder draft Organisation
      prsb03-dataelement-12008
      Id prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Contact details
      prsb03-dataelement-12009
      Id prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
      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 0 transactions, 0 templates, inherited 3 times
       
      folder draft Medication name
      prsb03-dataelement-10536
      Id prsb03-dataelement-10536 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 5 times
       
      draft Coded value
      prsb03-dataelement-13622
      Id prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
      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 0 transactions, 0 templates, inherited once
       
      draft Free text
      prsb03-dataelement-13623
      Id prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Form
      prsb03-dataelement-10537
      Id prsb03-dataelement-10537 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 4 times
       
      draft Coded value
      prsb03-dataelement-13624
      Id prsb03-dataelement-13624 (2020‑09‑08 19:32:29)
      Description The coded value for form.
      Operationalization SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
      Value Domain
      draft Free text
      prsb03-dataelement-13625
      Id prsb03-dataelement-13625 (2020‑09‑08 19:33:34)
      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
      folder draft Quantity supplied
      prsb03-dataelement-10539
      Id prsb03-dataelement-10539 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Value
      prsb03-dataelement-14271
      Id prsb03-dataelement-14271 (2021‑03‑31 16:58:30)
      Description The value of the quantity supplied
      Operationalization Enumerated value
      Value Domain
      draft Unit of measure
      prsb03-dataelement-14272
      Id prsb03-dataelement-14272 (2021‑03‑31 16:59:56)
      Description Unit of measure of quantity supplied
      Relationship
      Operationalization UCUM code
      Value Domain
      draft Date supplied
      prsb03-dataelement-13792
      Id prsb03-dataelement-13792 (2020‑10‑22 18:56:07)
      Description The date/time the medication was supplied.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      folder draft Route
      prsb03-dataelement-10538
      Id prsb03-dataelement-10538 (2018‑10‑31)
      Description The route by which the medication is administered e.g. oral, IM, IV

      Properties

      FHIR MedicationStatement.dosage.route
      target Used by 0 transactions, 0 templates, inherited 5 times
       
      draft Coded value
      prsb03-dataelement-13655
      Id prsb03-dataelement-13655 (2020‑09‑08 20:30:38)
      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 0 transactions, 0 templates, inherited once
       
      draft Free text
      prsb03-dataelement-13656
      Id prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
      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 0 transactions, 0 templates, inherited once
       
      folder draft Site
      prsb03-dataelement-10540
      Id prsb03-dataelement-10540 (2018‑10‑31)
      Description The anatomical site at which the medication is to be administered.

      Properties

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

      SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 2 times
       
      draft Free text
      prsb03-dataelement-13658
      Id prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
      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 0 transactions, 0 templates, inherited 2 times
       
      folder draft Method
      prsb03-dataelement-10541
      Id prsb03-dataelement-10541 (2018‑10‑31)
      Description The technique or method by which the medication is to be administered.

      Properties

      FHIR MedicationStatement.dosage.method
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Coded value
      prsb03-dataelement-13845
      Id prsb03-dataelement-13845 (2020‑12‑29 23:05:59)
      Description The coded value for method
      Operationalization FHIR value set : - Method
      Value Domain
      draft Free text
      prsb03-dataelement-13846
      Id prsb03-dataelement-13846 (2020‑12‑29 23:07:37)
      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
      draft Supply type
      prsb03-dataelement-13754
      Id prsb03-dataelement-13754 (2020‑09‑29 11:32:50)
      Description A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
      Value Domain
      folder cancelled Batch number
      prsb03-dataelement-13752
      Id prsb03-dataelement-13752 (2020‑09‑29 10:51:55) 0.1
      Description The batch number of the medicine
      Operationalization Derived from FMD code/Free text
      folder draft Batch number
      prsb03-dataelement-13789
      Id prsb03-dataelement-13789 (2020‑10‑22 18:25:26)
      Concept inherits from draft prsb03-dataelement-10697 (2018‑12‑04 15:10:59)
      Description The batch number of the product.
      draft Coded value
      prsb03-dataelement-13790
      Id prsb03-dataelement-13790 (2020‑10‑22 18:26:28)
      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
      draft Free text
      prsb03-dataelement-13791
      Id prsb03-dataelement-13791 (2020‑10‑22 18:26:28)
      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
      draft Over the counter medication flag
      prsb03-dataelement-13379
      Id prsb03-dataelement-13379 (2020‑08‑10 16:51:27)
      Description Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counter
      Operationalization Flag : - Yes or No
      Value Domain
      draft Dose directions description
      prsb03-dataelement-10544
      Id prsb03-dataelement-10544 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 4 times
       
      draft Dose amount description
      prsb03-dataelement-10542
      Id prsb03-dataelement-10542 (2018‑10‑31)
      Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

      Properties

      FHIR MedicationStatement.dosage.text
      Operationalization Free text
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 4 times
       
      draft Dose timing description
      prsb03-dataelement-10543
      Id prsb03-dataelement-10543 (2018‑10‑31)
      Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

      Properties

      FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
      Operationalization Free text
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 4 times
       
      draft Parsable dose directions
      prsb03-dataelement-10552
      Id prsb03-dataelement-10552 (2018‑10‑31)
      Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
      Value Domain
      Property
      max length
      150
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      folder draft Structured dose direction cluster
      prsb03-dataelement-11639
      Id prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
      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 0 transactions, 0 templates, inherited 3 times
       
      cancelled Structured dose direction
      prsb03-dataelement-10553
      Id prsb03-dataelement-10553 (2018‑10‑31)
      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.
      Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Structured dose amount
      prsb03-dataelement-10554
      Id prsb03-dataelement-10554 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Structured dose timing
      prsb03-dataelement-10555
      Id prsb03-dataelement-10555 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Dose direction duration
      prsb03-dataelement-10548
      Id prsb03-dataelement-10548 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Additional instructions
      prsb03-dataelement-10545
      Id prsb03-dataelement-10545 (2018‑10‑31)
      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 0 transactions, 0 templates, inherited 3 times
       
      draft Request for advice
      prsb03-dataelement-10559
      Id prsb03-dataelement-10559 (2018‑10‑31)
      Description Request for advice and recommendation about medication
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Matters identified during discussion
      prsb03-dataelement-13753
      Id prsb03-dataelement-13753 (2020‑09‑29 11:01:13)
      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
      cancelled Person completing record
      prsb03-dataelement-10961
      Id prsb03-dataelement-10961 (2019‑05‑18 21:23:41)
      Description This is the person recording the medication.

      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
      Relationship
      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
      Value Domain
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      folder draft Course details cluster
      prsb03-dataelement-10561
      Id prsb03-dataelement-10561 (2018‑10‑31)
      Description Details of the overall course of medication.
      target Used by 0 transactions, 0 templates, inherited 3 times
       
      draft Course status
      prsb03-dataelement-10666
      Id prsb03-dataelement-10666 (2018‑11‑13 16:47:55)
      Description The status of this prescription.
      Operationalization FHIR value set : - Medication status
        Value Domain
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft Indication
        prsb03-dataelement-10546
        Id prsb03-dataelement-10546 (2018‑10‑31)
        Description Reason for medication being prescribed, where known.

        Properties

        FHIR MedicationStatement.reasonCode
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft Start date/time
        prsb03-dataelement-10667
        Id prsb03-dataelement-10667 (2018‑11‑13 16:49:22)
        Description The date and/or time that the medication course should begin.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft End date/time
        prsb03-dataelement-10557
        Id prsb03-dataelement-10557 (2018‑10‑31)
        Description The date and/or time that the medication course should finish.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft Link to indication record
        prsb03-dataelement-10668
        Id prsb03-dataelement-10668 (2018‑11‑13 16:59:09)
        Description A link to the record which contains the indication for this medication order.
        Operationalization Free text with URL
        Value Domain
        Property
        max length
        150
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft Comment/recommendation
        prsb03-dataelement-10547
        Id prsb03-dataelement-10547 (2018‑10‑31)
        Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

        Properties

        FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        folder draft Medication change summary cluster
        prsb03-dataelement-10568
        Id prsb03-dataelement-10568 (2018‑10‑31)
        Description Records the changes made to medication.
        target Used by 0 transactions, 0 templates, inherited 3 times
         
        draft Status
        prsb03-dataelement-10669
        Id prsb03-dataelement-10669 (2018‑11‑13 17:00:50)
        Description The nature of any change made to the medication.
        Operationalization FHIR value set : Medication status
          Value Domain
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Indication
          prsb03-dataelement-10670
          Id prsb03-dataelement-10670 (2018‑11‑13 17:02:07)
          Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Date of change
          prsb03-dataelement-10671
          Id prsb03-dataelement-10671 (2018‑11‑13 17:03:03)
          Description The date of the change - addition, or amendment
          Operationalization Date and time
          Value Domain
          Property
          Timestamp precision
          at least day, month and year, hour and minute
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Description of amendment
          prsb03-dataelement-10672
          Id prsb03-dataelement-10672 (2018‑11‑13 17:03:42)
          Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Total dose daily quantity
          prsb03-dataelement-10665
          Id prsb03-dataelement-10665 (2018‑11‑13 16:44:41)
          Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
          Operationalization Free text
          Value Domain
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Anticipatory medicines/equipment
          prsb03-dataelement-14023
          Id prsb03-dataelement-14023 (2021‑02‑15 17:36:45)
          Concept inherits from draft prsb03-dataelement-10370 (2018‑10‑31)
          Description Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          folder draft Person completing record
          prsb03-dataelement-11993
          Id prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Name
          prsb03-dataelement-11994
          Id prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Role
          prsb03-dataelement-11995
          Id prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Grade
          prsb03-dataelement-11996
          Id prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Specialty
          prsb03-dataelement-11997
          Id prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          folder draft Organisation
          prsb03-dataelement-11998
          Id prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Professional identifier
          prsb03-dataelement-11999
          Id prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Date completed
          prsb03-dataelement-12000
          Id prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          draft Contact details
          prsb03-dataelement-12001
          Id prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
          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 0 transactions, 0 templates, inherited 3 times
           
          folder draft Medical devices entry
          prsb03-dataelement-10583
          Id prsb03-dataelement-10583 (2018‑10‑31)
          Description Medical devices
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Medical device
          prsb03-dataelement-10673
          Id prsb03-dataelement-10673 (2018‑11‑13 17:10:15)
          Description Any medical device that isn't prescribed.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Comments
          prsb03-dataelement-11280
          Id prsb03-dataelement-11280 (2019‑05‑29 17:47:02)
          Description Any information regarding the medical device.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          folder draft Medication discontinued entry
          prsb03-dataelement-10576
          Id prsb03-dataelement-10576 (2018‑10‑31)
          Description Medication discontinued entry
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          folder draft Name of discontinued medication
          prsb03-dataelement-10577
          Id prsb03-dataelement-10577 (2018‑10‑31)
          Description The name of the medication or medical device being discontinued
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Coded value
          prsb03-dataelement-13659
          Id prsb03-dataelement-13659 (2020‑09‑08 20:57:52)
          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
          draft Free text
          prsb03-dataelement-13660
          Id prsb03-dataelement-13660 (2020‑09‑08 20:58:40)
          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
          draft Status
          prsb03-dataelement-12472
          Id prsb03-dataelement-12472 (2019‑06‑25 11:42:23)
          Description The status of any change made to the medication. MUST CONTAIN STOPPED.
          Operationalization FHIR value set: - Medication status
          Value Domain
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          cancelled Status
          prsb03-dataelement-10578
          Id prsb03-dataelement-10578 (2018‑10‑31)
          Description The nature of any change made to the medication.
          Operationalization Free text
          Value Domain
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Indication
          prsb03-dataelement-10579
          Id prsb03-dataelement-10579 (2018‑10‑31)
          Description The clinical indication for any changes in medication status
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 3 times
           
          draft Date of change
          prsb03-dataelement-10580
          Id prsb03-dataelement-10580 (2018‑10‑31)
          Description The date of the discontinuation
          Operationalization Date and time
          Value Domain
          Property
          Timestamp precision
          at least day, month and year, hour and minute
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Description of amendment
          prsb03-dataelement-10581
          Id prsb03-dataelement-10581 (2018‑10‑31)
          Description A description of any amendment
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          draft Comment
          prsb03-dataelement-10582
          Id prsb03-dataelement-10582 (2018‑10‑31)
          Description Any additional comment about the discontinuation or amendment.
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          target Used by 0 transactions, 0 templates, inherited 2 times
           
          folder cancelled Over the counter medication item entry
          prsb03-dataelement-13109
          Id prsb03-dataelement-13109 (2020‑06‑24 16:04:03) 0.1
          Description The details of, and instructions for, over the counter purchased medications that the person is using. All over the counter medications that the person uses regularly that are not prescribed by a medical professional. These may or may not be required for the treatment and management of their health condition(s). Examples include analgesics for pain relief (brufen tablets); topical anaesthetics (voltarol gel); vitamin and mineral supplements (folic acid and calcium); herbal medicines (St Johns Wort). Include details of reason for use, dose amount, frequency, start date and duration of medication.
          folder cancelled Medication name
          prsb03-dataelement-13200
          Id prsb03-dataelement-13200 (2020‑06‑24 17:45:11) 0.1
          Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
          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)
          cancelled Indication
          prsb03-dataelement-13201
          Id prsb03-dataelement-13201 (2020‑06‑24 17:46:45) 0.1
          Description Reason for medication being taken, where known.

          Properties

          FHIR MedicationStatement.reasonCode
          Relationship
          Operationalization A free text or Coded text term giving the clinical indication or reason for ordering the medication. Coded terms are preferable.
          Value Domain
          folder cancelled Form
          prsb03-dataelement-13202
          Id prsb03-dataelement-13202 (2020‑06‑24 17:49:30) 0.1
          Concept inherits from draft prsb03-dataelement-10537 (2018‑10‑31)
          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
          folder cancelled Route
          prsb03-dataelement-13203
          Id prsb03-dataelement-13203 (2020‑06‑24 17:50:25) 0.1
          Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
          Description The route by which the medication is administered e.g. oral, IM, IV

          Properties

          FHIR MedicationStatement.dosage.route
          cancelled Site
          prsb03-dataelement-13204
          Id prsb03-dataelement-13204 (2020‑06‑24 17:51:17) 0.1
          Description The anatomical site at which the medication is administered.

          Properties

          FHIR MedicationStatement.dosage.site
          Relationship
          Operationalization TextCoded text - constraint: SiteOfMedicationAdministration.



          Any valid site for the administration of a medication.



          Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration
          Value Domain
          target Used by 0 transactions, 0 templates, inherited once
           
          cancelled Method
          prsb03-dataelement-13205
          Id prsb03-dataelement-13205 (2020‑06‑24 17:53:03) 0.1
          Description The technique or method by which the medication is administered.

          Properties

          FHIR MedicationStatement.dosage.method
          Relationship
          Operationalization Free text
          Value Domain
          cancelled Dose directions description
          prsb03-dataelement-13206
          Id prsb03-dataelement-13206 (2020‑06‑24 17:54:29) 0.1
          Concept inherits from draft prsb03-dataelement-10544 (2018‑10‑31)
          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
          cancelled Dose amount description
          prsb03-dataelement-13207
          Id prsb03-dataelement-13207 (2020‑06‑24 17:55:24) 0.1
          Concept inherits from draft prsb03-dataelement-10542 (2018‑10‑31)
          Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

          Properties

          FHIR MedicationStatement.dosage.text
          Operationalization Free text
          Value Domain
          cancelled Dose timing description
          prsb03-dataelement-13208
          Id prsb03-dataelement-13208 (2020‑06‑24 17:56:17) 0.1
          Concept inherits from draft prsb03-dataelement-10543 (2018‑10‑31)
          Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

          Properties

          FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
          Operationalization Free text
          Value Domain
          folder cancelled Person completing record
          prsb03-dataelement-13210
          Id prsb03-dataelement-13210 (2020‑06‑24 18:00:25) 0.1
          Description A record of the details of the person that entered the information about the over the counter medications, and the date on which it was entered.
          Relationship
          cancelled Name
          prsb03-dataelement-13211
          Id prsb03-dataelement-13211 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13192 (2020‑06‑24 17:27:59)
          Description The name of the person completing the record.
          Relationship
          Rationale Composition.author.Practitioner.name
          Operationalization Free text.
          Value Domain
          Property
          max length
          70
          cancelled Role
          prsb03-dataelement-13212
          Id prsb03-dataelement-13212 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13193 (2020‑06‑24 17:27:59)
          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
          cancelled Grade
          prsb03-dataelement-13213
          Id prsb03-dataelement-13213 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13194 (2020‑06‑24 17:27:59)
          Description The grade of the person completing the record.
          Relationship
          Rationale PractitionerRole.code
          Operationalization Free text.
          Value Domain
          Property
          max length
          150
          cancelled Specialty
          prsb03-dataelement-13214
          Id prsb03-dataelement-13214 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13195 (2020‑06‑24 17:27:59)
          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
          folder cancelled Organisation
          prsb03-dataelement-13215
          Id prsb03-dataelement-13215 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13196 (2020‑06‑24 17:27:59)
          Description The organisation the person completing the record works for.
          Relationship
          cancelled Professional identifier
          prsb03-dataelement-13216
          Id prsb03-dataelement-13216 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13197 (2020‑06‑24 17:27:59)
          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
          cancelled Date completed
          prsb03-dataelement-13217
          Id prsb03-dataelement-13217 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13198 (2020‑06‑24 17:27:59)
          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
          cancelled Contact details
          prsb03-dataelement-13218
          Id prsb03-dataelement-13218 (2020‑06‑24 18:01:03) 0.1
          Concept inherits from draft prsb03-dataelement-13199 (2020‑06‑24 17:27:59)
          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
          cancelled Person completing record
          prsb03-dataelement-13209
          Id prsb03-dataelement-13209 (2020‑06‑24 17:58:16) 0.1
          Concept inherits from cancelled prsb03-dataelement-10956 (2019‑05‑18 21:09:13)
          Description This is the person recording the investigation request.

          Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
          Relationship
          Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
          Value Domain
          folder cancelled Medication item entry
          prsb03-dataelement-13110
          Id prsb03-dataelement-13110 (2020‑06‑24 16:05:21) 0.1
          Concept inherits from draft prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
          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.
          folder cancelled Medication item cluster
          prsb03-dataelement-13111
          Id prsb03-dataelement-13111 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
          Description Medication item cluster
          cancelled Date
          prsb03-dataelement-13112
          Id prsb03-dataelement-13112 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
          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
          folder cancelled Location
          prsb03-dataelement-13113
          Id prsb03-dataelement-13113 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
          Description The location where the medication or the medical device was prescribed.
          cancelled Performing professional
          prsb03-dataelement-13114
          Id prsb03-dataelement-13114 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from cancelled prsb03-dataelement-10845 (2019‑03‑27 17:01:47)
          Description Details of the professional prescribing the medication or medical device.
          Value Domain
          folder cancelled Performing professional
          prsb03-dataelement-13115
          Id prsb03-dataelement-13115 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
          Description The professional who prescribed the medication or medical device.
          Relationship
          cancelled Name
          prsb03-dataelement-13116
          Id prsb03-dataelement-13116 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
          Description The name of the professional.
          Rationale Practitioner.name
          Operationalization Free text.
          Value Domain
          Property
          max length
          70
          cancelled Role
          prsb03-dataelement-13117
          Id prsb03-dataelement-13117 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
          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
          cancelled Grade
          prsb03-dataelement-13118
          Id prsb03-dataelement-13118 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
          Description The grade of the professional.
          Rationale PractitionerRole.code
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          cancelled Speciality
          prsb03-dataelement-13119
          Id prsb03-dataelement-13119 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
          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
          cancelled Professional identifier
          prsb03-dataelement-13120
          Id prsb03-dataelement-13120 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
          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
          folder cancelled Organisation
          prsb03-dataelement-13121
          Id prsb03-dataelement-13121 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
          Description The name of the organisation the professional works for.
          cancelled Contact details
          prsb03-dataelement-13122
          Id prsb03-dataelement-13122 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
          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
          folder cancelled Medication name
          prsb03-dataelement-13123
          Id prsb03-dataelement-13123 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
          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)
          folder cancelled Form
          prsb03-dataelement-13124
          Id prsb03-dataelement-13124 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10537 (2018‑10‑31)
          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
          folder cancelled Quantity supplied
          prsb03-dataelement-13125
          Id prsb03-dataelement-13125 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10539 (2018‑10‑31)
          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
          folder cancelled Route
          prsb03-dataelement-13126
          Id prsb03-dataelement-13126 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
          Description The route by which the medication is administered e.g. oral, IM, IV

          Properties

          FHIR MedicationStatement.dosage.route
          folder cancelled Site
          prsb03-dataelement-13127
          Id prsb03-dataelement-13127 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10540 (2018‑10‑31)
          Description The anatomical site at which the medication is to be administered.

          Properties

          FHIR MedicationStatement.dosage.site
          folder cancelled Method
          prsb03-dataelement-13128
          Id prsb03-dataelement-13128 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10541 (2018‑10‑31)
          Description The technique or method by which the medication is to be administered.

          Properties

          FHIR MedicationStatement.dosage.method
          cancelled Dose directions description
          prsb03-dataelement-13129
          Id prsb03-dataelement-13129 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10544 (2018‑10‑31)
          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
          cancelled Dose amount description
          prsb03-dataelement-13130
          Id prsb03-dataelement-13130 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10542 (2018‑10‑31)
          Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

          Properties

          FHIR MedicationStatement.dosage.text
          Operationalization Free text
          Value Domain
          cancelled Dose timing description
          prsb03-dataelement-13131
          Id prsb03-dataelement-13131 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10543 (2018‑10‑31)
          Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

          Properties

          FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
          Operationalization Free text
          Value Domain
          cancelled Parsable dose directions
          prsb03-dataelement-13132
          Id prsb03-dataelement-13132 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10552 (2018‑10‑31)
          Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
          Value Domain
          Property
          max length
          150
          folder cancelled Structured dose direction cluster
          prsb03-dataelement-13133
          Id prsb03-dataelement-13133 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
          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.
          cancelled Structured dose direction
          prsb03-dataelement-13134
          Id prsb03-dataelement-13134 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from cancelled prsb03-dataelement-10553 (2018‑10‑31)
          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.
          Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
          Value Domain
          cancelled Structured dose amount
          prsb03-dataelement-13135
          Id prsb03-dataelement-13135 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10554 (2018‑10‑31)
          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
          cancelled Structured dose timing
          prsb03-dataelement-13136
          Id prsb03-dataelement-13136 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10555 (2018‑10‑31)
          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
          cancelled Dose direction duration
          prsb03-dataelement-13137
          Id prsb03-dataelement-13137 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10548 (2018‑10‑31)
          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
          cancelled Additional instructions
          prsb03-dataelement-13138
          Id prsb03-dataelement-13138 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10545 (2018‑10‑31)
          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
          cancelled Request for advice
          prsb03-dataelement-13139
          Id prsb03-dataelement-13139 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10559 (2018‑10‑31)
          Description Request for advice and recommendation about medication
          Operationalization Free text
          Value Domain
          Property
          max length
          150
          cancelled Person completing record
          prsb03-dataelement-13140
          Id prsb03-dataelement-13140 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from cancelled prsb03-dataelement-10961 (2019‑05‑18 21:23:41)
          Description This is the person recording the medication.

          Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
          Relationship
          Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
          Value Domain
          folder cancelled Course details cluster
          prsb03-dataelement-13141
          Id prsb03-dataelement-13141 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10561 (2018‑10‑31)
          Description Details of the overall course of medication.
          cancelled Course status
          prsb03-dataelement-13142
          Id prsb03-dataelement-13142 (2020‑06‑24 16:06:14) 0.1
          Concept inherits from draft prsb03-dataelement-10666 (2018‑11‑13 16:47:55)
          Description The status of this prescription.
          Operationalization FHIR value set : - Medication status
            Value Domain
            cancelled Indication
            prsb03-dataelement-13143
            Id prsb03-dataelement-13143 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10546 (2018‑10‑31)
            Description Reason for medication being prescribed, where known.

            Properties

            FHIR MedicationStatement.reasonCode
            Operationalization Free text
            Value Domain
            Property
            max length
            150
            cancelled Start date/time
            prsb03-dataelement-13144
            Id prsb03-dataelement-13144 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10667 (2018‑11‑13 16:49:22)
            Description The date and/or time that the medication course should begin.
            Operationalization Date and time
            Value Domain
            Property
            Timestamp precision
            at least day, month and year, hour and minute
            cancelled End date/time
            prsb03-dataelement-13145
            Id prsb03-dataelement-13145 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10557 (2018‑10‑31)
            Description The date and/or time that the medication course should finish.
            Operationalization Date and time
            Value Domain
            Property
            Timestamp precision
            at least day, month and year, hour and minute
            cancelled Link to indication record
            prsb03-dataelement-13146
            Id prsb03-dataelement-13146 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10668 (2018‑11‑13 16:59:09)
            Description A link to the record which contains the indication for this medication order.
            Operationalization Free text with URL
            Value Domain
            Property
            max length
            150
            cancelled Comment/recommendation
            prsb03-dataelement-13147
            Id prsb03-dataelement-13147 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10547 (2018‑10‑31)
            Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

            Properties

            FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
            Operationalization Free text
            Value Domain
            Property
            max length
            150
            folder cancelled Medication change summary cluster
            prsb03-dataelement-13148
            Id prsb03-dataelement-13148 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10568 (2018‑10‑31)
            Description Records the changes made to medication.
            cancelled Status
            prsb03-dataelement-13149
            Id prsb03-dataelement-13149 (2020‑06‑24 16:06:14) 0.1
            Concept inherits from draft prsb03-dataelement-10669 (2018‑11‑13 17:00:50)
            Description The nature of any change made to the medication.
            Operationalization FHIR value set : Medication status
              Value Domain
              cancelled Indication
              prsb03-dataelement-13150
              Id prsb03-dataelement-13150 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10670 (2018‑11‑13 17:02:07)
              Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              cancelled Date of change
              prsb03-dataelement-13151
              Id prsb03-dataelement-13151 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10671 (2018‑11‑13 17:03:03)
              Description The date of the change - addition, or amendment
              Operationalization Date and time
              Value Domain
              Property
              Timestamp precision
              at least day, month and year, hour and minute
              cancelled Description of amendment
              prsb03-dataelement-13152
              Id prsb03-dataelement-13152 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10672 (2018‑11‑13 17:03:42)
              Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              cancelled Total dose daily quantity
              prsb03-dataelement-13153
              Id prsb03-dataelement-13153 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10665 (2018‑11‑13 16:44:41)
              Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
              Operationalization Free text
              Value Domain
              folder cancelled Person completing record
              prsb03-dataelement-13154
              Id prsb03-dataelement-13154 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
              Description Details of the person completing the record.
              Relationship
              cancelled Name
              prsb03-dataelement-13155
              Id prsb03-dataelement-13155 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
              Description The name of the person completing the record.
              Relationship
              Rationale Composition.author.Practitioner.name
              Operationalization Free text.
              Value Domain
              Property
              max length
              70
              cancelled Role
              prsb03-dataelement-13156
              Id prsb03-dataelement-13156 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
              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
              cancelled Grade
              prsb03-dataelement-13157
              Id prsb03-dataelement-13157 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
              Description The grade of the person completing the record.
              Relationship
              Rationale PractitionerRole.code
              Operationalization Free text.
              Value Domain
              Property
              max length
              150
              cancelled Specialty
              prsb03-dataelement-13158
              Id prsb03-dataelement-13158 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
              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
              folder cancelled Organisation
              prsb03-dataelement-13159
              Id prsb03-dataelement-13159 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
              Description The organisation the person completing the record works for.
              Relationship
              cancelled Professional identifier
              prsb03-dataelement-13160
              Id prsb03-dataelement-13160 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
              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
              cancelled Date completed
              prsb03-dataelement-13161
              Id prsb03-dataelement-13161 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
              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
              cancelled Contact details
              prsb03-dataelement-13162
              Id prsb03-dataelement-13162 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
              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
              folder cancelled Medication discontinued entry
              prsb03-dataelement-13163
              Id prsb03-dataelement-13163 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10576 (2018‑10‑31)
              Description Medication discontinued entry
              folder cancelled Name of discontinued medication
              prsb03-dataelement-13164
              Id prsb03-dataelement-13164 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10577 (2018‑10‑31)
              Description The name of the medication or medical device being discontinued
              cancelled Status
              prsb03-dataelement-13165
              Id prsb03-dataelement-13165 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-12472 (2019‑06‑25 11:42:23)
              Description The status of any change made to the medication. MUST CONTAIN STOPPED.
              Operationalization FHIR value set: - Medication status
              Value Domain
              cancelled Status
              prsb03-dataelement-13166
              Id prsb03-dataelement-13166 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from cancelled prsb03-dataelement-10578 (2018‑10‑31)
              Description The nature of any change made to the medication.
              Operationalization Free text
              Value Domain
              cancelled Indication
              prsb03-dataelement-13167
              Id prsb03-dataelement-13167 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10579 (2018‑10‑31)
              Description The clinical indication for any changes in medication status
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              cancelled Date of change
              prsb03-dataelement-13168
              Id prsb03-dataelement-13168 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10580 (2018‑10‑31)
              Description The date of the discontinuation
              Operationalization Date and time
              Value Domain
              Property
              Timestamp precision
              at least day, month and year, hour and minute
              cancelled Description of amendment
              prsb03-dataelement-13169
              Id prsb03-dataelement-13169 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10581 (2018‑10‑31)
              Description A description of any amendment
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              cancelled Comment
              prsb03-dataelement-13170
              Id prsb03-dataelement-13170 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10582 (2018‑10‑31)
              Description Any additional comment about the discontinuation or amendment.
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              folder cancelled Medical devices entry
              prsb03-dataelement-13171
              Id prsb03-dataelement-13171 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10583 (2018‑10‑31)
              Description Medical devices
              cancelled Medical device
              prsb03-dataelement-13172
              Id prsb03-dataelement-13172 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-10673 (2018‑11‑13 17:10:15)
              Description Any medical device that isn't prescribed.
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              cancelled Comments
              prsb03-dataelement-13173
              Id prsb03-dataelement-13173 (2020‑06‑24 16:06:14) 0.1
              Concept inherits from draft prsb03-dataelement-11280 (2019‑05‑29 17:47:02)
              Description Any information regarding the medical device.
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              folder draft Acute medications
              prsb03-dataelement-12646
              Id prsb03-dataelement-12646 (2019‑11‑19 15:49:41)
              Description This is the sub-section where all acute medications within a specific period are recorded.
              draft Acute medication extraction period
              prsb03-dataelement-12647
              Id prsb03-dataelement-12647 (2019‑11‑19 15:51:07)
              Description Acute medications (For the 12 month period <dd-Mmm-yyyy> to <dd-Mmm-yyyy>)
              Value Domain
              Property
              Timestamp precision
              at least day, month and year
              cancelled 
              prsb03-dataelement-12648
              Id prsb03-dataelement-12648 (2019‑11‑19 17:03:31)
              Value Domain
              folder draft Medication item cluster
              prsb03-dataelement-12649
              Id prsb03-dataelement-12649 (2019‑11‑19 17:03:32)
              Description Medication item cluster
              Relationship
              cancelled Date
              prsb03-dataelement-12650
              Id prsb03-dataelement-12650 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
              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 0 transactions, 0 templates, inherited once
               
              folder cancelled Location
              prsb03-dataelement-12651
              Id prsb03-dataelement-12651 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
              Description The location where the medication or the medical device was prescribed.
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Performing professional
              prsb03-dataelement-12652
              Id prsb03-dataelement-12652 (2019‑11‑19 17:11:10)
              Concept inherits from cancelled prsb03-dataelement-10845 (2019‑03‑27 17:01:47)
              Description Details of the professional prescribing the medication or medical device.
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              folder cancelled Performing professional
              prsb03-dataelement-12653
              Id prsb03-dataelement-12653 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
              Description The professional who prescribed the medication or medical device.
              Relationship
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Name
              prsb03-dataelement-12654
              Id prsb03-dataelement-12654 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
              Description The name of the professional.
              Rationale Practitioner.name
              Operationalization Free text.
              Value Domain
              Property
              max length
              70
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Role
              prsb03-dataelement-12655
              Id prsb03-dataelement-12655 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
              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 0 transactions, 0 templates, inherited once
               
              cancelled Grade
              prsb03-dataelement-12656
              Id prsb03-dataelement-12656 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
              Description The grade of the professional.
              Rationale PractitionerRole.code
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Speciality
              prsb03-dataelement-12657
              Id prsb03-dataelement-12657 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
              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 0 transactions, 0 templates, inherited once
               
              cancelled Professional identifier
              prsb03-dataelement-12658
              Id prsb03-dataelement-12658 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
              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 0 transactions, 0 templates, inherited once
               
              folder cancelled Organisation
              prsb03-dataelement-12659
              Id prsb03-dataelement-12659 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
              Description The name of the organisation the professional works for.
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Contact details
              prsb03-dataelement-12660
              Id prsb03-dataelement-12660 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
              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 0 transactions, 0 templates, inherited once
               
              folder draft Medication name
              prsb03-dataelement-12661
              Id prsb03-dataelement-12661 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              folder draft Form
              prsb03-dataelement-12662
              Id prsb03-dataelement-12662 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10537 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              folder cancelled Quantity supplied
              prsb03-dataelement-12663
              Id prsb03-dataelement-12663 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10539 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              folder draft Route
              prsb03-dataelement-12664
              Id prsb03-dataelement-12664 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
              Description The route by which the medication is administered e.g. oral, IM, IV

              Properties

              FHIR MedicationStatement.dosage.route
              target Used by 0 transactions, 0 templates, inherited once
               
              folder draft Site
              prsb03-dataelement-12665
              Id prsb03-dataelement-12665 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10540 (2018‑10‑31)
              Description The anatomical site at which the medication is to be administered.

              Properties

              FHIR MedicationStatement.dosage.site
              target Used by 0 transactions, 0 templates, inherited once
               
              folder draft Method
              prsb03-dataelement-12666
              Id prsb03-dataelement-12666 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10541 (2018‑10‑31)
              Description The technique or method by which the medication is to be administered.

              Properties

              FHIR MedicationStatement.dosage.method
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Dose directions description
              prsb03-dataelement-12667
              Id prsb03-dataelement-12667 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10544 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              cancelled Dose amount description
              prsb03-dataelement-12668
              Id prsb03-dataelement-12668 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10542 (2018‑10‑31)
              Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

              Properties

              FHIR MedicationStatement.dosage.text
              Operationalization Free text
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Dose timing description
              prsb03-dataelement-12669
              Id prsb03-dataelement-12669 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10543 (2018‑10‑31)
              Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

              Properties

              FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
              Operationalization Free text
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Parsable dose directions
              prsb03-dataelement-12670
              Id prsb03-dataelement-12670 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10552 (2018‑10‑31)
              Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
              Value Domain
              Property
              max length
              150
              target Used by 0 transactions, 0 templates, inherited once
               
              folder draft Structured dose direction cluster
              prsb03-dataelement-12671
              Id prsb03-dataelement-12671 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
              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 0 transactions, 0 templates, inherited once
               
              draft Structured dose direction
              prsb03-dataelement-12672
              Id prsb03-dataelement-12672 (2019‑11‑19 17:11:10)
              Concept inherits from cancelled prsb03-dataelement-10553 (2018‑10‑31)
              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.
              Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              draft Structured dose amount
              prsb03-dataelement-12673
              Id prsb03-dataelement-12673 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10554 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              draft Structured dose timing
              prsb03-dataelement-12674
              Id prsb03-dataelement-12674 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10555 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              draft Dose direction duration
              prsb03-dataelement-12675
              Id prsb03-dataelement-12675 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10548 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              draft Prescribed quantity
              prsb03-dataelement-12701
              Id prsb03-dataelement-12701 (2019‑11‑19 17:22:14)
              Description Medication quantity prescribed
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              draft Authorised date
              prsb03-dataelement-12702
              Id prsb03-dataelement-12702 (2019‑11‑19 17:23:30)
              Concept inherits from cancelled prsb03-dataelement-10558 (2018‑10‑31)
              Description Date prescriber created prescription
              Operationalization Date and Time
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled 
              prsb03-dataelement-12703
              Id prsb03-dataelement-12703 (2019‑11‑19 17:24:54)
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              draft Valid from date
              prsb03-dataelement-12704
              Id prsb03-dataelement-12704 (2019‑11‑19 17:24:55)
              Concept inherits from cancelled prsb03-dataelement-10560 (2018‑10‑31)
              Description Date the prescription can be issued from. Valid for 6 months
              Operationalization Date and Time
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              draft Indication
              prsb03-dataelement-12705
              Id prsb03-dataelement-12705 (2019‑11‑19 17:26:09)
              Concept inherits from draft prsb03-dataelement-10579 (2018‑10‑31)
              Description The clinical indication for any changes in medication status
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              target Used by 0 transactions, 0 templates, inherited once
               
              draft Additional instructions
              prsb03-dataelement-12676
              Id prsb03-dataelement-12676 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10545 (2018‑10‑31)
              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 0 transactions, 0 templates, inherited once
               
              draft Request for advice
              prsb03-dataelement-12677
              Id prsb03-dataelement-12677 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10559 (2018‑10‑31)
              Description Request for advice and recommendation about medication
              Operationalization Free text
              Value Domain
              Property
              max length
              150
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Person completing record
              prsb03-dataelement-12678
              Id prsb03-dataelement-12678 (2019‑11‑19 17:11:10)
              Concept inherits from cancelled prsb03-dataelement-10961 (2019‑05‑18 21:23:41)
              Description This is the person recording the medication.

              Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
              Relationship
              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
              Value Domain
              target Used by 0 transactions, 0 templates, inherited once
               
              folder cancelled Course details cluster
              prsb03-dataelement-12679
              Id prsb03-dataelement-12679 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10561 (2018‑10‑31)
              Description Details of the overall course of medication.
              target Used by 0 transactions, 0 templates, inherited once
               
              cancelled Course status
              prsb03-dataelement-12680
              Id prsb03-dataelement-12680 (2019‑11‑19 17:11:10)
              Concept inherits from draft prsb03-dataelement-10666 (2018‑11‑13 16:47:55)
              Description The status of this prescription.
              Operationalization FHIR value set : - Medication status
                Value Domain
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled Indication
                prsb03-dataelement-12681
                Id prsb03-dataelement-12681 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10546 (2018‑10‑31)
                Description Reason for medication being prescribed, where known.

                Properties

                FHIR MedicationStatement.reasonCode
                Operationalization Free text
                Value Domain
                Property
                max length
                150
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled Start date/time
                prsb03-dataelement-12682
                Id prsb03-dataelement-12682 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10667 (2018‑11‑13 16:49:22)
                Description The date and/or time that the medication course should begin.
                Operationalization Date and time
                Value Domain
                Property
                Timestamp precision
                at least day, month and year, hour and minute
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled End date/time
                prsb03-dataelement-12683
                Id prsb03-dataelement-12683 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10557 (2018‑10‑31)
                Description The date and/or time that the medication course should finish.
                Operationalization Date and time
                Value Domain
                Property
                Timestamp precision
                at least day, month and year, hour and minute
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled Link to indication record
                prsb03-dataelement-12684
                Id prsb03-dataelement-12684 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10668 (2018‑11‑13 16:59:09)
                Description A link to the record which contains the indication for this medication order.
                Operationalization Free text with URL
                Value Domain
                Property
                max length
                150
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled Comment/recommendation
                prsb03-dataelement-12685
                Id prsb03-dataelement-12685 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10547 (2018‑10‑31)
                Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

                Properties

                FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
                Operationalization Free text
                Value Domain
                Property
                max length
                150
                target Used by 0 transactions, 0 templates, inherited once
                 
                folder cancelled Medication change summary cluster
                prsb03-dataelement-12686
                Id prsb03-dataelement-12686 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10568 (2018‑10‑31)
                Description Records the changes made to medication.
                target Used by 0 transactions, 0 templates, inherited once
                 
                cancelled Status
                prsb03-dataelement-12687
                Id prsb03-dataelement-12687 (2019‑11‑19 17:11:10)
                Concept inherits from draft prsb03-dataelement-10669 (2018‑11‑13 17:00:50)
                Description The nature of any change made to the medication.
                Operationalization FHIR value set : Medication status
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Indication
                  prsb03-dataelement-12688
                  Id prsb03-dataelement-12688 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-10670 (2018‑11‑13 17:02:07)
                  Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
                  Operationalization Free text
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Date of change
                  prsb03-dataelement-12689
                  Id prsb03-dataelement-12689 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-10671 (2018‑11‑13 17:03:03)
                  Description The date of the change - addition, or amendment
                  Operationalization Date and time
                  Value Domain
                  Property
                  Timestamp precision
                  at least day, month and year, hour and minute
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Description of amendment
                  prsb03-dataelement-12690
                  Id prsb03-dataelement-12690 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-10672 (2018‑11‑13 17:03:42)
                  Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
                  Operationalization Free text
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Total dose daily quantity
                  prsb03-dataelement-12691
                  Id prsb03-dataelement-12691 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-10665 (2018‑11‑13 16:44:41)
                  Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
                  Operationalization Free text
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Person completing record
                  prsb03-dataelement-12692
                  Id prsb03-dataelement-12692 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
                  Description Details of the person completing the record.
                  Relationship
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Name
                  prsb03-dataelement-12693
                  Id prsb03-dataelement-12693 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Role
                  prsb03-dataelement-12694
                  Id prsb03-dataelement-12694 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Grade
                  prsb03-dataelement-12695
                  Id prsb03-dataelement-12695 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Specialty
                  prsb03-dataelement-12696
                  Id prsb03-dataelement-12696 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Organisation
                  prsb03-dataelement-12697
                  Id prsb03-dataelement-12697 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
                  Description The organisation the person completing the record works for.
                  Relationship
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Professional identifier
                  prsb03-dataelement-12698
                  Id prsb03-dataelement-12698 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Date completed
                  prsb03-dataelement-12699
                  Id prsb03-dataelement-12699 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Contact details
                  prsb03-dataelement-12700
                  Id prsb03-dataelement-12700 (2019‑11‑19 17:11:10)
                  Concept inherits from draft prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder draft Repeat medications
                  prsb03-dataelement-10585
                  Id prsb03-dataelement-10585 (2018‑10‑31)
                  Description This is the sub-section where all repeat medications within a specific period are recorded
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder draft Medication item cluster
                  prsb03-dataelement-12706
                  Id prsb03-dataelement-12706 (2019‑11‑19 17:33:23)
                  Description Medication item cluster
                  Relationship
                  cancelled Date
                  prsb03-dataelement-12707
                  Id prsb03-dataelement-12707 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12650 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Location
                  prsb03-dataelement-12708
                  Id prsb03-dataelement-12708 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12651 (2019‑11‑19 17:11:10)
                  Description The location where the medication or the medical device was prescribed.
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Performing professional
                  prsb03-dataelement-12709
                  Id prsb03-dataelement-12709 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12652 (2019‑11‑19 17:11:10)
                  Description Details of the professional prescribing the medication or medical device.
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Performing professional
                  prsb03-dataelement-12710
                  Id prsb03-dataelement-12710 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12653 (2019‑11‑19 17:11:10)
                  Description The professional who prescribed the medication or medical device.
                  Relationship
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Name
                  prsb03-dataelement-12711
                  Id prsb03-dataelement-12711 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12654 (2019‑11‑19 17:11:10)
                  Description The name of the professional.
                  Rationale Practitioner.name
                  Operationalization Free text.
                  Value Domain
                  Property
                  max length
                  70
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Role
                  prsb03-dataelement-12712
                  Id prsb03-dataelement-12712 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12655 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Grade
                  prsb03-dataelement-12713
                  Id prsb03-dataelement-12713 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12656 (2019‑11‑19 17:11:10)
                  Description The grade of the professional.
                  Rationale PractitionerRole.code
                  Operationalization Free text
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Speciality
                  prsb03-dataelement-12714
                  Id prsb03-dataelement-12714 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12657 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Professional identifier
                  prsb03-dataelement-12715
                  Id prsb03-dataelement-12715 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12658 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Organisation
                  prsb03-dataelement-12716
                  Id prsb03-dataelement-12716 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12659 (2019‑11‑19 17:11:10)
                  Description The name of the organisation the professional works for.
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Contact details
                  prsb03-dataelement-12717
                  Id prsb03-dataelement-12717 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12660 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder draft Medication name
                  prsb03-dataelement-12718
                  Id prsb03-dataelement-12718 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12661 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder draft Form
                  prsb03-dataelement-12719
                  Id prsb03-dataelement-12719 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12662 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Quantity supplied
                  prsb03-dataelement-12720
                  Id prsb03-dataelement-12720 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12663 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  folder draft Route
                  prsb03-dataelement-12721
                  Id prsb03-dataelement-12721 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12664 (2019‑11‑19 17:11:10)
                  Description The route by which the medication is administered e.g. oral, IM, IV

                  Properties

                  FHIR MedicationStatement.dosage.route
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder draft Site
                  prsb03-dataelement-12722
                  Id prsb03-dataelement-12722 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12665 (2019‑11‑19 17:11:10)
                  Description The anatomical site at which the medication is to be administered.

                  Properties

                  FHIR MedicationStatement.dosage.site
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder draft Method
                  prsb03-dataelement-12723
                  Id prsb03-dataelement-12723 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12666 (2019‑11‑19 17:11:10)
                  Description The technique or method by which the medication is to be administered.

                  Properties

                  FHIR MedicationStatement.dosage.method
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Dose directions description
                  prsb03-dataelement-12724
                  Id prsb03-dataelement-12724 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12667 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  cancelled Dose amount description
                  prsb03-dataelement-12725
                  Id prsb03-dataelement-12725 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12668 (2019‑11‑19 17:11:10)
                  Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

                  Properties

                  FHIR MedicationStatement.dosage.text
                  Operationalization Free text
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Dose timing description
                  prsb03-dataelement-12726
                  Id prsb03-dataelement-12726 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12669 (2019‑11‑19 17:11:10)
                  Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

                  Properties

                  FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
                  Operationalization Free text
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Parsable dose directions
                  prsb03-dataelement-12727
                  Id prsb03-dataelement-12727 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12670 (2019‑11‑19 17:11:10)
                  Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder draft Structured dose direction cluster
                  prsb03-dataelement-12728
                  Id prsb03-dataelement-12728 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12671 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  draft Structured dose direction
                  prsb03-dataelement-12729
                  Id prsb03-dataelement-12729 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12672 (2019‑11‑19 17:11:10)
                  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.
                  Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Structured dose amount
                  prsb03-dataelement-12730
                  Id prsb03-dataelement-12730 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12673 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  draft Structured dose timing
                  prsb03-dataelement-12731
                  Id prsb03-dataelement-12731 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12674 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  draft Dose direction duration
                  prsb03-dataelement-12732
                  Id prsb03-dataelement-12732 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12675 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  draft Prescribed quantity
                  prsb03-dataelement-12733
                  Id prsb03-dataelement-12733 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12701 (2019‑11‑19 17:22:14)
                  Description Medication quantity prescribed
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Date started
                  prsb03-dataelement-12763
                  Id prsb03-dataelement-12763 (2019‑11‑19 17:40:42)
                  Description This is when the medication was first prescribed.
                  Value Domain
                  Property
                  Timestamp precision
                  at least day, month and year
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Authorised date
                  prsb03-dataelement-12734
                  Id prsb03-dataelement-12734 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12702 (2019‑11‑19 17:23:30)
                  Description Date prescriber created prescription
                  Operationalization Date and Time
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled 
                  prsb03-dataelement-12735
                  Id prsb03-dataelement-12735 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12703 (2019‑11‑19 17:24:54)
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Valid from date
                  prsb03-dataelement-12736
                  Id prsb03-dataelement-12736 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12704 (2019‑11‑19 17:24:55)
                  Description Date the prescription can be issued from. Valid for 6 months
                  Operationalization Date and Time
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Number of issues permissable
                  prsb03-dataelement-12764
                  Id prsb03-dataelement-12764 (2019‑11‑19 17:41:55)
                  Description The number of repeat issues permissible
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Number of issues made
                  prsb03-dataelement-12765
                  Id prsb03-dataelement-12765 (2019‑11‑19 17:43:17)
                  Description The number of repeats already issued
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Valid to date
                  prsb03-dataelement-12766
                  Id prsb03-dataelement-12766 (2019‑11‑19 17:44:06)
                  Description Date the prescription is valid to
                  Value Domain
                  Property
                  Timestamp precision
                  at least day, month and year
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Indication
                  prsb03-dataelement-12737
                  Id prsb03-dataelement-12737 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12705 (2019‑11‑19 17:26:09)
                  Description The clinical indication for any changes in medication status
                  Operationalization Free text
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Additional instructions
                  prsb03-dataelement-12738
                  Id prsb03-dataelement-12738 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12676 (2019‑11‑19 17:11:10)
                  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 0 transactions, 0 templates, inherited once
                   
                  draft Request for advice
                  prsb03-dataelement-12739
                  Id prsb03-dataelement-12739 (2019‑11‑19 17:33:50)
                  Concept inherits from draft prsb03-dataelement-12677 (2019‑11‑19 17:11:10)
                  Description Request for advice and recommendation about medication
                  Operationalization Free text
                  Value Domain
                  Property
                  max length
                  150
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  draft Request dispensed
                  prsb03-dataelement-12767
                  Id prsb03-dataelement-12767 (2019‑11‑19 17:45:17)
                  Description This is an indicator as to whether the item will be repeat dispensed by pharmacy
                  Operationalization Repeat dispense by pharmacy, not repeat dispense by pharmacy.
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Person completing record
                  prsb03-dataelement-12740
                  Id prsb03-dataelement-12740 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12678 (2019‑11‑19 17:11:10)
                  Description This is the person recording the medication.

                  Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                  Relationship
                  Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                  Value Domain
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  folder cancelled Course details cluster
                  prsb03-dataelement-12741
                  Id prsb03-dataelement-12741 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12679 (2019‑11‑19 17:11:10)
                  Description Details of the overall course of medication.
                  target Used by 0 transactions, 0 templates, inherited once
                   
                  cancelled Course status
                  prsb03-dataelement-12742
                  Id prsb03-dataelement-12742 (2019‑11‑19 17:33:50)
                  Concept inherits from cancelled prsb03-dataelement-12680 (2019‑11‑19 17:11:10)
                  Description The status of this prescription.
                  Operationalization FHIR value set : - Medication status
                    Value Domain
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled Indication
                    prsb03-dataelement-12743
                    Id prsb03-dataelement-12743 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12681 (2019‑11‑19 17:11:10)
                    Description Reason for medication being prescribed, where known.

                    Properties

                    FHIR MedicationStatement.reasonCode
                    Operationalization Free text
                    Value Domain
                    Property
                    max length
                    150
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled Start date/time
                    prsb03-dataelement-12744
                    Id prsb03-dataelement-12744 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12682 (2019‑11‑19 17:11:10)
                    Description The date and/or time that the medication course should begin.
                    Operationalization Date and time
                    Value Domain
                    Property
                    Timestamp precision
                    at least day, month and year, hour and minute
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled End date/time
                    prsb03-dataelement-12745
                    Id prsb03-dataelement-12745 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12683 (2019‑11‑19 17:11:10)
                    Description The date and/or time that the medication course should finish.
                    Operationalization Date and time
                    Value Domain
                    Property
                    Timestamp precision
                    at least day, month and year, hour and minute
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled Link to indication record
                    prsb03-dataelement-12746
                    Id prsb03-dataelement-12746 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12684 (2019‑11‑19 17:11:10)
                    Description A link to the record which contains the indication for this medication order.
                    Operationalization Free text with URL
                    Value Domain
                    Property
                    max length
                    150
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled Comment/recommendation
                    prsb03-dataelement-12747
                    Id prsb03-dataelement-12747 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12685 (2019‑11‑19 17:11:10)
                    Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

                    Properties

                    FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
                    Operationalization Free text
                    Value Domain
                    Property
                    max length
                    150
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    folder cancelled Medication change summary cluster
                    prsb03-dataelement-12748
                    Id prsb03-dataelement-12748 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12686 (2019‑11‑19 17:11:10)
                    Description Records the changes made to medication.
                    target Used by 0 transactions, 0 templates, inherited once
                     
                    cancelled Status
                    prsb03-dataelement-12749
                    Id prsb03-dataelement-12749 (2019‑11‑19 17:33:50)
                    Concept inherits from cancelled prsb03-dataelement-12687 (2019‑11‑19 17:11:10)
                    Description The nature of any change made to the medication.
                    Operationalization FHIR value set : Medication status
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Indication
                      prsb03-dataelement-12750
                      Id prsb03-dataelement-12750 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12688 (2019‑11‑19 17:11:10)
                      Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
                      Operationalization Free text
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Date of change
                      prsb03-dataelement-12751
                      Id prsb03-dataelement-12751 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12689 (2019‑11‑19 17:11:10)
                      Description The date of the change - addition, or amendment
                      Operationalization Date and time
                      Value Domain
                      Property
                      Timestamp precision
                      at least day, month and year, hour and minute
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Description of amendment
                      prsb03-dataelement-12752
                      Id prsb03-dataelement-12752 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12690 (2019‑11‑19 17:11:10)
                      Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
                      Operationalization Free text
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Total dose daily quantity
                      prsb03-dataelement-12753
                      Id prsb03-dataelement-12753 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12691 (2019‑11‑19 17:11:10)
                      Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
                      Operationalization Free text
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Person completing record
                      prsb03-dataelement-12754
                      Id prsb03-dataelement-12754 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12692 (2019‑11‑19 17:11:10)
                      Description Details of the person completing the record.
                      Relationship
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Name
                      prsb03-dataelement-12755
                      Id prsb03-dataelement-12755 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12693 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Role
                      prsb03-dataelement-12756
                      Id prsb03-dataelement-12756 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12694 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Grade
                      prsb03-dataelement-12757
                      Id prsb03-dataelement-12757 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12695 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Specialty
                      prsb03-dataelement-12758
                      Id prsb03-dataelement-12758 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12696 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Organisation
                      prsb03-dataelement-12759
                      Id prsb03-dataelement-12759 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12697 (2019‑11‑19 17:11:10)
                      Description The organisation the person completing the record works for.
                      Relationship
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Professional identifier
                      prsb03-dataelement-12760
                      Id prsb03-dataelement-12760 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12698 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Date completed
                      prsb03-dataelement-12761
                      Id prsb03-dataelement-12761 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12699 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Contact details
                      prsb03-dataelement-12762
                      Id prsb03-dataelement-12762 (2019‑11‑19 17:33:50)
                      Concept inherits from cancelled prsb03-dataelement-12700 (2019‑11‑19 17:11:10)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder draft Discontinued medications
                      prsb03-dataelement-12768
                      Id prsb03-dataelement-12768 (2019‑11‑19 17:50:19)
                      Description This is the sub-section where all discontinued repeat medications are recorded.
                      draft Discontinued medication extraction period
                      prsb03-dataelement-12769
                      Id prsb03-dataelement-12769 (2019‑11‑19 17:51:54)
                      Description Date range of discontinued medications
                      Operationalization Discontinued Medications (For the <X> month period <dd-Mmm-yyyy> to <dd-Mmm-yyyy>)
                      Value Domain
                      Property
                      Timestamp precision
                      at least day, month and year
                      folder draft Medication item cluster
                      prsb03-dataelement-12770
                      Id prsb03-dataelement-12770 (2019‑11‑19 17:56:27)
                      Description Medication item cluster
                      Relationship
                      cancelled Date
                      prsb03-dataelement-12832
                      Id prsb03-dataelement-12832 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12707 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Location
                      prsb03-dataelement-12833
                      Id prsb03-dataelement-12833 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12708 (2019‑11‑19 17:33:50)
                      Description The location where the medication or the medical device was prescribed.
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Performing professional
                      prsb03-dataelement-12834
                      Id prsb03-dataelement-12834 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12709 (2019‑11‑19 17:33:50)
                      Description Details of the professional prescribing the medication or medical device.
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Performing professional
                      prsb03-dataelement-12835
                      Id prsb03-dataelement-12835 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12710 (2019‑11‑19 17:33:50)
                      Description The professional who prescribed the medication or medical device.
                      Relationship
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Name
                      prsb03-dataelement-12836
                      Id prsb03-dataelement-12836 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12711 (2019‑11‑19 17:33:50)
                      Description The name of the professional.
                      Rationale Practitioner.name
                      Operationalization Free text.
                      Value Domain
                      Property
                      max length
                      70
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Role
                      prsb03-dataelement-12837
                      Id prsb03-dataelement-12837 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12712 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Grade
                      prsb03-dataelement-12838
                      Id prsb03-dataelement-12838 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12713 (2019‑11‑19 17:33:50)
                      Description The grade of the professional.
                      Rationale PractitionerRole.code
                      Operationalization Free text
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Speciality
                      prsb03-dataelement-12839
                      Id prsb03-dataelement-12839 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12714 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Professional identifier
                      prsb03-dataelement-12840
                      Id prsb03-dataelement-12840 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12715 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Organisation
                      prsb03-dataelement-12841
                      Id prsb03-dataelement-12841 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12716 (2019‑11‑19 17:33:50)
                      Description The name of the organisation the professional works for.
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Contact details
                      prsb03-dataelement-12842
                      Id prsb03-dataelement-12842 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12717 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder draft Medication name
                      prsb03-dataelement-12843
                      Id prsb03-dataelement-12843 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12718 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder draft Form
                      prsb03-dataelement-12844
                      Id prsb03-dataelement-12844 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12719 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Quantity supplied
                      prsb03-dataelement-12845
                      Id prsb03-dataelement-12845 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12720 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      folder draft Route
                      prsb03-dataelement-12846
                      Id prsb03-dataelement-12846 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12721 (2019‑11‑19 17:33:50)
                      Description The route by which the medication is administered e.g. oral, IM, IV

                      Properties

                      FHIR MedicationStatement.dosage.route
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder draft Site
                      prsb03-dataelement-12847
                      Id prsb03-dataelement-12847 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12722 (2019‑11‑19 17:33:50)
                      Description The anatomical site at which the medication is to be administered.

                      Properties

                      FHIR MedicationStatement.dosage.site
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder draft Method
                      prsb03-dataelement-12848
                      Id prsb03-dataelement-12848 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12723 (2019‑11‑19 17:33:50)
                      Description The technique or method by which the medication is to be administered.

                      Properties

                      FHIR MedicationStatement.dosage.method
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Dose directions description
                      prsb03-dataelement-12849
                      Id prsb03-dataelement-12849 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12724 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Dose amount description
                      prsb03-dataelement-12850
                      Id prsb03-dataelement-12850 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12725 (2019‑11‑19 17:33:50)
                      Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

                      Properties

                      FHIR MedicationStatement.dosage.text
                      Operationalization Free text
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Dose timing description
                      prsb03-dataelement-12851
                      Id prsb03-dataelement-12851 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12726 (2019‑11‑19 17:33:50)
                      Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

                      Properties

                      FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
                      Operationalization Free text
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Parsable dose directions
                      prsb03-dataelement-12852
                      Id prsb03-dataelement-12852 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12727 (2019‑11‑19 17:33:50)
                      Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder draft Structured dose direction cluster
                      prsb03-dataelement-12853
                      Id prsb03-dataelement-12853 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12728 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      draft Structured dose direction
                      prsb03-dataelement-12854
                      Id prsb03-dataelement-12854 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12729 (2019‑11‑19 17:33:50)
                      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.
                      Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Structured dose amount
                      prsb03-dataelement-12855
                      Id prsb03-dataelement-12855 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12730 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      draft Structured dose timing
                      prsb03-dataelement-12856
                      Id prsb03-dataelement-12856 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12731 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      draft Dose direction duration
                      prsb03-dataelement-12857
                      Id prsb03-dataelement-12857 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12732 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      draft Prescribed quantity
                      prsb03-dataelement-12858
                      Id prsb03-dataelement-12858 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12733 (2019‑11‑19 17:33:50)
                      Description Medication quantity prescribed
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Date started
                      prsb03-dataelement-12859
                      Id prsb03-dataelement-12859 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12763 (2019‑11‑19 17:40:42)
                      Description This is when the medication was first prescribed.
                      Value Domain
                      Property
                      Timestamp precision
                      at least day, month and year
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Date discontinued
                      prsb03-dataelement-12893
                      Id prsb03-dataelement-12893 (2019‑11‑19 18:02:44)
                      Description This is when the medication was stopped.
                      Operationalization Date/time
                      Value Domain
                      Property
                      Timestamp precision
                      at least day, month and year
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Authorised date
                      prsb03-dataelement-12860
                      Id prsb03-dataelement-12860 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12734 (2019‑11‑19 17:33:50)
                      Description Date prescriber created prescription
                      Operationalization Date and Time
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled 
                      prsb03-dataelement-12861
                      Id prsb03-dataelement-12861 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12735 (2019‑11‑19 17:33:50)
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Valid from date
                      prsb03-dataelement-12862
                      Id prsb03-dataelement-12862 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12736 (2019‑11‑19 17:33:50)
                      Description Date the prescription can be issued from. Valid for 6 months
                      Operationalization Date and Time
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Number of issues permissable
                      prsb03-dataelement-12863
                      Id prsb03-dataelement-12863 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12764 (2019‑11‑19 17:41:55)
                      Description The number of repeat issues permissible
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Number of issues made
                      prsb03-dataelement-12864
                      Id prsb03-dataelement-12864 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12765 (2019‑11‑19 17:43:17)
                      Description The number of repeats already issued
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Valid to date
                      prsb03-dataelement-12865
                      Id prsb03-dataelement-12865 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12766 (2019‑11‑19 17:44:06)
                      Description Date the prescription is valid to
                      Value Domain
                      Property
                      Timestamp precision
                      at least day, month and year
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Indication
                      prsb03-dataelement-12866
                      Id prsb03-dataelement-12866 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12737 (2019‑11‑19 17:33:50)
                      Description The clinical indication for any changes in medication status
                      Operationalization Free text
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Reason for discontinuation
                      prsb03-dataelement-12894
                      Id prsb03-dataelement-12894 (2019‑11‑19 18:10:11)
                      Description Reason medication was discontinued
                      Operationalization Free text
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      draft Additional instructions
                      prsb03-dataelement-12867
                      Id prsb03-dataelement-12867 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12738 (2019‑11‑19 17:33:50)
                      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 0 transactions, 0 templates, inherited once
                       
                      cancelled Request for advice
                      prsb03-dataelement-12868
                      Id prsb03-dataelement-12868 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12739 (2019‑11‑19 17:33:50)
                      Description Request for advice and recommendation about medication
                      Operationalization Free text
                      Value Domain
                      Property
                      max length
                      150
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Request dispensed
                      prsb03-dataelement-12869
                      Id prsb03-dataelement-12869 (2019‑11‑19 17:57:19)
                      Concept inherits from draft prsb03-dataelement-12767 (2019‑11‑19 17:45:17)
                      Description This is an indicator as to whether the item will be repeat dispensed by pharmacy
                      Operationalization Repeat dispense by pharmacy, not repeat dispense by pharmacy.
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Person completing record
                      prsb03-dataelement-12870
                      Id prsb03-dataelement-12870 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12740 (2019‑11‑19 17:33:50)
                      Description This is the person recording the medication.

                      Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                      Relationship
                      Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                      Value Domain
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      folder cancelled Course details cluster
                      prsb03-dataelement-12871
                      Id prsb03-dataelement-12871 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12741 (2019‑11‑19 17:33:50)
                      Description Details of the overall course of medication.
                      target Used by 0 transactions, 0 templates, inherited once
                       
                      cancelled Course status
                      prsb03-dataelement-12872
                      Id prsb03-dataelement-12872 (2019‑11‑19 17:57:19)
                      Concept inherits from cancelled prsb03-dataelement-12742 (2019‑11‑19 17:33:50)
                      Description The status of this prescription.
                      Operationalization FHIR value set : - Medication status
                        Value Domain
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled Indication
                        prsb03-dataelement-12873
                        Id prsb03-dataelement-12873 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12743 (2019‑11‑19 17:33:50)
                        Description Reason for medication being prescribed, where known.

                        Properties

                        FHIR MedicationStatement.reasonCode
                        Operationalization Free text
                        Value Domain
                        Property
                        max length
                        150
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled Start date/time
                        prsb03-dataelement-12874
                        Id prsb03-dataelement-12874 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12744 (2019‑11‑19 17:33:50)
                        Description The date and/or time that the medication course should begin.
                        Operationalization Date and time
                        Value Domain
                        Property
                        Timestamp precision
                        at least day, month and year, hour and minute
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled End date/time
                        prsb03-dataelement-12875
                        Id prsb03-dataelement-12875 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12745 (2019‑11‑19 17:33:50)
                        Description The date and/or time that the medication course should finish.
                        Operationalization Date and time
                        Value Domain
                        Property
                        Timestamp precision
                        at least day, month and year, hour and minute
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled Link to indication record
                        prsb03-dataelement-12876
                        Id prsb03-dataelement-12876 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12746 (2019‑11‑19 17:33:50)
                        Description A link to the record which contains the indication for this medication order.
                        Operationalization Free text with URL
                        Value Domain
                        Property
                        max length
                        150
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled Comment/recommendation
                        prsb03-dataelement-12877
                        Id prsb03-dataelement-12877 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12747 (2019‑11‑19 17:33:50)
                        Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

                        Properties

                        FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
                        Operationalization Free text
                        Value Domain
                        Property
                        max length
                        150
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        folder cancelled Medication change summary cluster
                        prsb03-dataelement-12878
                        Id prsb03-dataelement-12878 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12748 (2019‑11‑19 17:33:50)
                        Description Records the changes made to medication.
                        target Used by 0 transactions, 0 templates, inherited once
                         
                        cancelled Status
                        prsb03-dataelement-12879
                        Id prsb03-dataelement-12879 (2019‑11‑19 17:57:19)
                        Concept inherits from cancelled prsb03-dataelement-12749 (2019‑11‑19 17:33:50)
                        Description The nature of any change made to the medication.
                        Operationalization FHIR value set : Medication status
                          Value Domain
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Indication
                          prsb03-dataelement-12880
                          Id prsb03-dataelement-12880 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12750 (2019‑11‑19 17:33:50)
                          Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
                          Operationalization Free text
                          Value Domain
                          Property
                          max length
                          150
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Date of change
                          prsb03-dataelement-12881
                          Id prsb03-dataelement-12881 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12751 (2019‑11‑19 17:33:50)
                          Description The date of the change - addition, or amendment
                          Operationalization Date and time
                          Value Domain
                          Property
                          Timestamp precision
                          at least day, month and year, hour and minute
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Description of amendment
                          prsb03-dataelement-12882
                          Id prsb03-dataelement-12882 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12752 (2019‑11‑19 17:33:50)
                          Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
                          Operationalization Free text
                          Value Domain
                          Property
                          max length
                          150
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Total dose daily quantity
                          prsb03-dataelement-12883
                          Id prsb03-dataelement-12883 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12753 (2019‑11‑19 17:33:50)
                          Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
                          Operationalization Free text
                          Value Domain
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          folder cancelled Person completing record
                          prsb03-dataelement-12884
                          Id prsb03-dataelement-12884 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12754 (2019‑11‑19 17:33:50)
                          Description Details of the person completing the record.
                          Relationship
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Name
                          prsb03-dataelement-12885
                          Id prsb03-dataelement-12885 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12755 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          cancelled Role
                          prsb03-dataelement-12886
                          Id prsb03-dataelement-12886 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12756 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          cancelled Grade
                          prsb03-dataelement-12887
                          Id prsb03-dataelement-12887 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12757 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          cancelled Specialty
                          prsb03-dataelement-12888
                          Id prsb03-dataelement-12888 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12758 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          folder cancelled Organisation
                          prsb03-dataelement-12889
                          Id prsb03-dataelement-12889 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12759 (2019‑11‑19 17:33:50)
                          Description The organisation the person completing the record works for.
                          Relationship
                          target Used by 0 transactions, 0 templates, inherited once
                           
                          cancelled Professional identifier
                          prsb03-dataelement-12890
                          Id prsb03-dataelement-12890 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12760 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          cancelled Date completed
                          prsb03-dataelement-12891
                          Id prsb03-dataelement-12891 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12761 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          cancelled Contact details
                          prsb03-dataelement-12892
                          Id prsb03-dataelement-12892 (2019‑11‑19 17:57:19)
                          Concept inherits from cancelled prsb03-dataelement-12762 (2019‑11‑19 17:33:50)
                          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 0 transactions, 0 templates, inherited once
                           
                          folder draft Prescribed elsewhere
                          prsb03-dataelement-12895
                          Id prsb03-dataelement-12895 (2019‑11‑20 12:01:16)
                          Description Prescribed elsewhere: Medication managed by another organisation
                          Relationship
                          folder draft Medication item cluster
                          prsb03-dataelement-12896
                          Id prsb03-dataelement-12896 (2019‑11‑20 12:12:23)
                          Description Medication item cluster
                          Relationship
                          cancelled Date
                          prsb03-dataelement-12897
                          Id prsb03-dataelement-12897 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12832 (2019‑11‑19 17:57:19)
                          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
                          folder cancelled Location
                          prsb03-dataelement-12898
                          Id prsb03-dataelement-12898 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12833 (2019‑11‑19 17:57:19)
                          Description The location where the medication or the medical device was prescribed.
                          cancelled Performing professional
                          prsb03-dataelement-12899
                          Id prsb03-dataelement-12899 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12834 (2019‑11‑19 17:57:19)
                          Description Details of the professional prescribing the medication or medical device.
                          Value Domain
                          folder cancelled Performing professional
                          prsb03-dataelement-12900
                          Id prsb03-dataelement-12900 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12835 (2019‑11‑19 17:57:19)
                          Description The professional who prescribed the medication or medical device.
                          Relationship
                          cancelled Name
                          prsb03-dataelement-12901
                          Id prsb03-dataelement-12901 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12836 (2019‑11‑19 17:57:19)
                          Description The name of the professional.
                          Rationale Practitioner.name
                          Operationalization Free text.
                          Value Domain
                          Property
                          max length
                          70
                          cancelled Role
                          prsb03-dataelement-12902
                          Id prsb03-dataelement-12902 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12837 (2019‑11‑19 17:57:19)
                          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
                          cancelled Grade
                          prsb03-dataelement-12903
                          Id prsb03-dataelement-12903 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12838 (2019‑11‑19 17:57:19)
                          Description The grade of the professional.
                          Rationale PractitionerRole.code
                          Operationalization Free text
                          Value Domain
                          Property
                          max length
                          150
                          cancelled Speciality
                          prsb03-dataelement-12904
                          Id prsb03-dataelement-12904 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12839 (2019‑11‑19 17:57:19)
                          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
                          cancelled Professional identifier
                          prsb03-dataelement-12905
                          Id prsb03-dataelement-12905 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12840 (2019‑11‑19 17:57:19)
                          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
                          folder cancelled Organisation
                          prsb03-dataelement-12906
                          Id prsb03-dataelement-12906 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12841 (2019‑11‑19 17:57:19)
                          Description The name of the organisation the professional works for.
                          cancelled Contact details
                          prsb03-dataelement-12907
                          Id prsb03-dataelement-12907 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12842 (2019‑11‑19 17:57:19)
                          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
                          folder draft Medication name
                          prsb03-dataelement-12908
                          Id prsb03-dataelement-12908 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12843 (2019‑11‑19 17:57:19)
                          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)
                          folder draft Form
                          prsb03-dataelement-12909
                          Id prsb03-dataelement-12909 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12844 (2019‑11‑19 17:57:19)
                          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
                          folder cancelled Quantity supplied
                          prsb03-dataelement-12910
                          Id prsb03-dataelement-12910 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12845 (2019‑11‑19 17:57:19)
                          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
                          folder draft Route
                          prsb03-dataelement-12911
                          Id prsb03-dataelement-12911 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12846 (2019‑11‑19 17:57:19)
                          Description The route by which the medication is administered e.g. oral, IM, IV

                          Properties

                          FHIR MedicationStatement.dosage.route
                          folder draft Site
                          prsb03-dataelement-12912
                          Id prsb03-dataelement-12912 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12847 (2019‑11‑19 17:57:19)
                          Description The anatomical site at which the medication is to be administered.

                          Properties

                          FHIR MedicationStatement.dosage.site
                          folder draft Method
                          prsb03-dataelement-12913
                          Id prsb03-dataelement-12913 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12848 (2019‑11‑19 17:57:19)
                          Description The technique or method by which the medication is to be administered.

                          Properties

                          FHIR MedicationStatement.dosage.method
                          cancelled Dose directions description
                          prsb03-dataelement-12914
                          Id prsb03-dataelement-12914 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12849 (2019‑11‑19 17:57:19)
                          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
                          cancelled Dose amount description
                          prsb03-dataelement-12915
                          Id prsb03-dataelement-12915 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12850 (2019‑11‑19 17:57:19)
                          Description A description of the medication single dose amount e.g. "30 mg" or "2 tabs".

                          Properties

                          FHIR MedicationStatement.dosage.text
                          Operationalization Free text
                          Value Domain
                          cancelled Dose timing description
                          prsb03-dataelement-12916
                          Id prsb03-dataelement-12916 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12851 (2019‑11‑19 17:57:19)
                          Description A description of the frequency of taking or administration of a medication dose. e.g. "Twice a day", "At 8am, 2pm and 10pm".

                          Properties

                          FHIR MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats]
                          Operationalization Free text
                          Value Domain
                          cancelled Parsable dose directions
                          prsb03-dataelement-12917
                          Id prsb03-dataelement-12917 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12852 (2019‑11‑19 17:57:19)
                          Description A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information, e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems
                          Value Domain
                          Property
                          max length
                          150
                          folder draft Structured dose direction cluster
                          prsb03-dataelement-12918
                          Id prsb03-dataelement-12918 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12853 (2019‑11‑19 17:57:19)
                          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.
                          draft Structured dose direction
                          prsb03-dataelement-12919
                          Id prsb03-dataelement-12919 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12854 (2019‑11‑19 17:57:19)
                          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.
                          Operationalization As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
                          Value Domain
                          draft Structured dose amount
                          prsb03-dataelement-12920
                          Id prsb03-dataelement-12920 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12855 (2019‑11‑19 17:57:19)
                          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
                          draft Structured dose timing
                          prsb03-dataelement-12921
                          Id prsb03-dataelement-12921 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12856 (2019‑11‑19 17:57:19)
                          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
                          draft Dose direction duration
                          prsb03-dataelement-12922
                          Id prsb03-dataelement-12922 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12857 (2019‑11‑19 17:57:19)
                          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
                          cancelled Prescribed quantity
                          prsb03-dataelement-12923
                          Id prsb03-dataelement-12923 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12858 (2019‑11‑19 17:57:19)
                          Description Medication quantity prescribed
                          Value Domain
                          draft Date started
                          prsb03-dataelement-12924
                          Id prsb03-dataelement-12924 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12859 (2019‑11‑19 17:57:19)
                          Description This is when the medication was first prescribed.
                          Value Domain
                          Property
                          Timestamp precision
                          at least day, month and year
                          cancelled Date discontinued
                          prsb03-dataelement-12925
                          Id prsb03-dataelement-12925 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12893 (2019‑11‑19 18:02:44)
                          Description This is when the medication was stopped.
                          Operationalization Date/time
                          Value Domain
                          Property
                          Timestamp precision
                          at least day, month and year
                          cancelled Authorised date
                          prsb03-dataelement-12926
                          Id prsb03-dataelement-12926 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12860 (2019‑11‑19 17:57:19)
                          Description Date prescriber created prescription
                          Operationalization Date and Time
                          Value Domain
                          cancelled 
                          prsb03-dataelement-12927
                          Id prsb03-dataelement-12927 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12861 (2019‑11‑19 17:57:19)
                          Value Domain
                          cancelled Valid from date
                          prsb03-dataelement-12928
                          Id prsb03-dataelement-12928 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12862 (2019‑11‑19 17:57:19)
                          Description Date the prescription can be issued from. Valid for 6 months
                          Operationalization Date and Time
                          Value Domain
                          cancelled Number of issues permissable
                          prsb03-dataelement-12929
                          Id prsb03-dataelement-12929 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12863 (2019‑11‑19 17:57:19)
                          Description The number of repeat issues permissible
                          Value Domain
                          cancelled Number of issues made
                          prsb03-dataelement-12930
                          Id prsb03-dataelement-12930 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12864 (2019‑11‑19 17:57:19)
                          Description The number of repeats already issued
                          Value Domain
                          cancelled Valid to date
                          prsb03-dataelement-12931
                          Id prsb03-dataelement-12931 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12865 (2019‑11‑19 17:57:19)
                          Description Date the prescription is valid to
                          Value Domain
                          Property
                          Timestamp precision
                          at least day, month and year
                          draft Indication
                          prsb03-dataelement-12932
                          Id prsb03-dataelement-12932 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12866 (2019‑11‑19 17:57:19)
                          Description The clinical indication for any changes in medication status
                          Operationalization Free text
                          Value Domain
                          Property
                          max length
                          150
                          cancelled Reason for discontinuation
                          prsb03-dataelement-12933
                          Id prsb03-dataelement-12933 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12894 (2019‑11‑19 18:10:11)
                          Description Reason medication was discontinued
                          Operationalization Free text
                          Value Domain
                          draft Additional instructions
                          prsb03-dataelement-12934
                          Id prsb03-dataelement-12934 (2019‑11‑20 12:13:29)
                          Concept inherits from draft prsb03-dataelement-12867 (2019‑11‑19 17:57:19)
                          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
                          draft Comment/recommendation
                          prsb03-dataelement-12960
                          Id prsb03-dataelement-12960 (2019‑11‑20 12:24:31)
                          Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication.
                          Operationalization Free text
                          Value Domain
                          draft Organisation
                          prsb03-dataelement-12961
                          Id prsb03-dataelement-12961 (2019‑11‑20 12:25:46)
                          Description Prescribing organisation
                          Operationalization ODS code
                          Value Domain
                          cancelled Request for advice
                          prsb03-dataelement-12935
                          Id prsb03-dataelement-12935 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12868 (2019‑11‑19 17:57:19)
                          Description Request for advice and recommendation about medication
                          Operationalization Free text
                          Value Domain
                          Property
                          max length
                          150
                          cancelled Request dispensed
                          prsb03-dataelement-12936
                          Id prsb03-dataelement-12936 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12869 (2019‑11‑19 17:57:19)
                          Description This is an indicator as to whether the item will be repeat dispensed by pharmacy
                          Operationalization Repeat dispense by pharmacy, not repeat dispense by pharmacy.
                          Value Domain
                          cancelled Person completing record
                          prsb03-dataelement-12937
                          Id prsb03-dataelement-12937 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12870 (2019‑11‑19 17:57:19)
                          Description This is the person recording the medication.

                          Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                          Relationship
                          Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                          Value Domain
                          folder cancelled Course details cluster
                          prsb03-dataelement-12938
                          Id prsb03-dataelement-12938 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12871 (2019‑11‑19 17:57:19)
                          Description Details of the overall course of medication.
                          cancelled Course status
                          prsb03-dataelement-12939
                          Id prsb03-dataelement-12939 (2019‑11‑20 12:13:29)
                          Concept inherits from cancelled prsb03-dataelement-12872 (2019‑11‑19 17:57:19)
                          Description The status of this prescription.
                          Operationalization FHIR value set : - Medication status
                            Value Domain
                            cancelled Indication
                            prsb03-dataelement-12940
                            Id prsb03-dataelement-12940 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12873 (2019‑11‑19 17:57:19)
                            Description Reason for medication being prescribed, where known.

                            Properties

                            FHIR MedicationStatement.reasonCode
                            Operationalization Free text
                            Value Domain
                            Property
                            max length
                            150
                            cancelled Start date/time
                            prsb03-dataelement-12941
                            Id prsb03-dataelement-12941 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12874 (2019‑11‑19 17:57:19)
                            Description The date and/or time that the medication course should begin.
                            Operationalization Date and time
                            Value Domain
                            Property
                            Timestamp precision
                            at least day, month and year, hour and minute
                            cancelled End date/time
                            prsb03-dataelement-12942
                            Id prsb03-dataelement-12942 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12875 (2019‑11‑19 17:57:19)
                            Description The date and/or time that the medication course should finish.
                            Operationalization Date and time
                            Value Domain
                            Property
                            Timestamp precision
                            at least day, month and year, hour and minute
                            cancelled Link to indication record
                            prsb03-dataelement-12943
                            Id prsb03-dataelement-12943 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12876 (2019‑11‑19 17:57:19)
                            Description A link to the record which contains the indication for this medication order.
                            Operationalization Free text with URL
                            Value Domain
                            Property
                            max length
                            150
                            cancelled Comment/recommendation
                            prsb03-dataelement-12944
                            Id prsb03-dataelement-12944 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12877 (2019‑11‑19 17:57:19)
                            Description Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations

                            Properties

                            FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
                            Operationalization Free text
                            Value Domain
                            Property
                            max length
                            150
                            folder cancelled Medication change summary cluster
                            prsb03-dataelement-12945
                            Id prsb03-dataelement-12945 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12878 (2019‑11‑19 17:57:19)
                            Description Records the changes made to medication.
                            cancelled Status
                            prsb03-dataelement-12946
                            Id prsb03-dataelement-12946 (2019‑11‑20 12:13:29)
                            Concept inherits from cancelled prsb03-dataelement-12879 (2019‑11‑19 17:57:19)
                            Description The nature of any change made to the medication.
                            Operationalization FHIR value set : Medication status
                              Value Domain
                              cancelled Indication
                              prsb03-dataelement-12947
                              Id prsb03-dataelement-12947 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12880 (2019‑11‑19 17:57:19)
                              Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              cancelled Date of change
                              prsb03-dataelement-12948
                              Id prsb03-dataelement-12948 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12881 (2019‑11‑19 17:57:19)
                              Description The date of the change - addition, or amendment
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              cancelled Description of amendment
                              prsb03-dataelement-12949
                              Id prsb03-dataelement-12949 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12882 (2019‑11‑19 17:57:19)
                              Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              cancelled Total dose daily quantity
                              prsb03-dataelement-12950
                              Id prsb03-dataelement-12950 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12883 (2019‑11‑19 17:57:19)
                              Description The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
                              Operationalization Free text
                              Value Domain
                              folder cancelled Person completing record
                              prsb03-dataelement-12951
                              Id prsb03-dataelement-12951 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12884 (2019‑11‑19 17:57:19)
                              Description Details of the person completing the record.
                              Relationship
                              cancelled Name
                              prsb03-dataelement-12952
                              Id prsb03-dataelement-12952 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12885 (2019‑11‑19 17:57:19)
                              Description The name of the person completing the record.
                              Relationship
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              cancelled Role
                              prsb03-dataelement-12953
                              Id prsb03-dataelement-12953 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12886 (2019‑11‑19 17:57:19)
                              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
                              cancelled Grade
                              prsb03-dataelement-12954
                              Id prsb03-dataelement-12954 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12887 (2019‑11‑19 17:57:19)
                              Description The grade of the person completing the record.
                              Relationship
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              cancelled Specialty
                              prsb03-dataelement-12955
                              Id prsb03-dataelement-12955 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12888 (2019‑11‑19 17:57:19)
                              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
                              folder cancelled Organisation
                              prsb03-dataelement-12956
                              Id prsb03-dataelement-12956 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12889 (2019‑11‑19 17:57:19)
                              Description The organisation the person completing the record works for.
                              Relationship
                              cancelled Professional identifier
                              prsb03-dataelement-12957
                              Id prsb03-dataelement-12957 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12890 (2019‑11‑19 17:57:19)
                              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
                              cancelled Date completed
                              prsb03-dataelement-12958
                              Id prsb03-dataelement-12958 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12891 (2019‑11‑19 17:57:19)
                              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
                              cancelled Contact details
                              prsb03-dataelement-12959
                              Id prsb03-dataelement-12959 (2019‑11‑20 12:13:29)
                              Concept inherits from cancelled prsb03-dataelement-12892 (2019‑11‑19 17:57:19)
                              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
                              cancelled Performing Professional
                              prsb03-dataelement-10549
                              Id prsb03-dataelement-10549 (2018‑10‑31) 0.1
                              Description Details of the professional administering the Medication (including name and role)
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Location
                              prsb03-dataelement-10550
                              Id prsb03-dataelement-10550 (2018‑10‑31) 0.1
                              Description Details of where the Medication was administered
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Date
                              prsb03-dataelement-10551
                              Id prsb03-dataelement-10551 (2018‑10‑31) 0.1
                              Description The date on which the Medication was administered
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Start date/time
                              prsb03-dataelement-10556
                              Id prsb03-dataelement-10556 (2018‑10‑31) 0.1
                              Description The date and/or time that the medication course should begin.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Authorised date
                              prsb03-dataelement-10558
                              Id prsb03-dataelement-10558 (2018‑10‑31) 0.1
                              Description Date prescriber created prescription
                              Operationalization Date and Time
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              cancelled Valid from date
                              prsb03-dataelement-10560
                              Id prsb03-dataelement-10560 (2018‑10‑31) 0.1
                              Description Date the prescription can be issued from. Valid for 6 months
                              Operationalization Date and Time
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              folder cancelled For medications that have been changed
                              prsb03-dataelement-10607
                              Id prsb03-dataelement-10607 (2018‑10‑31) 0.1
                              Description i.e. additions, amendments and discontinued, in addition to the above, also record: is the sub-section where all current repeat medications are recorded.
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder cancelled •Prescribed elsewhere
                              prsb03-dataelement-10629
                              Id prsb03-dataelement-10629 (2018‑10‑31) 0.1
                              Description Prescribed elsewhere: Medication managed by another organisation
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Equipment and adaptations
                              prsb03-dataelement-12969
                              Id prsb03-dataelement-12969 (2020‑04‑06 18:25:26)
                              Description Details of equipment/asset (or modifications) that the Local Authority has provided to the patient.
                              folder draft Equipment record entry
                              prsb03-dataelement-12970
                              Id prsb03-dataelement-12970 (2020‑04‑06 18:27:46)
                              Description This is a equipment record entry. There may be 1 to many record entries under a section.
                              folder draft Equipment name
                              prsb03-dataelement-12971
                              Id prsb03-dataelement-12971 (2020‑04‑06 19:22:47)
                              Description The name of the equipment (e.g. 'Keysafe', 'Handrail' 'Lifeline Alarm', etc.)
                              draft Coded value
                              prsb03-dataelement-13780
                              Id prsb03-dataelement-13780 (2020‑10‑21 16:01:39)
                              Description The coded value for equipment name
                              Operationalization SNOMED CT
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13782
                              Id prsb03-dataelement-13782 (2020‑10‑21 16:08:03)
                              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
                              cancelled Free text
                              prsb03-dataelement-13781
                              Id prsb03-dataelement-13781 (2020‑10‑21 16:02:39) 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
                              draft Date
                              prsb03-dataelement-13066
                              Id prsb03-dataelement-13066 (2020‑05‑18 17:47:43)
                              Description
                              The date the equipment was issued.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Comment
                              prsb03-dataelement-12972
                              Id prsb03-dataelement-12972 (2020‑04‑06 19:25:30)
                              Description Any further details about the equipment, e.g. position of handrail(s) within the person's home
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Clinical Review of Systems
                              prsb03-dataelement-314
                              Id prsb03-dataelement-314 (2018‑10‑31)
                              Description Clinical Review of Systems
                              draft Clinical review of systems
                              prsb03-dataelement-10214
                              Id prsb03-dataelement-10214 (2018‑10‑31)
                              Description The clinical review of systems. The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake (increasing/decreasing) weight change, swallowing difficulties etc.

                              Properties

                              FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
                              Operationalization This is the record of the review of systems as volunteered by the patient or their representative or carer. Text or coded text (SNOMED CT).
                              Value Domain
                              folder draft Information and advice given
                              prsb03-dataelement-315
                              Id prsb03-dataelement-315 (2018‑10‑31)
                              Description Information and advice given
                              draft Information and advice given
                              prsb03-dataelement-10215
                              Id prsb03-dataelement-10215 (2018‑10‑31)
                              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
                              draft Date
                              prsb03-dataelement-10216
                              Id prsb03-dataelement-10216 (2018‑10‑31)
                              Description The date on which the information and advice was given.
                              Value Domain
                              draft Location
                              prsb03-dataelement-10217
                              Id prsb03-dataelement-10217 (2018‑10‑31)
                              Description Details of where the information and advice was given.
                              Value Domain
                              draft Performing Professional
                              prsb03-dataelement-10218
                              Id prsb03-dataelement-10218 (2018‑10‑31)
                              Description Details of the professional giving the information and advice (including name and role).
                              Value Domain
                              folder draft Contact for further information
                              prsb03-dataelement-329
                              Id prsb03-dataelement-329 (2018‑10‑31)
                              Description Contact for further information
                              folder draft Contact for further information record entry
                              prsb03-dataelement-10659
                              Id prsb03-dataelement-10659 (2018‑11‑13 13:14:13)
                              Description This is a Contact for further information 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.
                              draft Contact for further information
                              prsb03-dataelement-10229
                              Id prsb03-dataelement-10229 (2018‑10‑31)
                              Description The contact details of whom to contact for information regarding this attendance.
                              Operationalization The contact details may be for an individual or team (for example a phone number for the emergency department administrator). Free text.
                              Value Domain
                              folder draft Distribution list
                              prsb03-dataelement-330
                              Id prsb03-dataelement-330 (2018‑10‑31)
                              Description Distribution list
                              folder draft Distribution list record entry
                              prsb03-dataelement-10660
                              Id prsb03-dataelement-10660 (2018‑11‑13 13:21:33)
                              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.
                              draft Name
                              prsb03-dataelement-10230
                              Id prsb03-dataelement-10230 (2018‑10‑31)
                              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
                              draft Role
                              prsb03-dataelement-10231
                              Id prsb03-dataelement-10231 (2018‑10‑31)
                              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
                              draft Grade
                              prsb03-dataelement-10232
                              Id prsb03-dataelement-10232 (2018‑10‑31)
                              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
                              draft Organisation name
                              prsb03-dataelement-10233
                              Id prsb03-dataelement-10233 (2018‑10‑31)
                              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
                              draft Team
                              prsb03-dataelement-10234
                              Id prsb03-dataelement-10234 (2018‑10‑31)
                              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
                              folder cancelled Relationship
                              prsb03-dataelement-10235
                              Id prsb03-dataelement-10235 (2018‑10‑31) 0.1
                              Description The relationship of the receiver to the person for example, carer or parent

                              Properties

                              FHIR RelatedPerson.relationship
                              draft Relationship
                              prsb03-dataelement-13793
                              Id prsb03-dataelement-13793 (2020‑11‑02 15:35:45)
                              Description The relationship of the receiver to the person for example, carer or parent
                              Relationship
                              Operationalization FHIR value set : - Related person
                              Value Domain
                              folder draft Birth Details
                              prsb03-dataelement-336
                              Id prsb03-dataelement-336 (2018‑10‑31)
                              Description Birth Details
                              draft APGAR score
                              prsb03-dataelement-10236
                              Id prsb03-dataelement-10236 (2018‑10‑31)
                              Description A set of observations made on the baby following birth to check adaptation to life outside the womb. This includes 1 minute, 5 minutes and 10 minutes
                              Value Domain
                              draft Birth Order
                              prsb03-dataelement-10237
                              Id prsb03-dataelement-10237 (2018‑10‑31)
                              Description The sequence in which this baby was born (one of one, one of two etc.)
                              Value Domain
                              draft Birth weight
                              prsb03-dataelement-10238
                              Id prsb03-dataelement-10238 (2018‑10‑31)
                              Description Numeric value for weight at birth.
                              Value Domain
                              draft Date & Time of birth
                              prsb03-dataelement-10239
                              Id prsb03-dataelement-10239 (2018‑10‑31)
                              Description The date and time of birth of the baby.
                              Value Domain
                              draft Delivery place type
                              prsb03-dataelement-10240
                              Id prsb03-dataelement-10240 (2018‑10‑31)
                              Description The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc. )
                              Value Domain
                              draft Fetal Problems Diagnosed Before Birth
                              prsb03-dataelement-10241
                              Id prsb03-dataelement-10241 (2018‑10‑31)
                              Description Problems with the fetus diagnosed with screening or ultrasound. e.g. Down syndrome, congenital heart disease etc.
                              Value Domain
                              draft Length of gestation
                              prsb03-dataelement-10242
                              Id prsb03-dataelement-10242 (2018‑10‑31)
                              Description Gestational age in weeks and days (usually equivalent to length of pregnancy).
                              Value Domain
                              draft Location of birth
                              prsb03-dataelement-10243
                              Id prsb03-dataelement-10243 (2018‑10‑31)
                              Description The place of birth (including the address and organisation name where relevant).
                              Value Domain
                              draft Maternal problems in pregnancy
                              prsb03-dataelement-10244
                              Id prsb03-dataelement-10244 (2018‑10‑31)
                              Description Maternal medical conditions or infectious diseases arising in pregnancy which may have an impact on the fetus, e.g. gestational diabetes, rubella etc.
                              Value Domain
                              draft Multiple Birth
                              prsb03-dataelement-10245
                              Id prsb03-dataelement-10245 (2018‑10‑31)
                              Description Where the baby is one of a multiple birth, to include the total number of offspring and to include whether the baby is identical to one of the siblings.
                              Value Domain
                              draft Neonatal resuscitation
                              prsb03-dataelement-10246
                              Id prsb03-dataelement-10246 (2018‑10‑31)
                              Description Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.
                              Value Domain
                              draft Physical problems detected at birth
                              prsb03-dataelement-10247
                              Id prsb03-dataelement-10247 (2018‑10‑31)
                              Description Physical problems identified with the baby at, or shortly after, birth. E.g. cleft lip/palate, extensive bruising, cephalohematoma etc.
                              Value Domain
                              draft Name
                              prsb03-dataelement-10248
                              Id prsb03-dataelement-10248 (2018‑10‑31)
                              Description The given name as recorded by the midwife
                              Value Domain
                              draft NHS Number
                              prsb03-dataelement-10249
                              Id prsb03-dataelement-10249 (2018‑10‑31)
                              Description The unique identifier for a woman within the NHS in England and Wales.
                              Value Domain
                              draft Baby Identifier
                              prsb03-dataelement-10250
                              Id prsb03-dataelement-10250 (2018‑10‑31)
                              Description Baby identifier details
                              Value Domain
                              draft Gender
                              prsb03-dataelement-10251
                              Id prsb03-dataelement-10251 (2018‑10‑31)
                              Description The person’s phenotypic sex. Determines how the person will be treated clinically.
                              Value Domain
                              draft Birth Outcome
                              prsb03-dataelement-10252
                              Id prsb03-dataelement-10252 (2018‑10‑31)
                              Description The birth outcome of each fetus
                              Value Domain
                              draft Rhesus Status
                              prsb03-dataelement-10253
                              Id prsb03-dataelement-10253 (2018‑10‑31)
                              Description An indication of whether the fetus has or does not have the rhesus factor (or Rh D antigen) on the surface of their red blood cells, using the Rh System.
                              Value Domain
                              draft Congenital Abnormalities
                              prsb03-dataelement-10254
                              Id prsb03-dataelement-10254 (2018‑10‑31)
                              Description (Yes no field) as per NHSDD and recorded on Birth Notification
                              Value Domain
                              draft Investigations Requested
                              prsb03-dataelement-10255
                              Id prsb03-dataelement-10255 (2018‑10‑31)
                              Description To include any investigations requested including post mortem investigations)
                              Value Domain
                              draft Problems during delivery
                              prsb03-dataelement-10256
                              Id prsb03-dataelement-10256 (2018‑10‑31)
                              Description Problems experienced by the baby during delivery e.g. cord prolapse, meconium aspiration, fetal distress etc.
                              Value Domain
                              draft Put To Breast
                              prsb03-dataelement-10257
                              Id prsb03-dataelement-10257 (2018‑10‑31)
                              Description Whether or not the baby was put to the breast.
                              Value Domain
                              draft Spontaneous Respiration
                              prsb03-dataelement-10258
                              Id prsb03-dataelement-10258 (2018‑10‑31)
                              Description Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.
                              Value Domain
                              draft Type of delivery
                              prsb03-dataelement-10259
                              Id prsb03-dataelement-10259 (2018‑10‑31)
                              Description Type of delivery for the baby, e.g. Vacuum extraction, breech extraction, elective caesarean section etc.
                              Value Domain
                              draft Types of delivery (attempted)
                              prsb03-dataelement-10260
                              Id prsb03-dataelement-10260 (2018‑10‑31)
                              Description The type(s) of delivery for the baby that was attempted, but was not the final delivery method.
                              Value Domain
                              folder draft Demographic History
                              prsb03-dataelement-361
                              Id prsb03-dataelement-361 (2018‑10‑31)
                              Description Demographic History
                              draft Date of birth
                              prsb03-dataelement-10261
                              Id prsb03-dataelement-10261 (2018‑10‑31)
                              Description History of date of birth changes.
                              Value Domain
                              draft Gender
                              prsb03-dataelement-10262
                              Id prsb03-dataelement-10262 (2018‑10‑31)
                              Description History of gender change.
                              Value Domain
                              draft Patient address
                              prsb03-dataelement-10263
                              Id prsb03-dataelement-10263 (2018‑10‑31)
                              Description History of Patient’s usual place of residence.
                              Value Domain
                              draft Patient name
                              prsb03-dataelement-10264
                              Id prsb03-dataelement-10264 (2018‑10‑31)
                              Description Any previous names, aliases and preferred name. This will normally be given by a Patient Demographics Service (PDS) patient trace, or the name of the patient held on the local Patient Administration System (PAS).
                              Value Domain
                              draft Patient telephone number
                              prsb03-dataelement-10265
                              Id prsb03-dataelement-10265 (2018‑10‑31)
                              Description History of Telephone contact details of the patient. To include, e.g., mobile, work and home number if available.
                              Value Domain
                              folder draft Developmental Skills
                              prsb03-dataelement-366
                              Id prsb03-dataelement-366 (2018‑10‑31)
                              Description Developmental Skills
                              draft Date first achieved
                              prsb03-dataelement-10267
                              Id prsb03-dataelement-10267 (2018‑10‑31)
                              Description The date the developmental skill was first achieved (developmental first) as reported by the parent. This is primarily for parent reporting as part of parent child health record at the time the skill is acquired.
                              Value Domain
                              draft Date of enquiry
                              prsb03-dataelement-10268
                              Id prsb03-dataelement-10268 (2018‑10‑31)
                              Description The date the parent or carer was asked by a health professional about the developmental skill (milestone).
                              Value Domain
                              draft Date of observation
                              prsb03-dataelement-10269
                              Id prsb03-dataelement-10269 (2018‑10‑31)
                              Description The date a health professional observed or tested a developmental skill (milestone).
                              Value Domain
                              draft Health and care professional
                              prsb03-dataelement-10852
                              Id prsb03-dataelement-10852 (2019‑03‑27 17:20:36)
                              Description The name and designation of the professional recording the developmental skills.

                              Properties

                              FHIR Encounter.participant
                              Relationship
                              Operationalization Text
                              Value Domain
                              draft Location
                              prsb03-dataelement-10853
                              Id prsb03-dataelement-10853 (2019‑03‑27 17:22:18)
                              Description The location where the developmental skills were recorded.
                              Relationship
                              Value Domain
                              draft Developmental Skill
                              prsb03-dataelement-10270
                              Id prsb03-dataelement-10270 (2018‑10‑31)
                              Description The name of the developmental skill (e.g. Walks independently, smiles, finger feeds etc.).
                              Value Domain
                              draft Result of enquiry
                              prsb03-dataelement-10271
                              Id prsb03-dataelement-10271 (2018‑10‑31)
                              Description Whether the developmental skill was achieved, not achieved or equivocal.
                              Value Domain
                              draft Result of observation
                              prsb03-dataelement-10272
                              Id prsb03-dataelement-10272 (2018‑10‑31)
                              Description Whether the developmental skill was achieved, not achieved or equivocal.
                              Value Domain
                              draft Comments
                              prsb03-dataelement-10266
                              Id prsb03-dataelement-10266 (2018‑10‑31)
                              Description Supporting text may be given regarding the developmental skill.
                              Value Domain
                              folder draft Educational History
                              prsb03-dataelement-373
                              Id prsb03-dataelement-373 (2018‑10‑31)
                              Description Educational History
                              draft Educational Assessment
                              prsb03-dataelement-10273
                              Id prsb03-dataelement-10273 (2018‑10‑31)
                              Description The outcome of an educational assessment.
                              Value Domain
                              draft Educational establishment
                              prsb03-dataelement-10274
                              Id prsb03-dataelement-10274 (2018‑10‑31)
                              Description Name of Educational establishment.
                              Value Domain
                              draft Type of Educational establishment
                              prsb03-dataelement-10275
                              Id prsb03-dataelement-10275 (2018‑10‑31)
                              Description Phase/Type of Education establishment.
                              Value Domain
                              draft Type of Special Educational Need
                              prsb03-dataelement-10276
                              Id prsb03-dataelement-10276 (2018‑10‑31)
                              Description The type of special educational needs for the child.
                              Value Domain
                              draft Year From
                              prsb03-dataelement-10277
                              Id prsb03-dataelement-10277 (2018‑10‑31)
                              Description The year the child attended the school from.
                              Value Domain
                              draft Year To
                              prsb03-dataelement-10278
                              Id prsb03-dataelement-10278 (2018‑10‑31)
                              Description The year the child left the school.
                              Value Domain
                              folder draft Feeding Status
                              prsb03-dataelement-392
                              Id prsb03-dataelement-392 (2018‑10‑31)
                              Description Feeding Status
                              draft Date
                              prsb03-dataelement-10292
                              Id prsb03-dataelement-10292 (2018‑10‑31)
                              Description The date the feeding status was recorded.
                              Value Domain
                              draft Date breast milk feeding stopped
                              prsb03-dataelement-10293
                              Id prsb03-dataelement-10293 (2018‑10‑31)
                              Description Date of last breast milk feed to the nearest month and year.
                              Value Domain
                              draft Feeding concerns
                              prsb03-dataelement-10294
                              Id prsb03-dataelement-10294 (2018‑10‑31)
                              Description A record of any concerns about the baby’s feeding.
                              Value Domain
                              draft Feeding method
                              prsb03-dataelement-10295
                              Id prsb03-dataelement-10295 (2018‑10‑31)
                              Description A record of the predominant feeding method for the baby, e.g., breast fed, bottle/cup fed, gastrostomy, nasogastric feeds etc.
                              Value Domain
                              draft First milk feed
                              prsb03-dataelement-10296
                              Id prsb03-dataelement-10296 (2018‑10‑31)
                              Description Whether or not the baby's first feed was breast milk.
                              Value Domain
                              draft Introduction of solids
                              prsb03-dataelement-10297
                              Id prsb03-dataelement-10297 (2018‑10‑31)
                              Description Whether the baby has been introduced to solid foods at the time seen.
                              Value Domain
                              draft Milk feeding status of the baby
                              prsb03-dataelement-10298
                              Id prsb03-dataelement-10298 (2018‑10‑31)
                              Description Whether the baby is totally breast milk fed, partially breast milk fed or not breast milk fed. To be recorded each time a baby has contact with a health professional.
                              Value Domain
                              folder draft Health and Wellbeing Assessment and Reviews
                              prsb03-dataelement-399
                              Id prsb03-dataelement-399 (2018‑10‑31)
                              Description Health and Wellbeing Assessment and Reviews
                              draft Date
                              prsb03-dataelement-10299
                              Id prsb03-dataelement-10299 (2018‑10‑31)
                              Description The date the feeding status was recorded.
                              Value Domain
                              draft Post Birth Review
                              prsb03-dataelement-10300
                              Id prsb03-dataelement-10300 (2018‑10‑31)
                              Description This details those checks and assessments done on the baby prior to leaving hospital that do not make up the NIPE screening
                              Value Domain
                              draft New Baby Review
                              prsb03-dataelement-10301
                              Id prsb03-dataelement-10301 (2018‑10‑31)
                              Description The details captured as part of the New Baby Review
                              Value Domain
                              draft 6-8 Week Health Visitor Review
                              prsb03-dataelement-10302
                              Id prsb03-dataelement-10302 (2018‑10‑31)
                              Description The details captured as part of the 6-8 Heath Visitor Review
                              Value Domain
                              draft 1 Year Review
                              prsb03-dataelement-10303
                              Id prsb03-dataelement-10303 (2018‑10‑31)
                              Description The details captured as part of the 1 Year Review
                              Value Domain
                              draft 2-2 1/2 Year Health and Development Review
                              prsb03-dataelement-10304
                              Id prsb03-dataelement-10304 (2018‑10‑31)
                              Description The details captured as part of the 2- 2 1/2 Health and Development Review
                              Value Domain
                              draft School Entry Review
                              prsb03-dataelement-10305
                              Id prsb03-dataelement-10305 (2018‑10‑31)
                              Description The details captured as part of the school entry review including the outcome of the hearing and screening check
                              Value Domain
                              draft Ad-Hoc Health Review
                              prsb03-dataelement-10306
                              Id prsb03-dataelement-10306 (2018‑10‑31)
                              Description The details captured as part of any ad-hoc Health Review undertaken
                              Value Domain
                              folder draft Immunisations
                              prsb03-dataelement-407
                              Id prsb03-dataelement-407 (2018‑10‑31)
                              Description Immunisations
                              draft Batch number
                              prsb03-dataelement-10307
                              Id prsb03-dataelement-10307 (2018‑10‑31)
                              Description The batch number of the vaccine.
                              Value Domain
                              draft Date
                              prsb03-dataelement-10308
                              Id prsb03-dataelement-10308 (2018‑10‑31)
                              Description The date on which the Immunisation was administered.
                              Value Domain
                              draft Dose Amount
                              prsb03-dataelement-10309
                              Id prsb03-dataelement-10309 (2018‑10‑31)
                              Description Amount of vaccine administered.
                              Value Domain
                              draft Dose sequence
                              prsb03-dataelement-10310
                              Id prsb03-dataelement-10310 (2018‑10‑31)
                              Description Nominal position in a series of vaccines.
                              Value Domain
                              draft Indication
                              prsb03-dataelement-10311
                              Id prsb03-dataelement-10311 (2018‑10‑31)
                              Description The clinical indication or reason for administering the immunisation
                              Value Domain
                              draft Location
                              prsb03-dataelement-10312
                              Id prsb03-dataelement-10312 (2018‑10‑31)
                              Description Details of where the immunisation was performed.
                              Value Domain
                              draft Manufacturer
                              prsb03-dataelement-10313
                              Id prsb03-dataelement-10313 (2018‑10‑31)
                              Description The vaccine manufacturer.
                              Value Domain
                              draft Name of immunisation
                              prsb03-dataelement-10314
                              Id prsb03-dataelement-10314 (2018‑10‑31)
                              Description Which immunisation has been administered (SNOMED CT code – list of available immunisations).
                              Value Domain
                              draft Outcome status
                              prsb03-dataelement-10315
                              Id prsb03-dataelement-10315 (2018‑10‑31)
                              Description Whether the vaccine was administered or not, including the reason why
                              Value Domain
                              draft Performing Professional
                              prsb03-dataelement-10316
                              Id prsb03-dataelement-10316 (2018‑10‑31)
                              Description Details of the professional performing the immunisation (including name and role)
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Reported
                              prsb03-dataelement-10317
                              Id prsb03-dataelement-10317 (2018‑10‑31)
                              Description A flag to indicate the information was reported to a healthcare professional
                              Value Domain
                              draft Route
                              prsb03-dataelement-10318
                              Id prsb03-dataelement-10318 (2018‑10‑31)
                              Description How vaccine entered the body.
                              Value Domain
                              draft Site
                              prsb03-dataelement-10319
                              Id prsb03-dataelement-10319 (2018‑10‑31)
                              Description Body site vaccine was administered into.
                              Value Domain
                              draft Vaccine product
                              prsb03-dataelement-10320
                              Id prsb03-dataelement-10320 (2018‑10‑31)
                              Description Vaccine product administered.
                              Value Domain
                              folder draft Measurements
                              prsb03-dataelement-421
                              Id prsb03-dataelement-421 (2018‑10‑31)
                              Description Measurements
                              draft BMI Centile
                              prsb03-dataelement-10321
                              Id prsb03-dataelement-10321 (2018‑10‑31)
                              Description Child BMI centile calculated using the height/weight/gender and age of the child.
                              Value Domain
                              draft Date
                              prsb03-dataelement-10322
                              Id prsb03-dataelement-10322 (2018‑10‑31)
                              Description The date on which the measurement was recorded.
                              Value Domain
                              draft Head Circumference
                              prsb03-dataelement-10323
                              Id prsb03-dataelement-10323 (2018‑10‑31)
                              Description Numeric value for the head circumference
                              Value Domain
                              draft Height/Length
                              prsb03-dataelement-10324
                              Id prsb03-dataelement-10324 (2018‑10‑31)
                              Description Numeric value for the body length.
                              Value Domain
                              draft Location
                              prsb03-dataelement-10325
                              Id prsb03-dataelement-10325 (2018‑10‑31)
                              Description The location where the measurement was recorded.
                              Value Domain
                              draft Performing Professional
                              prsb03-dataelement-10326
                              Id prsb03-dataelement-10326 (2018‑10‑31)
                              Description Details of the professional performing the measurement (including name and role).
                              Value Domain
                              draft Weight
                              prsb03-dataelement-10327
                              Id prsb03-dataelement-10327 (2018‑10‑31)
                              Description Numeric value for weight.
                              Value Domain
                              folder draft National Screening Programme
                              prsb03-dataelement-428
                              Id prsb03-dataelement-428 (2018‑10‑31)
                              Description National Screening Programme
                              draft Newborn Blood Spot Screening
                              prsb03-dataelement-10328
                              Id prsb03-dataelement-10328 (2018‑10‑31)
                              Description The details captured as part of the NBS programme which screens for sickle cell disease (SCD), cystic fibrosis (CF), congenital hypothyroidism (CHT) and inherited metabolic diseases (IMDs).
                              Value Domain
                              draft Newborn Hearing Screening
                              prsb03-dataelement-10329
                              Id prsb03-dataelement-10329 (2018‑10‑31)
                              Description The details captured as part of the NHSP programme which offers 2 types of test for babies:

                              •automated otoacoustic emission (AOAE)

                              •automated auditory brainstem response (AABR)

                              Value Domain
                              draft Newborn and Infant Physical Examination (72 hours)
                              prsb03-dataelement-10330
                              Id prsb03-dataelement-10330 (2018‑10‑31)
                              Description The details captured as part of the NIPE programme which tests babies within 72 hours of birth for conditions relating to their:

                              •heart

                              •hips

                              •eyes

                              •testes

                              Value Domain
                              draft Newborn and Infant Physical Examination (6-8 Weeks)
                              prsb03-dataelement-10331
                              Id prsb03-dataelement-10331 (2018‑10‑31)
                              Description The details captured as part of the NIPE programme which tests babies again at 6-8 weeks for conditions relating to their:

                              •heart

                              •hips

                              •eyes

                              •testes
                              Value Domain
                              draft National screening programme
                              prsb03-dataelement-10332
                              Id prsb03-dataelement-10332 (2018‑10‑31)
                              Description The overarching screening programme. e.g.

                              - NHS Fetal Anomaly Screening Programme

                              - NHS Infectious Diseases in Pregnancy Screening Programme

                              - NHS Sickle Cell and Thalassaemia Screening Programme

                              Value Domain
                              draft Specific test performed
                              prsb03-dataelement-10333
                              Id prsb03-dataelement-10333 (2018‑10‑31)
                              Description The specific screening test performed, e.g. Combined test, Quadruple test, HIV, Syphilis etc.

                              This may include site and laterality where applicable

                              Value Domain
                              draft Screening test outcome
                              prsb03-dataelement-10334
                              Id prsb03-dataelement-10334 (2018‑10‑31)
                              Description The overall outcome of the screening test (this may include the status e.g. declined, deferred etc.).
                              Value Domain
                              draft Comments
                              prsb03-dataelement-10335
                              Id prsb03-dataelement-10335 (2018‑10‑31)
                              Description Supporting text may be given regarding the screening test, outcome and actions taken.
                              Value Domain
                              draft •National antenatel screening programme
                              prsb03-dataelement-10336
                              Id prsb03-dataelement-10336 (2018‑10‑31)
                              draft NHS Fetal Anomaly Screening Programme - Down’s, Edwards’ and Patau’s Syndromes.
                              prsb03-dataelement-10337
                              Id prsb03-dataelement-10337 (2018‑10‑31)
                              Description The details captured as part of the NHS Fetal Anomaly Screening Programme which screens for Down’s, Edwards’ and Patau’s syndromes
                              Value Domain
                              draft NHS Fetal Anomaly Screening Programme - Structural Anomalies
                              prsb03-dataelement-10338
                              Id prsb03-dataelement-10338 (2018‑10‑31)
                              Description The details captured as part of the NHS Fetal Anomaly Screening Programme which screens for fetal anomalies
                              Value Domain
                              draft NHS Infectious Diseases in Pregnancy Screening Programme
                              prsb03-dataelement-10339
                              Id prsb03-dataelement-10339 (2018‑10‑31)
                              Description The details captured as part of the NHS Infectious Diseases in Pregnancy Screening Programme which screens for Hepatitis B, HIV and Syphilis via a blood test

                              Chlamydia for under 25s and Hepatitis C can be recorded here as required
                              Value Domain
                              draft NHS Sickle Cell and Thalassaemia Screening Programme
                              prsb03-dataelement-10340
                              Id prsb03-dataelement-10340 (2018‑10‑31)
                              Description The details captured as part of the NHS Sickle Cell and Thalassaemia Screening Programme which screens to find out if the woman is a carrier of the sickle cell or thalassaemia gene and therefore likely to pass it on to the baby. This may also be applicable to the baby's father if the woman is identified as a carrier of a haemoglobin disease.
                              Value Domain
                              draft NHS Diabetic Eye Screening Programme
                              prsb03-dataelement-10341
                              Id prsb03-dataelement-10341 (2018‑10‑31)
                              Description The details captured as part of the NHS Diabetic Eye Screening Programme which is offered to women with diabetes in pregnancy
                              Value Domain
                              folder draft Parent/Guardian/Personal Comment
                              prsb03-dataelement-442
                              Id prsb03-dataelement-442 (2018‑10‑31)
                              Description Parent/Guardian/Personal Comment
                              draft Date
                              prsb03-dataelement-10342
                              Id prsb03-dataelement-10342 (2018‑10‑31)
                              Description Date the comment was entered and shared
                              Value Domain
                              draft Who
                              prsb03-dataelement-10343
                              Id prsb03-dataelement-10343 (2018‑10‑31)
                              Description Who recorded the comment and what relationship they are to the child
                              Value Domain
                              draft Parent / guardian or personal comment
                              prsb03-dataelement-10344
                              Id prsb03-dataelement-10344 (2018‑10‑31)
                              Description Free text comment made by the parent / guardian of the child, or the child themselves
                              Value Domain
                              folder draft Plan and requested actions
                              prsb03-dataelement-535
                              Id prsb03-dataelement-535 (2018‑10‑31)
                              Description The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
                              folder draft Plan and requested actions record entry
                              prsb03-dataelement-10661
                              Id prsb03-dataelement-10661 (2018‑11‑13 13:38:58)
                              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.
                              draft Date
                              prsb03-dataelement-10445
                              Id prsb03-dataelement-10445 (2018‑10‑31)
                              Description The date on which the plan and requested actions were prepared.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              cancelled Performing Professional
                              prsb03-dataelement-10446
                              Id prsb03-dataelement-10446 (2018‑10‑31)
                              Description Details of the professional making the plan and requested actions.
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12167
                              Id prsb03-dataelement-12167 (2019‑05‑31 16:13:42)
                              Description The professional who prepared the plan and requested actions.
                              Relationship
                              draft Name
                              prsb03-dataelement-12168
                              Id prsb03-dataelement-12168 (2019‑05‑31 16:14:03)
                              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
                              draft Role
                              prsb03-dataelement-12169
                              Id prsb03-dataelement-12169 (2019‑05‑31 16:14:03)
                              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
                              draft Grade
                              prsb03-dataelement-12170
                              Id prsb03-dataelement-12170 (2019‑05‑31 16:14:03)
                              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
                              draft Speciality
                              prsb03-dataelement-12171
                              Id prsb03-dataelement-12171 (2019‑05‑31 16:14:03)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12172
                              Id prsb03-dataelement-12172 (2019‑05‑31 16:14:03)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12173
                              Id prsb03-dataelement-12173 (2019‑05‑31 16:14:03)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12174
                              Id prsb03-dataelement-12174 (2019‑05‑31 16:14:03)
                              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
                              folder draft Location
                              prsb03-dataelement-10842
                              Id prsb03-dataelement-10842 (2019‑03‑27 16:46:10)
                              Description The location where the plan and requested actions were prepared.
                              draft Coded value
                              prsb03-dataelement-13684
                              Id prsb03-dataelement-13684 (2020‑09‑09 13:11:31)
                              Description The coded value for location
                              Operationalization NHS data dictionary : - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13685
                              Id prsb03-dataelement-13685 (2020‑09‑09 13:12:37)
                              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
                              draft Actions
                              prsb03-dataelement-10435
                              Id prsb03-dataelement-10435 (2018‑10‑31)
                              Description Including planned investigations, procedures, Interventions and treatment for a patient’s identified conditions and priorities. For each action the following should be identified: a) person responsible - name and designation / department / hospital / patient etc or role (eg GP) responsible for carrying out the proposed action, and where action should take place.b) status - requested, planned or completed. c) When action requested for - requested date, time, or period - as relevant. d) suggested strategies - suggested strategies for potential problems. e) outcome expectations, including patient’s expectations.
                              Operationalization Free text
                              Value Domain
                              draft Actions for professionals
                              prsb03-dataelement-10436
                              Id prsb03-dataelement-10436 (2018‑10‑31)
                              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
                              draft Actions for person or their carer
                              prsb03-dataelement-10437
                              Id prsb03-dataelement-10437 (2018‑10‑31)
                              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
                              draft Agreed with the person or their legitimate representative
                              prsb03-dataelement-10438
                              Id prsb03-dataelement-10438 (2018‑10‑31)
                              Description Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.
                              Operationalization Free text
                              Value Domain
                              draft Outcome of plan and requested actions
                              prsb03-dataelement-10950
                              Id prsb03-dataelement-10950 (2019‑05‑16 17:36:54)
                              Description The details of the outcome of the plan and requested actions.
                              Operationalization Free text.
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-12175
                              Id prsb03-dataelement-12175 (2019‑05‑31 16:15:12)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12176
                              Id prsb03-dataelement-12176 (2019‑05‑31 16:15:32)
                              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
                              draft Role
                              prsb03-dataelement-12177
                              Id prsb03-dataelement-12177 (2019‑05‑31 16:15:32)
                              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
                              draft Grade
                              prsb03-dataelement-12178
                              Id prsb03-dataelement-12178 (2019‑05‑31 16:15:32)
                              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
                              draft Specialty
                              prsb03-dataelement-12179
                              Id prsb03-dataelement-12179 (2019‑05‑31 16:15:32)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12180
                              Id prsb03-dataelement-12180 (2019‑05‑31 16:15:32)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12181
                              Id prsb03-dataelement-12181 (2019‑05‑31 16:15:32)
                              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
                              draft Date completed
                              prsb03-dataelement-12182
                              Id prsb03-dataelement-12182 (2019‑05‑31 16:15:32)
                              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
                              draft Contact details
                              prsb03-dataelement-12183
                              Id prsb03-dataelement-12183 (2019‑05‑31 16:15:32)
                              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
                              draft Care planning arrangements
                              prsb03-dataelement-10439
                              Id prsb03-dataelement-10439 (2018‑10‑31)
                              Description Record if CPA (Care Programme Approach) documentation is available and how and where it can be accessed; care and treatment plan in Wales and Scotland. In Wales this is superseded by the Mental Health Measure 2010.
                              Operationalization Free text
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Special monitoring required
                              prsb03-dataelement-10440
                              Id prsb03-dataelement-10440 (2018‑10‑31) 0.1
                              Description Eg neuro-obs, 02 saturation etc
                              Value Domain
                              cancelled Aims and limitations of treatment and special instructions
                              prsb03-dataelement-10441
                              Id prsb03-dataelement-10441 (2018‑10‑31) 0.1
                              Description The current aim of treatment including limitations to treatment and communications issues, eg, not for ITU
                              Value Domain
                              cancelled Escalation plan
                              prsb03-dataelement-10442
                              Id prsb03-dataelement-10442 (2018‑10‑31) 0.1
                              Description Who needs to be contacted in the event of significant problems or patient deterioration include, eg seniority/name/ contact details of person to be called
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Investigations requested
                              prsb03-dataelement-10443
                              Id prsb03-dataelement-10443 (2018‑10‑31)
                              Description This includes a name or description of the investigation requested and the date requested.
                              Operationalization Free text
                              Value Domain
                              draft Procedures requested
                              prsb03-dataelement-10444
                              Id prsb03-dataelement-10444 (2018‑10‑31)
                              Description These are the diagnostic or therapeutic procedures that have actually been requested (and the date requested).
                              Operationalization Free text
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-12605
                              Id prsb03-dataelement-12605 (2019‑11‑14 12:34:50)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12606
                              Id prsb03-dataelement-12606 (2019‑11‑14 12:35:42)
                              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
                              draft Role
                              prsb03-dataelement-12607
                              Id prsb03-dataelement-12607 (2019‑11‑14 12:35:42)
                              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
                              draft Grade
                              prsb03-dataelement-12608
                              Id prsb03-dataelement-12608 (2019‑11‑14 12:35:42)
                              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
                              draft Specialty
                              prsb03-dataelement-12609
                              Id prsb03-dataelement-12609 (2019‑11‑14 12:35:42)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12610
                              Id prsb03-dataelement-12610 (2019‑11‑14 12:35:42)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12611
                              Id prsb03-dataelement-12611 (2019‑11‑14 12:35:42)
                              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
                              draft Date completed
                              prsb03-dataelement-12612
                              Id prsb03-dataelement-12612 (2019‑11‑14 12:35:42)
                              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
                              draft Contact details
                              prsb03-dataelement-12613
                              Id prsb03-dataelement-12613 (2019‑11‑14 12:35:42)
                              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
                              folder draft Senior Reviewing Clinician
                              prsb03-dataelement-12614
                              Id prsb03-dataelement-12614 (2019‑11‑14 17:14:10)
                              Concept inherits from draft prsb03-dataelement-327 (2018‑10‑31)
                              Description Senior Reviewing Clinician
                              draft Name
                              prsb03-dataelement-12615
                              Id prsb03-dataelement-12615 (2019‑11‑14 17:14:36)
                              Concept inherits from draft prsb03-dataelement-10227 (2018‑10‑31)
                              Description The name of the senior clinician responsible for reviewing the patient treatment and discharge plan.
                              Operationalization The person name as held on the source system. Where possible this should be broken down into its constituent parts (prefix, given name, family name, suffix).
                              Value Domain
                              draft Professional identifier
                              prsb03-dataelement-12616
                              Id prsb03-dataelement-12616 (2019‑11‑14 17:14:36)
                              Concept inherits from draft prsb03-dataelement-10228 (2018‑10‑31)
                              Description The unique identifier issued by the regulatory body e.g., GMC number, HCPC number etc.
                              Operationalization The professional identifier type and the identifier itself as held on the source system. An identifier for the person completing the record will be sent (but may not be displayed in the rendered message).
                              Value Domain
                              folder cancelled Mental health
                              prsb03-dataelement-10790
                              Id prsb03-dataelement-10790 (2019‑03‑19 18:14:47) 0.1
                              Description Details of information relating to a person's mental health and social care
                              cancelled Care planning arrangements
                              prsb03-dataelement-10791
                              Id prsb03-dataelement-10791 (2019‑03‑19 18:17:47) 0.1
                              Concept inherits from draft prsb03-dataelement-10439 (2018‑10‑31)
                              Description Record if CPA (Care Programme Approach) documentation is available and how and where it can be accessed; care and treatment plan in Wales and Scotland. In Wales this is superseded by the Mental Health Measure 2010.
                              Operationalization Free text
                              Value Domain
                              cancelled Escalation plan
                              prsb03-dataelement-10792
                              Id prsb03-dataelement-10792 (2019‑03‑19 18:18:19) 0.1
                              Concept inherits from cancelled prsb03-dataelement-10442 (2018‑10‑31)
                              Description Who needs to be contacted in the event of significant problems or patient deterioration include, eg seniority/name/ contact details of person to be called
                              Value Domain
                              cancelled Formulation
                              prsb03-dataelement-10793
                              Id prsb03-dataelement-10793 (2019‑03‑19 18:19:23) 0.1
                              Concept inherits from draft prsb03-dataelement-10148 (2018‑10‑31)
                              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
                              folder cancelled Mental health act or equivalent status
                              prsb03-dataelement-10794
                              Id prsb03-dataelement-10794 (2019‑03‑19 18:20:35) 0.1
                              Concept inherits from draft prsb03-dataelement-10427 (2018‑10‑31)
                              Description Details of the persons mental health act record
                              folder cancelled Mental capacity assessment
                              prsb03-dataelement-10795
                              Id prsb03-dataelement-10795 (2019‑03‑19 18:21:26) 0.1
                              Concept inherits from draft prsb03-dataelement-10424 (2018‑10‑31)
                              Description Details of the persons mental capacity assessment
                              folder cancelled Deprivation of Liberty Safeguards or equivalent
                              prsb03-dataelement-10796
                              Id prsb03-dataelement-10796 (2019‑03‑19 18:23:37) 0.1
                              Concept inherits from draft prsb03-dataelement-10426 (2018‑10‑31)
                              Description Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
                              cancelled Treatments and interventions and changes made to treatments.
                              prsb03-dataelement-10826
                              Id prsb03-dataelement-10826 (2019‑03‑21 14:22:11) 0.1
                              Concept inherits from draft prsb03-dataelement-10149 (2018‑10‑31)
                              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
                              folder draft Person and carer concerns expectations and wishes
                              prsb03-dataelement-292
                              Id prsb03-dataelement-292 (2018‑10‑31)
                              Description Person and carer concerns, expectations and wishes
                              draft Date
                              prsb03-dataelement-10193
                              Id prsb03-dataelement-10193 (2018‑10‑31)
                              Description The date on which the concerns, wishes or goals of the person were recorded
                              Value Domain
                              draft Location
                              prsb03-dataelement-10856
                              Id prsb03-dataelement-10856 (2019‑03‑27 17:32:49)
                              Description The location where the concerns, expectations and wishes were recorded.
                              Relationship
                              Value Domain
                              draft Patient and carer concerns, expectations and wishes
                              prsb03-dataelement-10192
                              Id prsb03-dataelement-10192 (2018‑10‑31)
                              Description Description of the concerns, wishes or goals of the person in relation to their care, as expressed by the person, their representative or carer. Record who has expressed these (patient or carer/ representative on behalf of the patient).Where the person lacks capacity this may include their representative's concerns, expectations or wishes.

                              Properties

                              FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject Observation.comment
                              Operationalization A record of statements expressed by the person or their carer or representative. Free Text
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-13740
                              Id prsb03-dataelement-13740 (2020‑09‑25 16:27:48)
                              Concept inherits from draft prsb03-dataelement-13052 (2020‑04‑28 19:36:14)
                              Description
                              A record of the details of the person that entered the impairment and the date on which it was entered.
                              Relationship
                              draft Name
                              prsb03-dataelement-13741
                              Id prsb03-dataelement-13741 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
                              Description The name of the person completing the record.
                              Relationship
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              draft Role
                              prsb03-dataelement-13742
                              Id prsb03-dataelement-13742 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
                              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
                              draft Grade
                              prsb03-dataelement-13743
                              Id prsb03-dataelement-13743 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
                              Description The grade of the person completing the record.
                              Relationship
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-13744
                              Id prsb03-dataelement-13744 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
                              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
                              folder draft Organisation
                              prsb03-dataelement-13745
                              Id prsb03-dataelement-13745 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-13746
                              Id prsb03-dataelement-13746 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
                              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
                              draft Date completed
                              prsb03-dataelement-13747
                              Id prsb03-dataelement-13747 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
                              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
                              draft Contact details
                              prsb03-dataelement-13748
                              Id prsb03-dataelement-13748 (2020‑09‑25 16:28:39)
                              Concept inherits from draft prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
                              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
                              cancelled Person completing record
                              prsb03-dataelement-10857
                              Id prsb03-dataelement-10857 (2019‑03‑27 17:34:07) 0.1
                              Description This is the person recording the concerns, wished and expectations.

                              Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details.
                              Relationship
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              draft Maternity Care Plan Type
                              prsb03-dataelement-10194
                              Id prsb03-dataelement-10194 (2018‑10‑31)
                              Description The stage of maternity to which the care plan applies e.g. antenatal
                              Value Domain
                              draft Planned delivery setting
                              prsb03-dataelement-10195
                              Id prsb03-dataelement-10195 (2018‑10‑31)
                              Description The planned delivery setting where the pregnant woman plans to have her baby as designated by the Care Professional in consultation with the woman
                              Value Domain
                              draft Reason for change of planned delivery setting
                              prsb03-dataelement-10196
                              Id prsb03-dataelement-10196 (2018‑10‑31)
                              Description The reason why the planned delivery setting has changed
                              Value Domain
                              draft Advance statement
                              prsb03-dataelement-10197
                              Id prsb03-dataelement-10197 (2018‑10‑31)
                              Description Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity. Include the location of the document if known.
                              Operationalization Coded text and/or text. A record of the presence of an advance statement using the following SNOMED CT concept from the National Information Standard (SCCI1580): SNOMED CT: 816281000000101. Has advance statement (Mental Capacity Act 2005). The content of the advance statement should also be included as text or attached as a document where available.
                              Value Domain
                              draft Preferred place of care
                              prsb03-dataelement-10198
                              Id prsb03-dataelement-10198 (2018‑10‑31)
                              Description The preferences that a person has identified as their preferred place to receive care.
                              Operationalization A record of the preferences that a person has identified as their preferred place to receive care. Free Text
                              Value Domain
                              draft Preferred place of death
                              prsb03-dataelement-10199
                              Id prsb03-dataelement-10199 (2018‑10‑31)
                              Description The preferences that a person has identified as their preferred place to die.
                              Operationalization End of life care plan use case only. Preferences will be identified as 1st/2nd choice etc as given by the person. Each recorded preference should include the name of the place that the person has identified. It may also include coded values from the National Information Standard (SCCI1580), together with the associated text:10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103

                              Preferred place of death: patient unable to express preference517131000000106

                              Preferred place of death: discussion not appropriate766391000000108

                              Preferred place of death: patient declined discussion517161000000101

                              Preferred place of death: patient undecided
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Care and support plan
                              prsb03-dataelement-508
                              Id prsb03-dataelement-508 (2018‑10‑31)
                              Description This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
                              draft Strengths
                              prsb03-dataelement-10419
                              Id prsb03-dataelement-10419 (2018‑10‑31)
                              Description Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
                              Operationalization Free text
                              Value Domain
                              folder draft Needs, concerns or problems
                              prsb03-dataelement-10414
                              Id prsb03-dataelement-10414 (2018‑10‑31)
                              Description Needs, concerns or problems the person has that relating to their health and well-being. May be linked to the problem list from the person’s record to avoid duplication. May include biological, psychological and social needs, concerns or problems. May include (eg) financial concerns over debt.
                              Operationalization Free text
                              folder draft Goals and hopes
                              prsb03-dataelement-10413
                              Id prsb03-dataelement-10413 (2018‑10‑31)
                              Description The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
                              Operationalization Free text
                              folder draft Actions and activities
                              prsb03-dataelement-10408
                              Id prsb03-dataelement-10408 (2018‑10‑31)
                              Description Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

                              draft Stage goal
                              prsb03-dataelement-10674
                              Id prsb03-dataelement-10674 (2018‑11‑15 13:32:26)
                              Description A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.
                              Operationalization Free text
                              Value Domain
                              draft What
                              prsb03-dataelement-10675
                              Id prsb03-dataelement-10675 (2018‑11‑15 13:33:22)
                              Description What the action is and how it is to be carried out?
                              Operationalization Free text.
                              Value Domain
                              draft Who
                              prsb03-dataelement-10676
                              Id prsb03-dataelement-10676 (2018‑11‑15 13:34:04)
                              Description Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
                              Operationalization Free text.
                              Value Domain
                              draft When
                              prsb03-dataelement-10677
                              Id prsb03-dataelement-10677 (2018‑11‑15 13:34:38)
                              Description Planned date, time, or interval, as relevant
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Suggested strategies
                              prsb03-dataelement-10678
                              Id prsb03-dataelement-10678 (2018‑11‑15 13:35:19)
                              Description Suggested strategies for potential problems.
                              Operationalization Free text.
                              Value Domain
                              draft Status
                              prsb03-dataelement-10679
                              Id prsb03-dataelement-10679 (2018‑11‑15 13:35:57)
                              Description The status of the action or activity e.g. started, not started, completed, not applicable.
                              Operationalization Free text.
                              Value Domain
                              draft Confidence
                              prsb03-dataelement-10680
                              Id prsb03-dataelement-10680 (2018‑11‑15 13:54:04)
                              Description How confident the person feels to carry it out
                              Operationalization Free text.
                              Value Domain
                              draft Outcome
                              prsb03-dataelement-10681
                              Id prsb03-dataelement-10681 (2018‑11‑15 13:54:34)
                              Description The outcome of the stage goal
                              Operationalization Free text.
                              Value Domain
                              draft Date last updated
                              prsb03-dataelement-10682
                              Id prsb03-dataelement-10682 (2018‑11‑15 13:55:05)
                              Description Date when action/activity record was last updated
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Review date
                              prsb03-dataelement-10683
                              Id prsb03-dataelement-10683 (2018‑11‑15 13:55:47)
                              Description When the stage goal and action need to be reviewed.
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Outcomes
                              prsb03-dataelement-10416
                              Id prsb03-dataelement-10416 (2018‑10‑31)
                              Description Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
                              Operationalization Free text
                              Value Domain
                              draft Agreed with person or legitimate representative
                              prsb03-dataelement-10409
                              Id prsb03-dataelement-10409 (2018‑10‑31)
                              Description Indicates whether the plan was discussed and agreed with the person or legitimate representative. A record of the agreement of the decisions made.
                              Operationalization Free text
                              Value Domain
                              draft Care funding source
                              prsb03-dataelement-10410
                              Id prsb03-dataelement-10410 (2018‑10‑31)
                              Description A reference to the funding source and any conditions or limitations associated.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              cancelled Date last updated
                              prsb03-dataelement-10411
                              Id prsb03-dataelement-10411 (2018‑10‑31)
                              Description Date when action/activity record was last updated
                              Operationalization Date and Time
                              Value Domain
                              draft Date this plan was last updated
                              prsb03-dataelement-10412
                              Id prsb03-dataelement-10412 (2018‑10‑31)
                              Description This is a record of the date that this care and support plan was last updated.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Other care planning documents
                              prsb03-dataelement-10415
                              Id prsb03-dataelement-10415 (2018‑10‑31)
                              Description Reference other care planning documents, including the type, location and date.

                              This may include condition-specific plans, advance care plans, end of life care plan, etc.
                              Operationalization Free text.
                              Value Domain
                              draft Planned review date/interval
                              prsb03-dataelement-10417
                              Id prsb03-dataelement-10417 (2018‑10‑31)
                              Description This is the date/interval when this information will next be reviewed.
                              Operationalization Date and time
                              Value Domain
                              draft Responsibility for review
                              prsb03-dataelement-10418
                              Id prsb03-dataelement-10418 (2018‑10‑31)
                              Description This is a record of who has responsibility for arranging review of this information.

                              Should include their name, role and contact details.
                              Operationalization Free text.
                              Value Domain
                              folder draft Location
                              prsb03-dataelement-12044
                              Id prsb03-dataelement-12044 (2019‑05‑31 15:32:03)
                              Description The location where the care and support plan was prepared.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13665
                              Id prsb03-dataelement-13665 (2020‑09‑08 22:17:08)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13666
                              Id prsb03-dataelement-13666 (2020‑09‑08 22:18:17)
                              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
                              folder draft Performing professional
                              prsb03-dataelement-12027
                              Id prsb03-dataelement-12027 (2019‑05‑31 15:30:22)
                              Description The professional who prepared the care and support plan.
                              Relationship
                              draft Name
                              prsb03-dataelement-12028
                              Id prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Role
                              prsb03-dataelement-12029
                              Id prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Grade
                              prsb03-dataelement-12030
                              Id prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Speciality
                              prsb03-dataelement-12031
                              Id prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Professional identifier
                              prsb03-dataelement-12032
                              Id prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Organisation
                              prsb03-dataelement-12033
                              Id prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Contact details
                              prsb03-dataelement-12034
                              Id prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Person completing record
                              prsb03-dataelement-12035
                              Id prsb03-dataelement-12035 (2019‑05‑31 15:31:01)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12036
                              Id prsb03-dataelement-12036 (2019‑05‑31 15:31:27)
                              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
                              draft Role
                              prsb03-dataelement-12037
                              Id prsb03-dataelement-12037 (2019‑05‑31 15:31:27)
                              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
                              draft Grade
                              prsb03-dataelement-12038
                              Id prsb03-dataelement-12038 (2019‑05‑31 15:31:27)
                              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
                              draft Specialty
                              prsb03-dataelement-12039
                              Id prsb03-dataelement-12039 (2019‑05‑31 15:31:27)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12040
                              Id prsb03-dataelement-12040 (2019‑05‑31 15:31:27)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12041
                              Id prsb03-dataelement-12041 (2019‑05‑31 15:31:27)
                              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
                              draft Date completed
                              prsb03-dataelement-12042
                              Id prsb03-dataelement-12042 (2019‑05‑31 15:31:27)
                              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
                              draft Contact details
                              prsb03-dataelement-12043
                              Id prsb03-dataelement-12043 (2019‑05‑31 15:31:27)
                              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
                              cancelled Person completing record
                              prsb03-dataelement-10840
                              Id prsb03-dataelement-10840 (2019‑03‑27 16:19:24)
                              Concept inherits from cancelled prsb03-dataelement-10404 (2018‑10‑31)
                              Description This is the person contributing to an additional supporting plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              folder draft Contingency plans
                              prsb03-dataelement-469
                              Id prsb03-dataelement-469 (2018‑10‑31)
                              Description Contingency plans.
                              draft Agreed with person or legitimate representative
                              prsb03-dataelement-10369
                              Id prsb03-dataelement-10369 (2018‑10‑31)
                              Description Indicates whether the plan was discussed and agreed with the person or legitimate representative.
                              Operationalization Free text
                              Value Domain
                              draft Anticipatory medicines/equipment
                              prsb03-dataelement-10370
                              Id prsb03-dataelement-10370 (2018‑10‑31)
                              Description Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Advance statement
                              prsb03-dataelement-10777
                              Id prsb03-dataelement-10777 (2019‑03‑19 17:12:20)
                              Description Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
                              Relationship
                              draft Date
                              prsb03-dataelement-12267
                              Id prsb03-dataelement-12267 (2019‑05‑31 16:39:20)
                              Description The date when the advanced statements was made.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12268
                              Id prsb03-dataelement-12268 (2019‑05‑31 16:39:59)
                              Description The location where the advanced statement was made.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13698
                              Id prsb03-dataelement-13698 (2020‑09‑09 17:14:46)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13699
                              Id prsb03-dataelement-13699 (2020‑09‑09 17:16:21)
                              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
                              folder draft Advance statement
                              prsb03-dataelement-13695
                              Id prsb03-dataelement-13695 (2020‑09‑09 17:06:33)
                              Description Does the person have an advance statement.
                              draft Coded value
                              prsb03-dataelement-13696
                              Id prsb03-dataelement-13696 (2020‑09‑09 17:09:21)
                              Description The coded value for advance statement
                              Operationalization SNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13697
                              Id prsb03-dataelement-13697 (2020‑09‑09 17:10:48)
                              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
                              draft Location of document
                              prsb03-dataelement-13760
                              Id prsb03-dataelement-13760 (2020‑09‑29 14:53:49)
                              Description The location of where the advanced statement is held.
                              Relationship
                              Operationalization Free text or URL
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12269
                              Id prsb03-dataelement-12269 (2019‑05‑31 16:40:44)
                              Description The professional who made the advance statement.
                              Relationship
                              draft Name
                              prsb03-dataelement-12270
                              Id prsb03-dataelement-12270 (2019‑05‑31 16:41:01)
                              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
                              draft Role
                              prsb03-dataelement-12271
                              Id prsb03-dataelement-12271 (2019‑05‑31 16:41:01)
                              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
                              draft Grade
                              prsb03-dataelement-12272
                              Id prsb03-dataelement-12272 (2019‑05‑31 16:41:01)
                              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
                              draft Speciality
                              prsb03-dataelement-12273
                              Id prsb03-dataelement-12273 (2019‑05‑31 16:41:01)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12274
                              Id prsb03-dataelement-12274 (2019‑05‑31 16:41:01)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12275
                              Id prsb03-dataelement-12275 (2019‑05‑31 16:41:01)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12276
                              Id prsb03-dataelement-12276 (2019‑05‑31 16:41:01)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12277
                              Id prsb03-dataelement-12277 (2019‑05‑31 16:41:55)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12278
                              Id prsb03-dataelement-12278 (2019‑05‑31 16:42:15)
                              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
                              draft Role
                              prsb03-dataelement-12279
                              Id prsb03-dataelement-12279 (2019‑05‑31 16:42:15)
                              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
                              draft Grade
                              prsb03-dataelement-12280
                              Id prsb03-dataelement-12280 (2019‑05‑31 16:42:15)
                              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
                              draft Specialty
                              prsb03-dataelement-12281
                              Id prsb03-dataelement-12281 (2019‑05‑31 16:42:15)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12282
                              Id prsb03-dataelement-12282 (2019‑05‑31 16:42:15)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12283
                              Id prsb03-dataelement-12283 (2019‑05‑31 16:42:15)
                              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
                              draft Date completed
                              prsb03-dataelement-12284
                              Id prsb03-dataelement-12284 (2019‑05‑31 16:42:15)
                              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
                              draft Contact details
                              prsb03-dataelement-12285
                              Id prsb03-dataelement-12285 (2019‑05‑31 16:42:15)
                              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
                              draft Contingency plan name
                              prsb03-dataelement-10371
                              Id prsb03-dataelement-10371 (2018‑10‑31)
                              Description Name of the contingency plan – what condition or circumstances it is addressing.
                              Operationalization Free text
                              Value Domain
                              draft Date this plan was last updated
                              prsb03-dataelement-10372
                              Id prsb03-dataelement-10372 (2018‑10‑31)
                              Description The date that this contingency plan was last updated.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Planned review date/interval
                              prsb03-dataelement-10373
                              Id prsb03-dataelement-10373 (2018‑10‑31)
                              Description This is the date/interval when this contingency plan will next be reviewed.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Responsibility for review
                              prsb03-dataelement-10374
                              Id prsb03-dataelement-10374 (2018‑10‑31)
                              Description This is who has responsibility for arranging review of this information.

                              Should include their name, role and contact details.
                              Operationalization Free text.
                              Value Domain
                              draft Trigger factors
                              prsb03-dataelement-10375
                              Id prsb03-dataelement-10375 (2018‑10‑31)
                              Description Signs to watch out for that may indicate a significant change in health or other circumstances. A statement of trigger factors.
                              Operationalization Free text
                              Value Domain
                              folder draft Coping strategies
                              prsb03-dataelement-13850
                              Id prsb03-dataelement-13850 (2021‑01‑08 16:37:56)
                              Description Details of coping strategies used
                              draft Coping strategy
                              prsb03-dataelement-13851
                              Id prsb03-dataelement-13851 (2021‑01‑08 16:45:37)
                              Description The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Start date
                              prsb03-dataelement-13852
                              Id prsb03-dataelement-13852 (2021‑01‑08 16:47:18)
                              Description The date when the coping strategy started
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft End date
                              prsb03-dataelement-13853
                              Id prsb03-dataelement-13853 (2021‑01‑08 16:48:58)
                              Description The date when the coping strategy ended
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Relapse indicators / early warning signs
                              prsb03-dataelement-13854
                              Id prsb03-dataelement-13854 (2021‑01‑08 16:49:59)
                              Description Details of the relapse indicators for the person. These may also be called 'early warning signs'
                              Operationalization Free text

                              Value Domain
                              Property
                              max length
                              150
                              cancelled Early warning signs
                              prsb03-dataelement-13855
                              Id prsb03-dataelement-13855 (2021‑01‑08 16:56:37) Version 1.1 DCSP
                              Description Details of any early warning signs shown by the person
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft What should happen
                              prsb03-dataelement-10376
                              Id prsb03-dataelement-10376 (2018‑10‑31)
                              Description Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
                              Operationalization Free text
                              Value Domain
                              draft Who should be contacted
                              prsb03-dataelement-10377
                              Id prsb03-dataelement-10377 (2018‑10‑31)
                              Description Who should be contacted in the event of significant problems or deterioration in health or wellbeing. E.g. name, role and contact details.
                              Operationalization Free text
                              Value Domain
                              folder draft Location
                              prsb03-dataelement-12079
                              Id prsb03-dataelement-12079 (2019‑05‑31 15:39:45)
                              Description The location where the contingency plan was prepared.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13667
                              Id prsb03-dataelement-13667 (2020‑09‑08 22:19:58)
                              Description The coded value for location
                              Operationalization NHS data dictionary : - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13668
                              Id prsb03-dataelement-13668 (2020‑09‑08 22:21:39)
                              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
                              rejected Person completing record
                              prsb03-dataelement-10841
                              Id prsb03-dataelement-10841 (2019‑03‑27 16:20:18)
                              Description This is the person contributing to the contingency plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                              Relationship
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12045
                              Id prsb03-dataelement-12045 (2019‑05‑31 15:33:20)
                              Description The professional who prepared the contingency plans.
                              Relationship
                              draft Name
                              prsb03-dataelement-12046
                              Id prsb03-dataelement-12046 (2019‑05‑31 15:33:38)
                              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
                              draft Role
                              prsb03-dataelement-12047
                              Id prsb03-dataelement-12047 (2019‑05‑31 15:33:38)
                              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
                              draft Grade
                              prsb03-dataelement-12048
                              Id prsb03-dataelement-12048 (2019‑05‑31 15:33:38)
                              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
                              draft Speciality
                              prsb03-dataelement-12049
                              Id prsb03-dataelement-12049 (2019‑05‑31 15:33:38)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12050
                              Id prsb03-dataelement-12050 (2019‑05‑31 15:33:38)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12051
                              Id prsb03-dataelement-12051 (2019‑05‑31 15:33:38)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12052
                              Id prsb03-dataelement-12052 (2019‑05‑31 15:33:38)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12053
                              Id prsb03-dataelement-12053 (2019‑05‑31 15:33:49)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12054
                              Id prsb03-dataelement-12054 (2019‑05‑31 15:34:15)
                              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
                              draft Role
                              prsb03-dataelement-12055
                              Id prsb03-dataelement-12055 (2019‑05‑31 15:34:15)
                              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
                              draft Grade
                              prsb03-dataelement-12056
                              Id prsb03-dataelement-12056 (2019‑05‑31 15:34:15)
                              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
                              draft Specialty
                              prsb03-dataelement-12057
                              Id prsb03-dataelement-12057 (2019‑05‑31 15:34:15)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12058
                              Id prsb03-dataelement-12058 (2019‑05‑31 15:34:15)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12059
                              Id prsb03-dataelement-12059 (2019‑05‑31 15:34:15)
                              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
                              draft Date completed
                              prsb03-dataelement-12060
                              Id prsb03-dataelement-12060 (2019‑05‑31 15:34:15)
                              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
                              draft Contact details
                              prsb03-dataelement-12061
                              Id prsb03-dataelement-12061 (2019‑05‑31 15:34:15)
                              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
                              folder cancelled Outstanding Issues
                              prsb03-dataelement-478
                              Id prsb03-dataelement-478 (2018‑10‑31) 0.1
                              Description Outstanding Issues
                              cancelled Tasks which must be done
                              prsb03-dataelement-10378
                              Id prsb03-dataelement-10378 (2018‑10‑31) 0.1
                              Description Include timescales (appropriate seniority of staff for each task)
                              Value Domain
                              cancelled Tasks to be done if possible
                              prsb03-dataelement-10379
                              Id prsb03-dataelement-10379 (2018‑10‑31) 0.1
                              Description E.g. test review, pre-discharge documents, criteria for discharge, including who may discharge the patient.
                              Value Domain
                              folder cancelled Person handing over
                              prsb03-dataelement-480
                              Id prsb03-dataelement-480 (2018‑10‑31) 0.1
                              Description Person handing over
                              cancelled Name
                              prsb03-dataelement-10380
                              Id prsb03-dataelement-10380 (2018‑10‑31) 0.1
                              Description The name of the person completing the record, preferably in a structured format.
                              Value Domain
                              cancelled Role
                              prsb03-dataelement-10381
                              Id prsb03-dataelement-10381 (2018‑10‑31) 0.1
                              Description The role the person is playing within the organisation at the time record was updated.
                              Value Domain
                              cancelled Grade
                              prsb03-dataelement-10382
                              Id prsb03-dataelement-10382 (2018‑10‑31) 0.1
                              Description The grade of the person completing the record.
                              Value Domain
                              cancelled Specialty
                              prsb03-dataelement-10383
                              Id prsb03-dataelement-10383 (2018‑10‑31) 0.1
                              Description The main specialty of the person completing the record.
                              Value Domain
                              cancelled Contact details
                              prsb03-dataelement-10384
                              Id prsb03-dataelement-10384 (2018‑10‑31) 0.1
                              Description Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.
                              Value Domain
                              folder cancelled Person receiving handover
                              prsb03-dataelement-485
                              Id prsb03-dataelement-485 (2018‑10‑31) 0.1
                              Description Person receiving handover
                              cancelled Name
                              prsb03-dataelement-10385
                              Id prsb03-dataelement-10385 (2018‑10‑31) 0.1
                              Description The name of the person receiving the handover, preferably in a structured format.
                              Value Domain
                              cancelled Role
                              prsb03-dataelement-10386
                              Id prsb03-dataelement-10386 (2018‑10‑31) 0.1
                              Description The role the person is playing within the organisation at the time of handover.
                              Value Domain
                              cancelled Grade
                              prsb03-dataelement-10387
                              Id prsb03-dataelement-10387 (2018‑10‑31) 0.1
                              Description The grade of the person receiving the handover
                              Value Domain
                              cancelled Specialty
                              prsb03-dataelement-10388
                              Id prsb03-dataelement-10388 (2018‑10‑31) 0.1
                              Description The specialty of the person receiving the handover
                              Value Domain
                              cancelled Contact details
                              prsb03-dataelement-10389
                              Id prsb03-dataelement-10389 (2018‑10‑31) 0.1
                              Description Contact details of the person receiving the handover. For example a phone number, email address. Contact details are used to resolve queries about the record entry.
                              Value Domain
                              folder cancelled Handover Details
                              prsb03-dataelement-490
                              Id prsb03-dataelement-490 (2018‑10‑31) 0.1
                              Description Handover Details
                              cancelled Patient Location
                              prsb03-dataelement-10390
                              Id prsb03-dataelement-10390 (2018‑10‑31) 0.1
                              Description This is the physical location of the patient. For inpatient, e.g., hospital ward, bed, theatre. For ambulatory care, e.g., health centre, clinic. Resources centre, patient's home
                              Value Domain
                              cancelled Planned patient location
                              prsb03-dataelement-10391
                              Id prsb03-dataelement-10391 (2018‑10‑31) 0.1
                              Description If patient is changing location
                              Value Domain
                              cancelled Date of admission
                              prsb03-dataelement-10392
                              Id prsb03-dataelement-10392 (2018‑10‑31) 0.1
                              Description Date patient admitted to hospital
                              Value Domain
                              cancelled Expected date of discharge
                              prsb03-dataelement-10393
                              Id prsb03-dataelement-10393 (2018‑10‑31) 0.1
                              Description The date the patient is currently expected to be discharged from hospital
                              Value Domain
                              cancelled Responsible consultant
                              prsb03-dataelement-10394
                              Id prsb03-dataelement-10394 (2018‑10‑31) 0.1
                              Description The name and designation of the consultant, who has overall responsibility for the patient (may not actually see the patient)
                              Value Domain
                              cancelled Specialty
                              prsb03-dataelement-10395
                              Id prsb03-dataelement-10395 (2018‑10‑31) 0.1
                              Description Specialties designated by royal colleges and faculties. E.g. orthopedics, renal medicine, endocrinology, etc.
                              Value Domain
                              cancelled Service
                              prsb03-dataelement-10396
                              Id prsb03-dataelement-10396 (2018‑10‑31) 0.1
                              Description Subspecialties, treatment functions or services. E.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre-admission assessment clinic etc.
                              Value Domain
                              cancelled Date of decision to handover
                              prsb03-dataelement-10397
                              Id prsb03-dataelement-10397 (2018‑10‑31) 0.1
                              Description Date decision made to handover care.
                              Value Domain
                              cancelled New responsible consultant
                              prsb03-dataelement-10398
                              Id prsb03-dataelement-10398 (2018‑10‑31) 0.1
                              Description The name and designation of the consultant who is accepting responsibility for the patient’s inpatient care.
                              Value Domain
                              cancelled Date handover accepted
                              prsb03-dataelement-10399
                              Id prsb03-dataelement-10399 (2018‑10‑31) 0.1
                              Description Date decision made to accept handover of care
                              Value Domain
                              cancelled Reason for handover
                              prsb03-dataelement-10400
                              Id prsb03-dataelement-10400 (2018‑10‑31) 0.1
                              Description A clear statement of the reason for the temporary or permanent handover of care, e.g., low potassium, immediately post-op, unstable medical condition
                              Value Domain
                              cancelled Senior clinical contact
                              prsb03-dataelement-10401
                              Id prsb03-dataelement-10401 (2018‑10‑31) 0.1
                              Description If there is a particular requirement to call a specific person, e.g., consultant, SpR or special intervention team
                              Value Domain
                              folder draft Additional support plans
                              prsb03-dataelement-502
                              Id prsb03-dataelement-502 (2018‑10‑31)
                              Description Additional support plans
                              draft Additional support plan name
                              prsb03-dataelement-10402
                              Id prsb03-dataelement-10402 (2018‑10‑31)
                              Description The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
                              Operationalization Free text
                              Value Domain
                              draft Additional support plan content
                              prsb03-dataelement-10403
                              Id prsb03-dataelement-10403 (2018‑10‑31)
                              Description This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.
                              Operationalization Free text
                              Value Domain
                              cancelled Person completing record
                              prsb03-dataelement-10404
                              Id prsb03-dataelement-10404 (2018‑10‑31)
                              Description This is the person contributing to an additional supporting plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Planned review date/interval
                              prsb03-dataelement-10405
                              Id prsb03-dataelement-10405 (2018‑10‑31)
                              Description This is the date/interval when this information will next be reviewed.
                              Operationalization Date and time
                              Value Domain
                              draft Responsibility for review
                              prsb03-dataelement-10406
                              Id prsb03-dataelement-10406 (2018‑10‑31)
                              Description This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
                              Operationalization Free text.
                              Value Domain
                              draft Date this plan was last updated
                              prsb03-dataelement-10407
                              Id prsb03-dataelement-10407 (2018‑10‑31)
                              Description This is a record of the date that this information was last updated.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12080
                              Id prsb03-dataelement-12080 (2019‑05‑31 15:40:38)
                              Description The location where the additional support plan was prepared.
                              Relationship
                              Operationalization ODS code or free text
                              draft Coded value
                              prsb03-dataelement-13722
                              Id prsb03-dataelement-13722 (2020‑09‑14 13:50:06)
                              Description The coded value for location
                              Operationalization NHS data dictionary:- Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13723
                              Id prsb03-dataelement-13723 (2020‑09‑14 13:52:48)
                              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
                              folder draft Performing professional
                              prsb03-dataelement-12062
                              Id prsb03-dataelement-12062 (2019‑05‑31 15:36:17)
                              Description The professional who prepared the additional support plan.
                              Relationship
                              draft Name
                              prsb03-dataelement-12063
                              Id prsb03-dataelement-12063 (2019‑05‑31 15:36:35)
                              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
                              draft Role
                              prsb03-dataelement-12064
                              Id prsb03-dataelement-12064 (2019‑05‑31 15:36:35)
                              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
                              draft Grade
                              prsb03-dataelement-12065
                              Id prsb03-dataelement-12065 (2019‑05‑31 15:36:35)
                              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
                              draft Speciality
                              prsb03-dataelement-12066
                              Id prsb03-dataelement-12066 (2019‑05‑31 15:36:35)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12067
                              Id prsb03-dataelement-12067 (2019‑05‑31 15:36:35)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12068
                              Id prsb03-dataelement-12068 (2019‑05‑31 15:36:35)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12069
                              Id prsb03-dataelement-12069 (2019‑05‑31 15:36:35)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12070
                              Id prsb03-dataelement-12070 (2019‑05‑31 15:36:49)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12071
                              Id prsb03-dataelement-12071 (2019‑05‑31 15:37:13)
                              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
                              draft Role
                              prsb03-dataelement-12072
                              Id prsb03-dataelement-12072 (2019‑05‑31 15:37:13)
                              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
                              draft Grade
                              prsb03-dataelement-12073
                              Id prsb03-dataelement-12073 (2019‑05‑31 15:37:13)
                              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
                              draft Specialty
                              prsb03-dataelement-12074
                              Id prsb03-dataelement-12074 (2019‑05‑31 15:37:13)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12075
                              Id prsb03-dataelement-12075 (2019‑05‑31 15:37:13)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12076
                              Id prsb03-dataelement-12076 (2019‑05‑31 15:37:13)
                              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
                              draft Date completed
                              prsb03-dataelement-12077
                              Id prsb03-dataelement-12077 (2019‑05‑31 15:37:13)
                              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
                              draft Contact details
                              prsb03-dataelement-12078
                              Id prsb03-dataelement-12078 (2019‑05‑31 15:37:13)
                              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
                              folder draft End of life care
                              prsb03-dataelement-10743
                              Id prsb03-dataelement-10743 (2019‑03‑07 11:06:43)
                              Description Information relating to end of life care.

                              N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
                              cancelled Date
                              prsb03-dataelement-10867
                              Id prsb03-dataelement-10867 (2019‑03‑27 18:37:13) 0.1
                              Description The date the end of life care information was recorded.
                              Relationship
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              cancelled Location
                              prsb03-dataelement-10866
                              Id prsb03-dataelement-10866 (2019‑03‑27 18:36:09) 0.1
                              Description The location where the end of life care information was recorded.
                              Relationship
                              Value Domain
                              cancelled Person completing record
                              prsb03-dataelement-10865
                              Id prsb03-dataelement-10865 (2019‑03‑27 18:35:06) 0.1
                              Description This is the person contributing to the end of life care information. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                              Relationship
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              cancelled Consent for creation of end of life care plan
                              prsb03-dataelement-10769
                              Id prsb03-dataelement-10769 (2019‑03‑19 13:33:24) 0.1
                              Concept inherits from draft prsb03-dataelement-10431 (2018‑10‑31)
                              Description Separate explicit consent is required for creation of an end of life care record. This records how this consent has been granted in order to differentiate between person’s explicit consent, best interest decision, Lasting Power of Attorney decision and withdrawal of consent.
                              Operationalization End of life care plan use case only. This is a record of consent to create an end of life care plan.
                              Value Domain
                              cancelled Date plan was created
                              prsb03-dataelement-10787
                              Id prsb03-dataelement-10787 (2019‑03‑19 17:56:06) 0.1
                              Description This is a record of the date that this end of life care plan was last updated.
                              Value Domain
                              cancelled Planned review date
                              prsb03-dataelement-10770
                              Id prsb03-dataelement-10770 (2019‑03‑19 13:40:30) 0.1
                              Concept inherits from draft prsb03-dataelement-10208 (2018‑10‑31)
                              Description Date the plan is due for review.
                              Operationalization End of life care plan use case only. The date the plan is due for review.
                              Value Domain
                              folder draft Cardio-pulmonary resuscitation (CPR) decision
                              prsb03-dataelement-10771
                              Id prsb03-dataelement-10771 (2019‑03‑19 13:42:20)
                              Description Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
                              Relationship
                              draft Date
                              prsb03-dataelement-12210
                              Id prsb03-dataelement-12210 (2019‑05‑31 16:28:26)
                              Description The date when the cardio-pulmonary resuscitation decision was made.
                              Relationship
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12211
                              Id prsb03-dataelement-12211 (2019‑05‑31 16:29:12)
                              Description The location where the cardio-pulmonary resuscitation decision was made.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13689
                              Id prsb03-dataelement-13689 (2020‑09‑09 16:47:10)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13690
                              Id prsb03-dataelement-13690 (2020‑09‑09 16:48:20)
                              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
                              folder draft Cardio-pulmonary resuscitation (CPR) decision
                              prsb03-dataelement-13686
                              Id prsb03-dataelement-13686 (2020‑09‑09 16:35:43)
                              Description The cardio-pulmonary resuscitation (CPR) decision.
                              draft Coded value
                              prsb03-dataelement-13687
                              Id prsb03-dataelement-13687 (2020‑09‑09 16:40:50)
                              Description The coded value for CPR decision or DNACPR
                              Operationalization SNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13688
                              Id prsb03-dataelement-13688 (2020‑09‑09 16:45:48)
                              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
                              draft Date for review
                              prsb03-dataelement-13705
                              Id prsb03-dataelement-13705 (2020‑09‑10 12:10:08)
                              Description The date for review of CPR decision.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Location of document
                              prsb03-dataelement-13706
                              Id prsb03-dataelement-13706 (2020‑09‑10 12:30:14)
                              Description The location of the CPR decision document
                              Operationalization Free text or URL
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12212
                              Id prsb03-dataelement-12212 (2019‑05‑31 16:30:12)
                              Description The professional who made the cardio-pulmonary resuscitation decision.
                              Relationship
                              draft Name
                              prsb03-dataelement-12213
                              Id prsb03-dataelement-12213 (2019‑05‑31 16:30:28)
                              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
                              draft Role
                              prsb03-dataelement-12214
                              Id prsb03-dataelement-12214 (2019‑05‑31 16:30:28)
                              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
                              draft Grade
                              prsb03-dataelement-12215
                              Id prsb03-dataelement-12215 (2019‑05‑31 16:30:28)
                              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
                              draft Speciality
                              prsb03-dataelement-12216
                              Id prsb03-dataelement-12216 (2019‑05‑31 16:30:28)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12217
                              Id prsb03-dataelement-12217 (2019‑05‑31 16:30:28)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12218
                              Id prsb03-dataelement-12218 (2019‑05‑31 16:30:28)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12219
                              Id prsb03-dataelement-12219 (2019‑05‑31 16:30:28)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12220
                              Id prsb03-dataelement-12220 (2019‑05‑31 16:30:40)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12221
                              Id prsb03-dataelement-12221 (2019‑05‑31 16:31:04)
                              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
                              draft Role
                              prsb03-dataelement-12222
                              Id prsb03-dataelement-12222 (2019‑05‑31 16:31:04)
                              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
                              draft Grade
                              prsb03-dataelement-12223
                              Id prsb03-dataelement-12223 (2019‑05‑31 16:31:04)
                              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
                              draft Specialty
                              prsb03-dataelement-12224
                              Id prsb03-dataelement-12224 (2019‑05‑31 16:31:04)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12225
                              Id prsb03-dataelement-12225 (2019‑05‑31 16:31:04)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12226
                              Id prsb03-dataelement-12226 (2019‑05‑31 16:31:04)
                              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
                              draft Date completed
                              prsb03-dataelement-12227
                              Id prsb03-dataelement-12227 (2019‑05‑31 16:31:04)
                              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
                              draft Contact details
                              prsb03-dataelement-12228
                              Id prsb03-dataelement-12228 (2019‑05‑31 16:31:04)
                              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
                              cancelled Individual requirement
                              prsb03-dataelement-10772
                              Id prsb03-dataelement-10772 (2019‑03‑19 17:03:23)
                              Concept inherits from draft prsb03-dataelement-10060 (2018‑10‑31)
                              Description Individual requirement that a person has. These may be communication, cultural, cognitive or mobility needs.

                              Properties

                              FHIR Patient. nhsCommunications
                              Operationalization Information volunteered by the person or their representative or carer, or known about locally.Text or coded text (SNOMED CT), constrained as specified in SCCI1605.



                              Accessible Information standard

                              Accessible information - communications support refset ^999002121000000109https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/657

                              Accessible information - requires communications professional refset ^999002141000000102https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/660

                              Accessible information - requires specific contact method refset ^999002151000000104https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/658

                              Accessible information - requires specific information format refset ^999002131000000106https://dd4c.hscic.gov.uk/dd4c/publishedmetadatas/intid/659
                              Value Domain
                              cancelled Relevant contacts
                              prsb03-dataelement-10773
                              Id prsb03-dataelement-10773 (2019‑03‑19 17:07:45) 0.1
                              Concept inherits from draft prsb03-dataelement-10029 (2018‑10‑31)
                              Description Include the most important contacts including:

                              * Personal contacts e.g., next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc.

                              * Health/care professional contacts e.g., social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.

                              Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.

                              Properties

                              FHIR Patient.contact
                              Operationalization Details of relevant contacts, such as carers or family members, as recorded on the local system, or volunteered by the patient. This will be a free text list of relevant contacts.
                              Value Domain
                              cancelled Estimated prognosis
                              prsb03-dataelement-10774
                              Id prsb03-dataelement-10774 (2019‑03‑19 17:09:08)
                              Concept inherits from draft prsb03-dataelement-10202 (2018‑10‑31)
                              Description Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death. E.g., last days, weeks, months or year of life. Also include the date the prognosis was made.
                              Operationalization End of life care plan use case only. The prognosis estimated by a clinician.
                              Value Domain
                              folder draft Estimated prognosis
                              prsb03-dataelement-10745
                              Id prsb03-dataelement-10745 (2019‑03‑07 11:10:45)
                              Description Details of the persons estimated prognosis
                              Relationship
                              draft Date
                              prsb03-dataelement-12229
                              Id prsb03-dataelement-12229 (2019‑05‑31 16:31:46)
                              Description The date when the estimated prognosis was made.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12230
                              Id prsb03-dataelement-12230 (2019‑05‑31 16:32:37)
                              Description The location where the estimated prognosis was made.
                              Relationship
                              Operationalization ODS code or free text
                              draft Coded value
                              prsb03-dataelement-13703
                              Id prsb03-dataelement-13703 (2020‑09‑09 17:41:30)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13704
                              Id prsb03-dataelement-13704 (2020‑09‑09 17:42:40)
                              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
                              draft Estimated prognosis
                              prsb03-dataelement-13691
                              Id prsb03-dataelement-13691 (2020‑09‑09 16:49:55)
                              Description Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.
                              Operationalization Free text
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12231
                              Id prsb03-dataelement-12231 (2019‑05‑31 16:33:17)
                              Description The professional who made the estimated prognosis.
                              Relationship
                              draft Name
                              prsb03-dataelement-12232
                              Id prsb03-dataelement-12232 (2019‑05‑31 16:33:33)
                              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
                              draft Role
                              prsb03-dataelement-12233
                              Id prsb03-dataelement-12233 (2019‑05‑31 16:33:33)
                              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
                              draft Grade
                              prsb03-dataelement-12234
                              Id prsb03-dataelement-12234 (2019‑05‑31 16:33:33)
                              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
                              draft Speciality
                              prsb03-dataelement-12235
                              Id prsb03-dataelement-12235 (2019‑05‑31 16:33:33)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12236
                              Id prsb03-dataelement-12236 (2019‑05‑31 16:33:33)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12237
                              Id prsb03-dataelement-12237 (2019‑05‑31 16:33:33)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12238
                              Id prsb03-dataelement-12238 (2019‑05‑31 16:33:33)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12239
                              Id prsb03-dataelement-12239 (2019‑05‑31 16:33:44)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12240
                              Id prsb03-dataelement-12240 (2019‑05‑31 16:34:04)
                              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
                              draft Role
                              prsb03-dataelement-12241
                              Id prsb03-dataelement-12241 (2019‑05‑31 16:34:04)
                              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
                              draft Grade
                              prsb03-dataelement-12242
                              Id prsb03-dataelement-12242 (2019‑05‑31 16:34:04)
                              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
                              draft Specialty
                              prsb03-dataelement-12243
                              Id prsb03-dataelement-12243 (2019‑05‑31 16:34:04)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12244
                              Id prsb03-dataelement-12244 (2019‑05‑31 16:34:04)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12245
                              Id prsb03-dataelement-12245 (2019‑05‑31 16:34:04)
                              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
                              draft Date completed
                              prsb03-dataelement-12246
                              Id prsb03-dataelement-12246 (2019‑05‑31 16:34:04)
                              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
                              draft Contact details
                              prsb03-dataelement-12247
                              Id prsb03-dataelement-12247 (2019‑05‑31 16:34:04)
                              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
                              folder draft Awareness of prognosis
                              prsb03-dataelement-10775
                              Id prsb03-dataelement-10775 (2019‑03‑19 17:09:45)
                              Description Details of the persons awareness of prognosis
                              Relationship
                              draft Date
                              prsb03-dataelement-12248
                              Id prsb03-dataelement-12248 (2019‑05‑31 16:35:21)
                              Description The date when the assessment of the level of awareness of the prognosis was made.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12249
                              Id prsb03-dataelement-12249 (2019‑05‑31 16:36:50)
                              Description The location where the assessment of the level of awareness of the prognosis was made.
                              Relationship
                              Operationalization ODS code and free text
                              draft Coded value
                              prsb03-dataelement-13693
                              Id prsb03-dataelement-13693 (2020‑09‑09 16:57:59)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13694
                              Id prsb03-dataelement-13694 (2020‑09‑09 16:59:05)
                              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
                              draft Awareness of prognosis
                              prsb03-dataelement-13692
                              Id prsb03-dataelement-13692 (2020‑09‑09 16:53:36)
                              Description Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.
                              Operationalization Free text
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12250
                              Id prsb03-dataelement-12250 (2019‑05‑31 16:37:30)
                              Description The professional who made the assessment of the level of awareness of the prognosis.
                              Relationship
                              draft Name
                              prsb03-dataelement-12251
                              Id prsb03-dataelement-12251 (2019‑05‑31 16:37:48)
                              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
                              draft Role
                              prsb03-dataelement-12252
                              Id prsb03-dataelement-12252 (2019‑05‑31 16:37:48)
                              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
                              draft Grade
                              prsb03-dataelement-12253
                              Id prsb03-dataelement-12253 (2019‑05‑31 16:37:48)
                              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
                              draft Speciality
                              prsb03-dataelement-12254
                              Id prsb03-dataelement-12254 (2019‑05‑31 16:37:48)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12255
                              Id prsb03-dataelement-12255 (2019‑05‑31 16:37:48)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12256
                              Id prsb03-dataelement-12256 (2019‑05‑31 16:37:48)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12257
                              Id prsb03-dataelement-12257 (2019‑05‑31 16:37:48)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12258
                              Id prsb03-dataelement-12258 (2019‑05‑31 16:38:00)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12259
                              Id prsb03-dataelement-12259 (2019‑05‑31 16:38:20)
                              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
                              draft Role
                              prsb03-dataelement-12260
                              Id prsb03-dataelement-12260 (2019‑05‑31 16:38:20)
                              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
                              draft Grade
                              prsb03-dataelement-12261
                              Id prsb03-dataelement-12261 (2019‑05‑31 16:38:20)
                              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
                              draft Specialty
                              prsb03-dataelement-12262
                              Id prsb03-dataelement-12262 (2019‑05‑31 16:38:20)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12263
                              Id prsb03-dataelement-12263 (2019‑05‑31 16:38:20)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12264
                              Id prsb03-dataelement-12264 (2019‑05‑31 16:38:20)
                              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
                              draft Date completed
                              prsb03-dataelement-12265
                              Id prsb03-dataelement-12265 (2019‑05‑31 16:38:20)
                              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
                              draft Contact details
                              prsb03-dataelement-12266
                              Id prsb03-dataelement-12266 (2019‑05‑31 16:38:20)
                              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
                              cancelled Services and care
                              prsb03-dataelement-10776
                              Id prsb03-dataelement-10776 (2019‑03‑19 17:11:22) 0.1
                              Description The description of services and care providing support for person’s health and social wellbeing.
                              Relationship
                              Operationalization

                              This is the free text record of services and care as provided by the person or their representative.

                              Value Domain
                              draft Priorities of care
                              prsb03-dataelement-10201
                              Id prsb03-dataelement-10201 (2018‑10‑31)
                              Description The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.
                              Operationalization Free text
                              Value Domain
                              folder draft Anticipatory actions
                              prsb03-dataelement-10786
                              Id prsb03-dataelement-10786 (2019‑03‑19 17:23:36)
                              Description Details of the person's anticipatory actions
                              Relationship
                              draft Date
                              prsb03-dataelement-12286
                              Id prsb03-dataelement-12286 (2019‑05‑31 16:48:34)
                              Description The date when the anticipatory actions were identified.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12287
                              Id prsb03-dataelement-12287 (2019‑05‑31 16:49:03)
                              Description The location where the anticipatory actions were identified.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13701
                              Id prsb03-dataelement-13701 (2020‑09‑09 17:23:10)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13702
                              Id prsb03-dataelement-13702 (2020‑09‑09 17:24:16)
                              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
                              draft Anticipatory actions
                              prsb03-dataelement-13700
                              Id prsb03-dataelement-13700 (2020‑09‑09 17:17:57)
                              Description Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.
                              Operationalization Free text
                              Value Domain
                              Property
                              min length max length
                              3 5
                              folder draft Performing professional
                              prsb03-dataelement-12288
                              Id prsb03-dataelement-12288 (2019‑05‑31 16:49:45)
                              Description The professional who identified the anticipatory actions.
                              Relationship
                              draft Name
                              prsb03-dataelement-12289
                              Id prsb03-dataelement-12289 (2019‑05‑31 16:50:03)
                              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
                              draft Role
                              prsb03-dataelement-12290
                              Id prsb03-dataelement-12290 (2019‑05‑31 16:50:03)
                              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
                              draft Grade
                              prsb03-dataelement-12291
                              Id prsb03-dataelement-12291 (2019‑05‑31 16:50:03)
                              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
                              draft Speciality
                              prsb03-dataelement-12292
                              Id prsb03-dataelement-12292 (2019‑05‑31 16:50:03)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12293
                              Id prsb03-dataelement-12293 (2019‑05‑31 16:50:03)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12294
                              Id prsb03-dataelement-12294 (2019‑05‑31 16:50:03)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12295
                              Id prsb03-dataelement-12295 (2019‑05‑31 16:50:03)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12296
                              Id prsb03-dataelement-12296 (2019‑05‑31 16:50:15)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12297
                              Id prsb03-dataelement-12297 (2019‑05‑31 16:50:40)
                              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
                              draft Role
                              prsb03-dataelement-12298
                              Id prsb03-dataelement-12298 (2019‑05‑31 16:50:40)
                              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
                              draft Grade
                              prsb03-dataelement-12299
                              Id prsb03-dataelement-12299 (2019‑05‑31 16:50:40)
                              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
                              draft Specialty
                              prsb03-dataelement-12300
                              Id prsb03-dataelement-12300 (2019‑05‑31 16:50:40)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12301
                              Id prsb03-dataelement-12301 (2019‑05‑31 16:50:40)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12302
                              Id prsb03-dataelement-12302 (2019‑05‑31 16:50:40)
                              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
                              draft Date completed
                              prsb03-dataelement-12303
                              Id prsb03-dataelement-12303 (2019‑05‑31 16:50:40)
                              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
                              draft Contact details
                              prsb03-dataelement-12304
                              Id prsb03-dataelement-12304 (2019‑05‑31 16:50:40)
                              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
                              folder draft Anticipatory medicines/equipment
                              prsb03-dataelement-10785
                              Id prsb03-dataelement-10785 (2019‑03‑19 17:21:30)
                              Description Details of the persons availability or location regarding their anticipatory medicines/equipment.
                              Relationship
                              draft Date
                              prsb03-dataelement-12305
                              Id prsb03-dataelement-12305 (2019‑05‑31 16:52:30)
                              Description The date when the statement regarding anticipatory medicines/equipment was made.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12306
                              Id prsb03-dataelement-12306 (2019‑05‑31 16:53:01)
                              Description The location where the statement regarding anticipatory medicines/equipment was made.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13708
                              Id prsb03-dataelement-13708 (2020‑09‑10 15:57:43)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13709
                              Id prsb03-dataelement-13709 (2020‑09‑10 15:59:37)
                              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
                              draft Anticipatory medicines/equipment
                              prsb03-dataelement-13707
                              Id prsb03-dataelement-13707 (2020‑09‑10 15:27:00)
                              Description A statement regarding the availability or location of the anticipatory medicines/equipment.
                              Operationalization Free text
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12307
                              Id prsb03-dataelement-12307 (2019‑05‑31 16:53:39)
                              Description The professional who made the statement regarding anticipatory medicines/equipment was made.
                              Relationship
                              draft Name
                              prsb03-dataelement-12308
                              Id prsb03-dataelement-12308 (2019‑05‑31 16:53:59)
                              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
                              draft Role
                              prsb03-dataelement-12309
                              Id prsb03-dataelement-12309 (2019‑05‑31 16:53:59)
                              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
                              draft Grade
                              prsb03-dataelement-12310
                              Id prsb03-dataelement-12310 (2019‑05‑31 16:53:59)
                              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
                              draft Speciality
                              prsb03-dataelement-12311
                              Id prsb03-dataelement-12311 (2019‑05‑31 16:53:59)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12312
                              Id prsb03-dataelement-12312 (2019‑05‑31 16:53:59)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12313
                              Id prsb03-dataelement-12313 (2019‑05‑31 16:53:59)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12314
                              Id prsb03-dataelement-12314 (2019‑05‑31 16:53:59)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12315
                              Id prsb03-dataelement-12315 (2019‑05‑31 16:54:10)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12316
                              Id prsb03-dataelement-12316 (2019‑05‑31 16:54:34)
                              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
                              draft Role
                              prsb03-dataelement-12317
                              Id prsb03-dataelement-12317 (2019‑05‑31 16:54:34)
                              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
                              draft Grade
                              prsb03-dataelement-12318
                              Id prsb03-dataelement-12318 (2019‑05‑31 16:54:34)
                              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
                              draft Specialty
                              prsb03-dataelement-12319
                              Id prsb03-dataelement-12319 (2019‑05‑31 16:54:34)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12320
                              Id prsb03-dataelement-12320 (2019‑05‑31 16:54:34)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12321
                              Id prsb03-dataelement-12321 (2019‑05‑31 16:54:34)
                              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
                              draft Date completed
                              prsb03-dataelement-12322
                              Id prsb03-dataelement-12322 (2019‑05‑31 16:54:34)
                              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
                              draft Contact details
                              prsb03-dataelement-12323
                              Id prsb03-dataelement-12323 (2019‑05‑31 16:54:34)
                              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
                              folder cancelled Advance decision to refuse treatment (ADRT)
                              prsb03-dataelement-10778
                              Id prsb03-dataelement-10778 (2019‑03‑19 17:13:11) 0.1
                              Concept inherits from draft prsb03-dataelement-10428 (2018‑10‑31)
                              Description Details of the person's ADRT status.
                              folder cancelled Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
                              prsb03-dataelement-10779
                              Id prsb03-dataelement-10779 (2019‑03‑19 17:13:37) 0.1
                              Concept inherits from draft prsb03-dataelement-10425 (2018‑10‑31)
                              Description Details of the person's LPA record or equivalent
                              folder draft Preferred place of death
                              prsb03-dataelement-10780
                              Id prsb03-dataelement-10780 (2019‑03‑19 17:14:33)
                              Description Details of the person's preferred place of death
                              Relationship
                              draft Date
                              prsb03-dataelement-12324
                              Id prsb03-dataelement-12324 (2019‑05‑31 16:55:33)
                              Description The date when the preferred place of death was identified.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12325
                              Id prsb03-dataelement-12325 (2019‑05‑31 16:56:07)
                              Description The location where the preferred place of death was identified.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13713
                              Id prsb03-dataelement-13713 (2020‑09‑10 16:24:26)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13714
                              Id prsb03-dataelement-13714 (2020‑09‑10 16:25:48)
                              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
                              folder draft Preferred place of death 1st
                              prsb03-dataelement-13710
                              Id prsb03-dataelement-13710 (2020‑09‑10 16:01:29)
                              Description The preferences that a person has identified as their preferred place to die.
                              draft Name of the place
                              prsb03-dataelement-13711
                              Id prsb03-dataelement-13711 (2020‑09‑10 16:04:08)
                              Description The name of the preferred place of death
                              Operationalization Free text
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Type of place
                              prsb03-dataelement-13712
                              Id prsb03-dataelement-13712 (2020‑09‑10 16:11:41)
                              Description The type of preferred place of death
                              Operationalization SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Preferred place of death 2nd
                              prsb03-dataelement-13716
                              Id prsb03-dataelement-13716 (2020‑09‑10 16:33:13)
                              Description The preferences that a person has identified as their preferred place to die.
                              Relationship
                              draft Name of the place
                              prsb03-dataelement-13717
                              Id prsb03-dataelement-13717 (2020‑09‑10 16:33:46)
                              Concept inherits from draft prsb03-dataelement-13711 (2020‑09‑10 16:04:08)
                              Description The name of the preferred place of death
                              Operationalization Free text
                              Value Domain
                              draft Type of place
                              prsb03-dataelement-13718
                              Id prsb03-dataelement-13718 (2020‑09‑10 16:33:46)
                              Concept inherits from draft prsb03-dataelement-13712 (2020‑09‑10 16:11:41)
                              Description The type of preferred place of death
                              Operationalization SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
                              Value Domain
                              cancelled Preferred place of death
                              prsb03-dataelement-13715
                              Id prsb03-dataelement-13715 (2020‑09‑10 16:30:08) 0.1
                              Concept inherits from draft prsb03-dataelement-10199 (2018‑10‑31)
                              Description The preferences that a person has identified as their preferred place to die.
                              Operationalization End of life care plan use case only. Preferences will be identified as 1st/2nd choice etc as given by the person. Each recorded preference should include the name of the place that the person has identified. It may also include coded values from the National Information Standard (SCCI1580), together with the associated text:10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103

                              Preferred place of death: patient unable to express preference517131000000106

                              Preferred place of death: discussion not appropriate766391000000108

                              Preferred place of death: patient declined discussion517161000000101

                              Preferred place of death: patient undecided
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12326
                              Id prsb03-dataelement-12326 (2019‑05‑31 16:56:54)
                              Description The professional who identified the preferred place of death.
                              Relationship
                              draft Name
                              prsb03-dataelement-12327
                              Id prsb03-dataelement-12327 (2019‑05‑31 16:57:14)
                              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
                              draft Role
                              prsb03-dataelement-12328
                              Id prsb03-dataelement-12328 (2019‑05‑31 16:57:14)
                              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
                              draft Grade
                              prsb03-dataelement-12329
                              Id prsb03-dataelement-12329 (2019‑05‑31 16:57:14)
                              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
                              draft Speciality
                              prsb03-dataelement-12330
                              Id prsb03-dataelement-12330 (2019‑05‑31 16:57:14)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12331
                              Id prsb03-dataelement-12331 (2019‑05‑31 16:57:14)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12332
                              Id prsb03-dataelement-12332 (2019‑05‑31 16:57:14)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12333
                              Id prsb03-dataelement-12333 (2019‑05‑31 16:57:14)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12334
                              Id prsb03-dataelement-12334 (2019‑05‑31 16:57:26)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12335
                              Id prsb03-dataelement-12335 (2019‑05‑31 16:57:52)
                              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
                              draft Role
                              prsb03-dataelement-12336
                              Id prsb03-dataelement-12336 (2019‑05‑31 16:57:52)
                              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
                              draft Grade
                              prsb03-dataelement-12337
                              Id prsb03-dataelement-12337 (2019‑05‑31 16:57:52)
                              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
                              draft Specialty
                              prsb03-dataelement-12338
                              Id prsb03-dataelement-12338 (2019‑05‑31 16:57:52)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12339
                              Id prsb03-dataelement-12339 (2019‑05‑31 16:57:52)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12340
                              Id prsb03-dataelement-12340 (2019‑05‑31 16:57:52)
                              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
                              draft Date completed
                              prsb03-dataelement-12341
                              Id prsb03-dataelement-12341 (2019‑05‑31 16:57:52)
                              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
                              draft Contact details
                              prsb03-dataelement-12342
                              Id prsb03-dataelement-12342 (2019‑05‑31 16:57:52)
                              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
                              folder cancelled Agreed with person or legitimate person's representative
                              prsb03-dataelement-10784
                              Id prsb03-dataelement-10784 (2019‑03‑19 17:19:34) 0.1
                              Description Indicates whether the person or legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments.
                              Relationship
                              Operationalization A record of the agreement of the decisions made, Free text
                              cancelled Date
                              prsb03-dataelement-12343
                              Id prsb03-dataelement-12343 (2019‑05‑31 16:58:33) 0.1
                              Concept inherits from draft prsb03-dataelement-11688 (2019‑05‑31 11:50:22)
                              Description The date when the mental capacity assessment was made.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder cancelled Location
                              prsb03-dataelement-12344
                              Id prsb03-dataelement-12344 (2019‑05‑31 16:59:03) 0.1
                              Concept inherits from draft prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
                              Description The location where the mental capacity assessment was made.
                              folder cancelled Performing professional
                              prsb03-dataelement-12345
                              Id prsb03-dataelement-12345 (2019‑05‑31 16:59:45) 0.1
                              Concept inherits from draft prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
                              Description The professional who made the mental capacity assessment.
                              cancelled Name
                              prsb03-dataelement-12346
                              Id prsb03-dataelement-12346 (2019‑05‑31 17:00:07) 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
                              cancelled Role
                              prsb03-dataelement-12347
                              Id prsb03-dataelement-12347 (2019‑05‑31 17:00:07) 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
                              cancelled Grade
                              prsb03-dataelement-12348
                              Id prsb03-dataelement-12348 (2019‑05‑31 17:00:07) 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
                              cancelled Speciality
                              prsb03-dataelement-12349
                              Id prsb03-dataelement-12349 (2019‑05‑31 17:00:07) 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
                              cancelled Professional identifier
                              prsb03-dataelement-12350
                              Id prsb03-dataelement-12350 (2019‑05‑31 17:00:07) 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
                              folder cancelled Organisation
                              prsb03-dataelement-12351
                              Id prsb03-dataelement-12351 (2019‑05‑31 17:00:07) 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.
                              cancelled Contact details
                              prsb03-dataelement-12352
                              Id prsb03-dataelement-12352 (2019‑05‑31 17:00:07) 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
                              folder cancelled Person completing record
                              prsb03-dataelement-12353
                              Id prsb03-dataelement-12353 (2019‑05‑31 17:00:18) 0.1
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              cancelled Name
                              prsb03-dataelement-12354
                              Id prsb03-dataelement-12354 (2019‑05‑31 17:00:42) 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
                              cancelled Role
                              prsb03-dataelement-12355
                              Id prsb03-dataelement-12355 (2019‑05‑31 17:00:42) 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
                              cancelled Grade
                              prsb03-dataelement-12356
                              Id prsb03-dataelement-12356 (2019‑05‑31 17:00:42) 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
                              cancelled Specialty
                              prsb03-dataelement-12357
                              Id prsb03-dataelement-12357 (2019‑05‑31 17:00:42) 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
                              folder cancelled Organisation
                              prsb03-dataelement-12358
                              Id prsb03-dataelement-12358 (2019‑05‑31 17:00:42) 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
                              cancelled Professional identifier
                              prsb03-dataelement-12359
                              Id prsb03-dataelement-12359 (2019‑05‑31 17:00:42) 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
                              cancelled Date completed
                              prsb03-dataelement-12360
                              Id prsb03-dataelement-12360 (2019‑05‑31 17:00:42) 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
                              cancelled Contact details
                              prsb03-dataelement-12361
                              Id prsb03-dataelement-12361 (2019‑05‑31 17:00:42) 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
                              folder draft Preferred place of care
                              prsb03-dataelement-10781
                              Id prsb03-dataelement-10781 (2019‑03‑19 17:15:36)
                              Description Details of the persons preferred place of care
                              Relationship
                              draft Date
                              prsb03-dataelement-12362
                              Id prsb03-dataelement-12362 (2019‑05‑31 17:01:43)
                              Description The date when the preferred place of care was identified.
                              Relationship
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Location
                              prsb03-dataelement-12363
                              Id prsb03-dataelement-12363 (2019‑05‑31 17:02:33)
                              Description The location where the preferred place of care was identified.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13720
                              Id prsb03-dataelement-13720 (2020‑09‑10 17:00:51)
                              Description The coded value for location
                              Operationalization NHS data dictionary: - Organisation data service
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13721
                              Id prsb03-dataelement-13721 (2020‑09‑10 17:02:59)
                              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
                              draft Preferred place of care
                              prsb03-dataelement-13719
                              Id prsb03-dataelement-13719 (2020‑09‑10 16:56:48)
                              Description The preferences that the person has identified as their preferred place to receive care.
                              Operationalization Free text
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-12364
                              Id prsb03-dataelement-12364 (2019‑05‑31 17:03:08)
                              Description The professional who identified the preferred place of care.
                              Relationship
                              draft Name
                              prsb03-dataelement-12365
                              Id prsb03-dataelement-12365 (2019‑05‑31 17:03:28)
                              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
                              draft Role
                              prsb03-dataelement-12366
                              Id prsb03-dataelement-12366 (2019‑05‑31 17:03:28)
                              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
                              draft Grade
                              prsb03-dataelement-12367
                              Id prsb03-dataelement-12367 (2019‑05‑31 17:03:28)
                              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
                              draft Speciality
                              prsb03-dataelement-12368
                              Id prsb03-dataelement-12368 (2019‑05‑31 17:03:28)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12369
                              Id prsb03-dataelement-12369 (2019‑05‑31 17:03:28)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12370
                              Id prsb03-dataelement-12370 (2019‑05‑31 17:03:28)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12371
                              Id prsb03-dataelement-12371 (2019‑05‑31 17:03:28)
                              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
                              folder draft Person completing record
                              prsb03-dataelement-12372
                              Id prsb03-dataelement-12372 (2019‑05‑31 17:03:40)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12373
                              Id prsb03-dataelement-12373 (2019‑05‑31 17:04:03)
                              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
                              draft Role
                              prsb03-dataelement-12374
                              Id prsb03-dataelement-12374 (2019‑05‑31 17:04:03)
                              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
                              draft Grade
                              prsb03-dataelement-12375
                              Id prsb03-dataelement-12375 (2019‑05‑31 17:04:03)
                              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
                              draft Specialty
                              prsb03-dataelement-12376
                              Id prsb03-dataelement-12376 (2019‑05‑31 17:04:03)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12377
                              Id prsb03-dataelement-12377 (2019‑05‑31 17:04:03)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12378
                              Id prsb03-dataelement-12378 (2019‑05‑31 17:04:03)
                              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
                              draft Date completed
                              prsb03-dataelement-12379
                              Id prsb03-dataelement-12379 (2019‑05‑31 17:04:03)
                              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
                              draft Contact details
                              prsb03-dataelement-12380
                              Id prsb03-dataelement-12380 (2019‑05‑31 17:04:03)
                              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
                              cancelled Actual place of death
                              prsb03-dataelement-10782
                              Id prsb03-dataelement-10782 (2019‑03‑19 17:17:13) 0.1
                              Concept inherits from draft prsb03-dataelement-10211 (2018‑10‑31)
                              Description The location where the person actually died as recorded on the death certificate. If the person died somewhere other than their preferred place, record the reasons why this happened.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              cancelled Date of death
                              prsb03-dataelement-10783
                              Id prsb03-dataelement-10783 (2019‑03‑19 17:17:37) 0.1
                              Concept inherits from draft prsb03-dataelement-10213 (2018‑10‑31)
                              Description The date on which a person died or is officially deemed to have died, as recorded on the death certificate.

                              Properties

                              FHIR PDS
                              Operationalization Date and time
                              Value Domain
                              cancelled Date this plan was last updated
                              prsb03-dataelement-10788
                              Id prsb03-dataelement-10788 (2019‑03‑19 18:00:25) 0.1
                              Concept inherits from draft prsb03-dataelement-10412 (2018‑10‑31)
                              Description This is a record of the date that this care and support plan was last updated.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              cancelled Person completing record
                              prsb03-dataelement-10789
                              Id prsb03-dataelement-10789 (2019‑03‑19 18:02:49) 0.1
                              Description This is the person contributing to the end of life care plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details
                              Relationship
                              Operationalization Free text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
                              Value Domain
                              cancelled Cardio-pulmonary resuscitation (CPR) decision
                              prsb03-dataelement-10744
                              Id prsb03-dataelement-10744 (2019‑03‑07 11:07:59)
                              Concept inherits from draft prsb03-dataelement-10207 (2018‑10‑31)
                              Description Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
                              Operationalization A record of the decision made and the location of the documentation. May include the following SNOMED CT concepts from the National Information Standard (SCCI1580):450475007

                              For attempted cardiopulmonary resuscitation450476008

                              Not for attempted cardiopulmonary resuscitation
                              Value Domain
                              folder draft After death
                              prsb03-dataelement-309
                              Id prsb03-dataelement-309 (2018‑10‑31)
                              Description End of Life
                              draft Certification of death
                              prsb03-dataelement-10209
                              Id prsb03-dataelement-10209 (2018‑10‑31)
                              Description If person is in their last weeks of life, is there a doctor who has seen the person recently who could potentially sign a death certificate? Provide contact details.
                              Operationalization Free text or URL
                              Value Domain
                              Property
                              max length
                              150
                              draft Actions taken in anticipation of death
                              prsb03-dataelement-10210
                              Id prsb03-dataelement-10210 (2018‑10‑31)
                              Description Plan or statement of intent that has been agreed to facilitate certification of death and/or funeral arrangements e.g. anticipatory discussions with coroner to arrange funeral within 24 hours etc.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Actual place of death
                              prsb03-dataelement-10211
                              Id prsb03-dataelement-10211 (2018‑10‑31)
                              Description The location where the person actually died as recorded on the death certificate. If the person died somewhere other than their preferred place, record the reasons why this happened.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Cause of death
                              prsb03-dataelement-10212
                              Id prsb03-dataelement-10212 (2018‑10‑31)
                              Description The cause of death as recorded on the death certificate
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Date of death
                              prsb03-dataelement-10213
                              Id prsb03-dataelement-10213 (2018‑10‑31)
                              Description The date on which a person died or is officially deemed to have died, as recorded on the death certificate.

                              Properties

                              FHIR PDS
                              Operationalization Date and time
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Crisis Care Plan
                              prsb03-dataelement-300
                              Id prsb03-dataelement-300 (2018‑10‑31)
                              Description Crisis Care Plan
                              draft Care funding details
                              prsb03-dataelement-10200
                              Id prsb03-dataelement-10200 (2018‑10‑31)
                              Description A record of the funding source and any conditions or limitations associated.
                              Operationalization End of life care plan use case only. Free text.
                              Value Domain
                              draft Estimated prognosis
                              prsb03-dataelement-10202
                              Id prsb03-dataelement-10202 (2018‑10‑31)
                              Description Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death. E.g., last days, weeks, months or year of life. Also include the date the prognosis was made.
                              Operationalization End of life care plan use case only. The prognosis estimated by a clinician.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Awareness of prognosis
                              prsb03-dataelement-10203
                              Id prsb03-dataelement-10203 (2018‑10‑31)
                              Description Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.
                              Operationalization End of life care plan use case only. The awareness statement made by a clinician.
                              Value Domain
                              draft Anticipatory actions
                              prsb03-dataelement-10204
                              Id prsb03-dataelement-10204 (2018‑10‑31)
                              Description Please provide guidance on specific interventions or actions that may be required or should be avoided in specific situations.
                              Operationalization A statement of anticipatory actions. Usually expressed as: in the event of X do Y.
                              Value Domain
                              draft Anticipatory medicines/equipment
                              prsb03-dataelement-10205
                              Id prsb03-dataelement-10205 (2018‑10‑31)
                              Description Medicines or equipment available in the event of a crisis and their location.
                              Operationalization A statement regarding the availability or location of the anticipatory medicines/equipment.
                              Value Domain
                              draft Agreed with person or legitimate representative
                              prsb03-dataelement-10206
                              Id prsb03-dataelement-10206 (2018‑10‑31)
                              Description Indicates whether the crisis care plan was discussed and agreed with the person or legitimate representative. If agreement cannot be obtained the reason for this should be documented.
                              Operationalization A record of the agreement of the decisions made.
                              Value Domain
                              draft Cardio-pulmonary resuscitation (CPR) decision
                              prsb03-dataelement-10207
                              Id prsb03-dataelement-10207 (2018‑10‑31)
                              Description Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
                              Operationalization A record of the decision made and the location of the documentation. May include the following SNOMED CT concepts from the National Information Standard (SCCI1580):450475007

                              For attempted cardiopulmonary resuscitation450476008

                              Not for attempted cardiopulmonary resuscitation
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Planned review date
                              prsb03-dataelement-10208
                              Id prsb03-dataelement-10208 (2018‑10‑31)
                              Description Date the plan is due for review.
                              Operationalization End of life care plan use case only. The date the plan is due for review.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Personal comment/plan
                              prsb03-dataelement-581
                              Id prsb03-dataelement-581 (2018‑10‑31)
                              Description Personal comment/plan
                              draft Date
                              prsb03-dataelement-10481
                              Id prsb03-dataelement-10481 (2018‑10‑31)
                              Description The date on which the comment was entered and shared
                              Value Domain
                              draft Person Details
                              prsb03-dataelement-10482
                              Id prsb03-dataelement-10482 (2018‑10‑31)
                              Description Who recorded the comment and what relationship they are to the woman
                              Value Domain
                              draft Personal comment
                              prsb03-dataelement-10483
                              Id prsb03-dataelement-10483 (2018‑10‑31)
                              Description Free text comment recorded by the woman or her representative
                              Value Domain
                              draft Maternity Personalised Care Plan
                              prsb03-dataelement-10484
                              Id prsb03-dataelement-10484 (2018‑10‑31)
                              Description Personalised care plan details to include the data and plan details
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Pregnancy episode details
                              prsb03-dataelement-585
                              Id prsb03-dataelement-585 (2018‑10‑31)
                              Description Pregnancy episode details
                              draft Pregnancy ID
                              prsb03-dataelement-10485
                              Id prsb03-dataelement-10485 (2018‑10‑31)
                              Description Identifier used to tie together data relating to a specific pregnancy, allowing specific contacts and activities carried out (e.g. scans, tests, observations, findings, diagnoses) to be linked back to the booking appointment for that pregnancy
                              Value Domain
                              draft Fetal Identifier
                              prsb03-dataelement-10486
                              Id prsb03-dataelement-10486 (2018‑10‑31)
                              Description Identifier which allows woman babies to be identified in the event of multiple births, and in turn allow specific conditions to be attributed to specific babies and linked to labour/antenatal test details
                              Value Domain
                              draft Maternity Episode Start Date
                              prsb03-dataelement-10487
                              Id prsb03-dataelement-10487 (2018‑10‑31)
                              Description The start date of the maternity episode
                              Value Domain
                              draft Maternity Episode End Date
                              prsb03-dataelement-10488
                              Id prsb03-dataelement-10488 (2018‑10‑31)
                              Description The end date of the maternity episode
                              Value Domain
                              draft Maternity Episode End Reason
                              prsb03-dataelement-10489
                              Id prsb03-dataelement-10489 (2018‑10‑31)
                              Description The reason that the woman was discharged from maternity services.
                              Value Domain
                              folder draft Pregnancy outcome delivery and birth
                              prsb03-dataelement-590
                              Id prsb03-dataelement-590 (2018‑10‑31)
                              Description Pregnancy outcome delivery and birth
                              draft Date
                              prsb03-dataelement-10490
                              Id prsb03-dataelement-10490 (2018‑10‑31)
                              Description The date on which the pregnancy outcome/delivery/birth details were recorded
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Location
                              prsb03-dataelement-10491
                              Id prsb03-dataelement-10491 (2018‑10‑31)
                              Description The location where the pregnancy outcome/delivery/birth details was recorded
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Performing Professional
                              prsb03-dataelement-10492
                              Id prsb03-dataelement-10492 (2018‑10‑31)
                              Description Details of the professional recording the pregnancy outcome/delivery/birth details (including name and role).
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Pregnancy Outcome
                              prsb03-dataelement-10493
                              Id prsb03-dataelement-10493 (2018‑10‑31)
                              Description The pregnancy outcome of each fetus
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft •Birth
                              prsb03-dataelement-10494
                              Id prsb03-dataelement-10494 (2018‑10‑31)
                              draft Labour onset method
                              prsb03-dataelement-10495
                              Id prsb03-dataelement-10495 (2018‑10‑31)
                              Description Details of the method by which the process of labour began, or delivery by caesarean section occurred.
                              Value Domain
                              draft Date and time of Established Labour
                              prsb03-dataelement-10496
                              Id prsb03-dataelement-10496 (2018‑10‑31)
                              Description The Date/time when established labour is confirmed - regular painful contractions and progressive cervical dilatation
                              Value Domain
                              draft Date and time Fully Dilated
                              prsb03-dataelement-10497
                              Id prsb03-dataelement-10497 (2018‑10‑31)
                              Description The date and time that the woman is deemed to be fully dilated
                              Value Domain
                              draft Duration of 1st Stage
                              prsb03-dataelement-10498
                              Id prsb03-dataelement-10498 (2018‑10‑31)
                              Description A derived field based on the time of established labour to the time of full dilation
                              Value Domain
                              draft Onset of 2nd Stage of Labour
                              prsb03-dataelement-10499
                              Id prsb03-dataelement-10499 (2018‑10‑31)
                              Description The date and time that the second stage of labour was deemed to start
                              Value Domain
                              draft Date and time pushing commenced
                              prsb03-dataelement-10500
                              Id prsb03-dataelement-10500 (2018‑10‑31)
                              Description The date and time that pushing commenced
                              Value Domain
                              draft Location of birth
                              prsb03-dataelement-10501
                              Id prsb03-dataelement-10501 (2018‑10‑31)
                              Description The place of birth (including the address and organisation name where relevant).
                              Value Domain
                              draft Delivery place type
                              prsb03-dataelement-10502
                              Id prsb03-dataelement-10502 (2018‑10‑31)
                              Description The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc. )
                              Value Domain
                              draft Birth Attendants
                              prsb03-dataelement-10503
                              Id prsb03-dataelement-10503 (2018‑10‑31)
                              Description People present at the delivery
                              Value Domain
                              draft Ruptured Membranes Date/Time
                              prsb03-dataelement-10504
                              Id prsb03-dataelement-10504 (2018‑10‑31)
                              Description Date/time on which membranes ruptured if spontaneous
                              Value Domain
                              draft Duration of Rupture of Membranes
                              prsb03-dataelement-10505
                              Id prsb03-dataelement-10505 (2018‑10‑31)
                              Description The duration in hours and minutes as derived using the date of rupture versus current date time
                              Value Domain
                              draft Anaesthesia type
                              prsb03-dataelement-10506
                              Id prsb03-dataelement-10506 (2018‑10‑31)
                              Description The specific type of anaesthesia used to carry out the procedure (if applicable)
                              Value Domain
                              draft Pain Relief
                              prsb03-dataelement-10507
                              Id prsb03-dataelement-10507 (2018‑10‑31)
                              Description A record of pain relief used during labour and delivery where not anaesthetic or medication
                              Value Domain
                              draft Delivery Decision Date/Time
                              prsb03-dataelement-10508
                              Id prsb03-dataelement-10508 (2018‑10‑31)
                              Description The date and time of the decision to deliver
                              Value Domain
                              draft Delivery Decision Made by
                              prsb03-dataelement-10509
                              Id prsb03-dataelement-10509 (2018‑10‑31)
                              Description The details of the clinician making the decision to deliver
                              Value Domain
                              draft Reason for delivery decision
                              prsb03-dataelement-10510
                              Id prsb03-dataelement-10510 (2018‑10‑31)
                              Description The details of the reason for the decision to deliver
                              Value Domain
                              draft Date and Time of Delivery
                              prsb03-dataelement-10511
                              Id prsb03-dataelement-10511 (2018‑10‑31)
                              Description The date and time of the delivery of the baby
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Duration of second stage
                              prsb03-dataelement-10512
                              Id prsb03-dataelement-10512 (2018‑10‑31)
                              Description Derived field from the onset of the second stage to the date and time of delivery
                              Value Domain
                              draft Types of delivery (attempted)
                              prsb03-dataelement-10513
                              Id prsb03-dataelement-10513 (2018‑10‑31)
                              Description The type(s) of delivery for the baby that was attempted, but was not the final delivery method
                              Value Domain
                              draft Type of delivery
                              prsb03-dataelement-10514
                              Id prsb03-dataelement-10514 (2018‑10‑31)
                              Description Type of delivery for the baby, e.g. Spontaneous vaginal, vacuum extraction, breech extraction, elective caesarean section etc.
                              Value Domain
                              draft Length of Labour
                              prsb03-dataelement-10515
                              Id prsb03-dataelement-10515 (2018‑10‑31)
                              Description The length of the stages of labour and duration of the rupture of membranes (derived field)
                              Value Domain
                              draft Delayed Cord Clamping/duration
                              prsb03-dataelement-10516
                              Id prsb03-dataelement-10516 (2018‑10‑31)
                              Description Record the duration of which cord clamping occurred
                              Value Domain
                              draft Placenta Delivery Method
                              prsb03-dataelement-10517
                              Id prsb03-dataelement-10517 (2018‑10‑31)
                              Description The method by which the placenta was removed through physiological, active or manual means. Where more than one method is used, the final method should be recorded.
                              Value Domain
                              draft End of Third Stage
                              prsb03-dataelement-10518
                              Id prsb03-dataelement-10518 (2018‑10‑31)
                              Description The date and time of the end of the third stage of labour
                              Value Domain
                              draft Third stage duration
                              prsb03-dataelement-10519
                              Id prsb03-dataelement-10519 (2018‑10‑31)
                              Description The duration of the third stage of labour derived between the start of the third stage and the delivery of the placenta
                              Value Domain
                              draft Examination of Placenta
                              prsb03-dataelement-10520
                              Id prsb03-dataelement-10520 (2018‑10‑31)
                              Description A visual examination of the placenta to check completeness
                              Value Domain
                              draft Placenta Disposal
                              prsb03-dataelement-10521
                              Id prsb03-dataelement-10521 (2018‑10‑31)
                              Description The method by which the placenta was disposed
                              Value Domain
                              draft Placenta sent for histology
                              prsb03-dataelement-10522
                              Id prsb03-dataelement-10522 (2018‑10‑31)
                              Description An indication as to whether the placenta was sent for histology
                              Value Domain
                              draft Umbilical Cord Number of Vessels
                              prsb03-dataelement-10523
                              Id prsb03-dataelement-10523 (2018‑10‑31)
                              Description The number of umbilical cord vessels
                              Value Domain
                              draft Total Blood Loss
                              prsb03-dataelement-10524
                              Id prsb03-dataelement-10524 (2018‑10‑31)
                              Description The total volume of blood loss in mls following delivery
                              Value Domain
                              draft Comments
                              prsb03-dataelement-10525
                              Id prsb03-dataelement-10525 (2018‑10‑31)
                              Description Supporting text may be given covering regarding the outcome of the checks and actions taken.
                              Value Domain
                              folder draft Scan details
                              prsb03-dataelement-626
                              Id prsb03-dataelement-626 (2018‑10‑31)
                              Description Scan details
                              draft Date
                              prsb03-dataelement-10526
                              Id prsb03-dataelement-10526 (2018‑10‑31)
                              Description The date on which the scan was performed
                              Value Domain
                              draft Performing Professional
                              prsb03-dataelement-10527
                              Id prsb03-dataelement-10527 (2018‑10‑31)
                              Description Details of the professional performing the scan (including name and role)
                              Value Domain
                              draft Location
                              prsb03-dataelement-10528
                              Id prsb03-dataelement-10528 (2018‑10‑31)
                              Description The location where the scan was recorded
                              Value Domain
                              draft Scan
                              prsb03-dataelement-10529
                              Id prsb03-dataelement-10529 (2018‑10‑31)
                              Description The type of scan performed
                              Value Domain
                              draft Scan finding
                              prsb03-dataelement-10530
                              Id prsb03-dataelement-10530 (2018‑10‑31)
                              Description For each pregnancy scan, the finding of the scan (this includes the result value, with unit of observation and reference interval where applicable.
                              Value Domain
                              draft Comment
                              prsb03-dataelement-10531
                              Id prsb03-dataelement-10531 (2018‑10‑31)
                              Description Supporting text may be given regarding the scan
                              Value Domain
                              folder draft Professional comment
                              prsb03-dataelement-632
                              Id prsb03-dataelement-632 (2018‑10‑31)
                              Description Professional comment
                              draft Date
                              prsb03-dataelement-10532
                              Id prsb03-dataelement-10532 (2018‑10‑31)
                              Description The date on which the professional summary/comment was recorded
                              Value Domain
                              draft Location
                              prsb03-dataelement-10533
                              Id prsb03-dataelement-10533 (2018‑10‑31)
                              Description The location where the professional summary/comment was recorded.
                              Value Domain
                              draft Performing Professional
                              prsb03-dataelement-10534
                              Id prsb03-dataelement-10534 (2018‑10‑31)
                              Description Details of the professional performing the professional summary/comment (including name and role)
                              Value Domain
                              draft Professional summary
                              prsb03-dataelement-10535
                              Id prsb03-dataelement-10535 (2018‑10‑31)
                              Description Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results, opinion and specific action(s). Planned actions will be recorded under ‘plan’
                              Value Domain
                              folder draft Documents (including correspondence and images)
                              prsb03-dataelement-10820
                              Id prsb03-dataelement-10820 (2019‑03‑20 19:07:55)
                              Description Details about documents related to the person.
                              folder draft Documents
                              prsb03-dataelement-11259
                              Id prsb03-dataelement-11259 (2019‑05‑29 13:34:07)
                              Description This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
                              cancelled Author
                              prsb03-dataelement-10938
                              Id prsb03-dataelement-10938 (2019‑05‑16 15:22:35)
                              Description The author of the document.
                              Operationalization Free text
                              Value Domain
                              draft Date
                              prsb03-dataelement-10943
                              Id prsb03-dataelement-10943 (2019‑05‑16 15:34:53)
                              Description The date and time the document was created.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Performing professional
                              prsb03-dataelement-12422
                              Id prsb03-dataelement-12422 (2019‑06‑13 15:09:45)
                              Description The professional who authored the document.
                              Relationship
                              Operationalization Free text.
                              draft Name
                              prsb03-dataelement-12423
                              Id prsb03-dataelement-12423 (2019‑06‑13 15:10:21)
                              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
                              draft Role
                              prsb03-dataelement-12424
                              Id prsb03-dataelement-12424 (2019‑06‑13 15:10:21)
                              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
                              draft Grade
                              prsb03-dataelement-12425
                              Id prsb03-dataelement-12425 (2019‑06‑13 15:10:21)
                              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
                              draft Speciality
                              prsb03-dataelement-12426
                              Id prsb03-dataelement-12426 (2019‑06‑13 15:10:21)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12427
                              Id prsb03-dataelement-12427 (2019‑06‑13 15:10:21)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12428
                              Id prsb03-dataelement-12428 (2019‑06‑13 15:10:21)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12429
                              Id prsb03-dataelement-12429 (2019‑06‑13 15:10:21)
                              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
                              draft Documentation location
                              prsb03-dataelement-10946
                              Id prsb03-dataelement-10946 (2019‑05‑16 16:01:41)
                              Description The location of the document
                              Operationalization Free text or URL
                              Value Domain
                              Property
                              max length
                              150
                              draft Confidentiality
                              prsb03-dataelement-10942
                              Id prsb03-dataelement-10942 (2019‑05‑16 15:32:23)
                              Description The code specifying the level of confidentiality of the document.
                              Operationalization

                              FHIR value set : - Confidentiality

                              Value Domain
                              draft Class
                              prsb03-dataelement-10940
                              Id prsb03-dataelement-10940 (2019‑05‑16 15:29:15)
                              Description The document type e.g. report, summary, images, treatment plan, patient preferences, workflow
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Document title
                              prsb03-dataelement-10944
                              Id prsb03-dataelement-10944 (2019‑05‑16 15:58:49)
                              Description The title of the document.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Document name
                              prsb03-dataelement-10945
                              Id prsb03-dataelement-10945 (2019‑05‑16 16:00:44)
                              Description The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browser
                              Operationalization SNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
                              Value Domain
                              draft Document MIME type
                              prsb03-dataelement-10949
                              Id prsb03-dataelement-10949 (2019‑05‑16 16:57:32)
                              Description MIME type of the document e.g. application, pdf, audio, jpeg
                              Operationalization Free text
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-12430
                              Id prsb03-dataelement-12430 (2019‑06‑13 15:22:00)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12431
                              Id prsb03-dataelement-12431 (2019‑06‑13 15:22:28)
                              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
                              draft Role
                              prsb03-dataelement-12432
                              Id prsb03-dataelement-12432 (2019‑06‑13 15:22:28)
                              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
                              draft Grade
                              prsb03-dataelement-12433
                              Id prsb03-dataelement-12433 (2019‑06‑13 15:22:28)
                              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
                              draft Specialty
                              prsb03-dataelement-12434
                              Id prsb03-dataelement-12434 (2019‑06‑13 15:22:28)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12435
                              Id prsb03-dataelement-12435 (2019‑06‑13 15:22:28)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12436
                              Id prsb03-dataelement-12436 (2019‑06‑13 15:22:28)
                              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
                              draft Date completed
                              prsb03-dataelement-12437
                              Id prsb03-dataelement-12437 (2019‑06‑13 15:22:28)
                              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
                              draft Contact details
                              prsb03-dataelement-12438
                              Id prsb03-dataelement-12438 (2019‑06‑13 15:22:28)
                              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
                              folder draft Service
                              prsb03-dataelement-11163
                              Id prsb03-dataelement-11163 (2019‑05‑28 11:31:34)
                              Description The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)
                              Operationalization SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
                              draft Coded value
                              prsb03-dataelement-13749
                              Id prsb03-dataelement-13749 (2020‑09‑25 16:30:31)
                              Description The coded value for service
                              Operationalization SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13750
                              Id prsb03-dataelement-13750 (2020‑09‑25 16:31:24)
                              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
                              draft Comments
                              prsb03-dataelement-10941
                              Id prsb03-dataelement-10941 (2019‑05‑16 15:31:26)
                              Description Comments associated with the document.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Additional information required for images.
                              prsb03-dataelement-12449
                              Id prsb03-dataelement-12449 (2019‑06‑19 15:45:51)
                              Description Additional information required for images.
                              draft Image procedure
                              prsb03-dataelement-12450
                              Id prsb03-dataelement-12450 (2019‑06‑19 15:48:03)
                              Description The procedure used to capture the image
                              Operationalization Free text

                              Using DICOM code set https://dicom.innolitics.com/ciods
                              Value Domain
                              draft Image procedure date
                              prsb03-dataelement-12451
                              Id prsb03-dataelement-12451 (2019‑06‑19 15:53:41)
                              Description The date and time the image procedure was performed.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              folder draft Performing professional
                              prsb03-dataelement-12452
                              Id prsb03-dataelement-12452 (2019‑06‑19 15:54:56)
                              Description The professional who performed the image procedure.
                              Relationship
                              draft Name
                              prsb03-dataelement-12453
                              Id prsb03-dataelement-12453 (2019‑06‑19 15:55:27)
                              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
                              draft Role
                              prsb03-dataelement-12454
                              Id prsb03-dataelement-12454 (2019‑06‑19 15:55:27)
                              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
                              draft Grade
                              prsb03-dataelement-12455
                              Id prsb03-dataelement-12455 (2019‑06‑19 15:55:27)
                              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
                              draft Speciality
                              prsb03-dataelement-12456
                              Id prsb03-dataelement-12456 (2019‑06‑19 15:55:27)
                              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
                              draft Professional identifier
                              prsb03-dataelement-12457
                              Id prsb03-dataelement-12457 (2019‑06‑19 15:55:27)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12458
                              Id prsb03-dataelement-12458 (2019‑06‑19 15:55:27)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              draft Contact details
                              prsb03-dataelement-12459
                              Id prsb03-dataelement-12459 (2019‑06‑19 15:55:27)
                              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
                              folder draft Images
                              prsb03-dataelement-11158
                              Id prsb03-dataelement-11158 (2019‑05‑28 11:19:29)
                              folder cancelled Performing professional
                              prsb03-dataelement-12439
                              Id prsb03-dataelement-12439 (2019‑06‑13 16:21:27)
                              Concept inherits from draft prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
                              Description The professional who made the mental capacity assessment.
                              cancelled Name
                              prsb03-dataelement-12440
                              Id prsb03-dataelement-12440 (2019‑06‑13 16:21:54)
                              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
                              cancelled Role
                              prsb03-dataelement-12441
                              Id prsb03-dataelement-12441 (2019‑06‑13 16:21:54)
                              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
                              cancelled Grade
                              prsb03-dataelement-12442
                              Id prsb03-dataelement-12442 (2019‑06‑13 16:21:54)
                              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
                              cancelled Speciality
                              prsb03-dataelement-12443
                              Id prsb03-dataelement-12443 (2019‑06‑13 16:21:54)
                              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
                              cancelled Professional identifier
                              prsb03-dataelement-12444
                              Id prsb03-dataelement-12444 (2019‑06‑13 16:21:54)
                              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
                              folder cancelled Organisation
                              prsb03-dataelement-12445
                              Id prsb03-dataelement-12445 (2019‑06‑13 16:21:54)
                              Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
                              Description The name of the organisation the professional works for.
                              cancelled Contact details
                              prsb03-dataelement-12446
                              Id prsb03-dataelement-12446 (2019‑06‑13 16:21:54)
                              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
                              draft Image capture date
                              prsb03-dataelement-11159
                              Id prsb03-dataelement-11159 (2019‑05‑28 11:20:13)
                              Description The date and time when the image was captured.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Image ID
                              prsb03-dataelement-12460
                              Id prsb03-dataelement-12460 (2019‑06‑19 15:59:56)
                              Description A unique image identifier generated by the system.
                              Operationalization Free text
                              Value Domain
                              draft Image location
                              prsb03-dataelement-12461
                              Id prsb03-dataelement-12461 (2019‑06‑19 16:02:10)
                              Description The URL for the image
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              cancelled mimeType
                              prsb03-dataelement-11162
                              Id prsb03-dataelement-11162 (2019‑05‑28 11:26:27)
                              Description The type of image.
                              Operationalization Free text
                              Value Domain
                              cancelled Imagine capture date
                              prsb03-dataelement-11164
                              Id prsb03-dataelement-11164 (2019‑05‑28 16:35:28)
                              Description The date and time when the image was captured.
                              Operationalization Date and time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              cancelled Imagine procedure
                              prsb03-dataelement-11165
                              Id prsb03-dataelement-11165 (2019‑05‑28 16:39:02)
                              Description The procedure used to capture the image.
                              Operationalization DICOM code set or free text.
                              Value Domain
                              cancelled Unique id
                              prsb03-dataelement-11166
                              Id prsb03-dataelement-11166 (2019‑05‑28 16:53:10)
                              Description Image generated id.
                              Operationalization Free text.
                              Value Domain
                              draft Format code
                              prsb03-dataelement-11161
                              Id prsb03-dataelement-11161 (2019‑05‑28 11:25:19)
                              Description The format code of the document which provides information on how to display the document.
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Event code list
                              prsb03-dataelement-11160
                              Id prsb03-dataelement-11160 (2019‑05‑28 11:21:24)
                              Description The type of image (acquisition modality) and the anatomical site imaged.
                              Operationalization DICOM code
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-12462
                              Id prsb03-dataelement-12462 (2019‑06‑19 16:08:39)
                              Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
                              Description Details of the person completing the record.
                              Relationship
                              draft Name
                              prsb03-dataelement-12463
                              Id prsb03-dataelement-12463 (2019‑06‑19 16:09:03)
                              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
                              draft Role
                              prsb03-dataelement-12464
                              Id prsb03-dataelement-12464 (2019‑06‑19 16:09:03)
                              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
                              draft Grade
                              prsb03-dataelement-12465
                              Id prsb03-dataelement-12465 (2019‑06‑19 16:09:03)
                              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
                              draft Specialty
                              prsb03-dataelement-12466
                              Id prsb03-dataelement-12466 (2019‑06‑19 16:09:03)
                              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
                              folder draft Organisation
                              prsb03-dataelement-12467
                              Id prsb03-dataelement-12467 (2019‑06‑19 16:09:03)
                              Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
                              Description The organisation the person completing the record works for.
                              Relationship
                              draft Professional identifier
                              prsb03-dataelement-12468
                              Id prsb03-dataelement-12468 (2019‑06‑19 16:09:03)
                              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
                              draft Date completed
                              prsb03-dataelement-12469
                              Id prsb03-dataelement-12469 (2019‑06‑19 16:09:03)
                              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
                              draft Contact details
                              prsb03-dataelement-12470
                              Id prsb03-dataelement-12470 (2019‑06‑19 16:09:03)
                              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
                              draft Comments
                              prsb03-dataelement-12471
                              Id prsb03-dataelement-12471 (2019‑06‑19 16:09:28)
                              Description Comments associated with the imaging
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              cancelled Publication author
                              prsb03-dataelement-10947
                              Id prsb03-dataelement-10947 (2019‑05‑16 16:02:55)
                              Description The publication author of the document.
                              Operationalization This attribute contains the sub- attributes: Institution, Person, Role, Specialty, Telecommunication.
                              Value Domain
                              cancelled Date published
                              prsb03-dataelement-10948
                              Id prsb03-dataelement-10948 (2019‑05‑16 16:06:34)
                              Description The date the document is published.
                              Operationalization Date or time
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              cancelled Document status
                              prsb03-dataelement-10939
                              Id prsb03-dataelement-10939 (2019‑05‑16 15:25:04)
                              Description The lifecycle status of the Document
                              Value Domain
                              folder draft Property and equipment
                              prsb03-dataelement-13095
                              Id prsb03-dataelement-13095 (2020‑06‑22 15:07:43) 0.1
                              Description Possessions the person is taking into hospital with them e.g. clothes, glasses, hearing aids etc.
                              draft Property or equipment
                              prsb03-dataelement-13096
                              Id prsb03-dataelement-13096 (2020‑06‑22 15:14:31) 0.2
                              Description The list of property and equipment the person is taking into hosptial with them.
                              Operationalization Free text
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-13100
                              Id prsb03-dataelement-13100 (2020‑06‑24 15:58:27)
                              Description A record of the details of the person that entered the property or equipment the resident is taking into hospital, and the date on which it was entered.
                              Relationship
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Name
                              prsb03-dataelement-13101
                              Id prsb03-dataelement-13101 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Role
                              prsb03-dataelement-13102
                              Id prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Grade
                              prsb03-dataelement-13103
                              Id prsb03-dataelement-13103 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Specialty
                              prsb03-dataelement-13104
                              Id prsb03-dataelement-13104 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Organisation
                              prsb03-dataelement-13105
                              Id prsb03-dataelement-13105 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Professional identifier
                              prsb03-dataelement-13106
                              Id prsb03-dataelement-13106 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Date completed
                              prsb03-dataelement-13107
                              Id prsb03-dataelement-13107 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              draft Contact details
                              prsb03-dataelement-13108
                              Id prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
                              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 0 transactions, 0 templates, inherited 2 times
                               
                              folder cancelled End of life care plan summary
                              prsb03-dataelement-13329
                              Id prsb03-dataelement-13329 (2020‑08‑06 14:29:38) 0.1
                              Description Record the current end of life care plans that are in place for the person e.g. End of Life Plan; Amber Care Bundle; Gold Standards Framework; Right Care Form
                              cancelled Date
                              prsb03-dataelement-13330
                              Id prsb03-dataelement-13330 (2020‑08‑06 14:36:20) 0.1
                              Description The date the care plan was created.
                              Operationalization Date
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              cancelled Review date
                              prsb03-dataelement-13331
                              Id prsb03-dataelement-13331 (2020‑08‑06 14:39:49) 0.1
                              Description The date the care plan needs to be reviewed
                              Operationalization Date
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              folder draft Assessment notice
                              prsb03-dataelement-13401
                              Id prsb03-dataelement-13401 (2020‑08‑11 12:18:35) 0.1
                              Description Informs the social services team that an assessment will be required, with expected discharge date if known.
                              draft Issued date and time
                              prsb03-dataelement-13404
                              Id prsb03-dataelement-13404 (2020‑08‑11 12:24:59) 0.1
                              Description The date and time on which the Assessment Notice was given.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              draft Person consultation indicator
                              prsb03-dataelement-13408
                              Id prsb03-dataelement-13408 (2020‑08‑11 12:53:32) 0.1
                              Description Indicates whether or not the patient has been consulted in relation to the Assessment Notice.
                              Operationalization
                              Flag; N: No; Y: Yes
                              Value Domain
                              draft Carer consultation indicator
                              prsb03-dataelement-13407
                              Id prsb03-dataelement-13407 (2020‑08‑11 12:46:33) 0.1
                              Description
                              Indicates whether or not the carer (where applicable) has been consulted in relation to the Assessment Notice.
                              Operationalization
                              N: No; Y: Yes; NKC: No Known Carer
                              Value Domain
                              draft Person consent indicator
                              prsb03-dataelement-13406
                              Id prsb03-dataelement-13406 (2020‑08‑11 12:41:21) 0.1
                              Description Indicates whether or not the patient has consented to the Assessment Notice or lacks the mental capacity to do so.
                              Operationalization
                              N: No; Y: Yes; L: Lacks Mental Capacity
                              Value Domain
                              draft Third party person consent source
                              prsb03-dataelement-13405
                              Id prsb03-dataelement-13405 (2020‑08‑11 12:30:35) 0.1
                              Description A coded value specifying the source of consent where the patient lacks mental capacity and consent has been provided by a third party with the appropriate legal status.
                              Operationalization
                              C: Legal Representative (Carer); O: Legal Representative (Other); B: Best Interest Decision; N/A: Not Applicable
                              Value Domain
                              folder draft NHS CHC Assessment
                              prsb03-dataelement-13403
                              Id prsb03-dataelement-13403 (2020‑08‑11 12:24:26) 0.1
                              Description NHS Continuing Healthcare Assessment (checklist) entry
                              draft Assessment considered indicator
                              prsb03-dataelement-13409
                              Id prsb03-dataelement-13409 (2020‑08‑11 13:06:02) 0.1
                              Description Indicates whether or not the NHS body has considered providing the patient with NHS Continuing Health Care.
                              Operationalization
                              Flag: - yes/ no; N: No; Y: Yes
                              Value Domain
                              draft Assessment considered result
                              prsb03-dataelement-13410
                              Id prsb03-dataelement-13410 (2020‑08‑11 13:09:09) 0.1
                              Description Used to record the result of a consideration to provide the patient with NHS Continuing Care.
                              Operationalization Free text
                              Value Domain
                              folder draft Discharge notice
                              prsb03-dataelement-13402
                              Id prsb03-dataelement-13402 (2020‑08‑11 12:23:57) 0.1
                              Description Confirms discharge date to social services
                              draft Issued date and time
                              prsb03-dataelement-13411
                              Id prsb03-dataelement-13411 (2020‑08‑11 13:14:47) 0.1
                              Description The date and time on which the discharge notice was given.
                              Operationalization
                              The date and time on which the discharge notice was given.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              folder draft Withdrawal notice
                              prsb03-dataelement-13412
                              Id prsb03-dataelement-13412 (2020‑08‑11 13:23:00) 0.1
                              Description To withdraw either or both the assessment notice and/ or the discharge notice
                              draft Issued date and time
                              prsb03-dataelement-13413
                              Id prsb03-dataelement-13413 (2020‑08‑11 13:25:02) 0.1
                              Description The date and time on which the Withdrawal Notice was issued.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              draft Withdrawal type
                              prsb03-dataelement-13416
                              Id prsb03-dataelement-13416 (2020‑08‑11 13:34:37) 0.1
                              Description The type of notice that has been withdrawn.
                              Operationalization
                              1: Assessment Notice; 2: Discharge Notice; 3: Assessment Notice and Discharge Notice
                              Value Domain
                              draft Reason for withdrawal
                              prsb03-dataelement-13415
                              Id prsb03-dataelement-13415 (2020‑08‑11 13:30:35) 0.1
                              Description The reason why the notice has been withdrawn.
                              Operationalization
                              01: Patient is safe to discharge without a needs assessment; 02: Patient is eligible for NHS Continuing Health Care; 03: Proposed care package is inadequate;
                              04: Patient's proposed treatment has been cancelled or postponed; 05: Patient has refused a needs assessment; 06: Patient is resident in another local authority;
                              07: Patient's condition has deteriorated; 08: Patient has died; 09: Patient has transferred to intermediate care; 10: Patient has self- discharged; 11: Patient is making their own arrangements; 12: Notice sent in error; 13: Other
                              Value Domain
                              draft Reason for withdrawal - other
                              prsb03-dataelement-13414
                              Id prsb03-dataelement-13414 (2020‑08‑11 13:28:20) 0.1
                              Description A free format description of the reason why the notice has been withdrawn. To be used when 'Reason For Withdrawal = 'Other’.
                              Operationalization Free text
                              Value Domain
                              folder draft Notice receipt
                              prsb03-dataelement-13417
                              Id prsb03-dataelement-13417 (2020‑08‑11 13:39:01) 0.1
                              Description Notice receipt, from social services, entry. A receipt notice is issued and sent to the referring organisation to acknowledge that a notice has been received e.g. assessment, discharge, withdrawal.
                              draft Issued date and time
                              prsb03-dataelement-13421
                              Id prsb03-dataelement-13421 (2020‑08‑11 13:53:46) 0.1
                              Description The date and time on which the Notice Receipt was issued.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              draft Notice type
                              prsb03-dataelement-13420
                              Id prsb03-dataelement-13420 (2020‑08‑11 13:48:36) 0.1
                              Description The type of notice that the Notice Receipt relates to.
                              Operationalization
                              1: Assessment Notice; 2: Discharge Notice; 3: Withdrawal Notice (Assessment); 4: Withdrawal Notice (Discharge); 5: Withdrawal Notice (Assessment and Discharge)
                              Value Domain
                              draft Response type
                              prsb03-dataelement-13419
                              Id prsb03-dataelement-13419 (2020‑08‑11 13:45:56) 0.1
                              Description The Notice Receipt response type.
                              Operationalization
                              1: Accept ;2: Reject
                              Value Domain
                              draft Response details
                              prsb03-dataelement-13418
                              Id prsb03-dataelement-13418 (2020‑08‑11 13:43:31) 0.1
                              Description Supporting information for the Notice Receipt, for example the reason why a notice was rejected
                              Operationalization Free text
                              Value Domain
                              folder draft Shared decision making
                              prsb03-dataelement-13875
                              Id prsb03-dataelement-13875 (2021‑02‑01 16:10:46)
                              Description The details of the shared decision making process undertaken.
                              Comment Shared decision making (SDM) is a deliberative practice where individuals and clinicians faced with a decision collaborate to understand and select evidenced based options (such as tests, treatment, management, or support packages and including doing nothing), and where the person is supported to develop their informed preferences.
                              folder draft Shared decision making
                              prsb03-dataelement-13876
                              Id prsb03-dataelement-13876 (2021‑02‑01 16:13:46)
                              Description The details of the shared decision making process undertaken
                              Comment Shared decision making (SDM) is a deliberative practice where individuals and clinicians faced with a decision collaborate to understand and select evidenced based options (such as tests, treatment, management, or support packages and including doing nothing), and where the person is supported to develop their informed preferences.
                              folder draft Shared decision point
                              prsb03-dataelement-13877
                              Id prsb03-dataelement-13877 (2021‑02‑01 16:17:30)
                              Description This is a shared decision point 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.
                              folder draft Problem(s) or issue(s)
                              prsb03-dataelement-14096
                              Id prsb03-dataelement-14096 (2021‑02‑21 15:37:38)
                              Description Problem or issue to which the decision relates, including:
                              • A confirmed diagnosis
                              • Examination findings
                              • Investigation results
                              • Other problems or issues.
                              folder cancelled Examination finding
                              prsb03-dataelement-14097
                              Id prsb03-dataelement-14097 (2021‑02‑21 15:50:24)
                              Description Examination finding relevant to the shared decision.
                              folder cancelled Examination type
                              prsb03-dataelement-14098
                              Id prsb03-dataelement-14098 (2021‑02‑21 16:04:14)
                              Description The examination type
                              folder draft Problem(s) or issue(s)
                              prsb03-dataelement-14067
                              Id prsb03-dataelement-14067 (2021‑02‑17 12:14:59)
                              Description The problem or issue for which a shared decision was made. The problem will typically require an investigation, treatment, procedure or lifestyle intervention or a change to these e.g. starting, stopping, or switching a prescribed medication. Medical problems or issues would include signs, symptoms, a diagnosis, risk factors, examination findings or investigation results, or other issues.
                              draft Coded value
                              prsb03-dataelement-14068
                              Id prsb03-dataelement-14068 (2021‑02‑17 23:05:28)
                              Description The coded value for the problem or issue.
                              Operationalization SNOMED CT
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14069
                              Id prsb03-dataelement-14069 (2021‑02‑17 23:09:18)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder cancelled Diagnosis
                              prsb03-dataelement-14070
                              Id prsb03-dataelement-14070 (2021‑02‑17 23:13:19) 0.1
                              Description Confirmed diagnosis relevant to the shared decision.
                              cancelled Coded value
                              prsb03-dataelement-14071
                              Id prsb03-dataelement-14071 (2021‑02‑17 23:22:39) 0.1
                              Description The coded value for the confirmed diagnosis.
                              Operationalization SNOMED CT.
                              Value Domain
                              cancelled Free text
                              prsb03-dataelement-14072
                              Id prsb03-dataelement-14072 (2021‑02‑17 23:28:03) 0.1
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Encounter details
                              prsb03-dataelement-14077
                              Id prsb03-dataelement-14077 (2021‑02‑18 00:03:21)
                              Description Details of the encounter where a shared decision was discussed including a record of:

                              Location and location type
                              Date and time
                              Consultation method
                              Speciality
                              Professionals present
                              Person accompanying patient
                              Use of an interpreter
                              Recording of the conversation
                              draft Specialty
                              prsb03-dataelement-14015
                              Id prsb03-dataelement-14015 (2021‑02‑15 11:07:47)
                              Description The specialty to which the shared decision relates e.g. physiotherapy, oncology, mental health etc
                              Operationalization NHS data dictionary - Activity treatment function code

                              Value Domain
                              Property
                              max length
                              3
                              draft Date and time of encounter
                              prsb03-dataelement-13960
                              Id prsb03-dataelement-13960 (2021‑02‑03 15:40:11)
                              Description Date and time of the encounter where a shared decision was discussed.

                              Properties

                              FHIR Encounter.period
                              Relationship
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Location type
                              prsb03-dataelement-14016
                              Id prsb03-dataelement-14016 (2021‑02‑15 11:19:12)
                              Description The type of location where the encounter in which a shared decision was discussed took place e.g. person's home
                              Comment The General Medical Council guidance on Decision making and consent states in section 27 (GMC, 2020) : "To help patients understand and retain relevant information you should: share it in a place and at a time when they are most likely to understand and retain it."

                              Operationalization NHS data dictionary - Location type

                              Value Domain
                              folder draft Location
                              prsb03-dataelement-13961
                              Id prsb03-dataelement-13961 (2021‑02‑03 15:52:53)
                              Description The location of the encounter where the shared decision was discussed.
                              Relationship
                              draft Coded value
                              prsb03-dataelement-13962
                              Id prsb03-dataelement-13962 (2021‑02‑03 15:54:29)
                              Description The coded value for location.
                              Relationship
                              Operationalization NHS data dictionary : - Organisation data service code
                              Value Domain
                              Property
                              min length max length
                              3 5
                              draft Free text
                              prsb03-dataelement-13963
                              Id prsb03-dataelement-13963 (2021‑02‑03 15:54:29)
                              Concept inherits from draft prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
                              Description Free text field to be used if no code is available
                              Operationalization Free text
                              Value Domain
                              Property
                              max length
                              150
                              draft Consultation method
                              prsb03-dataelement-14014
                              Id prsb03-dataelement-14014 (2021‑02‑15 10:58:56)
                              Description Consultation method used e.g. face to face, telephone, video consultation
                              Operationalization NHS data dictionary - Consultation medium

                              Value Domain
                              folder draft Person accompanying patient
                              prsb03-dataelement-13964
                              Id prsb03-dataelement-13964 (2021‑02‑04 09:28:42)
                              Description Identify, where relevant to the shared decision, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).

                              Properties

                              FHIR Encounter.participant
                              Relationship
                              Comment The General Medical Council (GMC) guidance on Decision making and consent (GMC, 2020) states in section 27 "accommodate a patient’s wishes if they would like anyone else – a relative, partner, friend, carer or advocate – to be involved in discussions and/or help them make decisions."



                              The NICE guideline on Shared Decision Making ( in draft) states in section 1.2.3:



                              "Ask the person if they want to involve family members, friends or advocates (being aware of safeguarding). If so, include them in discussions as a way to help the person:

                              • actively engage in the consultation

                              • explain what is important to them

                              • make decisions about their care

                              • remember information they have been given during discussions."
                              draft Name
                              prsb03-dataelement-14008
                              Id prsb03-dataelement-14008 (2021‑02‑15 10:23:49)
                              Description The name of the person accompanying the patient.
                              Value Domain
                              draft Relationship
                              prsb03-dataelement-14009
                              Id prsb03-dataelement-14009 (2021‑02‑15 10:28:38)
                              Description The relationship the person accompanying the patient has to the person, e.g. father, grandmother, family friend etc.
                              Operationalization FHIR value set : - Related person

                              Value Domain
                              draft Role
                              prsb03-dataelement-14010
                              Id prsb03-dataelement-14010 (2021‑02‑15 10:33:50)
                              Description Additional roles the person accompanying the patient performs on behalf of the patient (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)
                              Operationalization Free text.
                              Value Domain
                              folder draft Professionals present
                              prsb03-dataelement-14011
                              Id prsb03-dataelement-14011 (2021‑02‑15 10:43:47)
                              Description The name and role of the additional individuals or team members present when the shared decision was made. Including consultant(s), nurse consultant(s), allied health professional(s), social worker(s) etc.
                              Operationalization The NICE guideline on Shared Decision Making ( in draft) states in section 1.2.5:



                              "If a person might find it difficult to share in decision making, for example if they have a mental health condition, English is not their first language or they have sensory difficulties, offer to arrange additional support for them if they do not have, or do not want, support from a partner, friend or carer. Support could come from a nurse, social worker, translator or volunteer (for example, an advocate) who can:



                              • help them to understand the resources provided

                              • encourage the person to take an active part in decision making

                              • reassure them that shared decision making will be supported by the healthcare professional they see."
                              draft Name
                              prsb03-dataelement-14012
                              Id prsb03-dataelement-14012 (2021‑02‑15 10:46:55)
                              Description The name of the professional present when the shared decision was made.
                              Operationalization Free text.
                              Value Domain
                              draft Relationsip
                              prsb03-dataelement-14234
                              Id prsb03-dataelement-14234 (2021‑02‑26 01:41:56)
                              Description The relationship the professional present or accompanying the patient has to the person e.g. advocate, friend, etc.

                              Operationalization Free text.
                              Value Domain
                              draft Job title
                              prsb03-dataelement-14013
                              Id prsb03-dataelement-14013 (2021‑02‑15 10:49:05)
                              Description The job title of the professional present when the shared decision was made.
                              Operationalization FHIR values set : - sdsjobrole
                              Value Domain
                              draft Use of an interpreter
                              prsb03-dataelement-13965
                              Id prsb03-dataelement-13965 (2021‑02‑04 09:37:32)
                              Description An indicator to record whether an interpreter was used at a care contact. If yes, records whether a professional interpreter, family member / friend, or other person was used for the purposes of communication. If no, records whether an interpreter was not required or did not attend.
                              Comment The General Medical Council (GMC) guidance on Decision making and consent (GMC, 2020) says in section 27e: "To help patients understand and retain relevant information you should: use an interpreter or translation service if they have difficulty understanding spoken English."
                              Operationalization NHS data dictionary : - Interpreter present at care contact indication code
                              Value Domain
                              folder draft Audio or video recording of the conversation
                              prsb03-dataelement-13966
                              Id prsb03-dataelement-13966 (2021‑02‑04 09:53:11)
                              Description Audio or video recording of the conversation cluster.
                              Comment The General Medical Council (GMC) guidance on Decision making and consent states in section 27c: "To help patients understand and retain relevant information you should: accommodate a patient’s wishes if they would like to to record the discussion."
                              draft Audio or visual recording made
                              prsb03-dataelement-13967
                              Id prsb03-dataelement-13967 (2021‑02‑04 09:57:03)
                              Description An indicator to record if an audio or video recording was made of the conversation.
                              Operationalization SNOMED CT : - 431315003 |Audio recording of patient interview (procedure)| or 282733006 |Video recording of patient interview (procedure)|.
                              Value Domain
                              draft Consent for audio or video recording of the conversation
                              prsb03-dataelement-13968
                              Id prsb03-dataelement-13968 (2021‑02‑04 10:25:25)
                              Description This is a record of consent for audio or visual recording of the conversation.
                              Comment The General Medical Council (GMC) Making and using video recordings of patients guidance (GMC, 2011) states in section 8 the following:



                              • "make recordings only where you have appropriate consent or other valid authority for doing so."
                              • "ensure that patients are under no pressure to give their consent for the recording to be made."
                              • "And you must not: disclose or use recordings for purposes outside the scope of the original consent without obtaining further consent (except in the circumstances set out [elsewhere in that document]."


                              The GMC guidance on Decision making and consent (GMC, 2020) makes clear that: 'While some interventions require a patient’s signature on a form, for most healthcare decisions you can rely on a patient’s verbal consent, as long as you are satisfied they’ve had the opportunity to consider any relevant information (see paragraph 10) and decided to go ahead. Although a patient can give consent verbally (or non-verbally) you should make sure this is recorded in their notes."
                              Operationalization Free text.
                              Value Domain
                              draft Copy of video or audio recording
                              prsb03-dataelement-13969
                              Id prsb03-dataelement-13969 (2021‑02‑04 10:39:30)
                              Description The conversation recording should be stored as a video/audio multimedia file or as a transcript (free text).
                              Comment The General Medical Council (GMC) guidance on Decision making and consent (GMC, 2020) states the following in section 23:



                              • "If you make a recording as part of a patient’s care you must follow our guidance on Making and using visual and audio recordings of patients. Such recordings form part of the medical record and should be treated in the same way as other records."
                              • "Recordings made by patients are owned by them and do not have to be stored with their medical records."
                              Operationalization Free text or multimedia file.
                              Value Domain
                              folder draft Person completing record
                              prsb03-dataelement-14078
                              Id prsb03-dataelement-14078 (2021‑02‑18 00:44:21)
                              Concept inherits from draft prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
                              Description Details of the person completing the record.
                              draft Name
                              prsb03-dataelement-14079
                              Id prsb03-dataelement-14079 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              draft Role
                              prsb03-dataelement-14080
                              Id prsb03-dataelement-14080 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              draft Grade
                              prsb03-dataelement-14081
                              Id prsb03-dataelement-14081 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14082
                              Id prsb03-dataelement-14082 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              folder draft Organisation
                              prsb03-dataelement-14083
                              Id prsb03-dataelement-14083 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
                              Description The organisation the person completing the record works for.
                              draft Coded value
                              prsb03-dataelement-14084
                              Id prsb03-dataelement-14084 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14085
                              Id prsb03-dataelement-14085 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Professional identifier
                              prsb03-dataelement-14086
                              Id prsb03-dataelement-14086 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              draft Date completed
                              prsb03-dataelement-14087
                              Id prsb03-dataelement-14087 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Contact details
                              prsb03-dataelement-14088
                              Id prsb03-dataelement-14088 (2021‑02‑18 00:46:15)
                              Concept inherits from draft prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder draft Supporting the shared decision
                              prsb03-dataelement-14073
                              Id prsb03-dataelement-14073 (2021‑02‑17 23:43:36)
                              Description A record of the interventions that have supported a shared decision. This includes actions taken before, during and after (or in-between) appointments where a shared decision was discussed. 
                              Comment Other interventions that support shared decision making such as use of an interpreter, recording of the discussion, and person(s) accompanying the patient can be found under encounter details.



                              The NICE guideline on Shared Decision Making ( in draft) states in section 1.2.1:



                              "Offer people interventions that support shared decision making at different stages, including before, during and after discussions with a healthcare professional, so that they are fully involved throughout their care."

                              cancelled In-between appointment interventions
                              prsb03-dataelement-14075
                              Id prsb03-dataelement-14075 (2021‑02‑17 23:57:10)
                              Description xxx
                              Value Domain
                              folder draft Pre-meeting information shared
                              prsb03-dataelement-14066
                              Id prsb03-dataelement-14066 (2021‑02‑17 11:43:19)
                              Description A record of the actions taken to prepare the patient to make a shared decision before the encounter where a shared decision was made. This should include a summary of any resources the person was offered to prepare them for the decision making process.
                              Comment The NICE guideline on Shared Decision Making ( in draft) states in section 1.2.4:



                              "Before an appointment where a decision will be discussed, offer the person access to resources in their preferred format (for example a booklet, flyer or app) to help them prepare for discussing options and making shared decisions. It should encourage them to think about what matters to them and what they hope to gain from the appointment (the 'preparation stage'). Resources could include links to relevant NICE guidance or NICE-endorsed information."



                              In section 1.2.5:



                              "If a person might find it difficult to share in decision making, for example if they have a mental health condition, English is not their first language or they have sensory difficulties, offer to arrange additional support for them if they do not have, or do not want, support from a partner, friend or carer. Support could come from a nurse, social worker, translator or volunteer (for example, an advocate) who can:



                              • help them to understand the resources provided

                              • encourage the person to take an active part in decision making

                              • reassure them that shared decision making will be supported by the healthcare professional they see."



                              Operationalization Free text.
                              folder draft Appointment actions
                              prsb03-dataelement-14074
                              Id prsb03-dataelement-14074 (2021‑02‑17 23:54:32)
                              Description A record of the actions taken to support shared decision making during the encounter.
                              folder draft Shared decision cluster
                              prsb03-dataelement-14095
                              Id prsb03-dataelement-14095 (2021‑02‑21 15:14:29)
                              Description A generic shared decision cluster.
                              Comment The following frameworks should be considered as alternative versions for recording the core shared decision making discussion:

                              • Shared decision cluster

                              • Ask 3 questions model cluster
                              • BRA(I)N model cluster
                              • Three talk model cluster
                              To avoid duplication in the record only one of the above needs to be recorded. 
                              folder draft Agenda setting
                              prsb03-dataelement-14089
                              Id prsb03-dataelement-14089 (2021‑02‑18 01:44:37)
                              Description A record of the agenda setting process undertaken to support the shared decision.
                              Comment The NICE guideline on Shared Decision Making ( in draft) in section 1.2.6:



                              "Agree an ‘agenda’ at the start of each appointment to prioritise together what to discuss. Say how long the appointment will last."
                              draft Patient agenda
                              prsb03-dataelement-14091
                              Id prsb03-dataelement-14091 (2021‑02‑18 01:58:28)
                              Description A record of what the patient said was their agenda for the appointment.
                              Comment This may have been elicited by encouraging the patient use the phrase 'My agenda for today is...'



                              The NICE guideline on Shared Decision Making ( in draft) states in section 1.2.6:



                              "Agree an ‘agenda’ at the start of each appointment to prioritise together what to discuss. Say how long the appointment will last."
                              Operationalization Free text.
                              Value Domain
                              draft Clinician agenda
                              prsb03-dataelement-14090
                              Id prsb03-dataelement-14090 (2021‑02‑18 01:51:20)
                              Description A record of the clinician's stated agenda for the appointment.
                              Comment This may have been communicated to the patient with phrases such as 'My agenda for today is...'



                              The NICE Shared Decision Making guideline (in draft) states in section 1.2.6: 



                              "Agree an ‘agenda’ at the start of each appointment to prioritise together what to discuss. Say how long the appointment will last."
                              Operationalization Free text.
                              Value Domain
                              folder draft Decision dialogue
                              prsb03-dataelement-14099
                              Id prsb03-dataelement-14099 (2021‑02‑21 16:43:09)
                              Description A record of the dialogue preceding the decision including the information shared that a person wanted or needed to know in order to make a decision, such as:
                              • Diagnosis & prognosis
                              • Options for further investigation, treatment or management (including the option to take no action).
                              • The potential benefits and risks of each option
                              Comment
                              The General Medical Council guidance on Decision making  (GMC, 2020) and consent states in section 10 that : "You must give patients the information they want or need to make a decision. This will usually include: diagnosis and prognosis, uncertainties about the diagnosis or prognosis, including options for further investigation, options for treating or managing the condition, including the option to take no action, the nature of each option, what would be involved, and the desired outcome, the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action."



                              The NICE Shared decision making guideline  (in development) states in section 1.2.9: "When offering tests, treatments or other healthcare services:
                              • openly discuss the risks, benefits and consequences of each option, making sure the person knows this includes choosing no treatment, or no change to what they are currently doing (the ‘option talk’ stage)."
                              folder draft Establishing the conversation.
                              prsb03-dataelement-14101
                              Id prsb03-dataelement-14101 (2021‑02‑22 13:16:02)
                              Description Details of what was said regarding the need to consider:
                              • Alternative treatment options
                              • The person's goals and hopes
                              Relationship
                              Comment
                              Overview: The team talk (previously choice talk) includes working together, describing choices, offering support and asking about the person's goals.
                              Suggested phrase: "Let's work as a team to make a decision that suits you best." (Elwyn, 2020)
                              A key purpose of the team talk is to make the the person, who by this point recognises that a health issue that requires a decision has been identified, aware that options exist. The team talk can be done face-to-face, by email or letter, telephone or other means and may include the use of patient decision support tools (Elwyn, 2016).



                              The NICE Shared decision making guideline (in development) states in section 1.2.7: "Ensure the person understands they can take part as fully as they want in making choices about their treatment or care (the ‘choice talk' stage of the three-talk model)."
                              draft Establishing the conversation
                              prsb03-dataelement-14103
                              Id prsb03-dataelement-14103 (2021‑02‑22 13:16:02)
                              Description A description of what was said to:

                              • Establish collaboration
                              • Declare the alternatives
                              • Purpose and reasons for the SDM conversation.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft Goals and hopes
                              prsb03-dataelement-14102
                              Id prsb03-dataelement-14102 (2021‑02‑22 13:16:02)
                              Description The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              folder draft Options entry
                              prsb03-dataelement-14105
                              Id prsb03-dataelement-14105 (2021‑02‑22 13:16:02)
                              Description Record of the options discussed.
                              Relationship
                              Comment The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states that when discussing options for treating or managing a condition the clinician involved must include the option to take no action:



                              "Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action (Principle 4)."
                              draft Coded value
                              prsb03-dataelement-14106
                              Id prsb03-dataelement-14106 (2021‑02‑22 13:16:02)
                              Description Coded value of the option discussed.
                              Relationship
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14107
                              Id prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13925 (2021‑02‑03 10:18:29)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Risks communication entry
                              prsb03-dataelement-14111
                              Id prsb03-dataelement-14111 (2021‑02‑22 13:16:02)
                              Description Record of the risks discussed for each option.
                              Relationship
                              Comment The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states in section 21 that when discussing benefits and harms a clinician should include the following: "Recognised risks of harm that [the clinician] believe[s] anyone in the patient’s position would want to know... the effect of the patient’s individual clinical circumstances on the probability of a benefit or harm occurring...risks of harm and potential benefits that the patient would consider significant for any reason...any risk of serious harm, however unlikely it is to occur...expected harms, including common side effects and what to do if they occur."



                              "It wouldn’t be reasonable to share every possible risk of harm, potential complication or side effect. Instead, you should tailor the discussion to each individual patient, guided by what matters to them, and share information in a way they can understand." (Section 22).
                              draft Coded value
                              prsb03-dataelement-14113
                              Id prsb03-dataelement-14113 (2021‑02‑22 13:16:02)
                              Description Coded value of the risk discussed.
                              Relationship
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14112
                              Id prsb03-dataelement-14112 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13931 (2021‑02‑03 10:46:20)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Benefits entry
                              prsb03-dataelement-14108
                              Id prsb03-dataelement-14108 (2021‑02‑22 13:16:02)
                              Description Record of the benefits discussed for each option.
                              Relationship
                              Comment
                              The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states in section 21: "You must give patients clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of each option, including the option to take no action."
                              draft Coded value
                              prsb03-dataelement-14109
                              Id prsb03-dataelement-14109 (2021‑02‑22 13:16:02)
                              Description Coded value of the benefit discussed.
                              Relationship
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14110
                              Id prsb03-dataelement-14110 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13928 (2021‑02‑03 10:35:02)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Recording the decision
                              prsb03-dataelement-14114
                              Id prsb03-dataelement-14114 (2021‑02‑22 13:16:02)
                              Description Details of the decision made with person. This includes details of the decisions made, what the person said was important to them in coming to the decision, and agreed timescales for review.
                              Relationship
                              Comment
                              Overview: The decision talk aims to establish a person's informed preferences and to make preference based decisions.
                              Suggested phrase: "Tell me what matters most to you for this decision." (Elwyn, 2020)
                              According to Elwyn (2016) the decision talk discussion may include the following key aspects: Focusing on preferences, eliciting and integrating preferences, moving to a decision, offering review.



                              The NICE guideline on Shared Decision Making (in draft) states:



                              In section 1.2.13:



                              "Make a joint decision or plan about treatment or care and agree when this will be reviewed (the ‘decision’ or ‘planning’ stage)."



                              In section 1.2.14:



                              "At the end of an appointment, state clearly what decisions have been made to make sure the person agrees with and understands what has been decided, what happens next, what the timescales are, and when it will be reviewed."



                              In section 1.2.15:



                              "When writing up the consultation, record any decisions made along with details of what the person said was important to them in making those decisions."
                              Operationalization Free text.
                              folder draft Decision entry
                              prsb03-dataelement-14191
                              Id prsb03-dataelement-14191 (2021‑02‑24 15:10:35)
                              Description Record of the decision.
                              Relationship
                              Comment GMC (DMC 50): "You should take a proportionate approach to the level of detail you record. Good medical practice states that you must include the decisions made and actions agreed - and who is making the decisions and agreeing the actions - in the patient's clinical records. This includes the decision to take no action."
                              draft Coded value
                              prsb03-dataelement-14192
                              Id prsb03-dataelement-14192 (2021‑02‑24 15:12:01)
                              Description Coded value of the decision agreed.
                              Relationship
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14193
                              Id prsb03-dataelement-14193 (2021‑02‑24 15:12:01)
                              Concept inherits from draft prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Actions for person or their carer
                              prsb03-dataelement-14189
                              Id prsb03-dataelement-14189 (2021‑02‑24 14:52:20)
                              Description Agreed actions for the person or their carer. For each action the following should be identified: outcome expectations, including person’s expectations.
                              Comment A record of the planned and requested actions for the person or their carer. May be structured (table), with actions, names, dates, status, location, strategies, or free text.



                              Kings Fund (2011):



                              "There should be a formal system for documenting:



                              1. the decision 

                              2. the agreed course of action 

                              3. the ongoing roles and responsibilities of each party 

                              4. the risk-sharing agreement.."
                              Operationalization Free text.
                              Value Domain
                              draft Actions for professionals
                              prsb03-dataelement-14188
                              Id prsb03-dataelement-14188 (2021‑02‑24 14:46:07)
                              Description Agreed actions for the professional including planned investigations, procedures and treatment for a person's identified conditions and priorities.
                              Comment A record of the agreed actions for the professional(s) . May be structured (table), with actions, names, dates, status, location, strategies, or free text.



                              Kings Fund (2011):



                              "There should be a formal system for documenting:



                              1. the decision

                              2. the agreed course of action

                              3. the ongoing roles and responsibilities of each party

                              4. the risk-sharing agreement.."
                              Operationalization Free text.
                              Value Domain
                              draft Planned review date/interval
                              prsb03-dataelement-14190
                              Id prsb03-dataelement-14190 (2021‑02‑24 15:03:16)
                              Description This is the date/interval when this information will next be reviewed.
                              Comment
                              GMC (DMC 56): "Unless treatment or care begins immediately after a patient has given consent, there will be opportunity for a decision to be reviewed."


                              GMC (DMC 57): "You should review a patient’s decision immediately before providing treatment or care and, if treatment is ongoing, make sure there are clear arrangements
                              in place to review decisions regularly, allowing patients opportunity to ask questions and discuss any concerns. You should also consider regularly reviewing a decision to take no action."


                              GMC (DMC 58): "Reviewing a decision is particularly important: if you haven’t personally had a discussion with the patient because they were initially seen by a colleague, if significant time has passed since the decision was made, if the patient’s condition has changed, if you have reason to believe the patient might have changed their mind, if any aspect of the chosen treatment or care has changed, if new information has become available about the potential benefits or risks of harm of any of the options that might make the patient choose differently."
                              Operationalization Date and time or free text.
                              Value Domain
                              folder draft Evaluating the decision
                              prsb03-dataelement-14228
                              Id prsb03-dataelement-14228 (2021‑02‑26 00:41:18)
                              Description A record of the perception of the decision and collaborative process from the perspective of the clinician and the patient, including:

                              • Clinician's view of the patient's level of health literacy
                              • A record of whether or not the clinician agreed with the decision
                              • A record of the patient's satisfaction with the decision made
                              • A record of decisional regret if experienced by the patient
                              Comment See also performance measures. 
                              draft Health literacy evaluation
                              prsb03-dataelement-14229
                              Id prsb03-dataelement-14229 (2021‑02‑26 00:54:20)
                              Description For further information Description of the clinician's assessment of the person's level of health literacy. This should include tools or techniques that were used during the conversation to support health literacy, such as:
                              • 'Teach back' or 'show me' method
                              • 'Chunking and checking'
                              • Readability tools used for any written materials shared
                              • SMOG test or calculator
                              Comment For further information see Health Education England's Health Literacy Toolkit ( HEE, 2018).
                              Operationalization Free text.
                              Value Domain
                              folder draft Decision satisfaction or regret
                              prsb03-dataelement-14231
                              Id prsb03-dataelement-14231 (2021‑02‑26 01:20:26)
                              Description A record of clinician and patient satisfaction (or regret) relating to the decision. 
                              draft Patient decision satisfaction
                              prsb03-dataelement-14232
                              Id prsb03-dataelement-14232 (2021‑02‑26 01:23:52)
                              Description A record of the person's level of satisfaction (or regret) with the decision made and the reasons for this.
                              Operationalization Free text.
                              Value Domain
                              draft Clinician decision satisfaction
                              prsb03-dataelement-14230
                              Id prsb03-dataelement-14230 (2021‑02‑26 01:15:05)
                              Description A record of whether the clinician agreed with the patient's chosen option and the reasons for this.
                              Operationalization Free text.
                              Value Domain
                              folder cancelled Motivational interviewing placeholder
                              prsb03-dataelement-14233
                              Id prsb03-dataelement-14233 (2021‑02‑26 01:29:18) 0.1
                              folder draft Performing professional
                              prsb03-dataelement-14115
                              Id prsb03-dataelement-14115 (2021‑02‑22 13:16:02)
                              Description The professional who conducted the shared decision making conversation.
                              Relationship
                              draft Organisation
                              prsb03-dataelement-14116
                              Id prsb03-dataelement-14116 (2021‑02‑22 13:16:02)
                              Concept inherits from cancelled prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
                              Description The name of the organisation the professional works for.
                              Value Domain
                              draft Name
                              prsb03-dataelement-14117
                              Id prsb03-dataelement-14117 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
                              Description The name of the professional.
                              Rationale Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              draft Role
                              prsb03-dataelement-14118
                              Id prsb03-dataelement-14118 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
                              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:- SDSjobrolename
                              Value Domain
                              draft Grade
                              prsb03-dataelement-14119
                              Id prsb03-dataelement-14119 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
                              Description The grade of the professional.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14120
                              Id prsb03-dataelement-14120 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
                              Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc.
                              Rationale PractitionerRole.speciality
                              Operationalization NHS data dictionary :- Care professional main speciality code
                              Value Domain
                              Property
                              min length max length
                              3 3
                              draft Professional identifier
                              prsb03-dataelement-14121
                              Id prsb03-dataelement-14121 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
                              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 entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              folder draft Organisation
                              prsb03-dataelement-14122
                              Id prsb03-dataelement-14122 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
                              Description The name of the organisation the professional works for.
                              draft Coded value
                              prsb03-dataelement-14123
                              Id prsb03-dataelement-14123 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisation identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14124
                              Id prsb03-dataelement-14124 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Contact details
                              prsb03-dataelement-14125
                              Id prsb03-dataelement-14125 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
                              Description Contact details of the professional.
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder draft Person completing record
                              prsb03-dataelement-14126
                              Id prsb03-dataelement-14126 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13944 (2021‑02‑03 11:48:41)
                              Description Details of the person completing the record.
                              draft Name
                              prsb03-dataelement-14127
                              Id prsb03-dataelement-14127 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13945 (2021‑02‑03 11:49:43)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              draft Role
                              prsb03-dataelement-14128
                              Id prsb03-dataelement-14128 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              draft Grade
                              prsb03-dataelement-14129
                              Id prsb03-dataelement-14129 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13947 (2021‑02‑03 11:49:43)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14130
                              Id prsb03-dataelement-14130 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              folder draft Organisation
                              prsb03-dataelement-14131
                              Id prsb03-dataelement-14131 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
                              Description The organisation the person completing the record works for.
                              draft Coded value
                              prsb03-dataelement-14132
                              Id prsb03-dataelement-14132 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13950 (2021‑02‑03 11:49:43)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14133
                              Id prsb03-dataelement-14133 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13951 (2021‑02‑03 11:49:43)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Professional identifier
                              prsb03-dataelement-14134
                              Id prsb03-dataelement-14134 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13952 (2021‑02‑03 11:49:43)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              draft Date completed
                              prsb03-dataelement-14135
                              Id prsb03-dataelement-14135 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13953 (2021‑02‑03 11:49:43)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Contact details
                              prsb03-dataelement-14136
                              Id prsb03-dataelement-14136 (2021‑02‑22 13:16:02)
                              Concept inherits from draft prsb03-dataelement-13954 (2021‑02‑03 11:49:43)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder cancelled Three talk model cluster
                              prsb03-dataelement-14100
                              Id prsb03-dataelement-14100 (2021‑02‑21 17:01:11)
                              Description A structured entry in the record for clinicians following the three talk model approach to shared decision making.
                              Relationship
                              folder cancelled Option talk placeholder
                              prsb03-dataelement-14104
                              Id prsb03-dataelement-14104 (2021‑02‑22 13:16:02)
                              Description Details of the option talk with the person (Three talk model).
                              Relationship
                              Comment
                              Overview: The option talk includes a discussion of the options and alternatives and the harms and benefits of these using evidence based risk communication principles.
                              Suggested phrase: "Let's compare the possible options." (Elwyn, 2020)
                              According to Elwyn (2016) the option talk discussion may include the following key aspects: Checking knowledge, listing options, describing options, exploring harms and benefits, providing patient decision support, summarising.



                              The General Medical Council guidance on Decision making (GMC, 2020) and consent states in section 10 that : "You must give patients the information they want or need to make a decision. This will usually include: diagnosis and prognosis, uncertainties about the diagnosis or prognosis, including options for further investigation, options for treating or managing the condition, including the option to take no action, the nature of each option, what would be involved, and the desired outcome, the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action."



                              The NICE Shared decision making guideline (in development) states in section 1.2.9: "When offering tests, treatments or other healthcare services:
                              • openly discuss the risks, benefits and consequences of each option, making sure the person knows this includes choosing no treatment, or no change to what they are currently doing (the ‘option talk’ stage)."
                              folder draft Decision support tool item entry
                              prsb03-dataelement-13955
                              Id prsb03-dataelement-13955 (2021‑02‑03 13:43:54)
                              Description Record of any decision support tools used.
                              Comment Examples of patient decision support tools include condition specific decision aids, issue cards, decision boxes, fact boxes, question prompt lists (e.g. BRAN) and generic communication frameworks. Where high-quality situation specific decision support tools do not exist the clinician may need to interpret evidence sources developed for health professionals.



                              The General Medical Council (GMC) Decision making and consent guidance (GMC, 2020) states in section 24: "You should consider using visual or other explanatory aids to support patients to understand their personalised risk, taking account of their individual clinical and personal circumstances, compared with population level risk."
                              draft Decision support tool identifier
                              prsb03-dataelement-14092
                              Id prsb03-dataelement-14092 (2021‑02‑18 02:21:49)
                              Description Any alphanumeric identifier associated with the decision support tool (if applicable). 
                              Operationalization Free text.
                              Value Domain
                              draft Decision support tool name
                              prsb03-dataelement-13956
                              Id prsb03-dataelement-13956 (2021‑02‑03 13:53:18)
                              Description The name of the decision support tool.
                              Operationalization Free text.
                              Value Domain
                              draft Decision support tool type
                              prsb03-dataelement-13957
                              Id prsb03-dataelement-13957 (2021‑02‑03 13:59:31)
                              Description The type of the decision support tool.
                              Comment Examples of patient decision support tools include condition specific decision aids, issue cards, decision boxes, fact boxes, question prompt lists and generic communication frameworks.
                              Operationalization Free text
                              Value Domain
                              draft Decision support tool location
                              prsb03-dataelement-13958
                              Id prsb03-dataelement-13958 (2021‑02‑03 14:14:39)
                              Description The URL for the decision support tool.
                              Operationalization Free text.
                              Value Domain
                              draft Decision support tool MIME type
                              prsb03-dataelement-13959
                              Id prsb03-dataelement-13959 (2021‑02‑03 14:32:12)
                              Description MIME type of the document e.g. application, pdf, website.
                              Operationalization Free text.
                              Value Domain
                              folder draft Ask 3 questions model cluster
                              prsb03-dataelement-14019
                              Id prsb03-dataelement-14019 (2021‑02‑15 12:25:33)
                              Description A structured entry in the record for use when a shared decision making conversation has been conducted using the 'Ask 3 questions' framework. This patient focused shared decision making tool encourages the patient to ask the following three questions when making decisions about their healthcare:

                              What are my options?

                              What are the pros and cons of each option for me?

                              How do I get support to help me make a decision that is right for me?


                              Comment Ask 3 questions is the patient focused part of the national Shared Decision Making programme. It has been adapted with permission for use in the NHS by the Advancing Quality Alliance (AQuA) from the Making Good Decisions in Collaboration ( MAGIC) improvement programme. AQuA has developed films, posters and other materials for its Ask 3 questions campaign to be seen by patients in advance of clinical encounters, where a decision may need to be made.



                              The framework is based on a set of questions originally tested by Shepherd et al. 2011 in a cross over trial. The questions tested were:



                              What are my options? What are the benefits and harms? How likely are these?



                              In the study, use of these questions was associated with improved scores in the Assessing Communication about Evidence and Patient Preferences (ACEPP) and OPTION (observing patient involvement) scales. 

                              draft Ask 3 questions item entry 1
                              prsb03-dataelement-14020
                              Id prsb03-dataelement-14020 (2021‑02‑15 16:13:27)
                              Description A record of what was discussed following the patient asking the question 'What are my options?' (Ask 3 questions framework).
                              Operationalization Free text.
                              Value Domain
                              draft Ask 3 questions item entry 2
                              prsb03-dataelement-14021
                              Id prsb03-dataelement-14021 (2021‑02‑15 16:31:13)
                              Description
                              A record of what was discussed following the patient asking the question 'What are the pros and cons of each option for me?' (Ask 3 questions framework).
                              Operationalization Free text.
                              Value Domain
                              draft Ask 3 questions item entry 3
                              prsb03-dataelement-14022
                              Id prsb03-dataelement-14022 (2021‑02‑15 16:38:01)
                              Description
                              A record of what was discussed following the patient asking the question ' What are my options?' (Ask 3 questions framework).
                              Operationalization Free text.
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-14024
                              Id prsb03-dataelement-14024 (2021‑02‑15 17:37:30)
                              Description The professional who conducted the shared decision making conversation (Ask 3 questions framework).
                              Relationship
                              draft Organisation
                              prsb03-dataelement-14045
                              Id prsb03-dataelement-14045 (2021‑02‑15 17:40:29)
                              Concept inherits from cancelled prsb03-dataelement-13902 (2021‑02‑02 18:16:27)
                              Description The name of the organisation the professional works for.
                              Value Domain
                              draft Name
                              prsb03-dataelement-14046
                              Id prsb03-dataelement-14046 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
                              Description The name of the professional.
                              Rationale Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              draft Role
                              prsb03-dataelement-14047
                              Id prsb03-dataelement-14047 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
                              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:- SDSjobrolename
                              Value Domain
                              draft Grade
                              prsb03-dataelement-14048
                              Id prsb03-dataelement-14048 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
                              Description The grade of the professional.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14049
                              Id prsb03-dataelement-14049 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
                              Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc.
                              Rationale PractitionerRole.speciality
                              Operationalization NHS data dictionary :- Care professional main speciality code
                              Value Domain
                              Property
                              min length max length
                              3 3
                              draft Professional identifier
                              prsb03-dataelement-14050
                              Id prsb03-dataelement-14050 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
                              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 entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              folder draft Organisation
                              prsb03-dataelement-14051
                              Id prsb03-dataelement-14051 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
                              Description The name of the organisation the professional works for.
                              draft Coded value
                              prsb03-dataelement-14052
                              Id prsb03-dataelement-14052 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisation identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14053
                              Id prsb03-dataelement-14053 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Contact details
                              prsb03-dataelement-14054
                              Id prsb03-dataelement-14054 (2021‑02‑15 17:40:29)
                              Concept inherits from draft prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
                              Description Contact details of the professional.
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder draft Person completing record
                              prsb03-dataelement-14055
                              Id prsb03-dataelement-14055 (2021‑02‑17 11:34:44)
                              Concept inherits from draft prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
                              Description Details of the person completing the record.
                              draft Name
                              prsb03-dataelement-14056
                              Id prsb03-dataelement-14056 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              draft Role
                              prsb03-dataelement-14057
                              Id prsb03-dataelement-14057 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              draft Grade
                              prsb03-dataelement-14058
                              Id prsb03-dataelement-14058 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14059
                              Id prsb03-dataelement-14059 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              folder draft Organisation
                              prsb03-dataelement-14060
                              Id prsb03-dataelement-14060 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
                              Description The organisation the person completing the record works for.
                              draft Coded value
                              prsb03-dataelement-14061
                              Id prsb03-dataelement-14061 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14062
                              Id prsb03-dataelement-14062 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Professional identifier
                              prsb03-dataelement-14063
                              Id prsb03-dataelement-14063 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              draft Date completed
                              prsb03-dataelement-14064
                              Id prsb03-dataelement-14064 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Contact details
                              prsb03-dataelement-14065
                              Id prsb03-dataelement-14065 (2021‑02‑17 11:36:42)
                              Concept inherits from draft prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder draft BRA(I)N model Cluster
                              prsb03-dataelement-13879
                              Id prsb03-dataelement-13879 (2021‑02‑01 16:24:40)
                              Description
                              A structured entry in the record for clinicians following the BRAN or BRAIN approach to shared decision making. The BRAN mnemonic covers the following:
                              B = Benefits
                              R = Risks
                              A = Alternatives
                              N = doing Nothing

                              Alternatively, the BRAIN mnemonic covers the following:
                              B = Benefits
                              R = Risks
                              A = Alternatives
                              I = Intuition
                              N = Next steps (as opposed to 'doing Nothing' in BRAN)
                              Comment The acronym BRAN is a decision support tool endorsed by the Academy of Medical Royal Colleges (AoMRC) for the purpose of structuring shared decision making conversations (BMJ, 2019).



                              The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative called BRAIN (CCMI, 2015).
                              folder draft Benefits entry
                              prsb03-dataelement-13880
                              Id prsb03-dataelement-13880 (2021‑02‑01 16:40:31)
                              Description A record of the benefits discussed as part of the shared decision making conversation (BRAN or BRAIN framework).
                              draft Coded value
                              prsb03-dataelement-13885
                              Id prsb03-dataelement-13885 (2021‑02‑01 18:38:52)
                              Description Coded value of the benefits discussed.
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13886
                              Id prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 12 times
                               
                              folder draft Risks entry
                              prsb03-dataelement-13881
                              Id prsb03-dataelement-13881 (2021‑02‑01 16:44:09)
                              Description A record of the risks discussed as part of the shared decision making conversation (BRAN or BRAIN framework).
                              draft Coded value
                              prsb03-dataelement-13887
                              Id prsb03-dataelement-13887 (2021‑02‑01 18:47:38)
                              Description Coded value of the risks discussed.
                              Operationalization SNOMED CT.
                              Value Domain
                              Choice list
                              Concept List
                              Concept Description
                              draft Free text
                              prsb03-dataelement-13888
                              Id prsb03-dataelement-13888 (2021‑02‑01 18:50:44)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Alternatives entry
                              prsb03-dataelement-13882
                              Id prsb03-dataelement-13882 (2021‑02‑01 16:47:00)
                              Description A record of the alternatives discussed as part of the shared decision making conversation (BRAN or BRAIN framework).
                              draft Coded value
                              prsb03-dataelement-13889
                              Id prsb03-dataelement-13889 (2021‑02‑01 18:55:16)
                              Description Coded value of the alternatives discussed.
                              Relationship
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13890
                              Id prsb03-dataelement-13890 (2021‑02‑01 18:59:37)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Intuition entry
                              prsb03-dataelement-13891
                              Id prsb03-dataelement-13891 (2021‑02‑01 19:10:42)
                              Description A record of the person's intuition (BRAIN framework).
                              Comment
                              The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative called BRAIN (CCMI, 2015). This model involves the patient first asking the following questions:
                              What is the decision I need to make?
                              How much time do I have to make this decision?
                              Who is involved in making this decision?
                              What are my values that affect this decision?
                              The BRAIN mnemonic covers the following:
                              B = Benefits
                              R = Risks
                              A = Alternatives
                              I = Intuition
                              N = Next steps (as opposed to 'doing Nothing' in BRAN)
                              At the intuition step the patient asks the following question:
                              What do I feel and think about these options? The outcome should be entered into the record here.
                              Operationalization Free text.
                              Value Domain
                              folder cancelled Intuition entry
                              prsb03-dataelement-13883
                              Id prsb03-dataelement-13883 (2021‑02‑01 16:50:05) 0.1
                              Description A record of the person's intuition (BRAIN framework).
                              Comment
                              The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative called BRAIN (CCMI, 2016). This model involves the patient first asking the following questions:
                              What is the decision I need to make?
                              How much time do I have to make this decision?
                              Who is involved in making this decision?
                              What are my values that affect this decision?
                              The BRAIN mnemonic covers the following:
                              B = Benefits
                              R = Risks
                              A = Alternatives
                              I = Intuition
                              N = Next steps (as opposed to 'doing Nothing' in BRAN)
                              At the intuition step the patient asks the following question:
                              What do I feel and think about these options? The outcome should be entered into the record here.
                              folder draft Nothing entry
                              prsb03-dataelement-13884
                              Id prsb03-dataelement-13884 (2021‑02‑01 18:34:45)
                              Description An indicator showing whether the option to do nothing was discussed as part of the shared decision making conversation (BRAN framework).
                              draft Coded value
                              prsb03-dataelement-13892
                              Id prsb03-dataelement-13892 (2021‑02‑01 19:16:02)
                              Description Coded value to indicate whether the option to do nothing was discussed.
                              Operationalization Y = yes ; N = no
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13893
                              Id prsb03-dataelement-13893 (2021‑02‑01 19:21:14)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Next steps entry
                              prsb03-dataelement-13894
                              Id prsb03-dataelement-13894 (2021‑02‑01 19:23:55)
                              Description A record of the next steps considered (BRAIN framework).
                              Comment
                              The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative called BRAIN:
                              B = Benefits
                              R = Risks
                              A = Alternatives
                              I = Intuition
                              N = Next steps (as opposed to 'doing Nothing' in BRAN)
                              Examples of questions that the patient may be encouraged to ask at the next steps stage include (CCMI,2015):
                              Do I need to talk to my family?
                              Do I need more time to think my decision through?
                              Do I want more information?
                              Would I like to wait on treatment?
                              Do I want a second opinion?
                              What would I like to do?
                              Value Domain
                              draft Decision entry
                              prsb03-dataelement-13895
                              Id prsb03-dataelement-13895 (2021‑02‑01 19:35:49)
                              Description A record of the decision made (BRAN or BRAIN framework).
                              Comment The General Medical Council (GMC) Decision making and consent guidance (GMC, 2020) states: "You should take a proportionate approach to the level of detail you record. Good medical practice states that you must include the decisions made and actions agreed - and who is making the decisions and agreeing the actions - in the patient's clinical records. This includes decisions to take no action."
                              Operationalization Free text.
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-13896
                              Id prsb03-dataelement-13896 (2021‑02‑01 19:50:38)
                              Description The professional who conducted the shared decision making conversation (BRAN or BRAIN framework).
                              Relationship
                              cancelled Organisation
                              prsb03-dataelement-13902
                              Id prsb03-dataelement-13902 (2021‑02‑02 18:16:27)
                              Description The name of the organisation the professional works for.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Name
                              prsb03-dataelement-13897
                              Id prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
                              Description The name of the professional.
                              Rationale Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Role
                              prsb03-dataelement-13898
                              Id prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
                              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:- SDSjobrolename
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Grade
                              prsb03-dataelement-13899
                              Id prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
                              Description The grade of the professional.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Specialty
                              prsb03-dataelement-13900
                              Id prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
                              Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc.
                              Rationale PractitionerRole.speciality
                              Operationalization NHS data dictionary :- Care professional main speciality code
                              Value Domain
                              Property
                              min length max length
                              3 3
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Professional identifier
                              prsb03-dataelement-13901
                              Id prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
                              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 entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Organisation
                              prsb03-dataelement-13903
                              Id prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
                              Description The name of the organisation the professional works for.
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Coded value
                              prsb03-dataelement-13904
                              Id prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisation identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Free text
                              prsb03-dataelement-13905
                              Id prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Contact details
                              prsb03-dataelement-13906
                              Id prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
                              Description Contact details of the professional.
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Person completing record
                              prsb03-dataelement-13907
                              Id prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
                              Description Details of the person completing the record.
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Name
                              prsb03-dataelement-13908
                              Id prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Role
                              prsb03-dataelement-13909
                              Id prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Grade
                              prsb03-dataelement-13910
                              Id prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Specialty
                              prsb03-dataelement-13911
                              Id prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              folder draft Organisation
                              prsb03-dataelement-13912
                              Id prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
                              Description The organisation the person completing the record works for.
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Coded value
                              prsb03-dataelement-13913
                              Id prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Free text
                              prsb03-dataelement-13914
                              Id prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Professional identifier
                              prsb03-dataelement-13915
                              Id prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Date completed
                              prsb03-dataelement-13916
                              Id prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              draft Contact details
                              prsb03-dataelement-13917
                              Id prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              target Used by 0 transactions, 0 templates, inherited 4 times
                               
                              folder draft Three talk model cluster
                              prsb03-dataelement-13918
                              Id prsb03-dataelement-13918 (2021‑02‑03 09:38:31)
                              Description A structured entry in the record for clinicians following the three talk model approach to shared decision making.
                              folder draft Team talk
                              prsb03-dataelement-13919
                              Id prsb03-dataelement-13919 (2021‑02‑03 09:46:21)
                              Description Details of the team talk (previously choice talk) with the person (Three talk model).
                              Comment
                              Overview: The team talk (previously choice talk) includes working together, describing choices, offering support and asking about the person's goals.
                              Suggested phrase: "Let's work as a team to make a decision that suits you best." (Elwyn, 2020)
                              A key purpose of the team talk is to make the the person, who by this point recognises that a health issue that requires a decision has been identified, aware that options exist. The team talk can be done face-to-face, by email or letter, telephone or other means and may include the use of patient decision support tools (Elwyn, 2016).



                              The NICE Shared decision making guideline (in development) states in section 1.2.7: "Ensure the person understands they can take part as fully as they want in making choices about their treatment or care (the ‘choice talk' stage of the three-talk model)."
                              draft Goals and hopes
                              prsb03-dataelement-13920
                              Id prsb03-dataelement-13920 (2021‑02‑03 09:51:28)
                              Description The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
                              Operationalization Free text.
                              Value Domain
                              draft Information and advice given
                              prsb03-dataelement-13921
                              Id prsb03-dataelement-13921 (2021‑02‑03 09:53:58)
                              Description A description of pertinent aspects, including the information and advice given to the person as part of the team talk. This should include any decision support tools used and where a copy of these can be securely obtained.
                              Comment According to Elwyn (2016) the team talk discussion may include the following aspects: Establishing collaboration, declaring alternatives, justifying deliberation, checking reaction, deferring closure. See references for further information.
                              Operationalization Free text.
                              Value Domain
                              folder draft Option talk
                              prsb03-dataelement-13922
                              Id prsb03-dataelement-13922 (2021‑02‑03 09:57:39)
                              Description Details of the option talk with the person (Three talk model).
                              Comment
                              Overview: The option talk includes a discussion of the options and alternatives and the harms and benefits of these using evidence based risk communication principles.
                              Suggested phrase: "Let's compare the possible options." (Elwyn, 2020)
                              According to Elwyn (2016) the option talk discussion may include the following key aspects: Checking knowledge, listing options, describing options, exploring harms and benefits, providing patient decision support, summarising.



                              The General Medical Council guidance on Decision making (GMC, 2020) and consent states in section 10 that : "You must give patients the information they want or need to make a decision. This will usually include: diagnosis and prognosis, uncertainties about the diagnosis or prognosis, including options for further investigation, options for treating or managing the condition, including the option to take no action, the nature of each option, what would be involved, and the desired outcome, the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action."



                              The NICE Shared decision making guideline (in development) states in section 1.2.9: "When offering tests, treatments or other healthcare services:
                              • openly discuss the risks, benefits and consequences of each option, making sure the person knows this includes choosing no treatment, or no change to what they are currently doing (the ‘option talk’ stage)."
                              folder draft Options entry
                              prsb03-dataelement-13923
                              Id prsb03-dataelement-13923 (2021‑02‑03 10:05:52)
                              Description Record of the options discussed.
                              Comment The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states that when discussing options for treating or managing a condition the clinician involved must include the option to take no action:



                              "Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action (Principle 4)."
                              draft Coded value
                              prsb03-dataelement-13924
                              Id prsb03-dataelement-13924 (2021‑02‑03 10:11:10)
                              Description Coded value of the option discussed.
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13925
                              Id prsb03-dataelement-13925 (2021‑02‑03 10:18:29)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Benefits entry
                              prsb03-dataelement-13926
                              Id prsb03-dataelement-13926 (2021‑02‑03 10:21:37)
                              Description Record of the benefits discussed for each option.
                              Comment
                              The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states in section 21: "You must give patients clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of each option, including the option to take no action."
                              draft Coded value
                              prsb03-dataelement-13927
                              Id prsb03-dataelement-13927 (2021‑02‑03 10:33:02)
                              Description Coded value of the benefit discussed.
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13928
                              Id prsb03-dataelement-13928 (2021‑02‑03 10:35:02)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Risks communication entry
                              prsb03-dataelement-13929
                              Id prsb03-dataelement-13929 (2021‑02‑03 10:39:01)
                              Description Record of the risks discussed for each option.
                              Comment The General Medical Council (GMC) Decision Making and Consent guidance (GMC, 2020) states in section 21 that when discussing benefits and harms a clinician should include the following: "Recognised risks of harm that [the clinician] believe[s] anyone in the patient’s position would want to know... the effect of the patient’s individual clinical circumstances on the probability of a benefit or harm occurring...risks of harm and potential benefits that the patient would consider significant for any reason...any risk of serious harm, however unlikely it is to occur...expected harms, including common side effects and what to do if they occur."



                              "It wouldn’t be reasonable to share every possible risk of harm, potential complication or side effect. Instead, you should tailor the discussion to each individual patient, guided by what matters to them, and share information in a way they can understand." (Section 22).
                              draft Coded value
                              prsb03-dataelement-13930
                              Id prsb03-dataelement-13930 (2021‑02‑03 10:44:43)
                              Description Coded value of the risk discussed.
                              Operationalization SNOMED CT.
                              Value Domain
                              draft Free text
                              prsb03-dataelement-13931
                              Id prsb03-dataelement-13931 (2021‑02‑03 10:46:20)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Decision talk
                              prsb03-dataelement-13932
                              Id prsb03-dataelement-13932 (2021‑02‑03 11:11:58)
                              Description Details of the decision talk with the person. This includes details of the decisions made, what the person said was important to them in coming to the decision, and agreed timescales for review.
                              Comment
                              Overview: The decision talk aims to establish a person's informed preferences and to make preference based decisions.
                              Suggested phrase: "Tell me what matters most to you for this decision." (Elwyn, 2020)
                              According to Elwyn (2016) the decision talk discussion may include the following key aspects: Focusing on preferences, eliciting and integrating preferences, moving to a decision, offering review.



                              The NICE guideline on Shared Decision Making (in draft) states:



                              In section 1.2.13:



                              "Make a joint decision or plan about treatment or care and agree when this will be reviewed (the ‘decision’ or ‘planning’ stage)."



                              In section 1.2.14:



                              "At the end of an appointment, state clearly what decisions have been made to make sure the person agrees with and understands what has been decided, what happens next, what the timescales are, and when it will be reviewed."



                              In section 1.2.15:



                              "When writing up the consultation, record any decisions made along with details of what the person said was important to them in making those decisions."
                              Operationalization Free text.
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-13933
                              Id prsb03-dataelement-13933 (2021‑02‑03 11:17:05)
                              Description The professional who conducted the shared decision making conversation (Three talk model).
                              Relationship
                              cancelled Organisation
                              prsb03-dataelement-13934
                              Id prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
                              Concept inherits from cancelled prsb03-dataelement-13902 (2021‑02‑02 18:16:27)
                              Description The name of the organisation the professional works for.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Name
                              prsb03-dataelement-13935
                              Id prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
                              Description The name of the professional.
                              Rationale Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Role
                              prsb03-dataelement-13936
                              Id prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
                              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:- SDSjobrolename
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Grade
                              prsb03-dataelement-13937
                              Id prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
                              Description The grade of the professional.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Specialty
                              prsb03-dataelement-13938
                              Id prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
                              Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc.
                              Rationale PractitionerRole.speciality
                              Operationalization NHS data dictionary :- Care professional main speciality code
                              Value Domain
                              Property
                              min length max length
                              3 3
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Professional identifier
                              prsb03-dataelement-13939
                              Id prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
                              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 entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Organisation
                              prsb03-dataelement-13940
                              Id prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
                              Description The name of the organisation the professional works for.
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Coded value
                              prsb03-dataelement-13941
                              Id prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisation identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Free text
                              prsb03-dataelement-13942
                              Id prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              draft Contact details
                              prsb03-dataelement-13943
                              Id prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
                              Concept inherits from draft prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
                              Description Contact details of the professional.
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              target Used by 0 transactions, 0 templates, inherited 2 times
                               
                              folder draft Person completing record
                              prsb03-dataelement-13944
                              Id prsb03-dataelement-13944 (2021‑02‑03 11:48:41)
                              Concept inherits from draft prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
                              Description Details of the person completing the record.
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Name
                              prsb03-dataelement-13945
                              Id prsb03-dataelement-13945 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Role
                              prsb03-dataelement-13946
                              Id prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Grade
                              prsb03-dataelement-13947
                              Id prsb03-dataelement-13947 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Specialty
                              prsb03-dataelement-13948
                              Id prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Organisation
                              prsb03-dataelement-13949
                              Id prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
                              Description The organisation the person completing the record works for.
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Coded value
                              prsb03-dataelement-13950
                              Id prsb03-dataelement-13950 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Free text
                              prsb03-dataelement-13951
                              Id prsb03-dataelement-13951 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Professional identifier
                              prsb03-dataelement-13952
                              Id prsb03-dataelement-13952 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Date completed
                              prsb03-dataelement-13953
                              Id prsb03-dataelement-13953 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Contact details
                              prsb03-dataelement-13954
                              Id prsb03-dataelement-13954 (2021‑02‑03 11:49:43)
                              Concept inherits from draft prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              folder draft Post-appointment actions
                              prsb03-dataelement-14076
                              Id prsb03-dataelement-14076 (2021‑02‑17 23:58:44)
                              Description A record of the actions taken to support the shared decision after the appointment. For example printouts summarising the options or decisions made, signposting to relevant online or physical information resources.
                              Comment The NICE Shared Decision Making guideline (in draft) states in section 1.2.16 that after appointments:



                              "Give people resources to help them understand what was discussed and decided in their appointment. This could be a printout summarising the options and decisions or plans made, and links to high-quality online resources (for example, relevant NICE guidelines). Ideally, give people this material to take away, or provide it very soon after the appointment."



                              In 1.2.17:



                              "In secondary or tertiary care, consider asking the person if they would like a letter detailing the information from their appointment to be sent to them and copied to their GP. Letters should be written in line with Academy of Medical Royal Colleges guidance on writing outpatient clinical letters to patients."
                              Operationalization Free text.
                              folder draft Performance measures
                              prsb03-dataelement-14093
                              Id prsb03-dataelement-14093 (2021‑02‑18 02:32:03)
                              Description A record of any performance measures used for measuring the effectiveness of shared decision making. e.g. CollaboRATE, Observer OPTION 5, Observer OPTION 12, SDM-Q-9 / SDM-Q-Doc etc.
                              folder draft Performance measure item entry
                              prsb03-dataelement-14157
                              Id prsb03-dataelement-14157 (2021‑02‑23 23:46:10)
                              Description Generic record of any shared decision performance measuring tools used.
                              Relationship
                              draft Performance measure identifier
                              prsb03-dataelement-14158
                              Id prsb03-dataelement-14158 (2021‑02‑23 23:57:25)
                              Description Any alphanumeric identifier associated with the performance measure (if applicable). 
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft Performance measure name
                              prsb03-dataelement-14159
                              Id prsb03-dataelement-14159 (2021‑02‑23 23:57:25)
                              Description The name of the performance measure.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              target Used by 0 transactions, 0 templates, inherited once
                               
                              draft Performance measure output
                              prsb03-dataelement-14160
                              Id prsb03-dataelement-14160 (2021‑02‑23 23:57:25)
                              Description The output of the performance measure e.g. score or free text.
                              Relationship
                              Operationalization Free text
                              Value Domain
                              draft Performance measure location
                              prsb03-dataelement-14161
                              Id prsb03-dataelement-14161 (2021‑02‑23 23:57:25)
                              Description The URL for the performance measure.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft Performance measure MIME type
                              prsb03-dataelement-14162
                              Id prsb03-dataelement-14162 (2021‑02‑23 23:57:25)
                              Description MIME type of the document e.g. application, pdf, website.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              folder draft CollaboRATE
                              prsb03-dataelement-14137
                              Id prsb03-dataelement-14137 (2021‑02‑22 13:24:45)
                              Description CollaboRATE is a patient-reported measure of shared decision making. The tool can be completed following a clinical encounter by patients, their parent(s) or guardian(s), or individuals representing the patient.
                              Comment CollaboRATE has been produced for use in research or as part of routine direct care. It can be used under a Creative Commons Attribution-NonCommerical-NoDerivs 3.0 Unported license
                              folder draft CollaboRATE for patients (5 point scale)
                              prsb03-dataelement-14149
                              Id prsb03-dataelement-14149 (2021‑02‑22 16:44:34)
                              Description A record of the person's CollaboRATE for patients score (5 point scale)
                              Relationship
                              draft Question 1 score
                              prsb03-dataelement-14150
                              Id prsb03-dataelement-14150 (2021‑02‑22 16:45:34)
                              Description Score (0 - 4) for CollaboRATE Q1:

                              Thinking about the appointment you have just had...How much effort was made to help you understand your health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 4)



                              0 = No effort was made ; 1 = A little effort was made ; 2 = Some effort was made ; 3 = A lot of effort was made ;  4 = Every effort was made

                              Value Domain
                              draft Question 2 score
                              prsb03-dataelement-14151
                              Id prsb03-dataelement-14151 (2021‑02‑22 16:45:34)
                              Description Score (0 - 9) for CollaboRATE Q2:

                              Thinking about the appointment you have just had...How much effort was made to listen to the things that matter most to you about your health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 4)



                              0 = No effort was made ; 1 = A little effort was made ; 2 = Some effort was made ; 3 = A lot of effort was made ;  4 = Every effort was made

                              Value Domain
                              draft Question 3 score
                              prsb03-dataelement-14152
                              Id prsb03-dataelement-14152 (2021‑02‑22 16:45:34)
                              Description Score (0 - 9) for CollaboRATE Q3:

                              Thinking about the appointment you have just had...How much effort was made to include what matters most to you in choosing what to do next?
                              Relationship
                              Operationalization Ordinal scale (0 - 4)



                              0 = No effort was made ; 1 = A little effort was made ; 2 = Some effort was made ; 3 = A lot of effort was made ;  4 = Every effort was made
                              Value Domain
                              folder draft CollaboRATE for patients (10 point scale)
                              prsb03-dataelement-14142
                              Id prsb03-dataelement-14142 (2021‑02‑22 14:03:15)
                              Description A record of the person's CollaboRATE for patients score (10 point scale)
                              Relationship
                              draft Question 1 score
                              prsb03-dataelement-14146
                              Id prsb03-dataelement-14146 (2021‑02‑22 14:06:37)
                              Description Score (0 - 9) for CollaboRATE Q1:

                              Thinking about the appointment you have just had...How much effort was made to help you understand your health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made

                              Value Domain
                              draft Question 2 score
                              prsb03-dataelement-14147
                              Id prsb03-dataelement-14147 (2021‑02‑22 14:06:37)
                              Description Score (0 - 9) for CollaboRATE Q2:

                              Thinking about the appointment you have just had...How much effort was made to listen to the things that matter most to you about your health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              draft Question 3 score
                              prsb03-dataelement-14148
                              Id prsb03-dataelement-14148 (2021‑02‑22 14:06:37)
                              Description Score (0 - 9) for CollaboRATE Q3:

                              Thinking about the appointment you have just had...How much effort was made to include what matters most to you in choosing what to do next?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              folder draft CollaboRATE for parents or guardians (10 point scale)
                              prsb03-dataelement-14138
                              Id prsb03-dataelement-14138 (2021‑02‑22 13:29:35)
                              Description A record of the person's CollaboRATE for parents or guardians score (10 point scale)
                              draft Question 1 score
                              prsb03-dataelement-14139
                              Id prsb03-dataelement-14139 (2021‑02‑22 13:36:41)
                              Description Score (0 - 9) for CollaboRATE Q1:

                              Thinking about the appointment you have just had...How much effort was made to help you understand your child's health issues?
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made

                              Value Domain
                              draft Question 2 score
                              prsb03-dataelement-14141
                              Id prsb03-dataelement-14141 (2021‑02‑22 13:51:37)
                              Description Score (0 - 9) for CollaboRATE Q2:

                              Thinking about the appointment you have just had...How much effort was made to listen to the things that matter most to you about your child's health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              draft Question 3 score
                              prsb03-dataelement-14140
                              Id prsb03-dataelement-14140 (2021‑02‑22 13:49:39)
                              Description Score (0 - 9) for CollaboRATE Q3:

                              Thinking about the appointment you have just had...How much effort was made to include what matters most to you in choosing what to do next?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              folder draft CollaboRATE for individuals acting on behalf of patients (10 point scale)
                              prsb03-dataelement-14153
                              Id prsb03-dataelement-14153 (2021‑02‑23 23:13:48)
                              Description A record of the person's CollaboRATE for individuals acting on behalf of patients (10 point scale)
                              Relationship
                              draft Question 1 score
                              prsb03-dataelement-14154
                              Id prsb03-dataelement-14154 (2021‑02‑23 23:16:54)
                              Description Score (0 - 9) for CollaboRATE Q1:

                              Thinking about the appointment you have just had...How much effort was made to help you understand the patient's health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made

                              Value Domain
                              draft Question 2 score
                              prsb03-dataelement-14155
                              Id prsb03-dataelement-14155 (2021‑02‑23 23:16:54)
                              Description Score (0 - 9) for CollaboRATE Q2:

                              Thinking about the appointment you have just had...How much effort was made to listen to the things that matter most to you about the patient's health issues?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              draft Question 3 score
                              prsb03-dataelement-14156
                              Id prsb03-dataelement-14156 (2021‑02‑23 23:16:54)
                              Description Score (0 - 9) for CollaboRATE Q3:

                              Thinking about the appointment you have just had...How much effort was made to include what matters most to you in choosing what to do next for the patient?
                              Relationship
                              Operationalization Ordinal scale (0 - 9)



                              0 = No effort was made ; 9 = Every effort was made
                              Value Domain
                              folder draft 9-item shared decision making questionnaire
                              prsb03-dataelement-14163
                              Id prsb03-dataelement-14163 (2021‑02‑24 00:11:44)
                              Description A digitised version of the 9-item shared decision making questionnaire, which is composed of the SDM-Q-9 (patient-reported) and SDM-Q-Doc (clinician reported) performance measures.
                              Comment The measures were developed for use in research and clinical practice and, according to the authors, should only be applied in the context of  preference sensitive decisions  i.e. where there are several treatment options for a particular disease.

                              folder draft SDM-Q-9
                              prsb03-dataelement-14164
                              Id prsb03-dataelement-14164 (2021‑02‑24 00:18:07)
                              Description Digitised entry for the SDM-Q-9 performance measure.
                              Comment The SDM-Q-9 is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

                              draft Health complaint/problem/illness entry
                              prsb03-dataelement-14165
                              Id prsb03-dataelement-14165 (2021‑02‑24 00:21:08)
                              Description Please indicate which health complaint/problem/illness the consultation was about: 
                              Operationalization Free text.
                              Value Domain
                              draft Decision entry
                              prsb03-dataelement-14166
                              Id prsb03-dataelement-14166 (2021‑02‑24 00:23:02)
                              Description Please indicate which decision was made:
                              Operationalization Free text.
                              Value Domain
                              draft Question 1 response
                              prsb03-dataelement-14175
                              Id prsb03-dataelement-14175 (2021‑02‑24 00:53:17)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor made clear that a decision needs to be made.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 2 response
                              prsb03-dataelement-14174
                              Id prsb03-dataelement-14174 (2021‑02‑24 00:49:22)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor wanted to know exactly how I want to be involved in making the decision.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 3 response
                              prsb03-dataelement-14173
                              Id prsb03-dataelement-14173 (2021‑02‑24 00:47:12)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor told me that there are different options for treating my medical condition.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 4 response
                              prsb03-dataelement-14172
                              Id prsb03-dataelement-14172 (2021‑02‑24 00:44:57)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor precisely explained the advantages and disadvantages of the treatment options.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 5 response
                              prsb03-dataelement-14171
                              Id prsb03-dataelement-14171 (2021‑02‑24 00:42:32)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor helped me understand all the information.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 6 response
                              prsb03-dataelement-14170
                              Id prsb03-dataelement-14170 (2021‑02‑24 00:39:55)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor asked me which treatment option I prefer.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 7 response
                              prsb03-dataelement-14169
                              Id prsb03-dataelement-14169 (2021‑02‑24 00:37:19)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor and I thoroughly weighed the different treatment options.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 8 response
                              prsb03-dataelement-14168
                              Id prsb03-dataelement-14168 (2021‑02‑24 00:30:29)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor and I selected a treatment option together.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 9 response
                              prsb03-dataelement-14167
                              Id prsb03-dataelement-14167 (2021‑02‑24 00:24:56)
                              Description For each statement please indicate how much you agree or disagree:

                              My doctor and I reached an agreement on how to proceed.


                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              folder draft SDM-Q-Doc
                              prsb03-dataelement-14176
                              Id prsb03-dataelement-14176 (2021‑02‑24 00:56:53)
                              Description Digitised entry for the SDM-Q-Doc performance measure (Physician version).
                              Relationship
                              Comment The SDM-Q-Doc is licensed under the  Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

                              draft Health complaint/problem/illness entry
                              prsb03-dataelement-14187
                              Id prsb03-dataelement-14187 (2021‑02‑24 00:57:54)
                              Description Please indicate which health complaint/problem/illness the consultation was about: 
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft Decision entry
                              prsb03-dataelement-14186
                              Id prsb03-dataelement-14186 (2021‑02‑24 00:57:54)
                              Description Please indicate which decision was made:
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft Question 1 response
                              prsb03-dataelement-14177
                              Id prsb03-dataelement-14177 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              I made clear to my patient that a decision needs to be made.

                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 2 response
                              prsb03-dataelement-14178
                              Id prsb03-dataelement-14178 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              I wanted to know exactly from my patient how he/she wants to be involved in making the decision.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 3 response
                              prsb03-dataelement-14179
                              Id prsb03-dataelement-14179 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              I told my patient that there are different options for treating his/her medical condition. 

                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 4 response
                              prsb03-dataelement-14180
                              Id prsb03-dataelement-14180 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              I precisely explained the advantages and disadvantages of the treatment options to my patient.

                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 5 response
                              prsb03-dataelement-14181
                              Id prsb03-dataelement-14181 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              I helped my patient understand all the information.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 6 response
                              prsb03-dataelement-14182
                              Id prsb03-dataelement-14182 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                               I asked my patient which treatment option he/she prefers. 

                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 7 response
                              prsb03-dataelement-14183
                              Id prsb03-dataelement-14183 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              My patient and I thoroughly weighed the different treatment options.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 8 response
                              prsb03-dataelement-14184
                              Id prsb03-dataelement-14184 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              My patient and I selected a treatment option together. 

                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              draft Question 9 response
                              prsb03-dataelement-14185
                              Id prsb03-dataelement-14185 (2021‑02‑24 00:57:54)
                              Description For each statement please indicate how much you agree or disagree:

                              My patient and I reached an agreement on how to proceed.


                              Relationship
                              Operationalization 1 = completely disagree ; 2 = strongly disagree ; 3 = somewhat disagree ; 4 = somewhat agree ; 5 = strongly agree ; 6 = completely agree
                              Value Domain
                              folder draft Documenting consent
                              prsb03-dataelement-14194
                              Id prsb03-dataelement-14194 (2021‑02‑25 23:10:18)
                              Description A record of documents recording consent for an intervention.
                              folder draft Consent for procedure record entry
                              prsb03-dataelement-14195
                              Id prsb03-dataelement-14195 (2021‑02‑25 23:14:06)
                              Description This is a consent for procedure record entry.  There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
                              cancelled Performance measure name
                              prsb03-dataelement-14205
                              Id prsb03-dataelement-14205 (2021‑02‑25 23:53:24)
                              Concept inherits from draft prsb03-dataelement-14159 (2021‑02‑23 23:57:25)
                              Description The name of the performance measure.
                              Relationship
                              Operationalization Free text.
                              Value Domain
                              draft date
                              prsb03-dataelement-14196
                              Id prsb03-dataelement-14196 (2021‑02‑25 23:18:47)
                              Description The date when consent was taken.
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year
                              folder draft Location
                              prsb03-dataelement-14197
                              Id prsb03-dataelement-14197 (2021‑02‑25 23:22:58)
                              Description The location where consent was taken.
                              draft Coded value
                              prsb03-dataelement-14198
                              Id prsb03-dataelement-14198 (2021‑02‑25 23:24:04)
                              Description The coded value for location.
                              Operationalization NHS data dictionary : -  Organisation data service code
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14199
                              Id prsb03-dataelement-14199 (2021‑02‑25 23:26:22)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              folder draft Consent form type
                              prsb03-dataelement-14200
                              Id prsb03-dataelement-14200 (2021‑02‑25 23:33:46)
                              Description Record of consent form used.
                              draft Coded value
                              prsb03-dataelement-14201
                              Id prsb03-dataelement-14201 (2021‑02‑25 23:37:05)
                              Description The coded value for the consent form used.
                              Operationalization SNOMED CT : - SNOMED CT: - : 849771000000105 |Obtaining consent using form 1 (patient agreement to investigation or treatment) (procedure)| OR 849781000000107 |Obtaining consent using form 2 (parental agreement to investigation or treatment for a child or young person) (procedure)| OR 849791000000109 |Obtaining consent using form 3 (patient or parental agreement to investigation or treatment) (procedure)| OR 849801000000108 |Obtaining consent using form 4 (adults who are unable to consent to investigation or treatment) (procedure)|
                              Value Domain
                              draft Free text
                              prsb03-dataelement-14202
                              Id prsb03-dataelement-14202 (2021‑02‑25 23:41:17)
                              Concept inherits from draft prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Consent form location
                              prsb03-dataelement-14203
                              Id prsb03-dataelement-14203 (2021‑02‑25 23:44:55)
                              Description The URL for the consent form.
                              Operationalization Free text.
                              Value Domain
                              draft Consent form MIME type
                              prsb03-dataelement-14204
                              Id prsb03-dataelement-14204 (2021‑02‑25 23:50:13)
                              Description MIME type of the document e.g. application, pdf, website.
                              Operationalization Free text.
                              Value Domain
                              folder draft Performing professional
                              prsb03-dataelement-14206
                              Id prsb03-dataelement-14206 (2021‑02‑25 23:56:44)
                              Description The professional who completed the consent form.
                              Relationship
                              draft Organisation
                              prsb03-dataelement-14207
                              Id prsb03-dataelement-14207 (2021‑02‑25 23:57:55)
                              Concept inherits from cancelled prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
                              Description The name of the organisation the professional works for.
                              Value Domain
                              draft Name
                              prsb03-dataelement-14208
                              Id prsb03-dataelement-14208 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
                              Description The name of the professional.
                              Rationale Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              70
                              draft Role
                              prsb03-dataelement-14209
                              Id prsb03-dataelement-14209 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
                              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:- SDSjobrolename
                              Value Domain
                              draft Grade
                              prsb03-dataelement-14210
                              Id prsb03-dataelement-14210 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
                              Description The grade of the professional.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14211
                              Id prsb03-dataelement-14211 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
                              Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc.
                              Rationale PractitionerRole.speciality
                              Operationalization NHS data dictionary :- Care professional main speciality code
                              Value Domain
                              Property
                              min length max length
                              3 3
                              draft Professional identifier
                              prsb03-dataelement-14212
                              Id prsb03-dataelement-14212 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
                              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 entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              folder draft Organisation
                              prsb03-dataelement-14213
                              Id prsb03-dataelement-14213 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
                              Description The name of the organisation the professional works for.
                              draft Coded value
                              prsb03-dataelement-14214
                              Id prsb03-dataelement-14214 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisation identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14215
                              Id prsb03-dataelement-14215 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Contact details
                              prsb03-dataelement-14216
                              Id prsb03-dataelement-14216 (2021‑02‑25 23:57:55)
                              Concept inherits from draft prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
                              Description Contact details of the professional.
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder draft Person completing record
                              prsb03-dataelement-14217
                              Id prsb03-dataelement-14217 (2021‑02‑26 00:07:31)
                              Concept inherits from draft prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
                              Description Details of the person completing the record.
                              draft Name
                              prsb03-dataelement-14218
                              Id prsb03-dataelement-14218 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
                              Description The name of the person completing the record.
                              Rationale Composition.author.Practitioner.name
                              Operationalization Free text.
                              Value Domain
                              draft Role
                              prsb03-dataelement-14219
                              Id prsb03-dataelement-14219 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
                              Description The organisational role of the person completing the record.

                              Properties

                              FHIR PractitionerRole.code of the practitioner completing the record
                              Rationale Composition.author.Practitioner.PractitionerRole.code
                              Operationalization FHIR value set :- SDSJobRoleName
                              Value Domain
                              Property
                              min length max length
                              5 5
                              draft Grade
                              prsb03-dataelement-14220
                              Id prsb03-dataelement-14220 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
                              Description The grade of the person completing the record.
                              Rationale PractitionerRole.code
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Specialty
                              prsb03-dataelement-14221
                              Id prsb03-dataelement-14221 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
                              Description The main specialty of the person completing the record.

                              Properties

                              FHIR PractitionerRole.specialty
                              Rationale PractitionerRole.specialty
                              Operationalization NHS data dictionary :- Activity treatment function code
                              Value Domain
                              Property
                              max length
                              3
                              folder draft Organisation
                              prsb03-dataelement-14222
                              Id prsb03-dataelement-14222 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
                              Description The organisation the person completing the record works for.
                              draft Coded value
                              prsb03-dataelement-14223
                              Id prsb03-dataelement-14223 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
                              Description The coded value for the organisation.
                              Operationalization NHS data dictionary :- Organisational identifier
                              Value Domain
                              Property
                              min length max length
                              3 8
                              draft Free text
                              prsb03-dataelement-14224
                              Id prsb03-dataelement-14224 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
                              Description Free text field to provide further detail or be used if no code is available.
                              Operationalization Free text.
                              Value Domain
                              Property
                              max length
                              150
                              draft Professional identifier
                              prsb03-dataelement-14225
                              Id prsb03-dataelement-14225 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
                              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)
                              Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
                              Operationalization NHS data dictionary :- Professional registration entry identifier
                              Value Domain
                              Property
                              max length
                              32
                              draft Date completed
                              prsb03-dataelement-14226
                              Id prsb03-dataelement-14226 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
                              Description The date and time the record was completed.
                              Rationale Composition.date
                              Operationalization Date and time.
                              Value Domain
                              Property
                              Timestamp precision
                              at least day, month and year, hour and minute
                              draft Contact details
                              prsb03-dataelement-14227
                              Id prsb03-dataelement-14227 (2021‑02‑26 00:08:20)
                              Concept inherits from draft prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
                              Description Contact details of the person completing the record (e.g. telephone number, email address etc.).

                              Properties

                              FHIR PractitionerRole.telecom
                              Rationale Practitioner.telecom



                              PractitionerRole.telecom



                              Organisation.telecom
                              Operationalization NHS data dictionary :- UK telephone number
                              Value Domain
                              Property
                              max length
                              35
                              folder cancelled Agenda Setting
                              prsb03-dataelement-14017
                              Id prsb03-dataelement-14017 (2021‑02‑15 11:52:12)
                              Description xxxxx
                              folder cancelled Generic item to be developed
                              prsb03-dataelement-13878
                              Id prsb03-dataelement-13878 (2021‑02‑01 16:21:59)
                              deprecated Test
                              prsb03-dataelement-12478
                              Id prsb03-dataelement-12478 (2019‑06‑27 14:43:45) 1
                              Description Test
                              Value Domain
                              cancelled Attachments
                              prsb03-dataelement-10915
                              Id prsb03-dataelement-10915 (2019‑04‑02 15:49:23)
                              Concept inherits from draft prsb03-dataelement-10012 (2018‑10‑31)
                              Description Documents included as attachments which accompany the communication Data items:

                              * number of attachments

                              * type of attachments

                              * attached documents.
                              Operationalization Number of attachments by category: present, pending, missing.

                              Supporting narrative: text for each attachment

                              Attachments: various formats, eg jpeg, word

                              Metadata about the attachments: document name standard under development by PRSB. Possibly use FHIR 'composition'.
                              Value Domain